Socioeconomic Risk Factors for Poor Outcomes of Developmental Dysplasia of the Hip.

OBJECTIVE: To examine the relationship between socioeconomic factors and outcomes of developmental dysplasia of the hip (DDH). STUDY DESIGN: A retrospective review of patients with DDH at a tertiary pediatric hospital from 2003 to 2012 with 2 years minimum follow-up was conducted. The relationship between socioeconomic factors with late presentation, treatment, and outcomes was examined. Socioeconomic factors included insurance status, language, and ethnicity. RESULTS: In total, 188 patients met criteria. Patients with late presentations were more likely to be Hispanic (P = .02). However, public insurance and a non-English language were not associated with late presentation. Hispanic patients (P = .01) and patients with a non-English language (P = .01) had a lower nonoperative treatment success rate. Hispanic patients had more surgical procedures performed than non-Hispanic patients (P = .04). Patients with range of motion limitations were more likely to have public insurance (P = .05) and be Hispanic (P = .04). On multiple logistic regression analysis controlling for late presentation, patients with public insurance had increased odds of range of motion limitations (OR 2.22, P = .04). Patients with public insurance (OR 0.44, P = .04), a non-English primary language (OR 0.30, P < .01), and Hispanic ethnicity (OR 0.37, P = .01) had decreased odds of successful nonoperative treatment. CONCLUSIONS: Public insurance, a non-English language, and Hispanic ethnicity are risk factors for inferior outcomes for DDH. When controlling for late presentation, these were significant risk factors for nonoperative treatment failure.

Upper extremity conversion disorder in children.

BACKGROUND: Conversion disorder in children presents a challenge to orthopedic surgeons. The condition is frequently associated with unnecessary diagnostic tests, treatments, and cost. The purpose of this study was to report a series of children with upper extremity conversion disorder to raise awareness for this uncommon condition and to assist with its diagnosis and management. METHODS: A retrospective review was conducted of 4 pediatric patients with upper extremity conversion disorder at a tertiary pediatric hospital from 2015 to 2017. Medical records were reviewed for patient demographics, including psychiatric history, clinical findings, diagnostic studies, treatment, and cost of care. RESULTS: Patients presented with upper extremity muscle stiffness, unremitting dysmorphic muscle spasms, weakness, pain, very limited shoulder range of motion, and complaints of recurrent shoulder dislocations. All patients had been evaluated by multiple specialists and had an extensive prior diagnostic workup that was inconclusive. Two patients had a history of prior psychiatric illness and suicidal ideation, and all patients expressed despair and depression. All patients had normal physical examination findings under anesthesia. Two patients with muscle stiffness were treated with botulism injections and improved their shoulder range of motion. The average total charge for care since presentation was $42,729. CONCLUSIONS: Conversion disorder should be considered in patients with an extensive prior diagnostic workup, deficits inconsistent with anatomic patterns or imaging findings, and a history of prior psychiatric illness. Examination under anesthesia is a successful diagnostic approach in children with suspected conversion disorder.

The Incidence of Pin Tract Infections and Septic Arthritis in Percutaneous Distal Femur Pinning.

