Bridge Plate Fixation of Distal Femur Fractures: Defining Deficient Radiographic Callus Formation and Its Associations.

OBJECTIVE: To determine whether deficient early callus formation can be defined objectively based on the association with an eventual nonunion and specific patient, injury, and treatment factors. METHODS: Final healing outcomes were documented for 160 distal femur fractures treated with locked bridge plate fixation. Radiographic callus was measured on postoperative radiographs until union or nonunion had been declared by the treating surgeon. Deficient callus was defined at 6 and 12 weeks based on associations with eventual nonunion through receiver-operator characteristic analysis. A previously described computational model estimated fracture site motion based on the construct used. Univariable and multivariable analyses then examined the association of patient, injury, and treatment factors with deficient callus formation. RESULTS: There were 26 nonunions. The medial callus area at 6 weeks <24.8 mm 2 was associated with nonunion (12 of 39, 30.8%) versus (12 of 109, 11.0%), P = 0.010. This association strengthened at 12 weeks with medial callus area <44.2 mm 2 more closely associated with nonunion (13 of 28, 46.4%) versus (11 of 120, 9.2%), P <0.001. Multivariable logistic regression analysis found limited initial longitudinal motion (OR 2.713 (1.12-6.60), P = 0.028)) and Charlson Comorbidity Index (1.362 (1.11-1.67), P = 0.003) were independently associated with deficient callus at 12 weeks. Open fracture, mechanism of injury, smoking, diabetes, plate material, bridge span, and shear were not significantly associated with deficient callus. CONCLUSION: Deficient callus at 6 and 12 weeks is associated with eventual nonunion, and such assessments may aid future research into distal femur fracture healing. Deficient callus formation was independently associated with limited initial longitudinal fracture site motion derived through computational modeling of the surgical construct but not more routinely discussed parameters such as plate material and bridge span. Given this, improved methods of in vivo assessment of fracture site motion are necessary to further our ability to optimize the mechanical environment for healing. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Pediatric Hand Fractures and Congenital Differences: An Analysis of Data From the American Board of Orthopaedic Surgery and the American Board of Plastic Surgery.

PURPOSE: Pediatric patients with hand trauma and congenital differences are treated across multiple surgical subspecialties. The purpose of this study was to assess operative trends over an 11-year period using the American Board of Orthopaedic Surgery and the American Board of Plastic Surgery databases to better understand which surgeons were caring for pediatric hand fractures and birth differences in the first 2 years of their practice. METHODS: We queried the American Board of Orthopaedic Surgery and the American Board of Plastic Surgery databases for surgical procedures performed by applicants for the oral examinations between 2004 and 2014. Candidates self-identified as general orthopedic surgeon, pediatric orthopedic surgeon, hand surgeon (orthopedic and plastic), and general plastic surgeon. This included a total of 2,453 Board applicants. A total of 6,835 surgeries for birth differences or hand trauma were identified and reviewed for patients <18 years of age. RESULTS: There were 5,759 trauma and 1,076 congenital difference surgeries. A total of 4,786 (70%) surgeries were performed by orthopedic surgeons. Fellowship-trained hand surgeons (orthopedic and plastic) performed 3,809 (56%) surgeries. Pediatric orthopedic surgeons performed 608 (9%) surgeries. Over the 11 years, general orthopedic surgeons performed 4.2 fewer surgeries per year, whereas surgeons in hand orthopedics and pediatric orthopedics performed 10.8 and 4.7 additional surgeries per year. There were 3.1 fewer general orthopedic surgeons per year, whereas there were 3.6 and 1.4 additional surgeons in hand orthopedics and pediatric orthopedics each year, respectively. The number of surgeries and the number of surgeons submitting surgeries did not significantly change for those in general plastics or hand plastics. CONCLUSIONS: This analysis of early practice patterns over 11 years demonstrates that the increasing numbers of surgeons in pediatric orthopedics and hand orthopedics are performing more surgeries compared with other fields. CLINICAL RELEVANCE: The care of children with hand injuries and congenital differences is evolving, with direct implications for residency and fellowship education.

40% reoperation rate in adolescents with spondylolisthesis.

