Thread Delamination in 4.5 mm AO Cannulated Screws: A Small Case Series in the Pediatric Trauma Population.

BACKGROUND: Thread delamination associated with cannulated screws have been reported but likely represent an under-recognized complication in the orthopaedic literature. The purpose of this study is to report the occurrence of repeated hardware failures through thread delamination in the setting of a commonly used orthopaedic cannulated screw implant in a small cohort involving pediatric fracture care at a single academic level I trauma center. METHODS: Between August 2015 and December 2020, 9 cases of hardware failure associated with 4.5 mm arbeitsgemeinschaft für osteosynthesefragen cannulated stainless-steel screws were identified within a pediatric orthopaedic division at a single academic level I trauma center. Three cases were excluded, and 6 cases of thread delamination were retrospectively reviewed. RESULTS: Six cases of thread delamination comprised a cohort of patients with a mean age of 13.7 years (range: 12 to 15 y). All cases involved 4.5 mm arbeitsgemeinschaft für osteosynthesefragen cannulated screws, including 5 partially threaded and 1 fully threaded screw. Five cases involved open reduction and internal fixation of incarcerated medial humeral epicondylar fragments and the other case was an open reduction and internal fixation of a displaced medial malleolar fracture. Five of these occurred within a recent 18-month period of time. There were 4 cases of partial, distal thread delamination, 1 case of partial proximal thread delamination and another case of complete thread delamination which had unwound into the tibiotalar joint and required an anterior ankle arthrotomy to retrieve the thread. None of the 5 patients in this series who currently harbor a retained thread have experienced symptoms because of this issue. CONCLUSIONS: Thread delamination associated with cannulated screw implantation likely represents an under-reported phenomenon in orthopaedic surgery. In cases where retained, delaminated threads exist, these do not appear to cause short-term concern. LEVEL OF EVIDENCE: Level IV-case series.

Use of L5-S1 transdiscal screws in the treatment of isthmic spondylolisthesis: a technical note.

Surgical treatment of L5-S1 isthmic spondylolisthesis consists of a combination of decompression and fusion. One previously discussed mode of fusion is via transdiscal screws. Biomechanical studies of transdiscal screws have demonstrated greater rigidity than traditional pedicle screw fixation, which theoretically translates to a higher fusion rate. Furthermore, when compared to pedicle screw fixation, transdiscal screw fixation also demonstrates improved functional and radiographic outcomes. However, transdiscal screw placement can be technically difficult. At this time, a detailed surgical technique has yet to be reported in the literature. Our surgical technique for transdiscal screw placement using intraoperative C-arm at L5-S1 is described. We include considerations for preoperative planning including necessary imaging and appropriate patient selection. We also discuss intraoperative concerns such as setup, surgical approach, proper screw trajectory, and our method for achieving indirect decompression. The results of thirteen consecutive patients treated with transdiscal screw fixation are described. One patient had subcutaneous seroma requiring reoperation (7.7%), three patients had implant failure (23.1%), and one patient had nonunion (7.7%). Our results suggest that transdiscal screw fixation is a safe and acceptable alternative for stabilization and indirect decompression of L5-S1 isthmic spondylolisthesis. Recent innovation in intraoperative navigation and robotic surgery may lessen the technical difficulty of transdiscal screw placement and make it even more effective.

Intermediate-term annualized curve progression of adolescent idiopathic scoliosis curves measuring 40° or greater.

STUDY DESIGN: Prospective cohort study. OBJECTIVES: The objective of this study was to examine intermediate-term progression for a large series of patients with adolescent idiopathic scoliosis (AIS) with curves 40° or greater. BACKGROUND: Curve progression in AIS has been well documented for smaller curves in adolescence up to skeletal maturity; however, the data on curve progression past 40° or into adulthood are limited. With many surgeons recommending surgical correction when patients reach this threshold, it is important to understand the radiographic progression of curves into adulthood. METHODS: A database of all patients seen by a single surgeon from 1984 through 2018 with AIS curves progressing to at least 40° entered prospectively was utilized for this study. This included a total of 738 patients. Curve progression was analyzed overall and stratified by length of follow-up, curve location, and Risser stage at the time of presentation among other variables. Curve magnitude and Risser stage designations in this study were validated by performing a separate inter- and intrarater agreement study using four independent reviewers reading 50 patients' Cobb angle and Risser stage blinded in triplicate to examine the reliability of the study measurements. RESULTS: Annualized curve progression (ACP) averaged 6.3 ± 10.4°. ACP varied with length of follow-up: patients with up to 1 year of follow-up had an average ACP of 11.5 ± 17.0°, while those with 1-2 years had 8.2 ± 8.8°, and 2-5 years had 3.7 ± 4.1°, tapering off further from there. Risser stage 0 or 1 was associated with the highest ACP as compared to Risser stage 2-3 or 4-5. Intraclass correlation (ICC) values for Cobb angle measurement and Risser stage designations from four raters measuring 50 patients' measures, blinded and in triplicate, were all > 0.80, signifying a high degree of reliability within and between readers. CONCLUSIONS: Annualized curve progression for 40° and greater curves was not linear over time; it was greatest immediately after a curve reaches 40° and tapered off over the next decade. Immature Risser stage at presentation was strongly associated with increasing ACP at all time frames. LEVEL OF EVIDENCE: Prognostic Level I.

