Microwave Ablation of the Pig Growth Plate: Proof of Concept for Minimally Invasive Epiphysiodesis.

BACKGROUND: Different surgical methods for epiphysiodesis of limb length discrepancy (LLD) have been described. Although these methods are variably effective, they are associated with morbidity (pain and limp) and potential complications. Microwave ablation is a less-invasive opportunity to halt growth by selectively destroying the growth plate via thermal energy to treat LLD in children. QUESTIONS/PURPOSES: In this proof-of-concept study using an in vivo pig model, we asked: (1) What is the durability of response 2 to 4 months after microwave ablation of the tibial growth plate as measured by length and angulation of the tibia via a CT scan? (2) Was articular cartilage maintained as measured by standard histologic staining for articular cartilage viability? METHODS: To develop an in vivo protocol for microwave ablation, we placed microwave antennas adjacent to the proximal tibia growth plate in the cadaveric hindlimbs of 18 3-month-old pigs. To determine the suitable time, we varied ablation from 90 to 270 seconds at 65-W power settings. After sectioning the tibia, we visually assessed for discoloration (implying growth plate destruction) that included the central growth plate but did not encroach into the epiphysis in a manner that could disrupt the articular surface. Using this information, we then performed microwave ablation on three live female pigs (3.5 to 4 months old) to evaluate physiologic changes and durability of response. A postprocedure MRI was performed to ensure the intervention led to spatial growth plate alterations similar to that seen in cadavers. This was followed by serial CT, which was used to assess the potential effect on local bone and growth until the animals were euthanized 2 to 4 months after the procedure. We analyzed LLD, angular deformity, and bony deformity using CT scans of both tibias. The visibility of articular cartilage was compared with that of the contralateral tibia via standard histologic staining, and growth rates of the proximal tibial growth plate were compared via fluorochrome labeling. RESULTS: Eighteen cadaveric specimens showed ablation zones across the growth plate without visual damage to the articular surface. The three live pigs did not exhibit changes in gait or require notable pain medication after the procedure. Each animal demonstrated growth plate destruction, expected limb shortening (0.8, 1.2, and 1.5 cm), and bony cavitation around the growth plate. Slight valgus bone angulation (4º, 5º, and 12º) compared with the control tibia was noted. No qualitatively observable articular cartilage damage was encountered from the histologic comparison with the contralateral tibia for articular cartilage thickness and cellular morphology. CONCLUSION: A microwave antenna placed into a pig's proximal tibia growth plate can slow the growth of the tibia without apparent pain and alteration of gait and function. CLINICAL RELEVANCE: Further investigation and refinement of our animal model is ongoing and includes shorter ablation times and comparison of dynamic ablation (moving the antennae during the ablation) as well as static ablation of the tibia from a medial and lateral portal. These refinements and planned comparison with standard mechanical growth arrest in our pig model may lead to a similar approach to ablate growth plates in children with LLD.

Scheduled methadone reduces overall opioid requirements after pediatric posterior spinal fusion: A single center retrospective case series.

BACKGROUND: Posterior spinal fusion to correct adolescent idiopathic scoliosis is associated with significant postoperative pain. Different modalities have been reported as part of a multimodal analgesic plan. Intravenous methadone acts as a mu-opioid agonist and N-Methyl-D-aspartate (NMDA) antagonist and has been shown to have opioid-sparing effects. Our multimodal approach has included hydromorphone patient-controlled analgesia (PCA) with and without preincisional methadone, and recently postoperative methadone without a PCA. AIMS: We hypothesized that a protocol including scheduled postoperative methadone doses would reduce opioid usage compared to PCA-based strategy. METHODS: A retrospective chart review of patients undergoing posterior spinal fusion for adolescent idiopathic scoliosis between 2015 and 2020 was performed. There were three patient groups: Group PCA received a hydromorphone PCA without methadone; Group PCA + Methadone received preincisional methadone and a hydromorphone PCA; Group Methadone received preincisional methadone, scheduled postoperative methadone, and no PCA. The primary outcome was postoperative opioid use over 72 h. Secondary outcomes included pain scores, sedation scores, and length of stay. RESULTS: Group PCA (n = 26) consumed 0.33 mg/kg (95% CI [0.28, 0.38]) total hydromorphone equivalents, Group PCA + methadone (n = 39) 0.30 mg/kg (95% CI [0.25, 0.36]) total hydromorphone equivalents, and Group methadone (n = 22) 0.18 mg/kg (95% CI [0.15, 0.21]) total hydromorphone equivalents (p = .00096). There were no statistically significant differences between the groups for secondary outcomes. CONCLUSION: A protocol with intraoperative and scheduled postoperative methadone doses resulted in a 45% reduction in opioid usage compared to a PCA-based protocol with similar analgesia after pediatric posterior spinal fusion.