STUDY DESIGN: Multicenter retrospective. OBJECTIVE: To determine the long-term complication rate associated with surgical treatment of spondylolisthesis in adolescents. There is limited information on the complication rate associated with posterior spinal fusion (PSF) of spondylolisthesis in the pediatric and adolescent population. METHODS: Patients who underwent PSF for spondylolisthesis between 2004 and 2015 at four spine centers, < 21 years of age, were included. Exclusion criteria were < 2 years of follow-up or anterior approach. Charts and radiographs were reviewed. RESULTS: 50 patients had PSF for spondylolisthesis, 26 had PSF alone, while 24 had PSF with trans-foraminal lumbar interbody fusion (TLIF). Mean age was 13.9 years (range 9.6-18.4). Mean follow-up was 5.5 years (range 2-15). Mean preoperative slip was 61.2%. 20/50 patients (40%) experienced 23 complications requiring reoperation at a mean of 2.1 years (range 0-9.3) for the following: implant failure (12), persistent radiculopathy (3), infection (3), persistent back pain (2), extension of fusion (2), and hematoma (1). In addition, there were 22 cases of radiculopathy (44%) that were transient. Rate of implant failure was related to preoperative slip angle (p = 0.02). Reoperation rate and rates of implant failure were not associated with preoperative % slip (reoperation: p = 0.42, implant failure: p = 0.15), postoperative % slip (reoperation: p = 0.42, implant failure: p = 0.99), postoperative kyphosis of the lumbosacral angle (reoperation: p = 0.81, implant failure: p = 0.48), change in % slip (reoperation: p = 0.30, implant failure: p = 0.12), change in slip angle (reoperation: p = 0.42, implant failure: p = 0.40), graft used (reoperation: p = 0.22, implant failure: p = 0.81), or addition of a TLIF (reoperation: p = 0.55, implant failure: p = 0.76). CONCLUSION: PSF of spondylolisthesis in the adolescent population was associated with a 40% reoperation rate and high rate of post-operative radiculopathy. Addition of a TLIF did not impact reoperation rate or rate of radiculopathy.

Dedicated spine nurses and scrub technicians improve intraoperative efficiency of surgery for adolescent idiopathic scoliosis.

STUDY DESIGN: Retrospective comparative study. OBJECTIVE: To determine how the use of dedicated spine surgical nurses and scrub technicians impacted surgical outcomes of posterior spinal fusions for adolescent idiopathic scoliosis (AIS). Dedicated team approaches to surgery have been shown to improve surgical outcomes. However, their study on orthopaedics and spine surgery is limited. METHODS: A retrospective review of all patients who underwent a primary posterior spinal fusion of seven or more levels for AIS at a tertiary care pediatric hospital with a minimum of 2 years of follow-up from 2006 to 2013 was conducted. Our institution had dedicated spine surgeons and anesthesiologists throughout the study period, but use of dedicated spine nurses and scrub technicians was variable. The relationship between the proportion of nurses and scrub technicians that were dedicated spine and surgical outcome variables was examined. A multiple regression was performed to control for the surgeon performing the case and the start time. RESULTS: A total of 146 patients met criteria. When teams were composed of < 60% dedicated spine nurses and scrub technicians, there was 34 min more total OR time (p = .008), 27 min more surgical time (p = .037), 7 min more nonsurgical OR time (p = .030), 30% more estimated blood loss (EBL) (p = .013), 27% more EBL per level instrumented (p = .020), 113% more allogeneic transfusion (p = .006), and 104% more allogeneic transfusion per level instrumented (p = .009). There was no significant difference in length of stay, unplanned staged procedures, surgical site infection, reoperation, or major medical complications. CONCLUSIONS: Performing posterior spinal fusions for AIS patients with dedicated spine nurses and scrub technicians is associated with a significant decrease in total OR time, blood loss, and transfusion rates. LEVEL OF EVIDENCE: III.

Changes in Pediatric Spine Surgery Patterns Over the Last 10 Years Among ABOS Part II Candidates.

STUDY DESIGN: A retrospective review of prospectively collected data. OBJECTIVE: Our purpose was to evaluate the volume of pediatric spine cases being done by surgeons applying for American Board of Orthopaedic Surgeons (ABOS) certification. SUMMARY OF BACKGROUND DATA: Pediatric orthopedic surgery has become increasingly subspecialized over the past decade. METHODS: Data were reviewed from the ABOS for surgeons undergoing part II of ABOS certification between 2004 and 2014. Applicants were divided into pediatric orthopedic surgeons and spine surgeons based on their self-declared subspecialty for the ABOS Part II examination. A total of 102,424 cases were reviewed to identify spine cases performed on patients <18 years old. RESULTS: Between 2004 and 2014, the total number of ABOS part II pediatric candidates increased significantly, from a low of 15 to a high of 44 (r = 0.68, P = 0.001). During this time frame, there has been no significant increase in the total number of pediatric spine cases reported (r = 0.09, P = 0.19). In 2004, 46.5% (33/71) of the pediatric spine cases were done by spine surgeons, which decreased to 17.3% (28/162) in 2014. Conversely in 2004, 53.5% (38/71) of pediatric spine cases were done by pediatric orthopedists, which increased to 82.7% (134/162) in 2014. The number of pediatric candidates performing pediatric spine cases decreased 35% from 2004 to 2014, but the percentage performing >20 spine cases during their candidate year has increased from 0% to 7% (r = 0.31, P = 0.04). CONCLUSION: The share of pediatric spine surgeries performed by pediatric candidates has increased from 54% in 2004 to 83%, with a corresponding fall in the share surgeries performed by spine candidates (47% to >17%). The percentage of pediatric candidates performing more than 20 spine cases/year increased from 0% to 7%, reflecting a trend of spine subspecialization within pediatric surgery. LEVEL OF EVIDENCE: 3.