SRS-22r Scores in Nonoperated Adolescent Idiopathic Scoliosis Patients With Curves Greater Than Forty Degrees.

STUDY DESIGN: Case control comparative series. OBJECTIVE: Describe surgical range adolescent idiopathic scoliosis (AIS) patients electing to forgo surgery and compare health-related quality-of-life outcomes to a similar cohort of operated AIS patients by the same single surgeon. SUMMARY OF BACKGROUND DATA: No data have been published either documenting SRS-22r scores of nonoperated patients with curves ≥40° or comparing these scores to a demographically similar operated cohort. METHODS: Individuals with curves ≥40°, age ≥18 years, and electing to forgo surgery were identified. All patients completed an SRS-22r questionnaire. This nonoperated cohort's SRS-22r scores were compared to those of a large demographically similar cohort operated by the same surgeon. Group differences between the SRS-22r scores were evaluated by comparing these to published Minimal Clinically Important Differences (MCID) for the SRS-22r. RESULTS: One hundred ninety subjects with nonoperated curves were compared to 166 individuals who underwent surgery. The nonoperated cohort averaged 23.5 years of age, averaged 7.7 years since curve reached 40°, and had an average 50° Cobb angle at last follow-up. No statistical significant differences were found between the groups on the Pain, Function, or Mental Health domains of the SRS-22r. Statistically significant differences in favor of the operative cohort were found for self-image, satisfaction, and total score. The observed group differences did not meet the established thresholds for minimal clinically important differences in any of the domain scores, the average total score, or raw scores. CONCLUSION: There are no meaningful clinically significant differences in SRS-22r scores at average 8-year follow-up between AIS patients with curves ≥40° treated with or without surgery. These data in conjunction with an absence of long-term evidence of serious medical consequences with nonsurgical management of curves ≥40° should encourage surgeons to reevaluate the benefits of routine surgical care. LEVEL OF EVIDENCE: 3.

Outcomes of Pediatric Fractures Managed With Closed Reduction by Orthopaedic Residents in the Emergency Department.

BACKGROUND: Closed reduction of pediatric fractures is commonly performed by orthopaedic residents using conscious sedation in the emergency department (ED). The purpose of this study was to determine the rate of satisfactory reductions as performed by residents, and to determine the outcomes of these procedures. METHODS: A retrospective review was performed of all fractures that underwent closed reduction under conscious sedation in the ED of a level 1 pediatric trauma center between January 1, 2010 and November 30, 2014. Initial and subsequent radiographs were reviewed and a determination was made as to whether the initial reduction was satisfactory, based on predetermined criteria for angulation and displacement. If a second reduction attempt in the operating room was necessary, this was noted. Chart notes were reviewed until a documented endpoint was reached, such as uneventful healing, malunion, nonunion, or growth arrest. RESULTS: A total of 838 subjects were identified. The upper extremity was involved in 85% of the fractures. Of the initial 838 fracture reductions performed, 39 (4.7%) were unsatisfactory. Residents on their first pediatric orthopaedic rotation had a higher unsatisfactory reduction rate compared with more experienced residents (7.0% vs. 3.4%, P=0.01). A second reduction was performed for 94 of 749 (12.6%) fractures. Of these, 35 (37.2%) required an open procedure to accomplish a satisfactory reduction. Fractures with initially satisfactory reductions were significantly less likely to require a second reduction attempt than those with initially unsatisfactory reductions (9.2% vs. 80.0%, P<0.01). The likelihood of a satisfactory reduction was significantly higher in the upper extremity than in the lower extremity. Overall, the vast majority (99.2%) of fractures had a satisfactory final outcome. CONCLUSIONS: Most attempts at closed reduction of pediatric fractures in the ED by orthopaedic residents are successful, and the likelihood of a satisfactory reduction was associated with increased levels of resident experience. Fractures with an initially successful reduction were far less likely to require remanipulation. LEVEL OF EVIDENCE: Level IV-this is a therapeutic case series.

