Correlations Between Eight Comprehensive Skeletal Maturity Systems in a Modern Peripubertal Pediatric Population.

BACKGROUND: Several skeletal maturity systems allow for accurate skeletal age assessment from a wide variety of joints. However, discrepancies in estimates have been noted when applying systems concurrently. The aims of our study were to (1) compare the agreement among 8 different skeletal maturity systems in modern pediatric patients and (2) compare these discrepancy trends qbetween modern and historic children. METHODS: We performed a retrospective (January 2000 to May 2022) query of our picture archiving and communication systems and included peripubertal patients who had at least two radiographs of different anatomic regions obtained ≤3 months apart for 8 systems: (1) proximal humerus ossification system (PHOS), (2) olecranon apophysis ossification staging system (OAOSS), (3) lateral elbow system, (4) modified Fels wrist system, (5) Sanders Hand Classification, (6) optimized oxford hip system, (7) modified Fels knee system, and (8) calcaneal apophysis ossification staging system (CAOSS). Any abnormal (ie, evidence of fracture or congenital deformity) or low-quality radiographs were excluded. These were compared with a cohort from a historic longitudinal study. SEM skeletal age, representing the variance of skeletal age estimates, was calculated for each system and used to compare system precision. RESULTS: A total of 700 radiographs from 350 modern patients and 954 radiographs from 66 historic patients were evaluated. In the modern cohort, the greatest variance was seen in PHOS (SEM: 0.28 y), Sanders Hand (0.26 y), and CAOSS (0.25 y). The modified Fels knee system demonstrated the smallest variance (0.20 y). For historic children, the PHOS, OAOSS, and CAOSS were the least precise (0.20 y for all). All other systems performed similarly in historic children with lower SEMs (range: 0.18 to 0.19 y). The lateral elbow system was more precise than the OAOSS in both cohorts. CONCLUSIONS: The precision of skeletal maturity systems varies across anatomic regions. Staged, single-parameter systems (eg, PHOS, Sanders Hand, OAOSS, and CAOSS) may correlate less with other systems than those with more parameters. LEVEL OF EVIDENCE: Level III-retrospective study.

The Reliability of the Modified Fels Knee Skeletal Maturity System.

BACKGROUND: The recently described Modified Fels knee skeletal maturity system (mFels) has proven utility in prediction of ultimate lower extremity length in modern pediatric patients. mFels users evaluate chronological age, sex, and 7 anteroposterior knee radiographic parameters to produce a skeletal age estimate. We developed a free mobile application to minimize the learning curve of mFels radiographic parameter evaluation. We sought to identify the reliability of mFels for new users. METHODS: Five pediatric orthopaedic surgeons, 5 orthopaedic surgery residents, 3 pediatric orthopaedic nurse practitioners, and 5 medical students completely naïve to mFels each evaluated a set of 20 pediatric anteroposterior knee radiographs with the assistance of the (What's the Skeletal Maturity?) mobile application. They were not provided any guidance beyond the instructions and examples embedded in the app. The results of their radiographic evaluations and skeletal age estimates were compared with those of the mFels app developers. RESULTS: Averaging across participant groups, inter-rater reliability for each mFels parameter ranged from 0.73 to 0.91. Inter-rater reliability of skeletal age estimates was 0.98. Regardless of group, steady proficiency was reached by the seventh radiograph measured. CONCLUSIONS: mFels is a reliable means of skeletal maturity evaluation. No special instruction is necessary for first time users at any level to utilize the (What's the Skeletal Maturity?) mobile application, and proficiency in skeletal age estimation is obtained by the seventh radiograph. LEVEL OF EVIDENCE: Level II.

Do Adolescent Idiopathic Scoliosis Patients With Vitamin D Deficiency Have Worse Spine Fusion Outcomes?

BACKGROUND: Prior research has shown that patients with adolescent idiopathic scoliosis (AIS) have a higher prevalence of vitamin D deficiency compared with healthy peers. In adult orthopaedic populations, vitamin D deficiency has been shown to be a risk factor for higher reported pain and lower function. We investigated whether there was an association between vitamin D levels and AIS patient-reported outcomes, as measured by the Scoliosis Research Society (SRS-30) questionnaire. METHODS: This was a single-center, cross-sectional study. Postoperative AIS patients were prospectively recruited during routine follow-up visits, 2 to 10 years after spine fusion. Vitamin D levels were measured by serum 25-hydroxyvitamin D (ng/mL). Patients were categorized based on vitamin D level: deficient (<20 ng/mL), insufficient (20 to 29 ng/mL), or sufficient (≥30 ng/mL). The correlation between vitamin D levels and SRS-30 scores was analyzed using multivariable analysis and pair-wise comparisons using Tukey method. RESULTS: Eighty-seven AIS patients (83% female) were enrolled who presented at median 3 years (interquartile range: 2 to 5 y; range: 2 to 10 y) after spine fusion. Age at time of surgery was mean 15 (SD±2) years. Major coronal curves were a mean of 57 (SD±8) degrees preoperatively and 18 (SD±7) degrees postoperatively. It was found that 30 (34%) of patients were vitamin D sufficient, 33 (38%) were insufficient, and 24 (28%) were deficient. Although there was no correlation between vitamin D level and Pain, Mental Health, or Satisfaction domains ( P >0.05), vitamin D-deficient patients were found to be younger ( P <0.001) and had lower SRS-30 function ( P =0.002), Self-image ( P <0.001), and total scores ( P =0.003). CONCLUSIONS: AIS patients with vitamin D deficiency (<20 ng/mL) are more likely to be younger age at time of surgery, and report lower Function, Self-image, and Total SRS-30 scores postoperatively. Further work is needed to determine whether vitamin D supplementation alters curve progression and patient outcomes. LEVEL OF EVIDENCE: Level II-prognostic study.

