Complications of Hardware Removal in Pediatric Orthopaedic Surgery.

BACKGROUND: Hardware removal (HR) is one of the most common surgical procedures in pediatric orthopaedics. Surgeons advocate for HR for a variety of reasons, including to limit peri-implant fracture risk, restore native anatomy for adult reconstruction surgery, permit bone growth and development, and mitigate implant-related pain/irritation. To our knowledge, no recent study has investigated the characteristics and complications of HR in pediatric orthopaedics. The goal of this study is to report the prevalence and complications of hardware removals across all of pediatric orthopaedic surgery. METHODS: A retrospective case series was conducted of all hardware removals from 2012 to 2023 performed at a single urban tertiary-care children's hospital. Cases were identified using CPT codes/billing records. Spinal hardware and cases for which hardware was either implanted or explanted at an outside hospital were excluded. Patient demographic and clinical data were recorded. For patients with multiple hardware removals, each case was recorded independently. RESULTS: A total of 2585 HR cases for 2176 children met study criteria (57.7% male; mean age 12.3±4.4 y). The median postoperative follow-up time was 1.7 months (interquartile range: 0.6 to 6.9). The most common sites of hardware removal were the femur/knee (32.7%), tibia/fibula/ankle (19.3%), and pelvis/hip (18.5%). The most common complications included sustained, new-onset postoperative pain (2.6%), incomplete hardware removal (1.6%), and perioperative fracture (1.4%). The overall complication rate of hardware removal was 9.5%. Eighty-eight percent of patients who underwent hardware removal for pain experienced pain relief postoperatively. HR >18 months after insertion had a 1.2x higher odds of overall complication (P=0.002) and 3x higher odds of incomplete removal/breakage (P<0.001) than hardware removed 9 to 18 months after insertion. CONCLUSIONS: The overall complication rate of hardware removal across a large series in the pediatric population was 9.5%. Despite hardware removal being one of the most common and often routine procedures in pediatric orthopaedics, the complication rate is not benign. Surgeons should inform patients and families about the likelihood of success and the risks of incomplete removal during the informed consent process. LEVEL OF EVIDENCE: IV.

Rib-on-Pelvis Deformity and Reported Pain in Neuromuscular Early-Onset Scoliosis.

BACKGROUND: Neuromuscular early-onset scoliosis (N-EOS) often presents with a long sweeping thoracolumbar scoliosis and pelvic obliquity. With severe pelvic obliquity, the ribs come into contact with the high side of the pelvis, termed rib-on-pelvis deformity (ROP). The goal of this study is to evaluate whether ROP is associated with reported pain and other health-related quality of life (HRQOL) measures. We hypothesize that ROP is associated with increased pain and negative HRQOL. METHODS: A multicenter international registry was queried for all nonambulatory patients with N-EOS from 2012 to 2022. Both surgical and nonsurgical patients were included. ROP was classified as a binary radiographic assessment of preoperative (surgical patients) and most recent follow-up (nonsurgical patients) upright radiographs. Reported pain and other HRQOL measures were assessed through the 24-Item Early Onset Scoliosis Questionnaire (EOSQ-24). Patients with nonupright radiographs or EOSQ-24 questionnaires and corresponding radiographs >4 months apart were excluded. RESULTS: Totally, 225 patients (8.4±3.1 y, 55% female) were included. The median major curve was 63.3 (IQR: 40.6 to 81.2) degrees and median pelvic obliquity was 15.5 degrees (IQR: 8.8 to 26.4). Eighty-three patients (37%) had ROP. ROP was associated with both frequency (P<0.001) and severity (P<0.001) of pain. ROP was associated with worse general health (P=0.01), increased difficulty with vocalization (P=0.02), increased frequency of shortness of breath (P=0.002), and increased difficulty sitting upright (P=0.04). Regarding overall EOSQ-24 domains, ROP was associated with worse general health, pain/discomfort, pulmonary function, and physical function (P<0.01). In a subanalysis of 76 patients who underwent surgical intervention with at least 2 years of follow-up, patients with preoperative ROP experienced significantly greater improvements in both frequency (P=0.004) and severity (P=0.001) of pain than the patients without preoperative ROP at 2 years postoperatively. CONCLUSIONS: The overall incidence of ROP in N-EOS is about 37%. ROP is associated with greater pain and worse HRQOL through the EOSQ-24 questionnaire. Furthermore, these patients experienced a greater reduction in pain after surgery. Clinicians and parents must be aware that ROP is possibly a pain generator, but responds positively to surgical intervention. LEVEL OF EVIDENCE: Level III.