Does a Weekly Didactic Conference Improve Resident Performance on the Pediatric Domain of the Orthopaedic In-Training Examination?

BACKGROUND: Performance on the Orthopaedic In-training Examination (OITE) has been correlated with performance on the written portion of the American Board of Orthopaedic Surgery examination. Herein we sought to discover whether adding a regular pediatric didactic lecture improved residents' performance on the OITE's pediatric domain. METHODS: In 2012, a didactic lecture series was started in the University of Pittsburgh Medical Center (UPMC) Hamot Orthopaedic Residency Program (Hamot). This includes all topics in pediatric orthopaedic surgery and has teaching faculty present, and occurs weekly with all residents attending. A neighboring program [UMPC Pittsburgh (Pitt)] shares in these conferences, but only during their pediatric rotation. We sought to determine the effectiveness of the conference by comparing the historic scores from each program on the pediatric domain of the OITE examination to scores after the institution of the conference, and by comparing the 2 programs' scores. RESULTS: Both programs demonstrated improvement in OITE scores. In 2008, the mean examination score was 19.6±4.3 (11.0 to 30.0), and the mean percentile was 57.7±12.6 (32.0 to 88.0); in 2014, the mean examination score was 23.5±4.2 (14.0 to 33.0) and the mean percentile was 67.1±12.1 (40.0 to 94.0). OITE scores and percentiles improved with post graduate year (P<0.0001). Compared with the preconference years, Hamot residents answered 3.99 more questions correctly (P<0.0001) and Pitt residents answered 2.93 more questions correctly (P<0.0001). Before the conference, site was not a predictor of OITE score (P=0.06) or percentile (P=0.08); there was no significant difference found between the mean scores per program. However, in the postconference years, site did predict OITE scores. Controlling for year in training, Hamot residents scored higher on the OITE (2.3 points higher, P=0.003) and had higher percentiles (0.07 higher, P=0.004) than Pitt residents during the postconference years. CONCLUSIONS: This study suggests that adding a didactic pediatric lecture improved residents' scores on the OITE and indirectly suggests that more frequent attendance is associated with better scores. LEVEL OF EVIDENCE: Level III-retrospective case-control study.

Exercise-induced Pediatric Lumbar Paravertebral Compartment Syndrome: A Case Report.

Acute compartment syndrome is described as an elevation of interstitial pressure in a closed fascial compartment that can lead to damage of the microvasculature with subsequent tissue necrosis. Although paravertebral compartment syndrome has been described there is no case of paravertebral compartment syndrome that has been described in the pediatric population. We report the case of a 17-year-old boy who presented at our institution with severe, acute-onset low back pain that started shortly after a rigorous 4-hour workout. He was diagnosed with acute lumbar paravertebral compartment syndrome and underwent emergent fasciotomy with 2 more debridements.

Hematoma block versus sedation for the reduction of distal radius fractures in children.

PURPOSE: To determine which mode of anesthesia, hematoma block (HB) or procedural sedation (PS), was preferable for distal radius fracture (DRF) reduction in children. METHODS: Fifty-two children (mean age, 12 y; range, 5-16 y) presenting with DRFs requiring reduction were prospectively enrolled and offered either PS or HB for anesthesia. Following reduction, families completed a satisfaction survey regarding mode of anesthesia and overall care (rated 0-10, with 10 being the best score) and an assessment of discomfort (rated 0-10, with 0 being no pain). Length of stay in the emergency department (ED) and complications related to procedure and method of anesthesia were recorded. Radiographic alignment was evaluated before and after reduction. RESULTS: Twenty-six patients underwent reduction with either PS or HB. Midazolam was used in addition to HB in 8 patients. One patient was converted from HB to PS due to inadequate block. There was no significant difference in prereduction and postreduction angulation between the groups, and reductions maintained satisfactory alignment. Overall satisfaction and satisfaction with anesthesia were excellent for both groups, with respective means of 9.5 and 9.5 for PS and 9.3 and 9.6 for HB. Patient discomfort was minimal in both groups, with a mean of 1.6 for PS and 2.2 for HB. Length of stay was significantly shorter for HB patients, with patients spending a mean of 2.2 hours less in the ED. Three patients required further intervention following initial reduction. One patient in each group required revision reduction, and 1 PS patient underwent closed reduction and pinning. CONCLUSIONS: Use of HB for the reduction of pediatric DRFs provided radiographic alignment, patient satisfaction, and pain control comparable with that of PS, while significantly decreasing ED time and resources.

