The Thoracolumbar Injury Classification and Severity Score Appropriately Predicts Treatment in Children Aged 10 and Under.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: This study aims to assess the validity of the Thoracolumbar Injury Classification and Severity Score (TLICS) in patients ≤10 years-old. SUMMARY OF BACKGROUND DATA: TLICS is a validated measure developed to help facilitate clinical decision-making regarding thoracolumbar spinal trauma in adults. Studies examining the utility of TLICS in children skew towards older pediatric patients, where the spine's biomechanical properties are more similar to adults. Due to differences in a pre-adolescent spine compared to a more mature, adolescent spine, it is unclear if TLICS can be applied to younger patients. METHODS: A single center spine trauma registry was queried for patients ≤10 with an acute, traumatic thoracolumbar fracture treated at a level-1 pediatric trauma center between 2006 and 2020. Test characteristics and Receiver-Operator Curve were used to evaluate TLICS based on TLICS <4=nonsurgical treatment and TLICS >4=surgery recommendation. RESULTS: We identified 94 patients with traumatic thoracolumbar fractures (surgical=20; non-surgical=74). Despite TLICS-suggested operative management in 28 patients with TLICS>4, 9 (32.1%) were initially treated non-operatively. All patients who deviated from TLICS-suggested treatment had flexion-distraction injuries (FDI). Sensitivity, specificity, positive predictive value, and negative predictive value were 100%, 89.2%, 70.4%, and 100%, respectively. The receiver operating characteristic curve demonstrated strong diagnostic ability of TLICS in predicting need for surgery (area under the curve: 0.97, F1-score: 0.86). CONCLUSION: TLICS score <4 showed strong validity and is highly specific in predicting non-operative management for patients ≤10 years-old with thoracolumbar fractures. However, TLICS >4 has more limited specificity in indicating the necessity for surgical intervention, as many FDIs were successfully treated without surgery. Additional factors other than TLICS score may need to be considered for these more severe injuries to optimize management in this age group.

Information exchange on adolescent scoliosis discussion forums among patients and caregivers: a thematic analysis.

PURPOSE: Online health-related support groups have increasingly become a regular resource for patients and caregivers; however, the content of these forums is largely unknown to medical teams. The purposes of this study were to (1) review posts from scoliosis discussion forums to establish common themes related to the care experience of patients with scoliosis and (2) understand how common themes vary among pediatric and adult patients, as well as caregivers. METHODS: Posts were collected from two public scoliosis forums. Analysis was performed using grounded theory-a methodology that relies on the repeated analyses of qualitative data to identify recurring concepts, which are then coded and grouped into categories and ultimately central themes that seek to synthesize the relationships between categories. Information posts were reviewed by a board-certified orthopedic surgeon who performs scoliosis surgery for factual basis or misinformation. RESULTS: Analysis of 911 posts revealed five central themes. The two most common themes among patients ≥ 18 and caregivers involve seeking out emotional support and information about surgical treatment. Patients < 18 frequently sought out emotional support but were also largely interested in information about bracing. The most prevalent theme among all contributors involved seeking out emotional support. There was very little medical misinformation found within posts. CONCLUSION: Scoliosis forums serve as an informal outlet where patients and families can offer emotional support and share experiences. Physicians should provide direct emotional support to patients and offer these forums as a resource, without significant concerns about propagating medical misinformation.

Clinical and radiographic outcomes following correction of idiopathic scoliosis in adolescence vs young adulthood.