Don't You Wish You Had Fused to the Pelvis the First Time: A Comparison of Reoperation Rate and Correction of Pelvic Obliquity.

STUDY DESIGN: A multicenter retrospective study. OBJECTIVE: The aim of this study was to compare pelvic obliquity correction and reoperation rate in neuromuscular scoliosis patients who had their pelvis included in a posterior spinal fusion (pelvic fusion, PF) at their index procedure versus revision procedures. SUMMARY OF BACKGROUND DATA: There is limited information on outcomes specific to fusing to the pelvis for neuromuscular scoliosis in a revision operation versus index surgery. METHODS: Charts and radiographs were reviewed of patients with PF for neuromuscular scoliosis from January 2003 to August 2015 at four high-volume pediatric spine centers with >2 year follow-up. RESULTS: Two hundred eighty-five patients met inclusion criteria; 271 had PF done at index surgery and 14 had PF done during revision surgery. Before index procedure, there were no significant differences in Cobb angle (P = 0.13). Before PF, there was no difference in pelvic obliquity (P = 0.26). At the time of fusion to the pelvis, estimated blood loss (P = 0.23) and operative time (P = 0.43) did not differ between index and revision groups. Percent correction in pelvic obliquity was similar for both groups (P = 0.72). Overall, 69 patients had complications requiring return to the operating room. Excluding the revision surgery for inclusion of the pelvis for the revision group, there was still a lower reoperation rate with index PF (22.9%, n = 62/271) than revision PF (50.0%, n = 7/14) (P = 0.02). Implant failures were significantly higher in the revision group (index = 7.4%, 20/271; revision = 42.9%, 6/14; P < 0.001). CONCLUSION: PF at the index spinal fusion led to similar correction of pelvic obliquity with approximately half the reoperation rate compared with PF at a revision surgery. Operative time and blood loss were similar between index and revision spinal fusion. LEVEL OF EVIDENCE: 4.

Pediatric Sports Medicine, A New Subspeciality in Orthopedics: An Analysis of the Surgical Volume of Candidates for the American Board of Orthopaedic Surgery Part II Certification Exam Over the Past Decade.

BACKGROUND: Pediatric orthopaedic surgery has become increasingly subspecialized over the past decade. The purpose of this study was to analyze the volume of pediatric sports medicine cases performed by surgeons applying for the American Board of Orthopaedic Surgeons (ABOS) Part II certification exam over the past decade, comparing caseloads according to the type(s) of fellowship completed. METHODS: The ABOS database was reviewed for all surgeons applying for the ABOS Part II certification exam from 2004 to 2014. Fellowship training of the candidates was recorded as Pediatrics, Sports, and Dual-Fellowship (fellowship in both Pediatrics and Sports). All other candidates were categorized as "Other". A total of 102,424 pediatric cases (patients below 18 years) were reviewed to identify sports medicine cases performed by CPT code. Multiple linear regression and Mann-Whitney U tests were used to determine trends in case volume overall and according to fellowship training for all patients, patients ≥13 and patients <13. One-way ANOVA testing was used to compare multiple means followed by multiple post hoc comparisons using a Tukey all pairwise approach using SPSS. RESULTS: A total of 14,636 pediatric sports medicine cases were performed. There was an increase in the number of sports medicine cases performed in patients <13 (117.5±31.8 from 2004-2009 to 212.4±70.1 from 2010-2014, P=0.035; r=0.743, P=0.0007). The number of Pediatrics (r=0.601, P=0.005), Sports (r=0.741, P=0.0007) and Dual-Fellowship candidates increased (r=0.600, P=0.005) from 2004-2014. Dual-Fellowship surgeons performed 21.4% of pediatric sports medicine cases in 2014 when compared to 2.1% in 2004 (919% increase). As a group, the number of pediatric sports cases performed by Dual-Fellowship (r=0.630, P=0.004) and Sports (r=0.567, P=0.007) candidates has increased, while the number performed by "Other" candidates has decreased (r=0.758, P=0.0005). Per surgeon, Dual-Fellowship candidates performed a greater number of pediatric sports cases per collection period (36.5±9.18) than Pediatrics (6.71±0.94), Sports (5.99±0.46), and "Other" (1.21±0.15, P<0.0001 for each) candidates from 2004 to 2014. CONCLUSIONS: Over the past decade operative sports injuries have increased in children with a similar increase in the number of orthopedic surgeons specializing in pediatric sports medicine. On a per surgeon basis, these dual fellowship-trained candidates have performed on average five times the number of pediatric sports medicine cases compared to all other ABOS Part II candidates. These trends may point towards the development of a new subspecialty of pediatric sports medicine among orthopedic surgeons. LEVEL OF EVIDENCE: Level IV-Retrospective Database Review.