Disparities in Pediatric Orthopedic Surgery Care During the COVID-19 Pandemic Pre-vaccine and Post-Vaccine Availability.

BACKGROUND: The COVID-19 pandemic has led to significant disruptions in medical care, resulting in an estimated 40% of US adults avoiding care. However, the return to baseline health care utilization following COVID-19 restrictions within the pediatric orthopedic population remains unexplored. We sought to analyze the visit volume and demographics of pediatric orthopedic patients at 3 timepoints: prepandemic (2019), pandemic (2020), and pandemic post-vaccine availability (2021), to determine the impact of COVID-19 restrictions on our single-center, multisite institution. METHODS: We performed a retrospective cohort study of 6318 patients seeking treatment at our institution from May through August in 2019, 2020, and 2021. Patient age, sex, address, encounter date, and ICD-10 codes were obtained. Diagnoses were classified into fractures and dislocations, non-fracture-related trauma, sports, elective, and other categories. Geospatial analysis comparing incidence and geospatial distribution of diagnoses across the time periods was performed and compared with the Centers for Disease Control (CDC) social vulnerability index (SVI). RESULTS: The total number of pediatric orthopedic visits decreased by 22.2% during the pandemic ( P <0.001) and remained 11.6% lower post-vaccine availability compared with prepandemic numbers ( P <0.001). There was no significant difference in age ( P =0.097) or sex ( P =0.248) of the patients across all 3 timepoints; however, patients seen during the pandemic were more often White race (67.7% vs. 59.3%, P <0.001). Post-vaccine availability, trauma visits increased by 18.2% ( P <0.001) and total fractures remained 13.4% lower than prepandemic volume ( P <0.001). Sports volume decreased during the pandemic but returned to prepandemic volume in the post-vaccine availability period ( P =0.298). Elective visits did not recover to prepandemic volume and remained 13.0% lower compared with baseline ( P <0.001). Geospatial analysis of patient distribution illustrated neighborhood trends in access to care during the COVID-19 pandemic, with fewer patients from high SVI and low socioeconomic status neighborhoods seeking fracture care during the pandemic than prepandemic. Post-vaccine availability, fracture population distribution resembled prepandemic levels, suggesting a return to baseline health care utilization. CONCLUSION: Pediatric orthopedic surgery visit volume broadly decreased during the COVID-19 pandemic and did not return to prepandemic levels. All categories increased in the post-vaccine availability time point except elective visits. Geospatial analysis revealed that neighborhoods with a high social vulnerability index (SVI) were associated with decreased fracture visits during the pandemic, whereas low SVI neighborhoods did not experience as much of a decline. Future research is needed to study these neighborhood trends and more completely characterize factors preventing equitable access to care in the pediatric orthopedic population. LEVEL OF EVIDENCE: Retrospective Study, Level III.

Providence Bracing: Predicting the Progression to Surgery in Patients With Braced Idiopathic Scoliosis.

BACKGROUND: Idiopathic scoliosis (IS) is a common spinal abnormality, in which orthotic management can reduce progression to surgery. However, predictors of bracing success are still not fully understood. We studied a large patient population treated with the nighttime Providence orthosis, utilizing multivariable logistic regression to assess results and predict future spine surgery. METHODS: We retrospectively reviewed patients with IS meeting Scoliosis Research Society inclusion and assessment criteria presenting from April 1994 to June 2020 at a single institution and treated with a Providence orthosis. A predictive logistic regression model was developed utilizing the following candidate features: age, sex, body mass index, Risser classification, Lenke classification, curve magnitude at brace initiation, percentage correction in a brace, and total months of brace use. Model performance was assessed using the area under the receiver operating characteristic curve, accuracy, sensitivity, and specificity. The importance of individual features was assessed using the variable importance score. RESULTS: There were 329 consecutive patients with IS with a mean age of 12.8 ± 1.4 years that met inclusion and assessment criteria. Of these, 113 patients (34%) ultimately required surgery. The model's area under the curve (AUC) was 0.72 on the testing set, demonstrating good discrimination. The initial curve magnitude (Importance score: 100.0) and duration of bracing (Importance score: 82.4) were the 2 most predictive features for curve progression leading to surgery. With respect to skeletal maturity, Risser 1 (Importance score: 53.9) had the most predictive importance for future surgery. For the curve pattern, Lenke 6 (Importance score: 52.0) had the most predictive importance for future surgery. CONCLUSION: Out of 329 patients with IS treated with a Providence nighttime orthosis, 34% required surgery. This is similar to the findings of the BrAist study of the Boston orthosis, in which 28% of monitored braced patients required surgery. In addition, we found that predictive logistic regression can evaluate the likelihood of future spine surgery in patients treated with the Providence orthosis. The severity of the initial curve magnitude and total months of bracing were the 2 most important variables when assessing the probability of future surgery. Surgeons can use this model to counsel families on the potential benefits of bracing and risk factors for curve progression.