PURPOSE: The natural history of adolescent idiopathic scoliosis (AIS) has been well documented, but the impact of age at the time of surgical correction is relatively understudied. In this study, we matched patients undergoing surgical correction of adult idiopathic scoliosis (AdIS) with a cohort of AIS patients to compare: (1) coronal and sagittal radiographic correction, (2) operative variables, and (3) postoperative complications. METHODS: A single-institution scoliosis registry was queried for patients undergoing idiopathic scoliosis surgery from 2000-2017. INCLUSION CRITERIA: patients with idiopathic scoliosis, no previous spine surgery, and 2-year follow-up. AdIS patients were matched 1:2 with AIS patients based on Lenke classification and curve characteristics. Independent sample t-test and Chi-square test was used to analyze the data. RESULTS: 31 adults underwent surgical correction of idiopathic scoliosis and were matched with 62 adolescents. Mean age of adults was 26.2 ± 11.05, mean BMI was 25.6 ± 6.0, and 22 (71.0%) were female. Mean age of adolescents was 14.2 ± 1.8, mean BMI was 22.7 ± 5.7, and 41(66.7%) were female. AdIS had significantly less postoperative major Cobb correction (63.9% vs 71.3%, p = 0.006) and final major Cobb correction (60.6% vs 67.9%, p = 0.025). AdIS also had significantly greater postoperative T1PA (11.8 vs 5.8, p = 0.002). AdIS had longer operative times (p = 0.003), higher amounts of pRBCs transfused (p = 0.005), longer LOS (p = 0.016), more ICU requirement (p = 0.013), higher overall complications (p < 0.001), higher rate of pseudarthrosis (p = 0.026), and more neurologic complications (p = 0.013). CONCLUSION: Adult patients undergoing surgical correction of idiopathic scoliosis had significantly worse postoperative coronal and sagittal alignment when compared with adolescent patients. Adult patients also had higher rates of complications, longer operative times, and longer hospital stays. LEVEL OF EVIDENCE: III.

Dysplasia Epiphysealis Hemimelica in the Lower Extremity.

BACKGROUND: Because of the rarity of dysplasia epiphysealis hemimelica (DEH), little is known about the relationship between disease classification and clinical symptoms or patient outcomes. This studies therefore aims to characterize DEH of the lower extremity and correlate radiographic classification to presenting symptomatology and need for surgical intervention. METHODS: A multi-center, retrospective review of all patients with DEH of the lower extremity over a 47-year period was conducted. Demographic data, presenting complaints, treatments, and symptoms at final follow-up were recorded. Radiographs were reviewed to classify lesions using the Universal Classification System for Osteochondromas (UCSO) and document the presence of solitary or multiple lesions within the involved joint. Correlative statistics were used to determine whether presenting complaints, lesion location or radiographic classification predicted the need for surgery or a pain-free outcome. RESULTS: Twenty-eight patients met inclusion criteria with an average age at presentation of 7.8 years. The ankle was the most commonly affected joint with 20/28 patients (71%) having lesions of the talus, distal tibia, or distal fibula. Patients with chief complaints of pain were more likely to undergo surgery than those with complaints of a mass or deformity ( P =0.03). Ankle lesions were more likely to be managed operatively than those of the hip or knee ( P =0.018) and all 12 patients with talar lesions underwent surgery. Neither the number of lesions nor lesion classification was predictive of surgical intervention or a pain-free outcome after surgery. Patients presenting with pain were more likely to have a pain-free outcome (11/14 patients) after surgery ( P =0.023) whereas all patients presenting with deformity who underwent surgery had pain at final follow-up. CONCLUSIONS: Although no single radiographic characteristic of DEH was predictive of surgical intervention or outcome, painful lesions of the ankle, and lesions of the talus were more likely to be managed operatively. Although surgery does not always result in a pain-free outcome, the operative management of painful lesions was more likely to provide a pain-free outcome than surgery for deformity or a mass.

Variable Response to Antifibrinolytics Correlates with Blood-loss and Transfusion in Posterior Spinal Fusion.

PURPOSE: Posterior spinal fusion (PSF) activates the fibrinolytic protease plasmin, which is implicated in blood loss and transfusion. While antifibrinolytic drugs have improved blood loss and reduced transfusion, variable blood loss has been observed in similar PSF procedures treated with the same dose of antifibrinolytics. However, both the cause of this and the appropriate measures to determine antifibrinolytic efficacy during high-blood-loss spine surgery are unknown, making clinical trials to optimize antifibrinolytic dosing in PSF difficult. We hypothesized that patients undergoing PSF respond differently to antifibrinolytic dosing, resulting in variable blood loss, and that specific diagnostic markers of plasmin activity will accurately measure the efficacy of antifibrinolytics in PSF. METHODS: A prospective study of 17 patients undergoing elective PSF with the same dosing regimen of TXA was conducted. Surgery-induced plasmin activity was exhaustively analyzed in perioperative blood samples and correlated to measures of inflammation, bleeding, and transfusion. RESULTS: While markers of in vivo plasmin activation (PAP and D-dimer) suggested significant breakthrough plasmin activation and fibrinolysis (P < 0.01), in vitro plasmin assays, including TEG, did not detect plasmin activation. In vivo measures of breakthrough plasmin activation correlated with blood loss (R2 = 0.400, 0.264; P < 0.01), transfusions (R2 = 0.388; P < 0.01), and complement activation (R2 = 0.346, P < 0.05). CONCLUSIONS: Despite all patients receiving a high dose of TXA, its efficacy among patients was variable, indicated by notable intra-operative plasmin activity. Markers of in vivo plasmin activation best correlated with clinical outcomes. These findings suggest that the efficacy of antifibrinolytic therapy to inhibit plasmin in PSF surgery should be determined by markers of in vivo plasmin activation in future studies. LEVEL OF EVIDENCE: Level II-diagnostic.