Preoperative MRI Reliably Predicts Pedicle Dimensions on Intraoperative CT Images in Structural Main Thoracic Curves in Patients With Adolescent Idiopathic Scoliosis.

STUDY DESIGN: A retrospective comparative study. OBJECTIVE: The aim of this study was to compare the length and diameter of thoracic pedicles in patients with adolescent idiopathic scoliosis (AIS) as measured on preoperative magnetic resonance imaging (pMRI) to intraoperative computed tomography (iCT) scan. SUMMARY OF BACKGROUND DATA: Optimally sized pedicle screw placement during instrumented posterior spinal fusion for AIS can maximize correction and minimize screw pullout. While iCT-guided navigation can quickly estimate screw position and size, this technology is not universally available. Many surgeons utilize pMRI, when obtained, to estimate screw sizes. Data comparing these measurements on pMRI and iCT is limited. We hypothesized that in patients with surgical magnitude AIS, pedicle length, and diameter measured on pMRI would have at least moderate reliability compared to those made on iCT images. MATERIALS AND METHODS: The pMRI and iCT for 60 patients with structural thoracic curves who underwent posterior spinal fusion for AIS at a single center between 2009 and 2017 were analyzed. Bilateral T5-T12 vertebral levels were evaluated for pedicle chord length and pedicle isthmic diameter on both pMRI and iCT. Between-study reliability and interrater reliability was evaluated for each level of the thoracic spine. RESULTS: There is good reliability for pedicle length [intraclass correlation coefficient (ICC)=0.8, 95% confidence interval (CI): 0.78-0.83] and diameter (ICC=0.86, 95% CI: 0.84-0.88) between pMRI and iCT. When assessed by level, T6 has the lowest reliability for length (ICC=0.52, 95% CI: 0.33-0.67) and diameter (ICC=0.55, 95% CI: 0.35-0.69). Interrater reliability ranged from moderate-to-good reliability for all pedicle measurements for both length and diameter on pMRI and iCT. CONCLUSION: Pedicle measurements made on pMRI may be used with reasonable reliability to predict pedicle dimensions visualized on iCT, allowing surgeons to preoperatively plan pedicle screw sizes based off magnetic resonance imaging.

Surviving in the Electronic Era: My Top EMR Hacks.

With many pediatric orthopaedic surgeons spending 3 or even more days a week in clinic, a thorough understanding of the ever-changing electronic medical record is paramount to providing excellent clinical care, overall job satisfaction, and minimizing clinician burnout. Here we provide 5 tips to optimize clinic workflow for the busy pediatric orthopaedic surgeon in the electronic medical record era.

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.

Standardizing a Postoperative Protocol for Supracondylar Humerus Fractures.

BACKGROUND: Supracondylar humerus fractures are the most commonly operated upper extremity fracture in pediatric orthopaedics, yet there does not currently exist a standardized recommendation for a postoperative protocol. As advanced practice providers take on larger roles in the care of fracture patients, it may alleviate confusion to standardize postoperative protocols. The aim of this study was to compare outcomes between three different postoperative management protocols following operative fixation of supracondylar humerus fractures. METHODS: This is a retrospective study of all patients who underwent operative fixation of a supracondylar humerus fracture during the 2014 to 2015 academic year. Postoperative protocols were classified as either "liberal," "intermediate," or "conservative," based on how quickly the surgeon allowed unrestricted motion of the elbow postoperatively. Patients were evaluated for range of motion, functional elbow motion, and elbow clinical function, as well for postoperative complications. Univariate analysis was conducted to detect the differences in outcomes between protocol groups with P<0.01 considered significant. RESULTS: One hundred patients were included in the final analysis, with 17 patients in the liberal group, 50 in the intermediate group, and 33 in the conservative group. There were no differences in patient population (age, sex, fracture type, concomitant nerve palsy, ipsilateral injuries, or physical therapy referrals) between the groups (P>0.01). There were no differences in range of motion, functional motion, or elbow clinical function (P>0.01) between the postoperative protocol groups. There were no postoperative complications (unplanned return to operating room, refracture, need for fixation revision, or infection) in any patient. CONCLUSIONS: There were no differences in postoperative complications or outcomes between the patients in the liberal, intermediate, or conservative protocol groups. In an efficiency-focused era, we conclude that a standardized liberal protocol be considered at a busy orthopaedic center. LEVEL OF EVIDENCE: This study is a level III therapeutic study. It is a retrospective study that compares the outcomes after following 1 of 3 different postoperative protocols.