The Reliability of the AO Spine Upper Cervical Classification System in Children: Results of a Multi-Center Study.

BACKGROUND: There is no uniform classification system for traumatic upper cervical spine injuries in children. This study assesses the reliability and reproducibility of the AO Upper Cervical Spine Classification System (UCCS), which was developed and validated in adults, to children. METHODS: Twenty-six patients under 18 years old with operative and nonoperative upper cervical injuries, defined as from the occipital condyle to the C2-C3 joint, were identified from 2000 to 2018. Inclusion criteria included the availability of computed tomography and magnetic resonance imaging at the time of injury. Patients with significant comorbidities were excluded. Each case was reviewed by a single senior surgeon to determine eligibility. Educational videos, schematics describing the UCCS, and imaging from 26 cases were sent to 9 pediatric orthopaedic surgeons. The surgeons classified each case into 3 categories: A, B, and C. Inter-rater reliability was assessed for the initial reading across all 9 raters by Fleiss's kappa coefficient (kF) along with 95% confidence intervals. One month later, the surgeons repeated the classification, and intra-rater reliability was calculated. All images were de-identified and randomized for each read independently. Intra-rater reproducibility across both reads was assessed using Fleiss's kappa. Interpretations for reliability estimates were based on Landis and Koch (1977): 0 to 0.2, slight; 0.2 to 0.4, fair; 0.4 to 0.6, moderate; 0.6 to 0.8, substantial; and >0.8, almost perfect agreement. RESULTS: Twenty-six cases were read by 9 raters twice. Sub-classification agreement was moderate to substantial with α κ estimates from 0.55 for the first read and 0.70 for the second read. Inter-rater agreement was moderate (kF 0.56 to 0.58) with respect to fracture location and fair (kF 0.24 to 0.3) with respect to primary classification (A, B, and C). Krippendorff's alpha for intra-rater reliability overall sub-classifications ranged from 0.41 to 0.88, with 0.75 overall raters. CONCLUSION: Traumatic upper cervical injuries are rare in the pediatric population. A uniform classification system can be vital to guide diagnosis and treatment. This study is the first to evaluate the use of the UCCS in the pediatric population. While moderate to substantial agreement was found, limitations to applying the UCCS to the pediatric population exist, and thus the UCCS can be considered a starting point for developing a pediatric classification. LEVEL OF EVIDENCE: Level III.

Crisis Leadership: Lessons Learned From the COVID Pandemic.

The coronavirus disease-2019 (COVID-19) pandemic had unique and profound personal and professional challenges for everyone. However, this is not the first or last health care crisis we will face. There are clear lessons learned from historical examples and the current pandemic that can be utilized to tackle future challenges. In this article a combination of personal experience, interviews with respected leaders, and literature were used to reflect on lessons learned as a leader navigating the COVID-19 pandemic. Key components to leadership through a crisis include communication, flexibility, patience, teamwork, resiliency, and understanding individuals' struggles. What was clear is that the ability of the health care system and the people that drive it to adapt and evolve so rapidly to the COVID-19 pandemic was truly remarkable.

Use of Vancomycin Powder in Spinal Deformity Surgery in Cerebral Palsy Patients is Associated With Proteus Surgical Site Infections.

PURPOSE: Surgical site infection (SSI) rates in pediatric spinal deformity surgery for cerebral palsy (CP) patients are higher than that in idiopathic scoliosis. The use of vancomycin powder is associated with decreased risk of SSI in neuromuscular patients. Prior studies in adult and pediatric early-onset scoliosis patients have shown that vancomycin powder alters microbacterial profile in patients that develop SSI. However, the effects of topical vancomycin powder on microbiology in spinal deformity surgery for CP patients has not been studied. METHODS: An international multicenter database of CP neuromuscular scoliosis patients was used in this retrospective cohort study. All patients that underwent posterior spinal instrumented fusion for CP neuromuscular scoliosis from 2008 to 2019 were queried, and 50 cases complicated by postoperative SSI were identified. Intraoperative antibiotic details were documented in 49 cases (98.0%). Microbiology details were documented in 45 cases (91.8%). Microbiology for patients that received topical vancomycin powder were compared with patients that did not. A multivariate regression model was used to control for potential confounders. RESULTS: There were 45 patients included in this study. There were 27 males (60.0%) and 18 females (40.0%). Mean age at surgery was 14.8±2.4 years. There were 24 patients that received topical vancomycin powder (53.3%). The mean time from index surgery to SSI was 4.3±11.3 months.On univariate analysis of microbiology cultures by vancomycin powder cohort, there were no significant differences in culture types. Proteus spp. trended on significance with association with vancomycin powder use (P=0.078). When controlling for potential confounders on multivariate analysis, intraoperative topical vancomycin powder was associated with increased risk for proteus infection (adjusted odds ratio: 262.900, 95% confidence interval: 1.806-38,267.121, P=0.028). DISCUSSION: In CP patients undergoing pediatric spinal deformity surgery, the use of vancomycin powder was independently associated with increased risk for proteus infections. Further study into antibiotic regimens for spinal deformity surgery in the CP population should be performed. LEVEL OF EVIDENCE: Level III-retrospective cohort study.