Somatosensory-evoked potential monitoring during instrumented scoliosis corrective procedures: validity revisited.

BACKGROUND: Intraoperative monitoring (IOM) using somatosensory-evoked potentials (SSEPs) plays an important role in reducing iatrogenic neurologic deficits during corrective pediatric idiopathic procedures for scoliosis. However, for unknown reasons, recent reports have cited that the sensitivity of SSEPs to detect neurologic deficits has decreased, in some to be less than 50%. This current trend, which is coincident with the addition of transcranial motor-evoked potentials, is surprising given that SSEPs are robust, reproducible responses that were previously shown to have sensitivity and specificity of >90%. PURPOSE: Our primary aim was to assess whether SSEPs alone can detect impending neurologic deficits with similar sensitivity and specificity as originally reported. Our secondary aim was to estimate the potential predictive value of adding transcranial motor-evoked potentials to SSEP monitoring in idiopathic scoliosis procedures. DESIGN: This was a retrospective review to analyze the efficacy of SSEP monitoring in the group of pediatric instrumented scoliosis fusion cases. PATIENT SAMPLE: We retrospectively reviewed all consecutive cases of patients who underwent idiopathic scoliosis surgery between 1999 and 2009 at Children's Hospital of Pittsburgh. We identified 477 patients who had the surgery with SSEP monitoring alone. Exclusion criteria included any patients with neuromuscular disorders or unreliable SSEP monitoring. Patients who had incomplete neurophysiology data or incomplete postoperative records were also excluded. OUTCOME MEASURES: Major outcomes measured were clinically significant postoperative sensory or motor deficits, as well as significant intraoperative SSEP changes. METHODS: Continuous interleaved upper- and lower-extremity SSEPs were obtained throughout the duration of all procedures. We considered a persistent 50% reduction in primary somatosensory cortical amplitude or a prolongation of response latency by >10% from baseline to be significant. Persistent changes represent significant deviation in SSEP amplitude or latency in more than two consecutive averaged trials. Patients were classified into one of four categories with respect to SSEP monitoring: true positive, false positive, true negative, and false negative. The sensitivity, specificity, positive predictive value, and negative predictive value were then calculated accordingly. RESULTS: Our review of 477 idiopathic scoliosis surgeries monitored using SSEPs alone revealed a new deficit rate of 0.63% with no cases of permanent injury. Sensitivity = 95.0%, specificity = 99.8%, positive predictive value = 95%, negative predictive value = 99.8%. Using evidence-based epidemiologic measures, we calculated that the number needed to treat was 1,587 patients for one intervention to be performed that would have been missed by SSEP monitoring alone. In addition, the number needed to harm, which represents the increase in false positives with the addition of transcranial electrical motor-evoked potentials, was 200. CONCLUSION: SSEP monitoring alone during idiopathic scoliosis continues to be a highly reliable method for the detection and prevention of iatrogenic injury. Our results confirm the high sensitivity and specificity of SSEP monitoring alone published in earlier literature. As such, we suggest the continued use of SSEP alone in idiopathic scoliosis surgeries. At this time we do not believe there are sufficient data to support the addition of MEP monitoring, although more studies and revised criteria for the use of MEP may provide added value for its use in the future.

Order of Inoculation during Heligmosomoides bakeri and Hymenolepis microstoma Coinfection Alters Parasite Life History and Host Responses.