A Mini-Open Approach to Medial Pinning in Pediatric Supracondylar Humeral Fractures May Be Safer Than Previously Thought.

BACKGROUND: Displaced pediatric supracondylar humeral fractures (SCHFs) are stabilized after reduction by smooth pins. Although some SCHFs are biomechanically stable after lateral-only entry pinning (lateral pinning), an additional medial entry pin (cross-pinning) confers superior stabilization in some SCHFs. There is a recognized risk of iatrogenic ulnar nerve injury with medial entry pinning. The best existing evidence has estimated an iatrogenic ulnar nerve injury rate of approximately 3.4% in cross-pinning. In similar studies, the rate of iatrogenic nerve injury (all nerves) in lateral pinning is estimated at 1.9%. This study aimed to use a large, single-center, single-technique (mini-open) retrospective case series to determine the rate of iatrogenic ulnar nerve injury in cross-pinning. METHODS: Patients undergoing percutaneous cross-pinning via the mini-open technique for SCHFs from 2007 to 2017 were retrospectively reviewed. Injury characteristics, operative variables, fixation technique, and complications, such as iatrogenic nerve injury, were recorded. Patients who underwent operative treatment at another hospital, had no postoperative follow-up, or died due to polytrauma were excluded. RESULTS: In this study, 698 patients undergoing cross-pinning during the study period were identified. Patients treated with cross-pinning had severe fractures, including a total of 198 preoperative neurovascular injuries (28.4%), 32 patients (4.6%) with skin tenting, and 19 patients (2.7%) with open fractures. Iatrogenic nerve injury was reported in 3 cases (0.43%), all of which affected the ulnar nerve. In 2 of 3 cases of iatrogenic nerve injury, the ulnar nerve symptoms resolved at a mean follow-up of 15 weeks. CONCLUSIONS: The mini-open approach for medial pin insertion is safer than previous estimates. Here, in the largest single-center study of cross-pinning for SCHFs, the iatrogenic ulnar nerve injury rate of 0.43% was nearly 10 times lower than estimated rates from recent meta-analyses. Considering all nerves, the iatrogenic injury rate for this cross-pinning cohort was also lower than the estimated iatrogenic nerve injury rate for lateral pinning. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Perioperative Considerations in Osteogenesis Imperfecta: A 20-Year Experience with the Use of Blood Pressure Cuffs, Arterial Lines, and Tourniquets.

Osteogenesis imperfecta (OI) is a rare genetic connective-tissue disorder with bone fragility. To avoid iatrogenic fractures, healthcare providers have traditionally avoided using non-invasive blood pressure (NIBP) cuffs and extremity tourniquets in the OI population in the perioperative setting. Here, we hypothesize that these procedures do not lead to iatrogenic fractures or other complications in patients with OI. A retrospective study of all children with OI who underwent surgery at a single tertiary care children's hospital from 1998 to 2018 was performed. Patient positioning and the use of NIBP cuffs, arterial lines, and extremity tourniquets were documented. Fractures and other complications were recorded. Forty-nine patients with a median age of 7.9 years (range: 0.2-17.7) were identified. These patients underwent 273 procedures, of which 229 were orthopaedic operations. A total of 246 (90.1%) procedures included the use of an NIBP cuff, 61 (22.3%) an extremity tourniquet, and 40 (14.7%) an arterial line. Pediatric patients with OI did not experience any iatrogenic fractures related to hemodynamic monitoring or extremity tourniquet use during the 20-year period of this study. Given the benefits of continuous intra-operative hemodynamic monitoring and extremity tourniquets, we recommend that NIBP cuffs, arterial lines, and tourniquets be selectively considered for use in children with OI.