When Will You Succeed Casting Patients With Early-onset Scoliosis? Prospective Evaluation of Predictive Radiographic Parameters.

BACKGROUND: In a recent retrospective study, in cast correction of the major curve correlated with final curve size in patients with early-onset scoliosis treated with casting. We therefore sought to perform a prospective study with controlled methodology to determine if there are parameters associated with reduction of coronal deformity. METHODS: A prospective, observational study was conducted between 2014 and 2019 at selected sites willing to comply with a standard radiographic and follow-up protocol. Radiographic data was collected at time points of precast, in traction, initial in-cast, and at minimum 1 year follow-up. Multivariate linear regression models were utilized to control for potential confounders using a stepwise procedure. Twenty-nine patients met inclusion criteria. RESULTS: On multivariate analysis, traction major curve (P=0.043) and initial in-cast (P=0.011) major curve Cobb angles were independently associated with final out of cast major curve Cobb angle. The only factor that was independently associated with failure to cure (<15-degree major curve) was traction major curve Cobb angle (P=0.046). A threshold traction major curve Cobb angle of 20 degrees was found to have good accuracy with 81% sensitivity and 73% specificity (receiver operator curve area: 0.869, P<0.001). A traction major curve Cobb angle over 20 degrees would accurately predict failure of casting treatment to cure scoliosis in 79% of cases. A threshold in-cast major curve Cobb angle of 21 degrees was found to have slightly less accuracy than traction with 69% sensitivity, 82% specificity, and 74% accuracy (receiver operator curve area: 0.830, P=0.004). CONCLUSIONS: Radiographic measurements in traction and initially in the cast are predictive of curve size at follow-up for children with early-onset scoliosis treated with casting. The standardization and utility of traction films should be further explored. LEVEL OF EVIDENCE: Level II.

Spinal Fusion in Pediatric Patients With Low Bone Density: Defining the Value of DXA.

BACKGROUND: Children with medical complexity are at increased risk of low bone mineral density (BMD) and complications after spinal fusion compared with idiopathic scoliosis patients. Our aim was to compare treatments and outcomes of children with medical complexity undergoing spinal fusion in those who had dual-energy x-ray absorptiometry (DXA) scans versus those who did not in an effort to standardize the workup of these patients before undergoing spinal surgery. METHODS: We conducted a retrospective review of patients with low BMD who underwent spinal fusion at a tertiary care pediatric hospital between 2004 and 2016. We consulted with a pediatric endocrinologist to create standard definitions for low BMD to classify each subject. Regardless of DXA status, all patients were given a clinical diagnosis of osteoporosis [at least 2 long bone or 1 vertebral pathologic fracture(s)], osteopenia (stated on radiograph or by the physician), or clinically low bone density belonging to neither category. The last classification was used for patients whose clinicians had documented low bone density not meeting the criteria for osteoporosis or osteopenia. Fifty-nine patients met the criteria, and 314 were excluded for insufficient follow-up and/or not meeting a diagnosis definition. BMD Z -scores compare bone density ascertained by DXA to an age-matched and sex-matched average. Patients who had a DXA scan were also given a DXA diagnosis of low bone density (≤-2 SD), slightly low bone density (-1.0 to -1.9 SD), or neither (>-1.0 SD) based on the lowest BMD Z -score recorded. RESULTS: Fifty-nine patients were analyzed. Fifty-four percent had at least 1 DXA scan preoperatively. Eighty-one percent of DXA patients received some form of treatment compared with 52% of non-DXA patients ( P =0.03). CONCLUSIONS: Patients referred for DXA scans were more likely to be treated for low BMD, although there is no standardized system in place to determine which patients should get scans. Our research highlights the need to implement clinical protocols to optimize bone health preoperatively. LEVEL OF EVIDENCE: Level II-retrospective prognostic study.

The Effect of Surgeon Experience on Outcomes Following Growth Friendly Instrumentation for Early Onset Scoliosis.