Parasite life history may differ during coinfection compared to single infections, and the order of infection may be an important predictor of life history traits. We subjected laboratory mice (Mus musculus) to single and coinfections with Heligmosomoides bakeri and Hymenolepis microstoma and measured life history traits of worms and also hepatobiliary and morphological responses by the host. We found that fewer H. bakeri larvae established, and adult worms were shorter and produced fewer eggs during a coinfection where H. microstoma occurred first. H. microstoma grew more and released more eggs after simultaneous inoculation of both parasites compared to a single H. microstoma infection, despite similar worm numbers. Mouse small intestine mass, but not length, varied with coinfection and bile duct mass was largest when H. microstoma was given alone or first. Mouse serum alkaline phosphatase levels were greatest for mice infected with H. microstoma only but did not vary with number of scolices; no change in mouse serum alanine transaminase levels was observed. Overall, the order of coinfection influenced life history traits of both H. bakeri and H. microstoma, but changes in survival, growth, and reproduction with order of inoculation were not consistent between the two parasites.

Converting Scoliosis Research Society-24 to Scoliosis Research Society-22r in a Surgical-Range, Medical/Interventional Adolescent Idiopathic Scoliosis Patient Cohort.

STUDY DESIGN: Prospective questionnaire administration study. OBJECTIVES: To assess the ability to translate total and domain scores from Scoliosis Research Society (SRS)-24 to SRS-22r in a surgical-range, medical/interventional adolescent idiopathic scoliosis (AIS) patient population. SUMMARY OF BACKGROUND DATA: Conversion of SRS-24 to SRS-22r is demonstrated in an operative cohort of patients with AIS, but not in a medical/interventional patient population. METHODS: We simultaneously administered SRS-24 and SRS-22r questionnaires to 75 surgical-range, medical/interventional AIS patients and compared them. We performed analysis by regression modeling to produce conversion equations from SRS-24 to SRS-22r. RESULTS: The total SRS-24 score for these medical/interventional AIS patients was 92.5 ± 9.45 (mean, 3.9 ± 0.39), and the total SRS-22r score was 93.5 ± 9.63 (mean, 4.3 ± 0.44). The correlation between these 2 groups was fair (R2 = 0.77) and improved to good when mental health or recall questions were removed. The correlation was also fair for total pain domains (R2 = 0.73). However, there was poor correlation for general self-image (R2 = 0.6) and unacceptable for post-treatment self-image (R2 = 0.01), general function (R2 = 0.52), activity function (R2 = 0.56), and satisfaction (R2 = 0.53). Compared with a published population of operative AIS patients, R2 values for total SRS-24 scores, pain, general self-image, activity function, and satisfaction were similar (p > .05). The R2 values for general function and combined general and activity function were significantly different between the operative and medical/interventional cohorts. CONCLUSIONS: Scoliosis Research Society-24 can be converted to SRS-22r scores with fair accuracy in the surgical-range, medical/interventional AIS patient population for total score, and total pain domains. The SRS-24 translates unacceptably to the SRS-22r in self-image, function, and satisfaction domains. The SRS-24 to SRS-22r conversion equations are similar to operative AIS patients, except for the function domain. Caution should be used when interpreting results based on translation of SRS-24 to SRS-22r values.

The current medical practice of the pediatric orthopaedic surgeon in North America.

Musculoskeletal disorders in children are common and comprise 20% to 30% of the complaints observed by primary care physicians. Most primary care physicians prefer to refer patients with pediatric musculoskeletal conditions to the pediatric orthopaedic surgeon; most of whom are treated nonoperatively. Pediatric orthopaedic surgeons are well trained to provide efficient, cost-effective, and definitive quality care. This article supports the supposition that pediatric orthopaedic surgeons are the primary care physicians for children with musculoskeletal disorders. This article focuses on the primary clinical responsibilities of the pediatric orthopaedic surgeon, describes the value of this practice, and contrasts their responsibilities from that of other orthopaedic subspecialties.

Adolescent idiopathic scoliosis: 5-year to 20-year evidence-based surgical results.

Surgical intervention for adolescent idiopathic scoliosis (AIS) should be proven to alter the natural history without introducing iatrogenic complications. The risks of surgery should be substantiated by a body of scientific research, which should show a clear superiority of surgery over observation, both in the short term and the long term. The purpose of this review was to conduct a systematic search of the literature to critically evaluate the scientific evidence on the long-term outcomes and complications of surgical intervention for AIS. Our search identified 39 distinct patient populations with a minimum average follow-up of 5 years. No long-term, prospective controlled studies exist to support the hypothesis that surgical intervention for AIS is superior to natural history. Although surgery reliably arrests the progression of deformity, achieves permanent correction, and improves appearance, there is no medical necessity for surgery based on the current body of literature. However, the surgeon must not underestimate the psychological indication that occurs when a patient is no longer able to cope with the deformity.