The financial burden of musculoskeletal firearm injuries in children with and without concomitant intra-cavitary injuries.

BACKGROUND: Musculoskeletal pediatric firearm injuries are a clinically significant and expensive public health problem in the United States. In this retrospective cohort analysis, we sought to characterize musculoskeletal firearm injuries in children and to describe the financial burden associated with these injuries. METHODS: This study is a single center, retrospective review. Patients were identified from January 2002 - December 2015 from an institutional database using ICD-9 codes pertaining to firearm injury. Inclusion criteria were: 1) age < 18 years at injury; 2) firearm injury to an extremity, spine, or pelvis; and 3) patient received orthopedic evaluation and/or treatment. 140 patients with 142 distinct orthopedic injuries meeting inclusion criteria were analyzed (N = 142). Primary measures were demographic and situational data including intent, length of stay, follow-up, and complications; and financial outcomes including charges, costs, and net revenues. RESULTS: Median age was 15.3 years [IQR: 13.3, 16.4], 84% were male, and 52% were African American. 59% of the firearm injuries were of violent intent. 32% of patients were privately insured, 61% were publicly insured, and 6% were uninsured. Median length of stay was 2 days [0, 4], with 73% of patients being admitted. 43% of patients required additional hospitalizations, emergency room visits, and/or outpatient surgeries, and 93% of patients had outpatient follow-up. 42% of patients experience an injury-related or long-term orthopedic complication. Total charges for the cohort were $11.4 million, with $3.7 million in costs and $45,042 in net revenues. In the multivariable analysis, more surgeries predicted higher charges, and more secondary encounters predicted higher costs and net revenues. Only privately-insured patients had a positive median net revenue. CONCLUSIONS: Children who sustain musculoskeletal injuries from firearms experience high rates of orthopedic complications. Institutional costs to manage these preventable injuries are excessive. Policy makers should continue to pursue measures to reduce gun violence and improve gun safety in the pediatric population. LEVEL OF EVIDENCE: Level III, economic/decision.

Os Odontoideum in Children: Treatment Outcomes and Neurological Risk Factors.

BACKGROUND: Treatment outcomes and risk factors for neurological deficits in pediatric patients with an os odontoideum are unclear. METHODS: We reviewed the data for 102 children with os odontoideum who were managed at 11 centers between 2000 and 2016 and had a minimum duration of follow-up of 2 years. Thirty-one children had nonoperative treatment, and 71 underwent instrumented posterior cervical spinal arthrodesis for the treatment of C1-C2 instability. Nonoperative treatment consisted of observation (n = 29) or immobilization with a cervical collar (n = 1) or halo body jacket (n = 1). Surgical treatment consisted of atlantoaxial (n = 50) or occipitocervical (n = 21) arthrodesis. One patient also underwent transoral odontoidectomy. RESULTS: Thirty children (29%) presented with neurological deficits, 28 of whom had radiographic atlantoaxial instability (atlantoaxial distance >5 mm) or limited space (≤13 mm) available for the spinal cord (risk ratio, 7.8 [95% confidence interval, 2.0 to 31] compared with children with no radiographic risk factors). The 27 children without neurological deficits or atlantoaxial instability at presentation underwent nonoperative treatment and remained asymptomatic. Of the initial nonoperative cohort, one child developed atlantoaxial instability, and another had a persistent neurological deficit; both children underwent spinal arthrodesis during the study period. One child with cervical instability declined surgery and remained asymptomatic. Spinal fusion occurred in 68 patients in the surgical group by the end of the study period (mean, 3.7 years; range, 2.0 to 11.8 years). Surgical complications occurred in 21 children, including nonunion in 12, new neurological deficits in 4, cerebrospinal fluid leak in 2, symptomatic instrumentation requiring removal 2, and vertebral artery injury in 1. Nine children underwent revision surgery. In the surgical group, Japanese Orthopaedic Association neurological function scores improved significantly from preoperatively to the latest follow-up for the upper extremities (p = 0.026) and lower extremities (p = 0.007). CONCLUSIONS: The risk of developing a neurological deficit was strongly associated with atlantoaxial instability and limited space available for the spinal cord in children with os odontoideum. Nonoperative treatment was safe for asymptomatic patients without atlantoaxial instability. Spinal arthrodesis resolved the neurological deficits of children with symptomatic os odontoideum. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Internal Rotation Stress Testing Improves Radiographic Outcomes of Type 3 Supracondylar Humerus Fractures.