BACKGROUND: Retrograde percutaneous pinning often involves intra-articular pin placement. Classic teaching has cautioned about the risk of septic arthritis with intra-articular pins, although an incidence has not been reported for this complication. The purpose of this study was to determine the incidence of pin tract infections and septic arthritis following retrograde percutaneous pinning of the distal femur. METHODS: A retrospective review identified patients who underwent retrograde percutaneous pinning of the distal femur for osteotomy or physeal fracture fixation at a tertiary pediatric hospital from 2006 to 2017 and had at least 3 months follow-up. The incidence of pin site infections and septic arthritis was determined. RESULTS: In total, 163 patients met criteria, 142 patients with osteotomies and 21 with physeal fractures. The mean pin duration was 33.2±9.0 days (range: 18 to 68 d). Pin duration of ≥30 days was associated with an increased rate of pin tract infections (11.2% vs. 1.4%, P=0.01). The incidence of pin tract infections was 6.7% (11/163), including 9.5% (2/21) in those with fractures and 6.3% (9/142) following osteotomy (P=0.64). There were no cases of septic arthritis. Of the 11 patients with pin tract infections, 9 were treated successfully with oral antibiotics and 2 patients (1.2%) underwent surgical intervention for infection. Treatment of pin infections with oral antibiotics alone was successful in all 7 patients whose pins were removed within 35 days of surgery, but in only 2 of 4 whose pins were removed later (P=0.11). Of the 2 patients who required irrigation and debridement, one had a superficial pin site infection and retained subcutaneous pin and the other had a pin tract abscess and osteomyelitis at the osteotomy site. CONCLUSIONS: Of 163 patients who underwent retrograde percutaneous pinning of the distal femur, no patient developed septic arthritis and the incidence of pin site infections was 6.7% (11/163). Intra-articular retrograde percutaneous pinning of the distal femur is a safe technique with a low risk of septic arthritis. LEVEL OF EVIDENCE: Level III-case-control study.

Foam Padding in Postoperative Lower Extremity Casting: An Inexpensive Way to Protect Patients.

BACKGROUND: Although postoperative cast immobilization is routinely used in children, it is not without complications. Few studies have focused on interventions to decrease their frequency. The purpose of this study was to determine if foam padding in postoperative lower extremity casts decreased the rate of cast complications. METHODS: A retrospective review of patients who underwent lower extremity casting after elective surgery at a tertiary pediatric hospital from 2006 to 2013 was conducted. Postoperative casts were classified by type (A-frame, short leg, long leg, spica) and the presence of foam. Charts were reviewed for skin complications, cast splits for apparent neurovascular deficits, cast splits for patient complaints, unplanned outpatient returns for cast-related issues, and compartment syndrome. RESULTS: In total, 920 patients with 2,481 casts were included. In total, 612 (24.7%) casts had foam placed during casting. The incidence of skin complications was significantly lower in A-frame casts with foam (4.5%, 5/112) than without (13.4%, 11/82) (P=0.03) and long leg casts with foam (0.9%, 2/225) than without (4.3%, 19/444) (P=0.02). Patients with static encephalopathy casted with foam had a lower incidence of skin complications (0.7%, 2/279) than those without (3.6%, 22/615) (P=0.01). There was no difference in the overall incidence of skin complications in casts with and without foam (P=0.44), short leg casts (P=0.37), and spica casts (P=0.34). Patients with skin complications (20.3±7.1 kg/m) had a higher body mass index than those without (18.9±5.4 kg/m) (P=0.04). Postoperative A-frame casts with foam (0.0%, 0/112) were split less often for apparent neurovascular deficits than those without foam (4.5%, 3/67) (P=0.05). The cast split rates for apparent neurovascular deficits in casts with and without foam (P=0.58), long leg casts (P=0.67), short leg casts (P=0.63), and spica casts (P=1.0) were comparable. CONCLUSIONS: The use of foam in postoperative lower extremity casting is an effective intervention to reduce the incidence of skin complications in patients with static encephalopathy, in an A-frame cast, or in a long leg cast. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Pediatric trigger thumb caused by a flexor tendon sheath ganglion.

Pediatric trigger thumb is a common reason for toddlers to present to a pediatric orthopaedic surgeon. There is controversy over the precise etiology and optimal treatment method. Current accepted diagnostic and treatment algorithms in children have not varied based on etiology. This report describes the clinical presentation and care of a 3-year-old child with pediatric trigger thumb and surgical findings of a large flexor tendon sheath ganglion at the level of the annular pulley with no apparent nodule within the FPL. The potential implications for consideration of etiology in current diagnostic and treatment guidelines are discussed.

Isolated femoral shaft fractures in children rarely require a blood transfusion.