Trevor's disease of the distal radioulnar joint in two children with achondroplasia.

Two children with achondroplasia who developed an abnormal bony outgrowth at the distal radioulnar joint (DRUJ), indistinguishable from an osteochondroma on histology, but the radiographic appearance, location, and asymmetry suggested the rare diagnosis of dysplasia epiphysealis hemimelica (DEH or "Trevor's disease"). One child experienced symptomatic relief with surgical excision and one was observed clinically due to lack of significant symptoms. These are the first presented cases of DEH in achondroplasia, both affecting the DRUJ. Due to the infrequency of DEH, more research is needed to better understand the potential connection to achondroplasia. For management, we suggest shared surgical decision making based on symptoms.

Compartment Syndrome in Operatively Managed Pediatric Monteggia Fractures and Equivalents.

BACKGROUND: Acute compartment syndrome (ACS) is not commonly associated with pediatric Monteggia fractures or Monteggia equivalents (MF/ME). The aims of this study were: (1) To document a rate of ACS among children with operatively managed MF/ME, comparing this to the rate of ACS in classically associated Type 3 supracondylar humerus (T3-SCH) fractures at the same institution; (2) To determine which patients with MF/ME are at highest risk for ACS. METHODS: Children ages 2 to 12 with MF/ME requiring operative management at an academic institution over a 14-year period were identified. The Monteggia fractures were characterized using the Bado classification; equivalent injuries were identified according to established criteria. Similarly, all patients with T3-SCH fractures managed over the same period were identified. Record review included demographic, procedural, and radiographic variables. Statistical analysis compared the rates of ACS in both groups and determined risk factors associated with developing ACS in patients with MF/ME. RESULTS: The rate of ACS in MF/ME was 9 of the 59 (15.3%), which was significantly higher than the rate of ACS in T3-SCH fractures 2 of the 230 (0.9%) (P=0.001). Comparing MF/ME with ACS to those without; there was no difference in sex (P=1.00), Bado Type (P=0.683), or Monteggia fracture versus equivalent (P=0.704). MF/ME with preoperative vascular deficits (22.2%) and those undergoing intramedullary fixation of the radius were more likely to develop ACS (P=0.021 and 0.015, respectively), and there was a trend toward higher rates of ACS among MF/ME with preoperative neurological deficits (P=0.064). CONCLUSIONS: Patients with operatively managed MF/ME had a significantly higher rate of ACS compared with patients with T3-SCH fractures. With no predisposition based on Bado classification or Monteggia fracture versus equivalent, all operatively managed MF/ME appear to be at risk for ACS. Patients with preoperative neurovascular deficits and those undergoing intramedullary radial fixation develop ACS at higher rates. Careful assessment of the forearm for signs and symptoms of ACS both before and after fixation is critical. LEVEL OF EVIDENCE: Level III-retrospective case control.

Variation Among Pediatric Orthopaedic Surgeons When Treating Medial Epicondyle Fractures.

BACKGROUND: Medial epicondyle fractures are a common pediatric and adolescent injury accounting for 11% to 20% of elbow fractures in this population. This purpose of this study was to determine the variability among pediatric orthopaedic surgeons when treating pediatric medial epicondyle fractures. METHODS: A discrete choice experiment was conducted to determine which patient and injury attributes influence the management of medial epicondyle fractures by pediatric orthopaedic surgeons. A convenience sample of 13 pediatric orthopaedic surgeons reviewed 60 case vignettes of medial epicondyle fractures that included elbow radiographs and patient/injury characteristics. Displacement was incorporated into the study model as a fixed effect. Surgeons were queried if they would treat the injury with immobilization alone or open reduction and internal fixation (ORIF). Statistical analysis was performed using a mixed effect regression model. In addition, surgeons filled out a demographic questionnaire and a risk assessment to determine if these factors affected clinical decision-making. RESULTS: Elbow dislocation and fracture displacement were the only attributes that significantly influenced surgeons to perform surgery (P<0.05). The presence of an elbow dislocation had the largest impact on surgeons when choosing operative care (ß=-0.14; P=0.02). In addition, for every 1 mm increase in displacement, surgeons tended to favor ORIF by a factor of 0.09 (P<0.01). Sex, mechanism of injury, and sport participation did not influence decision-making. In total, 54% of the surgeons demonstrated a preference for ORIF for the included scenarios. On the basis of the personality Likert scale, participants were neither high-risk takers nor extremely risk adverse with an average-risk score of 2.24. Participant demographics did not influence decision-making. CONCLUSIONS: There is substantial variation among pediatric orthopaedic surgeons when treating medial epicondyle fractures. The decision to operate is significantly based on the degree of fracture displacement and if there is a concomitant elbow dislocation. There is no standardization regarding how to treat medial epicondyle fractures and better treatment algorithms are needed to provide better patient outcomes. LEVEL OF EVIDENCE: Level V.