Risk of Scoliosis Progression in Nonoperatively Treated Adolescent Idiopathic Scoliosis Based on Skeletal Maturity.

BACKGROUND: Hand radiographs for skeletal maturity staging are now frequently used to evaluate remaining growth potential for patients with adolescent idiopathic scoliosis (AIS). Our objective was to create a model predicting a patient's risk of curve progression based on modern treatment standards. METHODS: We retrospectively reviewed all AIS patients presenting with a major curve <50 degrees, available hand radiographs, and complete follow up through skeletal maturity at our institution over a 3-year period. Patients with growth remaining underwent rigid bracing of curves >25 degrees, whereas patients between 10 and 25 degrees were observed. Treatment success was defined as reaching skeletal maturity with a major curve <50 degrees. Four risk categories were identified based on likelihood of curve progression. RESULTS: Of 609 AIS patients (75.4% female) presenting with curves over 10 degrees and reaching skeletal maturity at most recent follow up, 503 (82.6%) had major thoracic curves. 16.3% (82/503) of thoracic curves progressed into surgical treatment range. The highest risk group (Sanders 1 to 6 and curve 40 to 49 degrees, Sanders 1 to 2 and curve 30 to 39) demonstrate a 30% success rate with nonoperative treatment. This constitutes an 111.1 times (95% confidence interval: 47.6 to 250.0, P<0.001) higher risk of progression to surgical range than patients in the lowest risk categories (Sanders 1 to 8 and curve 10 to 19 degrees, Sanders 3 to 8 and curve 20 to 29 degrees, Sanders 5 to 8 and curve 30 to 39 degrees). CONCLUSIONS: Skeletal maturity and curve magnitude have strong predictive value for future curve progression. The results presented here represent a valuable resource for orthopaedic providers regarding a patient's risk of progression and ultimate surgical risk. LEVEL OF EVIDENCE: Level III-retrospective cohort study.

Rib-based Distraction Device Implantation Before Age 3 Associated With Higher Unplanned Rate of Return to the Operating Room.

BACKGROUND: Surgical treatment of early-onset scoliosis (EOS) with rib-based implants such as the vertical expandable prosthetic titanium rib (VEPTR) is associated with a high rate of complications including surgical site infection, skin breakdown, and implant migration. Many of these complications warrant the need for unplanned reoperations, increasing the burden on an already vulnerable patient population, and introducing the further risk of infection. To provide insight into the risks of early intervention, we investigate the relationship between initial device implantation before the age of 3 and the rate of unplanned reoperation. METHODS: A retrospective review was performed of all patients at a single institution who had undergone VEPTR insertion for EOS with at least a 2-year follow-up from 2007 to 2016. Patients were stratified into the case-cohort (0 to 2 y of age) or the comparison cohort (3 to 10 y of age) based on age at the time of device implantation. Multivariate regression accounting for age and scoliosis etiology was performed to identify factors predictive of unplanned reoperation. RESULTS: A total of 137 of 185 patients treated with VEPTR were identified with 76 (56%) undergoing at least 1 unplanned reoperation during the study time period. There were 68 and 69 patients in the age 0- to 2-year and 3- to 10-year cohorts, respectively. Patients aged 0 to 2 years underwent a higher number of total procedures compared with those aged 3 to 10 (13.1±6.5 vs. 10.6±4.8, P=0.032). A significant difference was found in the rate of unplanned reoperation between the 2 cohorts with 44 (65%) patients aged 0 to 2 and 32 (46%) patients aged 3 to 10 undergoing at least 1 unplanned reoperation (P=0.031). Binary logistic multivariate regression accounting for age and scoliosis etiology demonstrated that patients aged 0 to 2 had a significantly greater odds of undergoing an unplanned reoperation (odds ratio=3.050; 95% confidence interval: 1.285-7.241; P=0.011) compared with patients aged 3 to 10 years. CONCLUSION: Overall, EOS patients aged 0 to 2 at initial VEPTR implantation are up to 3 times higher risk of undergoing an unplanned reoperation compared with those aged 3 to 10. LEVEL OF EVIDENCE: Level III.