BACKGROUND: No recent study has examined how a trend toward surgical fixation for pediatric femoral shaft fractures has impacted blood loss and transfusion requirements. The purpose of this study was to determine the factors influencing transfusions in the treatment of pediatric femoral shaft fractures. METHODS: A retrospective review of patients with femoral shaft fractures treated surgically from 2004 - 2017 at a tertiary pediatric hospital was conducted. Electronic medical records were reviewed for fixation method, additional injuries, blood loss (estimated blood loss (EBL), hemoglobin, hematocrit) and transfusion. The relationship between fixation method with blood loss and transfusion was examined. Two groups were compared, those with and without additional injuries. Additional injuries were defined as additional fractures and/or abdominal, chest, or head injuries. RESULTS: 172 patients met inclusion criteria. There were 129 patients with isolated femoral shaft fractures and 43 patients with femoral shaft fractures and concomitant additional injuries. The transfusion rate in patients with isolated femoral shaft fractures was 0.8% (1/129) which was significantly lower than in patients with additional injuries; 39.5% (17/43) (p < 0.05). In patients with additional injuries, there was a significant relationship between number of additional surgeries and odds of transfusion (OR=2.1, CI: 1.2-3.6, p < 0.05). In patients with isolated femoral shaft fractures, EBL was higher in patients treated with rigid intramedullary nails (148.5 ± 119.0 mL) than flexible intramedullary nails (34.1 ± 56.3 mL) (p < 0.05). However, there was no significant difference in transfusion or changes in hemoglobin/hematocrit between fixation methods in patients with isolated femoral shaft fractures. CONCLUSION: Pediatric patients with surgically treated isolated femoral shaft fractures rarely require transfusion (<1%), while patients with femoral shaft fractures and additional injuries had a high transfusion rate (39.5%). Surgical fixation method had a significant impact on EBL, with rigid intramedullary nail fixation having a significantly higher EBL than flexible intramedullary nails, however it did not lead to higher rates of transfusions. Blood transfusions are rarely needed in isolated femoral shaft fractures, despite the trend towards increase in surgical fixation and newer fixation techniques.

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.

Limited Sequence MRIs for Early Onset Scoliosis Patients Detected 100% of Neural Axis Abnormalities While Reducing MRI Time by 68.

STUDY DESIGN: Diagnostic accuracy. OBJECTIVE: The purpose of this study was to determine if neural axis abnormalities in early onset scoliosis (EOS) patients can be reliably detected with limited magnetic resonance imaging (MRI) sequences (sagittal T1, sagittal T2). SUMMARY OF BACKGROUND DATA: MRIs are often performed in EOS patients as studies have shown there are neural axis abnormalities in up to 40% of this population. MRIs are expensive, lengthy, and often require general anesthesia. In young children prolonged or repeated exposure to general anesthesia may be associated with neurocognitive damage. METHODS: A retrospective review of consecutive EOS patients from February to December 2017 who received an MRI of the cervical, thoracic, and lumbar spine was conducted. MRI images were reviewed for neural axis abnormalities. Two sequences (sagittal T1, sagittal T2) of these previously reviewed MRIs were read at a separate time by an attending pediatric neuroradiologist. The imaging findings from these two select sequences were then compared with the prior radiology report based on all of the standard MRI sequences. RESULTS: Fifty patients met criteria. Ten patients (20%) had neural axis abnormalities detected by the full MRI. All of these neural axis abnormalities were detected on the combination of sagittal T1 + sagittal T2 images. Standard MRIs lasted 66 ±â€Š20 minutes and patients required 90 ±â€Š22 minutes of anesthesia. Sagittal T1 + sagittal T2 sequences lasted 21 ±â€Š7 minutes (P < 0.0001). CONCLUSION: Limited sequence MRIs with sagittal T1 and T2 sequences for EOS patients had 100% sensitivity for the detection of neural axis abnormalities and would allow for a 68% reduction in the length of MRI and significant reduction in anesthesia time. LEVEL OF EVIDENCE: 3.