Orthopaedic Fixation Devices Used in Children: A Radiologist's Guide.

Fractures are common in children with some requiring surgical reduction and fixation to maintain anatomical alignment. Although various surgical techniques and principles are shared between children and adults, certain unique considerations in children can influence the surgical approach and device selection. In particular, for skeletally immature children, it is of utmost importance to protect certain critical open growth plates because permanent injury can produce severe growth disturbances. The often robust healing response and potential limited patient compliance can also influence the treatment algorithm and decision making. Commonly encountered orthopaedic fixation devices, including screws, intramedullary devices, and plates, are reviewed with an emphasis on their mechanism and application in children. Additional miscellaneous devices that are commonly used to treat malalignment and guide bone growth including epiphysiodesis plates, proximal femur osteotomy plates, and spinal magnetic growing rods are also reviewed. The goal of this article is to provide a basic understanding of the principles and mechanisms of different types of pediatric orthopaedic devices and thereby improve the radiologist's diagnostic confidence and allow better anticipation of complications.

Predictability of Clinical Knowledge Through Mobile App-based Simulation for the Treatment of Pediatric Septic Arthritis: A Pilot Study.

BACKGROUND: Recently the American Board of Orthopaedic Surgery and the Accreditation Council of Graduate Medical Education have identified the treatment of septic arthritis of the hip in children as a milestone skill for all US orthopaedic residents. The purpose of this study was to test correlation between clinical knowledge and examination score on a mobile app-based training module for the treatment of pediatric septic hip arthritis. METHODS: A 4-part simulation model on surgical decision-making associated with the treatment of pediatric septic arthritis was developed through expert consensus. Orthopaedic trainees participating in the "Top Gun" program of the 2015 and 2016 International Pediatric Orthopaedic Symposiums were recruited to participate in this pilot study. Trainees completed a presimulation quiz on their knowledge of diagnosis, arthrocentesis, and surgical irrigation and debridement on a pediatric patient presenting with septic arthritis of the hip. Trainees then completed the 4-part simulation on the mobile app. Pearson correlation analysis was used to assess the relationship between the quiz and the simulation. RESULTS: A total of 53 orthopaedic residents and fellows participated in the simulation. Median quiz score was 87 points [interquartile range (IQR), 81 to 94] before the intervention and 100 points (IQR, 94 to 100) postintervention. The median simulation test score was 89 (IQR, 81 to 92) which demonstrated a positive correlation with the postintervention quiz (r=0.44, P<0.001). The preintervention metrics demonstrated a positive correlation with postintervention metrics (r=0.53, P<0.001). CONCLUSIONS: This study revealed a statistically significant positive correlation between the mobile app simulation and the clinical knowledge of the participants, as well as the ability to improve knowledge about a procedure during the testing period. These findings support the ability for the mobile app to test clinical knowledge. In the current environment of decreased work hours and patient exposure for orthopaedic trainees, mobile app-based simulation has the potential to safely aid in assessment of orthopaedic residents and fellows.

Residual Equinus After the Ponseti Method: An MRI-based 3-Dimensional Analysis.