Orthopaedic Care for Children: Who Provides It? How Has It Changed Over the Past Decade? Analysis of the Database of the American Board of Orthopaedic Surgery.

BACKGROUND: The field of orthopaedic surgery has subspecialized over the past decade with an increasing number of graduates of orthopaedic residency programs entering fellowship training. The number of graduates from pediatric orthopaedic fellowships has also increased over the past decade. We hypothesize as the number of pediatric orthopaedic fellowship graduates has increased, the proportion of orthopaedic cases completed by pediatric surgeons in comparison with adult surgeons has also increased. We have used the database of the American Board of Orthopaedic Surgery (ABOS) to analyze the trends in who is providing the orthopaedic care for children. METHODS: Procedure logs of applicants for ABOS part II certification from 2004 to 2014 were collected and pediatric cases were used for this study. Applicants were divided into pediatric orthopaedic surgeons and adult orthopaedic surgeons based on the self-declared subspecialty for part II examination. CPT codes were used to place the cases into different categories. Descriptive and statistical analysis were performed to evaluate the change in the practice of pediatric orthopaedics over the past decade. RESULTS: ABOS part II applicants performed 102,424 pediatric cases during this period. In total, 66,745 (65%) cases were performed by nonpediatric surgeons and 35,679 cases (35%) by pediatric surgeons. In total, 82% of the pediatric cases were done by adult surgeons in 2004 which decreased to 69% in 2009 and to 53% in 2014 (r=0.8232, P=0.0019). In pediatric sports medicine, pediatric orthopaedic surgeons performed 7% of the cases in 2004 which increased to 14% in 2009 and to 28% in 2014 (300% increase from 2004). Pediatric surgeons also increased their share of pediatric trauma cases. In total, 12% of lower extremity trauma cases were attended by pediatric surgeons in 2004 compared with 47% in 2014 (235% increase from 2004). In upper extremity trauma, pediatric surgeons increased their share of the cases from 12% in 2004 to 43% in 2014 (175% increase from 2004). CONCLUSIONS: Over the past decade, pediatric orthopaedic specialists are caring for an increasing share of pediatric cases. Pediatric trauma, pediatric spine, and pediatric sports medicine have seen the greatest increase in the percentage of cases performed by pediatric orthopaedic surgeons. LEVEL OF EVIDENCE: Level III.

Adolescent spine patients have an increased incidence of acetabular overcoverage.

Changes in spino-pelvic alignment can lead to changes in acetabular coverage and predispose those with spinal pathologies to hip pathologies. The purpose of this study was to define the incidence of acetabular overcoverage in pediatric spine patients. Retrospective review of charts and EOS radiographs was conducted for patients ≤21 years old with adolescent idiopathic scoliosis (AIS) or Scheuermann's Kyphosis (SK) who were treated with posterior spinal fusion (PSF) between 12/01/2015-7/26/2016. Radiographs were measured for lateral center edge angles (LCEA), anterior center edge angle (ACEA), and lumbar lordosis pre- and postoperatively. 32 patients met inclusion criteria. Preoperatively, mean LCEA was 44.1 degrees (range: 32-55, SD: 5.1) on the right and 42.8 degrees (range: 33-52, SD: 4.4) on the left. Mean preoperative ACEA was 56.0 degrees (range: 35-90, SD: 10.4). Mean preoperative lordosis was 56.0 degrees (range: -22-105, SD: 19.1) Preoperative LCEA was not associated with lordosis (right: r = 0.002, p = 0.78, left: r = 0.006, p = 0.66). Preoperative ACEA was no associated with lordosis (r = 0.02, p = 0.49). Overall, the mean percent change in LCEA was -3.4% (range: -19.6-21.9, SD: 10.3) on the right and -3.5% (range: -31.0-27.9, SD: 13.3) on the left. Mean percent change in ACEA was 9.1% (range: -20.6-35.7, SD: 15.1). Mean percent change in lordosis was -12.2% (range: -150-33.3, SD: 33.3. The incidence of acetabular overcoverage may be significantly higher in a pediatric spinal population than the general population. Careful monitoring of these patients for signs and symptoms of hip pathology may be warranted.