BACKGROUND: The purpose of this study was to utilize a multicenter, multisurgeon cohort to assess the effect of surgeon experience on outcomes of growth friendly instrumentation (GFI) in early onset scoliosis (EOS). We hypothesized that unplanned return to the operating room (UPROR), estimated blood loss (EBL), and surgical time would be greater amongst early career surgeons (ECSs) when compared with advanced career surgeons (ACSs). METHODS: An international pediatric spine database was queried for patients ages 2 to 10 years treated by posterior distraction-based GFI with at least of 2-year follow up. Two groups were created for analysis based on surgeon experience: ECSs (with ≤10 y of experience) and ACSs (with >10 y of experience). The primary outcome was UPROR. Additional outcomes included: operating room time, EBL, neurological deficits, infection rate, hardware failure, and the Early Onset Scoliosis Questionnaire (EOSQ-24). Subgroup analysis was performed for further assessment based on procedure type, superior anchor type, etiology, and curve severity. RESULTS: A total of 960 patients met inclusion criteria including 243 (25.3%) treated by ECS. Etiology, sex, superior anchor, and EOSQ-24 scores were similar between groups (P>0.05). There were no clinically significant differences in patient age or preoperative major coronal curve. UPROR (35.8% vs. 32.7%, P=0.532), infection (17.0% vs. 15.6%, P=0.698), operating room time (235 vs. 231 min, P=0.755), and EBL (151 vs. 155 mL, P=0.833) were comparable between ECS and ACS groups. The frequency of having at least 1 complication was relatively high but comparable among groups (60.7% vs. 62.6%, P=0.709). EOSQ-24 subdomain scores were similar between groups at 2-year follow-up (P>0.05). Subgroup analysis revealed that ECS had increased surgical time compared with ACS in severe curves >90 degrees (270 vs. 229 min, P=0.05). CONCLUSIONS: This study represents the first multicenter assessment of surgeon experience on outcomes in EOS. Overall, surgeon experience did not significantly influence UPROR, complication rates, EBL, or surgical time associated with GFI in this cohort of EOS patients. LEVEL OF EVIDENCE: Level III.

Mortality in Early-Onset Scoliosis During the Growth-friendly Surgery Era.

INTRODUCTION: Early-onset scoliosis (EOS) is a spinal deformity that occurs in patients 9 years of age or younger. Severe deformity may result in thoracic insufficiency, respiratory failure, and premature death. The purpose of this study is to describe the modern-day natural history of mortality in patients with EOS. METHODS: The multicenter Pediatric Spine Study Group database was queried for all patients with EOS who are deceased, without exclusion. Demographics, underlying diagnoses, EOS etiology, operative and nonoperative treatments or observation, complications, and date of death were retrieved. Descriptive statistics and survival analysis with Kaplan-Meier curves were performed. RESULTS: There were 130/8009 patients identified as deceased for a registry mortality rate of 16 per 1000 patients. The mean age at death was 10.6 years (range: 1.0 to 30.2 y) and the most common EOS etiology was neuromuscular (73/130, 56.2%; P<0.001). Deceased patients were more likely be treated operatively than nonoperatively or observed (P<0.001). The mean age of death for patients treated operatively (12.3 y) was older than those treated nonoperatively (7.0 y) or observed (6.3 y) (P<0.001) despite a larger deformity and similar index visit body mass index and ventilation requirements. Kaplan-Meier analysis confirmed an increased survival time in patients with a history of any spine operation compared with patients without a history of spine operation (P<0.0001). Operatively treated patients experienced a median of 3.0 complications from diagnosis to death. Overall, cardiopulmonary related complications were the most common (129/271, 47.6%; P<0.001), followed by implant-related (57/271, 21.0%) and wound-related (26/271, 9.6%). The primary cause of death was identified for 78/130 (60.0%) patients, of which 57/78 (73.1%) were cardiopulmonary related. CONCLUSIONS: This study represents the largest collection of EOS mortality to date, providing surgeons with a modern-day examination of the effects of surgical intervention to better council patients and families. Both fatal and nonfatal complications in children with EOS are most likely to involve the cardiopulmonary system. LEVEL OF EVIDENCE: Level IV-therapeutic.

Use of Vancomycin Powder in the Surgical Treatment of Early Onset Scoliosis Is Associated With Different Microbiology Cultures After Surgical Site Infection.

BACKGROUND: The use of vancomycin powder has been shown to decrease risk of surgical site infection (SSI) in early onset scoliosis (EOS). While there is potential benefit in SSI reduction, there is also theoretical risk in creating increased bacterial resistance to standard treatment regimens. However, the effects of topical vancomycin powder on microbiology in these patients has not been studied. METHODS: A multicenter database for EOS patients was retrospectively analyzed. All patients that underwent surgical treatment with traditional growing rods, magnetically controlled growing rods, vertical expandable prosthetic titanium rib, and Shilla for EOS performed after 2010 were identified (n=1115). Patients that sustained at least 1 SSI after guided growth surgery were assessed (n=104, 9.3%). Patients with culture and antibiotic details were included (n=55). Patients that received vancomycin powder at index surgery were compared with patients that did not. A multivariate regression model was used to control for potential confounders. RESULTS: There were 55 patients included in this study, including 26 males (47%) and 29 females (53%). Mean age at index surgery was 7.2±6.9 years. Vancomycin powder was utilized in 18 cases (33%). Mean time from index surgery to SSI was 2.0±1.3 years. There were 2 cases of wound dehiscence (4%), 7 cases of superficial infection (13%), and 46 cases of deep infection (84%).There were significant differences in overall microbiology results between vancomycin and no vancomycin cohorts (P=0.047). On univariate analysis, the vancomycin powder cohort had a significantly high incidence of cultures without growth (n=7, 39% vs. n=4, 11%, relative risk: 2.063, 95% confidence interval: 0.927-4.591, P=0.028). This association remained significant on multivariate analysis (adjusted odds ratio: 9.656, 95% confidence interval: 1.743-53.494, P=0.009). CONCLUSIONS: In EOS patients undergoing procedures complicated by SSI, the use of vancomycin powder was independently associated with increased risk of no culture growth. Surgeons and infectious disease physicians should be aware and adjust diagnostic and treatment strategies appropriately. LEVEL OF EVIDENCE: Level III-retrospective cohort study.