BACKGROUND: Residual equinus deformity is present in up to 20% of clubfeet treated by the Ponseti method. These patients may require surgical release to restore dorsiflexion. Despite complete posterior release; persistent intraoperative equinus may be present and suggest concurrent joint incongruity. The purpose of this study was to characterize differences in ankle morphology in toddlers with residual equinus following the Ponseti method. METHODS: Preoperative magnetic resonance imaging (MRI) data from 10 patients who underwent reconstruction (17 feet; 7 bilateral, 3 unilateral clubfeet) for persistent equinus were compared with 16 age-matched controls. Through reverse engineering software, MRI data were used to generate 3-dimensional (3D) models. Four talus-based measures were performed on both MRI data and 3D models-neck depth, neck angle, width, and length. Models were also used to calculate talus volume and arc of curvature (plafond and talar dome). Standard statistical analyses were performed. RESULTS: Talus volumes, width, and length were less in clubfeet then in control feet. Although some measures were significant there was no mismatch with the ankle mortise dimensions or arc curvature that could account for any decrease in dorsiflexion. We found that from MRI measures the clubfoot neck depth was 2.3 versus 3.6 mm in controls (P<0.001) and from 3D modeling the clubfoot neck depth was 2.3 and 3.5 mm in controls (P=0.003). With 3D modeling talus clubfoot neck angle was 153.7 versus 140.4 degrees in controls (P=0.01). The clubfoot neck angle obtained from MRI measures were also different yet not significant [126.6 in clubfeet versus 122.5 degrees in controls (P=0.12)]. CONCLUSIONS: In comparison to age-matched feet; we have noted a decrease in talar neck depth and an obtuse talar neck angle in clubfeet treated in the manner of Ponseti. This may result in anterior ankle impingement and be the cause of residual equinus despite posterior release. In these procedures, the surgeon should recognize this possibility when the amount of dorsiflexion is less than expected. LEVEL OF EVIDENCE: Level III-case control study.

Update in Pediatric Musculoskeletal Infections: When It Is, When It Isn't, and What to Do.

Musculoskeletal infections, including osteomyelitis, septic arthritis, and pyomyositis, are a substantial cause of morbidity in children and adolescents. The increased virulence of infectious agents and the increased prevalence of antimicrobial-resistant pathogens, particularly methicillin-resistant Staphylococcus aureus, have resulted in a more complicated clinical course for diagnosis and management, which is evidenced by an increased length of hospital stays, incidence of complications, and number of surgical interventions. Musculoskeletal infections are a challenge for surgeons because they vary substantially in their presentation and in their required treatment, which is based on the causative organism, the location of the infection, and the age of the patient. The necessity for a prompt diagnosis is complicated by several diseases that may mimic musculoskeletal infection, including transient synovitis, autoimmune arthritis, and tumors. Recent innovations in diagnosis and management have provided surgeons with new options to differentiate musculoskeletal infections from these rapidly evolving disease pathologies. As diagnostic and treatment modalities improve, collaboration among surgeons from multiple disciplines is required to develop evidence-based clinical practice guidelines that minimize the effect of musculoskeletal infection and optimize clinical outcomes for patients.

Guided Growth Implant Failure is a Result of Cyclic Fatigue: Explant Analysis With Scanning Electron Microscopy.

BACKGROUND: Guided growth is often used to correct limb deformity and yet implant screw failure in modular systems has been reported. There have been no reports of plate failure and we do not know the exact mode of failure when screws do break. METHODS: We report the first published case of a fractured plate in a modular plate and screw construct that was used to correct Blount disease in a child through guided growth. The implants were removed and analyzed for method of failure using scanning electron microscopy. RESULTS: Scanning electron microscopy of the explant confirms that the mode of failure was not a result of static tension from growth. Rather, analysis confirms cyclic fatigue that led to crack propagation across the anterior side of the plate until overload caused complete plate failure. CONCLUSIONS: This analysis confirms an in vivo cyclic compression-relaxation of the growth plate presumably to weight-bearing, and that when excessive may lead to implant failure as seen here in this case. LEVEL OF EVIDENCE: Level V.

Radiographic and Respiratory Effects of Growing Rods in Children With Spinal Muscular Atrophy.