BACKGROUND: The purpose of this study was to determine if routine use of an intraoperative internal rotation stress test (IRST) for type 3 supracondylar humerus fractures will safely improve maintenance of reduction. METHODS: An intraoperative protocol for type 3 supracondylar humerus fractures was adopted at our institution, consisting of fracture reduction, placement of 2 laterally based divergent pins, and then an IRST to determine the need for additional fixation with a medial column pin placed through a small open approach. Fractures treated with the prospective IRST protocol were compared with a retrospective cohort before adoption of the protocol (pre-IRST). The primary outcomes were differences in Baumann's angle, lateral humerocapitellar angle, and the rotation index between final intraoperative fluoroscopic images and radiographs at final follow-up. Secondary outcomes were complications such as iatrogenic nerve injury, loss of fixation, or need for reoperation. RESULTS: There were 78 fractures in the retrospective cohort (pre-IRST) and 49 in the prospective cohort (IRST). Overall rotational loss of reduction (>6%), measured by lateral rotation percentage, and major rotational loss of reduction (>12%) were less common in the IRST cohort (6/49 vs. 27/78, P=0.007 overall; 0/49 vs. 8/78, P=0.02 major loss). There were no major losses of reduction for Baumann's angle (>12 degrees) in either cohort. There were 5 subjects in the pre-IRST cohort (6.4%) with a major loss of reduction of the humerocapitellar angle (>12 degrees) and none in the IRST cohort (P=0.16) Loss of proximal fixation with need for reoperation occurred in 3 fractures in the pre-IRST cohort, and none in the IRST cohort (P=0.28). There were no postoperative nerve injuries in either group. CONCLUSIONS: Intraoperative IRST after placement of 2 lateral pins assists with the decision for additional fixation in type 3 supracondylar humerus fractures. This method improved the final radiographic rotational alignment, and was safely performed using a mini-open approach for medial pin placement. LEVEL OF EVIDENCE: Level III-prospective cohort compared with a retrospective cohort.

Dilutional coagulopathy in pediatric scoliosis surgery: A single center report.

BACKGROUND: Children undergoing posterior spinal fusion experience high blood loss often necessitating transfusion. An appropriately activated coagulation system provides hemostasis during surgery, but pathologic dysregulation can cause progressive bleeding and increased transfusions. Despite receiving antifibrinolytics for clot stabilization, many patients still require transfusions. AIMS: We sought to examine the association of dilutional coagulopathy with blood loss and blood transfusion in posterior spinal fusion for pediatric scoliosis patients. METHODS: A retrospective, single institution study of children undergoing posterior spinal fusion >6 levels with a standardized, prospective anesthetic protocol utilizing antifibrinolytics. Blood loss was evaluated using a hematocrit-based calculation. To evaluate transfusions, a normalized Blood Product Transfusion calculation was developed. Factors associated with blood loss and blood transfusions were determined by univariate analysis and multivariate regression modeling with multicollinearity and mediation analysis. RESULTS: Patients received 73.7 mL/kg (standard deviation ±30.8) of fluid poor in coagulation factors. Estimated blood loss was 42.6 mL/kg (standard deviation ±18.0). There was a significant association between estimated blood loss and total fluids delivered (Spearman's rho = 0.51, 95% confidence interval 0.33-0.65, P < 0.001). Factors significantly associated with normalized Blood Product Transfusion in this cohort included age, weight, scoliosis type, levels fused, total osteotomies, pelvic fixation, total fluid, maximum prothrombin time, and minimum fibrinogen. Regression modeling showed the best combination of variables for modeling normalized Blood Product Transfusion included patient weight, number of levels fused, total fluid administered, and maximum prothrombin time. CONCLUSION: Blood product transfusion remains a frustrating problem in pediatric scoliosis. Identifying and controlling dilutional coagulopathy in these patients may reduce blood loss and the need for blood transfusion.

Radiation Exposure During Operative Fixation of Pediatric Supracondylar Humerus Fractures: Is Lead Shielding Necessary?