Getting Them Back in the Game: When Can Athletes With Adolescent Idiopathic Scoliosis Safely Return to Sports? A Mixed-effects Study of the Pediatric Orthopaedic Association of North America.

BACKGROUND: Despite the relative frequency of posterior spinal fusion (PSF) and instrumentation for adolescent idiopathic scoliosis (AIS), there are limited guidelines for postoperative return to sports. Few studies explore factors influencing treating surgeons' recommendations. METHODS: A survey presenting several clinical vignettes of patients who had undergone PSF for AIS was distributed to 1496 Pediatric Orthopaedic Society of North America (POSNA) members. Of the 257 returned surveys, 170 met the inclusion criteria. Mixed-effects models were created to assess the effects of the surgeon and hypothetical patient characteristics on return to jogging, noncontact, contact, and collision sports. RESULTS: Estimated marginal mean time to return to sporting activities increased for more physically demanding sports [jogging: 4.1 mo, 95% confidence interval (CI): 3.8-4.3; noncontact: 4.6 mo, 95% CI: 4.3-4.9; contact: 6.8 mo, 95% CI: 6.4-7.1; collision: 9.8 mo, 95% CI: 9.2-10.4]. Hypothetical patient characteristics (sex, age, obesity, skeletal maturity, levels fused, and fusions ending in thoracic versus lumbar spine) were not associated with changes in return to sport recommendations for jogging, noncontact, contact, or collision activities. Surgeon volume, experience, fellowship type, and practice setting all affected return to all activities (P<0.05). Surgeons with prior complications from return to sport delayed return to collision activities (9.4 mo, 95% CI: 8.4-10.3) versus surgeons without complications (7.2 mo, 95% CI: 5.7-8.7, P<0.001). CONCLUSIONS: Surgeons currently allow earlier return to high-intensity sports after PSF for AIS compared with previous studies. Protocol trends vary based on physician-related factors such as years in practice, case volume, fellowship training, practice type, and prior experience with complications. Patient-related factors were not found to impact return to sport protocols. This survey provides a portrait of current practice trends and serves as a foundation for future investigation. LEVEL OF EVIDENCE: Level V-survey study.

Trends in Leadership at Pediatric Orthopaedic Fellowships.

BACKGROUND: Pediatric orthopaedic fellowship directors (FDs) have a valuable impact on the education of trainees and future leaders in the field. There is currently no research on the characteristics of pediatric orthopaedic FDs. METHODS: Programs were identified using the Pediatric Orthopaedic Society of North America fellowship directory. Operative, nonoperative, and specialty programs were included. Data was collected through Qualtrics survey, e-mail, telephone, and online searches. Variables included demographics (age, sex, race/ethnicity), Hirsch index (h-index) as a measure of research productivity, graduate education, residency and fellowship training, years of hire at current institution and as FD, and leadership roles. RESULTS: Fifty-five FDs were identified. The majority (49/55, 89%) were male and 77% (27/35) were Caucasian. The mean age at survey was 51.1±8.2 years. The mean h-index was 17.2. Older age correlated with higher h-index (r=0.48, P=0.0002). The average duration from fellowship graduation to FD appointment was 9.6±6.7 and 6.9±6.1 years from institutional hire. Sixteen FDs (29%) had additional graduate level degrees. Almost all (52/55, 95%) FDs completed orthopaedic surgery residencies and all graduated fellowship training. Twenty-nine percent (16/55) completed more than 1 fellowship. Most FDs (51/55, 93%) completed a fellowship in pediatric orthopaedic surgery. Ten FDs (18%) completed pediatric orthopaedic surgery fellowships that included spine-specific training. One-third of all current FDs were fellowship-trained at either Boston Children's Hospital (9/55, 16%) or Texas Scottish Rite Hospital for Children (9/55, 16%). CONCLUSIONS: Pediatric orthopaedic FDs are typically early-career to mid-career when appointed, with a strong research background. Nearly a third completed additional graduate degrees or multiple fellowships. Although male dominated, there are more female FDs leading pediatric orthopaedic programs compared with adult reconstruction, trauma, and spine fellowships. As fellowships continue to grow and diversify, this research will provide a baseline to determine changes in FD leadership.