BACKGROUND: Respiratory weakness and spinal deformity are common in patients with spinal muscular atrophy (SMA). Posterior (distraction type) growing rods have recently gained favor as a treatment option in this population, due to their ability to prevent spinal deformity progression and their potential to allow lung volumes to increase over time. The objective of this study was to determine the impact of posterior growing rods on the spinal alignment and respiratory function in children with SMA with intermediate term follow-up. METHODS: A single center, retrospective review was performed on SMA patients treated with growing rods, inserted between 2004 and 2010, with a minimum of 2-year follow-up. SMA type, changes in the route of bi-level positive airway pressure respiratory support and the amount of time receiving respiratory support are reported. Pulmonary function tests (PFTs) and radiographs were reviewed and data evaluated preinsertion, postinsertion, and at latest follow-up. RESULTS: Sixteen children with SMA (5 type I, 11 type II) met inclusion criteria. The average age of insertion was 5.8 (±1.5) years, the median number of lengthenings was 4 (range, 3 to 5), and the median time between insertion and last clinical review was 4.7 (range, 2.7 to 9.5) years. Radiographic review demonstrated significant (P<0.05) improvements in the following: Spinal curve magnitude, pelvic obliquity, space available for the lung, rib vertebral angle difference, and thoracic kyphosis following growing rod implantation. Thoracic and lumbar height and chest width and depth increased significantly (P<0.05) over the lengthening process. None of the patients initially required more than noninvasive positive pressure ventilation support. Fifteen of the 16 experienced no changes in their noninvasive positive pressure ventilation support needs throughout the study duration, requiring support only at night and naps. Serial PFTs were available for 6 children with SMA type II. PFTs demonstrated significant improvements in absolute forced vital capacity (FVC), minimal changes in the maximal inspiratory and expiratory pressures, and a gradual worsening of percent predicted FVC. CONCLUSIONS: Clinical respiratory support requirements appear to stabilize following the insertion and lengthening of posterior based growing rods in the SMA population. Similar to previous studies, increased spinal height and thoracic cavity size were noted throughout the process. Despite an increasing absolute FVC, the percent predicted FVC diminished over time. LEVEL OF EVIDENCE: Level IV-therapeutic.

To Cast, to Saw, and Not to Injure: Can Safety Strips Decrease Cast Saw Injuries?

BACKGROUND: Placement and removal of fiberglass casts are among the more-common interventions performed in pediatric orthopaedic surgery offices. However, cast removal is associated with abrasive injuries and burns from the oscillating cast saw, and these injuries can occur even when the cast is removed by experienced personnel. It is unknown whether an added barrier, such as a safety strip, can mitigate injuries from blade-to-skin contact during cast removal with the oscillating saw. QUESTIONS/PURPOSES: We asked: (1) Can a safety strip provide a physical barrier during cast removal, decreasing blade-to-skin contact? (2) Does the safety strip lessen heat transfer? (3) Will the use of the safety strip prevent cast pressure from being released when the cast is split? METHODS: Standard long-arm fiberglass casts were removed by experienced and inexperienced healthcare personnel (n = 35) from life-sized pediatric models. A commercially available woven cast saw safety strip, commonly incorporated in waterproof cast constructs, was chosen as the protective strip. Each participant removed a cast with and without the safety strip present. All participants were blinded to the presence or absence of the safety strip at the time of cast removal. The number of touches was compared between cast removal with and without protective strips. A separate model was designed to assess prevention of heat transfer. Temperatures were recorded, using thermocouples, for three designated temperatures. Five to six trials were conducted at each designated temperature for each of two conditions, with and without the safety strip. Finally, to assess if the safety strip would prevent cast pressure from being released, a third model was used. Thirty standard short-arm casts were applied and removed from the arm models by one of the authors. Pressure data were collected from between the padding layers, in casts with and without the safety strip present, after application, univalving and bivalving each cast. RESULTS: Use of the safety strip reduced the number of simulated skin touches compared with casts removed without the safety strip, among experienced users (mean, 9.0 [range, 1-28] versus 0.1 [range, 0-1], mean ratio, 0.0012; 95% CI, 0.002-0.063; p < 0.001) and inexperienced users (mean, 8.5 [range, 0-31] versus 0.6 [range, 0-3], mean ratio, 0.07; 95% CI, 0.03-0.15; p < 0.001). The safety strips decreased heat transfer, preventing temperatures at the cast-skin interface from reaching 50 °C. Finally, after splitting the cast, with the numbers available, there was no increase in the pressure beneath the casts in those with the safety strip present (mean without, 0.23 [SD, 0.070] versus safety strip in the padding 0.20 [SD, 0.091] and safety strip on top padding, 0.21 [SD, 0.090]; p = 0.446 and p = 0.65 respectively). CONCLUSIONS: Our study showed the effectiveness of a safety strip in reducing simulated touches with the oscillating cast saw during cast splitting. Additional studies are warranted to investigate the clinical use and utility of the safety strip in practice. CLINICAL RELEVANCE: The findings of this study suggest that using safety strips in clinical practice could decrease blade-to-skin contact and therefore minimize cast saw injuries. However, validation of these findings in the clinical setting is necessary before drawing a definitive conclusion.