Thoracic Quantitative Dynamic MRI to Understand Developmental Changes in Normal Ventilatory Dynamics.

BACKGROUND: A database of normative quantitative measures of regional thoracic ventilatory dynamics, which is essential to understanding better thoracic growth and function in children, does not exist. RESEARCH QUESTION: How to quantify changes in the components of ventilatory pump dynamics during childhood via thoracic quantitative dynamic MRI (QdMRI)? STUDY DESIGN AND METHODS: Volumetric parameters were derived via 51 dynamic MRI scans for left and right lungs, hemidiaphragms, and hemichest walls during tidal breathing. Volume-based symmetry and functional coefficients were defined to compare left and right sides and to compare contributions of the hemidiaphragms and hemichest walls with tidal volumes (TVs). Statistical analyses were performed to compare volume components among four age-based groups. RESULTS: Right thoracic components were significantly larger than left thoracic components, with average ratios of 1.56 (95% CI, 1.41-1.70) for lung TV, 1.81 (95% CI, 1.60-2.03) for hemidiaphragm excursion TV, and 1.34 (95% CI, 1.21-1.47) for hemichest wall excursion TV. Right and left lung volumes at end-expiration showed, respectively, a 44% and 48% increase from group 2 (8 ≤ age < 10) to group 3 (10 ≤ age < 12). These numbers from group 3 to group 4 (12 ≤ age ≤ 14) were 24% and 28%, respectively. Right and left hemichest wall TVs exhibited, respectively, 48% and 45% increases from group 3 to group 4. INTERPRETATION: Normal right and left ventilatory volume components have considerable asymmetry in morphologic features and dynamics and change with age. Chest wall and diaphragm contributions vary in a likewise manner. Thoracic QdMRI can provide quantitative data to characterize the regional function and growth of the thorax as it relates to ventilation.

Lengthening Less Than 7 Months Leads to Greater Spinal Height Gain With Rib-based Distraction.

BACKGROUND: Severe early-onset scoliosis (EOS) has been associated with a multitude of comorbidities, chief among them being deficient thoracic spine growth and pulmonary complications. EOS management with rib-based instrumentation involves repeated lengthening. Despite expansion practice patterns, there is limited literature and no evidence-based guidelines for optimal expansion intervals. Our study evaluates clinical outcomes in relation to lengthening intervals with the aim of optimizing the timing of surgical expansion in EOS patients. METHODS: A single-institution retrospective review of 60 EOS patients treated with rib-based growth instrumentation with a minimum of 3-year follow-up and 3 expansion/revision surgeries. Patients were separated into 2 expansion cohorts: (1) more frequent lengthening [MFL group (≤7 mo)] and (2) less frequent lengthening [LFL group (>7 mo)]. Demographic information and clinical factors were recorded. Univariate and bivariate analyses were performed. RESULTS: Both the MFL group (35 patients) and LFL group (25 patients) were similar in sex distribution, diagnosis, preoperative parameters of interest, and treatment duration. The mean follow-up was 6.0 years. There was an increase in postoperative T1-S1 spine height gained in the MFL group (P=0.006) as well as a higher percent expected spine growth based on normative values (P=0.03) when compared with the LFL group. The MFL group had more expansion/revision surgeries (P=0.003) but no increase in the number of complications (P=0.86). CONCLUSIONS: More frequent lengthenings were associated with statistically significant overall spinal height gain and percent expected growth without a significant increase in complication rates. It was shown that change in major curve and space available for the lungs was not associated with the lengthening intervals. LEVEL OF EVIDENCE: Level III-a comparative retrospective study.