BACKGROUND: Factors that impact radiation exposure during operative fixation of pediatric supracondylar humerus (SCH) fractures have been investigated; however, no studies have measured the equivalent dose at the patient's radiosensitive organs. Our hypothesis was that intraoperative fluoroscopy exposes pediatric patients to a significant radiation load and lead shielding of radiosensitive organs is important. The goal of the study was to quantify the patient's radiation exposure during the procedure by measuring the radiation load at the thyroid and gonads. METHODS: A prospective quality improvement project of radiation exposure during percutaneous fixation of isolated SCH fractures was performed over a 4-week period. The c-arm image intensifier was used as the operating table and radiation dosimeters were positioned over the thyroid and gonadal lead shields. Fluoroscopy times were recorded, doses were calculated, and the dosimeters were analyzed. To assure that the prospective cohort was representative of a larger population of SCH fractures, demographics and fluoroscopy time of the prospective cohort were compared with a 12-month retrospective cohort in which dosimetry was not performed. RESULTS: Prospective cohort-18 patients with type 2 (8) and type 3 (10) fractures were prospectively studied with intraoperative measurement of thyroid and gonadal radiation equivalent doses. Mean age was 4.9 years (1.9 to 9.5 y) and mean weight was 21.4 kg (13.1 to 33.5 kg). Mean fluoroscopy time was 65.0 seconds (25.3 to 168.4 s), and absorbed skin dose at the elbow was 0.47 mGy (0.18 to 1.21 mGy). The radiation dosimeters overlying the thyroid and gonads measured minimal radiation indicating equivalent doses of <0.01 mSv for all patients in the prospective cohort.Retrospective cohort-163 patients with type 2 (60) and type 3 (103) fractures were retrospectively studied. The mean age was 5.5 years (0.02 to 13.7 y) and weight was 21.6 kg (2.0 to 71.9 kg). Mean fluoroscopy time was 74.1 seconds (10.2 to 288.9 s), and absorbed skin dose at the elbow was 0.53 mGy (0.07 to 2.07 mGy).There were no statistically significant differences between the cohorts. CONCLUSIONS: The smaller prospective cohort had fluoroscopy times and radiation doses that were not statistically different from the larger retrospective cohort, suggesting that the dosimeter measurements are representative of intraoperative radiation exposure during fixation of pediatric SCH fractures. The equivalent dose to the thyroid and gonads was minimal and approximates daily background radiation. Shielding of radiosensitive organs is appropriate when practical to minimize cumulative lifetime radiation exposure, particularly in smaller patients and when longer fluoroscopy times are anticipated. LEVEL OF EVIDENCE: Level 2.

Leptin Elevation as a Risk Factor for Slipped Capital Femoral Epiphysis Independent of Obesity Status.

BACKGROUND: Slipped capital femoral epiphysis (SCFE) is strongly associated with childhood obesity, yet the prevalence of obesity is orders of magnitude greater than the prevalence of SCFE. Therefore, it is hypothesized that obesity is not, by itself, a sufficient condition for SCFE, but rather one component of a multifactorial process requiring preexisting physeal pathology. Leptin elevation is seen to varying degrees in patients with obesity, and as leptin has been shown to cause physeal pathology similar to the changes seen in SCFE, we propose that leptin may be a factor distinguishing between patients with SCFE and equally obese children without hip abnormalities. METHODS: Serum leptin levels were obtained from 40 patients with SCFE and 30 control patients with approximate body mass index (BMI) matching. BMI percentiles were calculated according to Centers for Disease Control and Prevention population data by patient age and sex. Patients were compared by demographic characteristics, leptin levels, odds of leptin elevation, and odds of SCFE. RESULTS: The odds of developing SCFE was increased by an odds ratio of 4.9 (95% confidence interval [CI], 1.31 to 18.48; p < 0.02) in patients with elevated leptin levels, regardless of obesity status, sex, and race. When grouping patients by their obesity status, non-obese patients with SCFE showed elevated median leptin levels at 5.8 ng/mL compared with non-obese controls at 1.7 ng/mL (p = 0.006). Similarly, obese patients with SCFE showed elevated median leptin levels at 17.9 ng/mL compared with equally obese controls at 10.5 ng/mL (p = 0.039). Serum leptin levels increased in association with obesity (p < 0.001), with an increase in leptin of 0.17 ng/mL (95% CI, 0.07 to 0.27 ng/mL) per BMI percentile point. CONCLUSIONS: To our knowledge, this study is the first to clinically demonstrate an association between elevated serum leptin levels and SCFE, regardless of BMI. This adds to existing literature suggesting that SCFE is a multifactorial process and that leptin levels may have profound physiological effects on the development of various disease states. Despite a strong association with adiposity, leptin levels vary between patients of equal BMI and may be a vital resource in prognostication of future obesity-related comorbidities. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Deep Spine Infection After Acupuncture in the Setting of Spinal Instrumentation.