Epidural Baclofen for the Management of Postoperative Pain in Children With Cerebral Palsy.

INTRODUCTION: Children with cerebral palsy undergoing soft tissue and bony procedures often experience pain and spasticity postoperatively. Differentiation of pain from spasticity complicates management, so controlling spasticity with a continuous infusion of baclofen, an antispasmodic, through an already present indwelling epidural catheter holds interest. METHODS: A retrospective chart review was performed of patients with cerebral palsy undergoing single event, multilevel lower extremity surgery at a single institution who received epidural analgesia with or without continuous baclofen infusion. Primary outcomes included need for supplemental narcotic analgesics and benzodiazepines postoperatively. Duration of hospitalization, pain scores, and complications were also evaluated. RESULTS: Forty-four patients were identified, ranging in age from 3 to 17 years, 19 of whom received epidural baclofen. No differences were found in use of supplemental narcotic analgesia, benzodiazepines, or duration of hospitalization. Differences in pain scores were not statistically significant (0.82±0.95 for baclofen vs. 1.48±0.99 for controls) (P=0.391). Mean arterial pressure was lower in patients receiving baclofen (P=0.004). No potential side effects attributable to baclofen were noted. CONCLUSIONS: Continuous epidural baclofen infusion seems unlikely to alter the pain-spasm cycle experienced by patients with cerebral palsy following orthopaedic surgery to a clinically significant degree. More effective, and cost-effective, measures at assessing and controlling pain and muscle spasm should be explored to benefit cerebral palsy patients postoperatively. LEVEL OF EVIDENCE: Level III-therapeutic study.

Can Radiographs Predict Outcome in Patients With Idiopathic Clubfeet Treated With the Ponseti Method?

BACKGROUND: The aim of this study was to determine if radiographic measurements, taken before tenotomy, can predict outcome in children with idiopathic clubfoot treated by the Ponseti method. METHODS: A retrospective chart and radiographic review was performed on children with idiopathic clubfoot treated with the Ponseti method over a 10-year period with minimum 2-year follow-up that had a forced dorsiflexion lateral foot radiograph before tenotomy. All angles were measured in duplicate on the pretenotomy radiographs, including: foot dorsiflexion (defined as the 90 minus the angle between the tibial shaft and a plastic plate used to dorsiflex the foot), tibio-calcaneal, talo-calcaneal, and talo-first metatarsal angles. Clinical review of patient records identified different patient outcomes: no additional treatment required, relapse (additional casting and/or surgery required), recurrence (any additional surgery required), or reconstruction (surgery not including repeat tenotomy). RESULTS: Forty-five patients (71 feet) were included in the study. The median age at follow-up was 4.6 years. The intrareader reliability was acceptable for all measures. Thirteen of the 71 (18%) feet required additional surgery, occurring at a median age of 3.6 years. Of the 4 radiographic measures, only pretenotomy foot dorsiflexion predicted recurrence (hazard ratio=0.96, P=0.03). Youden's method identified 16.6 degrees of dorsiflexion as the optimal cutoff. Feet with at least that amount of dorsiflexion pretenotomy (n=21) experienced no recurrences; feet with less than that amount of dorsiflexion (n=50) experienced 13 recurrences (P=0.007). CONCLUSIONS: Reduced foot dorsiflexion on lateral forced dorsiflexion pretenotomy radiograph was associated with an increased risk of recurrence. Radiographic dorsiflexion to 15 degrees past neutral before tenotomy appears to predict successful treatment via the Ponseti method.

Cast-saw injuries: assessing blade-to-skin contact during cast removal. Does experience or education matter?