Infection after the surgical treatment of adolescent idiopathic scoliosis: evaluation of the diagnosis, treatment, and impact on clinical outcomes.

STUDY DESIGN: Retrospective case-control. OBJECTIVE: The purpose of this study was to evaluate a single surgeon's experience with infection after surgical treatment of adolescent idiopathic scoliosis, with a focus on the diagnosis, treatment, and impact on radiographic and patient-reported outcomes. SUMMARY OF BACKGROUND DATA: Although previous studies have evaluated this postoperative complication, no studies to date have looked at the impact of this complication on both radiographic and patient-reported outcomes. METHODS: From 1986 to 2004, 236 patients were identified who underwent surgical treatment of adolescent idiopathic scoliosis and had at least 2-year follow-up. The medical records of patients who developed infection were retrospectively reviewed in detail. Preoperative and most recent postoperative radiographic parameters and Scoliosis Research Society 24 outcomes of both infected and noninfected patients were compared. RESULTS: Of 236 patients 7 (3%) developed an infection. One was acute (17 days postoperative), and 6 were delayed (average 34.2 months postoperative). The most common presenting complaints included back pain (5 of 7) and localized swelling (4 of 7). All patients with delayed infection were treated with 1 surgery (irrigation and debridement, instrumentation removal) and 6 weeks of intravenous antibiotics. Of 6 patients 3 had pseudarthrosis. Culture results were: Staphylococcus epidermidis (n = 2), Propionibacterium acnes (n = 1), Enterococcus faecalis (n = 1), Group A Streptococcus (n = 1), no growth (n = 1). The patient with acute infection required 6 surgical procedures and 16 weeks of antibiotics. Cultures were positive for methicillin resistant Staphylococcus aureus and Serratia marscesens. Revision fusion surgery was performed 5 months after the infection was treated. Compared with the noninfected patients, those with infection had lower percent thoracic (P = 0.01) and lumbar (P = 0.06) curve correction. There was no difference in the pain, function, self-image, satisfaction, or total Scoliosis Research Society 24 scores. CONCLUSION: Postoperative infection after the surgical treatment of idiopathic scoliosis can successfully be treated with irrigation and debridement, instrumentation removal, and a course of antibiotics. Although less curve correction was achieved in the infected group, there were no differences in patient-reported outcomes when compared with the noninfected group.

A comparison of the lenke and king classification systems in the surgical treatment of idiopathic thoracic scoliosis.

STUDY DESIGN: Retrospective case control study. OBJECTIVE: To evaluate the use of the Lenke and King classification systems in the surgical treatment of main thoracic adolescent idiopathic scoliosis (AIS), with a specific focus on radiographic and patient reported outcomes. SUMMARY OF BACKGROUND DATA: There is considerable debate as to whether King or Lenke classification best fulfills the criteria for a useful classification to determine distal fusion level, i.e., is mentally descriptive of the curve being treated, uses reproducible information to provide guidance in determining distal fusion level, is prognostic of patient reported and radiographic outcomes, and has good user reproducibility. METHODS: Patients operated for AIS between 1986 and 2002 with posterior spinal fusion and dual rod posterior instrumentation were retrospectively classified according to the Lenke and King classification systems. Only patients with Lenke type I curves and minimum 2-year follow-up were included. Preoperative and most recent postoperative radiographs were reviewed. The Lenke and King recommended distal fusion levels were calculated for each patient according to criteria obtained from the literature, and were compared to our actual fusion level. Patients were divided into groups based on our actual distal fusion level (i.e., longer, shorter, or in agreement with Lenke and King). The radiographic parameters and SRS 24 outcomes of patients within each group were compared. RESULTS: Seventy-five patients with Lenke type 1 AIS were included in the study. The distribution of King curve types were: 31 King II curves, 34 King III curves, 9 King IV curves, and 1 double major curve. Our actual distal fusion level was in agreement with the calculated Lenke recommendation in 49% and the King recommendation in 51% of the cases. Difficulties in using the Lenke classification system were identified in up to 59% of the study patients. There were no statistically significant objectives or patient reported (SRS) differences between the groups fused in agreement, longer, or shorter than the calculated Lenke or King recommendations. CONCLUSION: At intermediate follow-up, there does not seem to be significant radiographic or patient reported differences whether fusion levels are in agreement, longer, or shorter than those recommended by the Lenke or King classification systems.