Changes in the Practice of Pediatric Orthopaedic Surgeons Over the Past Decade: Analysis of the Database of the American Board of Orthopaedic Surgery.

BACKGROUND: There has been an increase in the number of the graduates of pediatric orthopaedic fellowship programs over the past decade creating the potential for increased competition in the field. The purpose of this study was to analyze the effect of increased number of pediatric orthopaedic fellowship graduates on case volume as well as the type of procedures performed by recent graduates of pediatric orthopaedic fellowship programs from 2004 to 2014. METHODS: Case logs submitted for the American Board of Orthopaedic Surgery Part II examination by applicants with the self-declared subspecialty of pediatric orthopaedics from 2004 to 2014 were analyzed. Cases were categorized as trauma (upper and lower extremity), spine, sports medicine, hip, deformity correction, foot and ankle, hardware removal, soft tissue procedures, and other. The period was divided into 3 sections: 2004-2007, 2008-2011, 2012-2014. Descriptive analysis was used to report the change in the volume and pattern of practices over the study period. RESULTS: Although the number of pediatric orthopaedic subspecialty applicants increased from 15 to 44 from 2004 to 2014, the average cases per year increased from 2142 in 2004-2007 to 2960 in 2007-2011, and to 4160 in 2012-2014. The number of cases performed per applicant remained stable over the study period. Upper extremity trauma cases were the largest category of cases reported and increased in case volume by 141% from 2004 to 2014. Sports medicine cases increased in volume by 175%. CONCLUSIONS: Despite a large increase in the number of pediatric orthopaedic surgeons over the past decade, there is a concomitant increased in case volume across almost all subspecialties within pediatric orthopaedics. As such, pediatric orthopaedic surgeons who start a new practice can expect to develop a robust practice with a diverse group of pathologies. LEVEL OF EVIDENCE: Level III.

Molding Spica Casts to Maintain Alignment of Femur Fractures.

BACKGROUND: Femur fractures in young children are frequently treated with spica casting. Texts recommend molding spica casts into valgus and recurvatum to counter deforming muscular forces, but how much overcorrection to aim for has not been evaluated. Our goal was to determine how much valgus and recurvatum is optimal at the time of casting to end up with anatomic alignment. METHODS: Patients 1 to 6 years old with femur fractures treated with spica casts between January 1, 2008 and January 31, 2014 who were followed until radiographic union were included in the study. Patients with underlying medical comorbidities affecting bone quality, refractures, or preexisting femur deformities or that did not have intraoperative imaging were excluded. RESULTS: A total of 52 patients met the inclusion criteria. Average intraoperative angulation was 2.6 degrees of valgus (range: 9 degrees varus to 13 degrees valgus, SD: 4.5) and 1.1 degrees of recurvatum (range: 10 degrees recurvatum to 17 degrees procurvatum, SD: 4.8). At the initial postoperative visit, the average angulation was 2.7 degrees of varus (range: 21 degrees varus to 11degrees valgus, SD: 6.4) and 7.2 degrees of procurvatum (range: 6 degrees recurvatum to 25 degrees procurvatum, SD: 6.6). At the time of radiographic union/wedging average angulation was 2.0 degrees of varus (range: 15 degrees varus to 10 degrees valgus, SD: 5.8) and 8.5 degrees of procurvatum (range: 5 degrees recurvatum to 29 degrees procurvatum, SD: 7.5). Between the intraoperative period to time of union or wedging, fracture alignment gained an average of 4.6 degrees of varus (range: 17 degrees varus to 13 degrees valgus, SD: 6.6) and 9.8 degrees of procurvatum (range: 8 degrees recurvatum to 30 degrees procurvatum, SD: 9.1). Seven patients underwent cast wedging due to loss of reduction before radiographic union, 2 patients underwent reoperation due to excessive angulation in the early postoperative period, and 5 patients developed malunions. CONCLUSION: Femur fractures treated with spica casts gain 5 degrees of varus and 10 degrees of procurvatum between cast application and fracture union. LEVEL OF EVIDENCE: Level IV.