BACKGROUND: Cast-saw injuries are sustained during cast removal or splitting of a cast when a hot cast-saw blade touches the patient's skin inadvertently during cast removal. Other studies have evaluated risk factors associated with saw-blade temperature, however, none have documented the number and duration of blade-to-skin contacts during cast removal. METHODS: Using a pediatric long-arm model capable of detecting cast-saw blade contact, we tested the ability of health care providers to apply and remove casts before and after a brief education module. The total number and duration of "touches" between the saw and the model's "skin" were recorded. Correlations between user "touches," and experience and comparisons between pre- and post-education "touches" were performed. RESULTS: Of the 18 study participants, 16 touched the model surface with the cast saw; 7 of the 18 participants maintained blade contact with the skin for > 1 second 22 times during the testing process. Participants with less experience averaged 20 (± 16) touches, whereas more experienced participants averaged 24 (± 19) touches (P = 0.7). Average number of touches was similar-before 22 (± 20) and after 25 (± 22); P = 0.5-participants completed an education module. No correlation between experience or participation in the education program was found with decreased number of blade-to-skin touches. CONCLUSION: Nearly all clinicians inadvertently contacted the underlying skin with the cast-saw blade. In our limited sample size, experience and education did not prevent this; therefore, minimizing time of contact and blade temperature may be more important factors in minimizing cast-saw injuries.

Using Preference Cards to Support a Thoughtful, Evidence-based Orthopaedic Surgery Practice.

INTRODUCTION: When orthopaedic surgeons begin or relocate their careers, they must communicate effectively about their instrumentation and equipment needs. 'Preference Cards' or 'Pick Lists' are generated by and for individual surgeons at the time of hire and can be updated over time to reflect their needs for common cases. Currently, such decisions are made without formal guidance or preparation. BODY: Surgeons must consider and plan for their operating room needs. Health system and industry factors affect these decisions, as do surgeons' unique interests, preferences, and biases. Orthopaedic surgeons currently face challenges: formal education is deficient in this space, material and reprocessing costs are not transparent, relationships and contracts with industry are complex, and few health systems have mechanisms to support preference card optimization. This complex landscape influences utilization decisions and leaves opportunities for integration, collaboration, and innovation. SUMMARY: Choices about instrument and resource utilization in the OR have wide-reaching impacts on costs, waste generation, OR efficiency, sterile processing, and industry trends. Surgeons and their teams have much to gain by making intentional choices and pursuing both individual and systematic improvements in this space.

Variations in AP and frog-leg pelvic radiographs in a pediatric population.

INTRODUCTION: It is common for pediatric patients with a history of hip dysplasia to undergo anteroposterior (AP) and frog-leg (FL) lateral radiographs to monitor development of the hip. Because of sensitivity of pediatric tissues to ionizing radiation, we sought to document the relationship between AP and FL radiographs and to determine which image was better to assess acetabular dysplasia. METHODS: An Institutional Review Board-approved, retrospective review was conducted on 33 patients screened for hip dysplasia at a single institution. We sought to determine whether either film was more likely to be qualitatively better in position and whether there were differences in acetabular measures between the 2 radiographs. Standard measurements on AP and FL radiographs were made by 5 observers on 2 different occasions to assess interobserver and intraobserver variability. RESULTS: The mean age was 23+1 months, and 80% were female; none of the children had hip dysplasia. There was no statistical significance in the quotient of pelvic rotation (AP 1.2 + 0.1 degrees and FL 1.1 + 0.1 degrees; P = 0.84). There was a statistical difference in obturator height in mm (AP 16.0 + 0.3 and FL 17.8 + 0.2; P = 7.2E-10). The mean intraobserver variability for the acetabular index was 1.8 + 0.2 and 1.7 + 0.2 degrees for AP and FL alignments, respectively (P = 0.58), and the mean interobserver variability was 1.7 + 0.1 and 1.7 + 0.1 degrees, respectively (P = 0.75). The measurements of linear variability between the AP and FL showed no statistical significant difference with the exception of the left Hilgenreiner distance in mm (AP 1.00 + 0.08 and FL 0.81 + 0.08; P = 0.02). DISCUSSION: These results demonstrate that there is little clinical difference in variability of positioning and rotational variables between AP and FL radiographs for hip dysplasia. These results indicate that either image could be used assess to acetabular dysplasia thus decreasing risks of ionizing radiation. LEVEL OF EVIDENCE: Level III.

Evidence-based medicine: management of pediatric forearm fractures.

Forearm fractures are common injuries in the pediatric population. Successful treatment of these fractures should result in complication-free functional pronosupination. Traditionally, these have been treated with closed reduction and casting, but the last several decades have seen a dramatic increase in the operative treatment of these fractures. However, little high-level evidence exists to guide management. The data from the limited set of studies available suggest that closed treatment does usually result in satisfactory outcomes, particularly in younger patients; operative fixation is usually successful as well but comes with a significantly increased complication rate. The ideal study to aid in evidence-based decision-making for pediatric forearm fractures would be a randomly controlled trial comparing closed reduction and casting versus intramedullary nailing versus plating; in children ranging from 8 years old to skeletally mature; with closed forearm fractures, complete or greenstick with >20 degrees of angulation; with a minimum of 5 years of follow-up (or to maturity); with the primary outcome defined as final pronation and supination; using an validated functional outcome tool; and precisely defining the complications from each treatment.