Demographic and financial implications of pediatric emergency department fracture manipulation.

BACKGROUND: The demographic features, work relative value units (WRVUs), and financial implications of pediatric emergency department (ED) manipulative fracture treatment are presented. The aims of this study are to quantify these parameters and gauge their impact on lifestyle and reimbursement. METHODS: All ED fracture reductions performed by orthopaedic residents in a children's hospital for fiscal year 2004 were grouped by month, day, time, anatomical location, and payer mix. Work relative value units and reimbursement were assigned for each fracture, contrasting the use of global current procedural terminology manipulation facture codes to the actual use of global current procedural terminology nonmanipulation codes first generated when the child presented to the senior staff office. RESULTS: Three hundred seventy-five fractures were manipulated in the ED. Eighty-one manipulations were done on Saturday and 61 on Sunday compared with an average of 47 for the other 5 days. Nineteen percent of manipulations were performed between 7 AM and 6 PM, 37% between 6 and 11 PM, and 44% between 11 PM and 7 AM. Sixty-nine percent of the children had private insurance, 29% had Medicaid, and 2% had no medical coverage. Potentially 2358 WRVUs could have been recorded had senior staff been present for the reduction in the ED compared with the actual total of 1168 WRVUs recorded in the office a few days later. Using a proxy model of 100% Western Pennsylvania Medicare coverage for these fractures, $179,754 of reimbursement was available with manipulation included compared with $106,010 without manipulation. For our actual payer mix, manipulation would have contributed a 37% increase to fracture care margin for these 375 fractures but would have only provided a 2.5% increase to overall pediatric orthopaedic revenue production for fiscal year 2004. CONCLUSIONS: The component of reimbursement resulting from manipulation contributed significantly to fracture care margin for those fractures requiring manipulation but did not have a significant impact on overall pediatric orthopaedic revenue production. The added senior staff work effort required to gain the manipulation reimbursement component of fracture care in the ED is substantial considering the small contribution to overall revenue. CLINICAL RELEVANCE: Alternative mechanisms of compensation should be devised if the goal is to offer financial incentive to senior staff for their availability for all fracture manipulations in the ED.

The impact of trauma in an urban pediatric orthopaedic practice.

BACKGROUND: National data documenting the impact of pediatric trauma in general and of pediatric orthopaedic trauma in particular on the rates of hospital admissions and emergency-room visits have been reported. This study documents the frequency of and work involved in the care of pediatric orthopaedic trauma by a single urban pediatric orthopaedic group practice. METHODS: The computerized billing records of a single practice group of 3.4 full-time-equivalent, fellowship-trained pediatric orthopaedic surgeons practicing in a freestanding pediatric hospital with a level-I trauma center were analyzed for one year (from July 2004 through June 2005). Every office visit and operative procedure was specifically sorted to determine the component of trauma care in the group's pediatric orthopaedic practice. Descriptive statistics, including the actual numbers and percentages of office fracture visits and operations for fracture care as well as the actual numbers and percentages of work relative value units generated by the physicians, are presented. RESULTS: The practice generated 36,771 work relative value units, with 18,693 units (51%) from treatment provided in the operating room and 18,078 units (49%) from treatment provided in the office. A total of 1903 new fractures was seen and accounted for 5698 work relative value units (32% of all work relative value units for treatment provided in the office). The four fractures that were most frequently seen in the office were in the distal aspect of the radius (23%), forearm (14%), tibia (13%), and elbow (10%). Of the 18,693 work relative value units generated in the operating room, 5975 (32%) were from fracture care, representing the largest single category of work done in the operating room. Trauma-related operations were most commonly done for fractures of the elbow (25.3%), tibia (12%), femur (9.8%), forearm (5.5%), and the distal aspect of the radius (5%). Technically demanding fixation techniques, which are commonly used to treat fractures in adults, were frequently used, particularly for femoral and tibial fractures. CONCLUSIONS AND CLINICAL RELEVANCE: This study documents the frequency and work relative value of the care of musculoskeletal injuries in an urban pediatric orthopaedic practice in the outpatient and inpatient settings. It is a snapshot in time of current trends in pediatric orthopaedic practice, but these data may have implications for future resource allocation of the pediatric orthopaedic manpower in North America.