Operative Treatment of Cervical Spine Injuries Sustained in Youth Sports.

BACKGROUND: Little data exists on surgical outcomes of sports-related cervical spine injuries (CSI) sustained in children and adolescent athletes. This study reviewed demographics, injury characteristics, management, and operative outcomes of severe CSI encountered in youth sports. METHODS: Children below 18 years with operative sports-related CSI at a Level 1 pediatric trauma center were reviewed (2004 to 2019). All patients underwent morden cervical spine instrumentation and fusion. Clinical, radiographic, and surgical characteristics were analyzed. RESULTS: A total of 3231 patients (mean, 11.3±4.6 y) with neck pain were evaluated for CSI. Sports/recreational activities were the most common etiology in 1358 cases (42.0%). Twenty-nine patients (2.1%) with sports-related CSI (mean age, 14.5 y; range, 6.4 to 17.8 y) required surgical intervention. Twenty-five were males (86%). Operative CSI occurred in football (n=8), wrestling (n=7), gymnastics (n=5), diving (n=4), trampoline (n=2), hockey (n=1), snowboarding (n=1), and biking (n=1). Mechanisms were 27 hyperflexion/axial loading (93%) and 2 hyperextension injuries (7%). Most were cervical fractures (79%) and subaxial injuries (79%). Seven patients (24%) sustained spinal cord injury (SCI) and 3 patients (10%) cord contusion or myelomalacia without neurological deficits. The risk of SCI increased with age (P=0.03). Postoperatively, 2 SCI patients (29%) improved 1 American Spinal Injury Association Impairment Scale Grade and 1 (14%) improved 2 American Spinal Injury Association Impairment Scale Grades. Increased complications developed in SCI than non-SCI cases (mean, 2.0 vs. 0.1 complications; P=0.02). Bony fusion occurred in 26/28 patients (93%) after a median of 7.2 months (interquartile range, 6 to 15 mo). Ten patients (34%) returned to their baseline sport and 9 (31%) to lower-level activities. CONCLUSIONS: The incidence of sports-related CSI requiring surgery is low with differences in age/sex, sport, and injury patterns. Older males with hyperflexion/axial loading injuries in contact sports were at greatest risk of SCI, complications, and permanent disability. Prevention campaigns, education on proper tackling techniques, and neck strength training are required in sports at high risk of hyperflexion/axial loading injury. LEVEL OF EVIDENCE: Level III-retrospective cohort study.

Variability in Antibiotic Treatment of Pediatric Surgical Site Infection After Spinal Fusion at A Single Institution.

BACKGROUND: Recent focus on surgical site infections (SSIs) after posterior spine fusion (PSF) has lowered infection rates by standardizing perioperative antibiotic prophylaxis. However, efforts have neglected to detail antibiotic treatment of SSIs. Our aim was to document variability in antibiotic regimens prescribed for acute and latent SSIs following PSF in children with idiopathic, neuromuscular, and syndromic scoliosis. METHODS: This study included patients who developed a SSI after PSF for scoliosis at a pediatric tertiary care hospital between 2004 and 2019. Patients had to be 21 years or younger at surgery. Exclusion criteria included growing rods, staged surgery, and revision or removal before SSI diagnosis. Infection was classified as acute (within 90 d) or latent. Clinical resolution of SSI was measured by return to normal lab values. Each antibiotic was categorized as empiric or tailored. RESULTS: Eighty subjects were identified. The average age at fusion was 14.7 years and 40% of the cohort was male. Most diagnoses were neuromuscular (53%) or idiopathic (41%).Sixty-three percent of patients had an acute infection and 88% had a deep infection. The majority (54%) of subjects began on tailored antibiotic therapy versus empiric (46%). Patients with a neuromuscular diagnosis had 4.0 times the odds of receiving initial empiric treatment compared with patients with an idiopathic diagnosis, controlling for infection type and time (P=0.01). Ninety-two percent of patients with acute SSI retained implants at the time of infection and 76% retained them as of August 2020. In the latent cohort, 27% retained implants at infection and 17% retained them as of August 2020. CONCLUSIONS: Patients with acute infections were on antibiotics longer than patients with latent infections. Those with retained implants were on antibiotics longer than those who underwent removal. By providing averages of antibiotic duration and lab normalization, we hope to standardize regimens moving forward and develop SSI-reducing pathways encompassing low-risk patients. LEVEL OF EVIDENCE: Level III.

Epiphysiodesis for Leg Length Discrepancy: A Cost Analysis of Drill Versus Screw Technique.

Research has demonstrated similar efficacy of drill epiphysiodesis and percutaneous epiphysiodesis using transphyseal screws for the management of adolescent leg length discrepancy. A cost analysis was performed to determine which procedure is more cost-effective. Patients seen for epiphysiodesis of the distal femur and/or proximal tibia and fibula between 2004 and 2017 were reviewed. A decision analysis model was used to compare costs. Two hundred thirty-five patients who underwent either drill (155/235, 66%) or screw (80/235, 34%) epiphysiodesis were analyzed with an average age at initial procedure of 13 years (range, 8.4 to 16.7 years). There was no significant difference in average initial procedure cost or total cost of all procedures across treatment groups (n = 184). The cost difference between drill and screw epiphysiodesis is minimal. In order for screw epiphysiodesis to be cost-favored, there would need to be a significant decrease in its cost or complication rate. (Journal of Surgical Orthopaedic Advances 30(3):181-184, 2021).