Biomechanical comparison between 2 guided-growth constructs.

BACKGROUND: Correction of deformity using guided growth with plate and screw constructs has shown good results in the correction of angular deformities in children. Some recent reports have shown device failure, perhaps because of increased patient weight as seen in Blount disease. The purpose of our study was to compare the strength to failure between 2 similar devices, the Orthofix 8-plate manufacturer 1 (M-1) and Biomet Peanut plate manufacturer 2 (M-2), using 2 different screw types: solid and cannulated. METHODS: A model of bone was developed using 30-pcf solid polyurethane foam as cancellous bone and high-density polyethylene as cortical bone. A 10.0-mm defect was created through the polyurethane foam and was spanned by a plate and screw system. Under the assumption that device failure is caused by cyclical loading, each device underwent fatigue testing on an MTS Bionix machine with a 4-Hz micromotion of 5.0 mm at -500-N compression, and the number of cycles to failure was recorded. RESULTS: All devices failed at the screw shaft; plates did not break under any circumstances. The highest mean number of cycles to failure was seen with the M-2 device using solid, stainless-steel screws (22,614 cycles; SD, 6885). On comparing with titanium screws, solid screws were significantly stronger in both the M-1 (P=0.002) and M-2 devices (P=0.013). The M-2 device with cannulated screws was noted to be significantly stronger than the M-1 device with cannulated screws (P=0.036). CONCLUSIONS: This study reveals a significant increase in strength in one titanium cannulated guided-growth system over another. Solid screws are also shown to be significantly stronger than cannulated screws. Long-term clinical data will be required to determine whether this difference results in lower failure rates. CLINICAL RELEVANCE: Use of a stronger guided-growth device may be of benefit for correction of deformity in children who are heavier, such as those with Blount disease. Comparative clinic trials will be needed to confirm the advantage of one device over another.

Pain management in patients with adolescent idiopathic scoliosis undergoing posterior spinal fusion: combined intrathecal morphine and continuous epidural versus PCA.

STUDY DESIGN: A retrospective case-comparison study. OBJECTIVE: Compare efficacy and safety of combined intrathecal morphine (ITM) and epidural analgesia (EPI) to that of conventional intravenous patient-controlled analgesia (IV-PCA) after posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: Pain control after PSF in AIS has been managed traditionally with IV-PCA. More recently studies have shown improvement in pain control with the use of continuous EPI or intraoperative ITM. No studies to our knowledge have compared the use of both ITM and EPI analgesia to that of IV-PCA. METHODS: An Institutional Review Board-approved retrospective case-comparison study was performed from 1989 to 2009 of all patients undergoing PSF for AIS. Patients received either IV-PCA or ITM/EPI. Daily pain scores were recorded along with total opioid and benzodiazepine use. Adverse events were recorded for all the patients. RESULTS: A total of 146 patients were initially included in the study; 95 patients received ITM/EPI and 51 received IV-PCA as a historical control. Eight patients from the ITM/EPI group were excluded from the pain comparison portion of the study. There were no statistical differences in age, sex, weight, or hospital stay between the 2 groups. The ITM/EPI group had, on average, 1 additional level of fusion (P = 0.001). Daily average pain scores were lower in the ITM/EPI group on all hospital days, and statistically lower in days 1 and 3 to 5. Total opioid requirement was significantly lower in the ITM/EPI patients, although oral opioid use was higher among this group. Total benzodiazepine use was lower among the IV-PCA group. A total of 15.7% of the IV-PCA patients had bladder hypotonia, compared with 1.1% of the ITM/EPI group (P = 0.002). The rate of illeus was 15.7% in the IV-PCA patients and 5.7% in the ITM/EPI (P = 0.071). Respiratory depression was reported in 4 ITM/EPI patients, 0 in our PCA group. Technical catheter malfunction was reported in 8.5% of the EPI group. CONCLUSIONS: The use of ITM/EPI after PSF for AIS is safe and effective, this methodology provided significantly lower pain scores and lowers total opioid use which can lead to urinary and bowel dysfunction.