BACKGROUND: Acupuncture can be used to manage chronic pain. The most common complications related to acupuncture include pain, bruising, bleeding, or symptom exacerbation. Rarely, more serious adverse events occur, including infection, pneumothorax, septic arthritis, and peripheral nerve injury. To our knowledge, there are no reports of complications associated with acupuncture following spinal instrumentation. PURPOSE: To report a case of deep infection as a rare complication of acupuncture following posterior spinal fusion for adolescent idiopathic scoliosis. STUDY DESIGN: Case report. METHODS: Case report. RESULTS: A 15-year-old female presented 21 months after spinal arthrodesis for idiopathic scoliosis with a deep spine infection. The patient had recently been receiving a variation of acupuncture (dry needling therapy) in her medial periscapular region to manage chronic back and shoulder pain. She underwent serial irrigation and debridement with implant removal. Intraoperative cultures revealed pseudomonas and aerobic diptheroids. Two weeks later, the patient developed a periscapular abscess requiring additional operative debridement; cultures from this abscess were negative. After an 8-week course of antibiotics, the patient remains infection free with normalized inflammatory markers 2 years postoperatively. CONCLUSIONS: Acupuncture is sometimes pursued as part of a multimodality pain management program for back pain, but it is not without risk and can lead to infection. Deep infection from acupuncture may contaminate existing spinal instrumentation and require operative debridement, implant removal, and long-term antibiotic therapy. Accordingly, there is an increased risk for deformity progression in this scenario related to the implant removal.

Intramedullary Nailing Compared with Spica Casts for Isolated Femoral Fractures in Four and Five-Year-Old Children.

BACKGROUND: Flexible intramedullary nailing (IMN) is a valuable tool in the treatment of femoral fractures in school-age children, whereas spica cast immobilization has been the standard of care for younger children. We compared these treatment modalities in a group of preschool-age children (four to five years of age). METHODS: A retrospective cohort of consecutive patients, four to five years of age, with an isolated, complete femoral shaft or subtrochanteric fracture treated with intramedullary nailing or early spica cast immobilization and followed until fracture-healing were identified from two centers. Radiographic and clinical outcomes were compared between the groups. Statistical methods included chi-square and Fisher exact tests for categorical variables and the Mann-Whitney test for continuous variables. RESULTS: Two hundred and sixty-two patients followed for a mean of thirty-two weeks were identified. One hundred and four patients underwent IMN and 158 patients were treated with immediate spica cast immobilization at the surgeon's discretion. The patients who underwent IMN were older than those who underwent spica cast immobilization (mean, 5.2 versus 4.7 years; p < 0.001), were heavier (mean, 21.5 versus 18.0 kg; p < 0.001), and were more likely to have a higher-energy mechanism of injury (p = 0.025). At the time of final follow-up, there was no difference between groups with regard to the percentages of patients who had acceptable coronal angulation (≤15°), sagittal angulation (≤20°), and early fracture shortening (≤20 mm) (96.2% in the spica group versus 99.0% in the IMN group; p = 0.09). While there was no significant difference in the percentages who had an unplanned return to the operating room (3.8% in the IMN group versus 4.4% in the spica group; p > 0.99), the patients in the IMN group had more clinic visits (mean, 5.8 versus 4.0; p < 0.001) and longer follow-up (mean, forty-four versus twenty-five weeks; p < 0.001) than the patients in the spica group and a higher percentage of them underwent repeat procedures (89.4% versus 5.1%; p < 0.001), primarily for elective implant removal. CONCLUSIONS: Preschool-age children (four to five years old) with an isolated femoral fracture have similar clinical and radiographic outcomes regardless of whether they are treated with immediate spica cast immobilization or IMN.