Spinal Deformity in Sotos Syndrome: First Results of Growth-friendly Spine Surgery.

BACKGROUND: Sotos syndrome (SS), or cerebral gigantism, describes children with macrocephaly, craniofacial abnormalities, general overgrowth, ligamentous laxity, developmental delay, and neurological disabilities. Fewer than 500 cases have been reported since Sotos and colleagues described the condition in 1964 and no literature exists on the management of spinal deformity in children under 10 years old.The aims of this study were: (1) to characterize the presentation of spinal deformities in patients with SS; and (2) to provide preliminary results of growth-friendly instrumentation (GFI) in these children. METHODS: Thirteen children (9 boys) with SS and minimum of 2-year follow-up were identified from 2 multicenter early-onset scoliosis (EOS) databases (1997-2017). Mean age at index surgery and follow-up duration were 5.0 years (range, 1.8 to 10 y) and 7.2 years (range, 2.1 to 14.9 y), respectively. Patients underwent GFI for a mean of 5.7 years (range, 2 to 10.2 y), with an average of 9 lengthenings (range, 2 to 18). Definitive spinal fusion was performed in 4 patients (31%). Major curve magnitude, T1-T12 and T1-S1 lengths, thoracic kyphosis, and lumbar lordosis were evaluated preindex, postindex, latest GFI, and postfusion, when possible. RESULTS: Five thoracolumbar (38%), 4 double major (31%), 2 main thoracic (15%), and 2 double thoracic curves (15%) were seen that spanned a mean of 6.8 levels (5 to 9). Major curves improved 36% (range, 5% to 71%), from a mean of 71 degrees (range, 48 to 90 degrees) to 46 degrees (range, 20 to 73 degrees) postindex surgery (P<0.001). Major curves remained stable at a mean of 52 degrees (range, 20 to 87 degrees) at latest GFI (P=0.36). True T1-T12 and T1-S1 growth velocities during GFI were 0.5 mm/mo (range, 0.4 to 0.8 mm/mo) and 0.8 mm/mo (range, 0.1 to 2.1 mm/mo), respectively. Twenty-six complications occurred in 9 patients (69%) averaging 2 complications per patient (range, 0 to 7). CONCLUSIONS: This is the first study to evaluate the outcomes of GFI in children with SS and EOS. Compared with published data for outcomes of GFI in EOS, children with SS may have less major curve correction. Growth-friendly surgery remains an effective treatment method for EOS in patients with SS. LEVELS OF EVIDENCE: Level IV-retrospective case-series.

Intraoperative Use of O-arm in Pediatric Cervical Spine Surgery.

INTRODUCTION: Traditionally, fluoroscopy and postoperative computed tomographic (CT) scans are used to evaluate screw position after pediatric cervical spine fusion. However, noncontained screws detected postoperatively can require revision surgery. Intraoperative O-arm is a 3-dimensional CT imaging technique, which allows intraoperative evaluation of screw position and potentially avoids reoperations because of implant malposition. This study's objective was to evaluate the use of intraoperative O-arm in determining the accuracy of cervical implants placed by a free-hand technique using anatomic landmarks or fluoroscopic guidance in pediatric cervical spine instrumentation. METHODS: A single-center retrospective study of consecutive examinations of children treated with cervical spine instrumentation and intraoperative O-arm from 2014 to 2018 was performed. In total, 44 cases (41 children, 44% men) with a mean age of 11.9 years (range, 2.1 to 23.5 y) were identified. Instability (n=16, 36%) and deformity (n=10, 23%) were the most frequent indications. Primary outcomes were screw revision rate, neurovascular complications caused by noncontained screws, and radiation exposure. RESULTS: A total of 272 screws were inserted (60 occipital and 212 cervical screws). All screws were evaluated on fluoroscopy as appropriately placed. Four screws (1.5%) in 4 cases (9%) were noncontained on O-arm imaging and required intraoperative revision. A mean of 7.7 levels (range, 5 to 13) were scanned. The mean CT dose index and dose-length product were 15.2±6.87 mGy and 212.3±120.48 mGy×cm. Mean effective dose was 1.57±0.818 mSv. There was no association between screw location and noncontainment (P=0.129). No vertebral artery injuries, dural injuries, or neurologic deficits were related to the 4 revised screws. CONCLUSIONS: Intraoperative non-navigated O-arm is a safe and efficient method to evaluate screw position in pediatric patients undergoing cervical spine instrumentation. Noncontained screws were detected in 9% of cases (n=4). O-arm delivers low radiation doses, allows for intraoperative screw revision, and negates the need for postoperative CT scans after confirmation of optimal implant position. LEVEL OF EVIDENCE: Level IV.