The Impact of Posterior Spinal Fusion (PSF) on Coronal Balance in Adolescent Idiopathic Scoliosis (AIS): A New Classification and Trends in the Postoperative Period.

INTRODUCTION: One of the primary goals of scoliosis surgery is to balance the head over the pelvis (or avoid creating imbalance). Historically, a normal coronal balance was defined as the C7 plumb line (C7PL) within 2 cm of the central sacral vertical line (CSVL); however, there is limited published information regarding the speed/magnitude and success/failure of balancing, rebalancing, or unbalancing in the postoperative period. The purpose of this study is to classify and quantify coronal plane balance postoperatively in adolescent idiopathic scoliosis when using pedicle screw instrumentation. METHODS: Evaluated patients with adolescent idiopathic scoliosis who had a posterior spinal fusion withstanding 2-view, posteroanterior and lateral radiographs of the entire spine performed at first erect visit, 6, 12, and 24 months. To measure coronal balance, a C7PL was measured and compared with the CSVL. A negative value denotes the leftward deviation of the C7PL and a positive value a rightward deviation. The authors then created a novel coronal balance classification system. RESULTS: A total of 954 patients met the inclusion criteria. There was a strong trend toward improving coronal balance, especially between first erect and 6 months; the proportion of out of balance patients declined throughout the 2-year period: preoperative 372 of 954 (39%), first erect 297 of 954 (31.1%), 6 months 167 of 954 (17.5%), 1 year 136 of 954 (14.3%), and 2 years 115 of 954 (12.0%). Analyzing the patients most out of balance immediately after posterior spinal fusion, 35 of 50 (70%) in group 3 regained balance by 2 years. Out of the remaining 15 patients, 12 corrected to group 1 (24%), 2 patients to group 2 (4%), and 1 patient remained in group 3 (2%). CONCLUSIONS: This large, longitudinal postoperative study of coronal balance documents a strong trend toward postoperative rebalancing, with the largest gains between first erect image and 6 months. The 31% of patients out of balance at first erect declined to only 12.1% at 2 years.

Prophylactic Decompression for Cervical Stenosis in Jeune Syndrome: Report From a Single Institution.

STUDY DESIGN: This is a level IV retrospective descriptive study at a single institution. OBJECTIVE: The objective of the study was to determine the preoperative signs or symptoms prompting cervicomedullary imaging in Jeune syndrome. SUMMARY OF BACKGROUND DATA: Jeune syndrome is a rare autosomal recessive disorder that results in pulmonary compromise from abnormal development of the thorax. Multiple medical comorbidities complicate timely diagnosis of cervicomedullary stenosis, which neurologically jeopardizes this patient population with regards to improper cervical manipulation. Currently, explicit screening of the cervicomedullary junction is not advocated in national guidelines. METHODS: The User Reporting Workbench and Center for Thoracic Insufficiency Syndrome (CTIS) Safety Registry was queried for patients with Jeune syndrome under the age of 18 with cervicomedullary stenosis with or without suboccipital craniectomy/craniotomy evaluated at the authors' institution from January 1, 2007 to August 21, 2018. The primary outcome was the clinical reason for cervicomedullary screening. Secondary outcomes were: age at time of surgery, preoperative myelopathy (spasticity, urinary retention), hydrocephalus, postoperative deficits (respiratory, motor, swallowing difficulty), and need for cervical fusion. RESULTS: Of 32 patients with Jeune syndrome, four (12.5%) had cervicomedullary stenosis requiring decompression. The average age at surgery was 5.25 months (2-9 mo). Two patients underwent imaging due to desaturation events while the other two patients were diagnosed with cervical stenosis as an incidental finding. No patients exhibited clinical myelopathy. Two patients had baseline preoperative swallowing difficulties. None of the patients postoperatively required cervical fusions, nor did they exhibit respiratory deficits, motor deficits, or worsening swallowing difficulties. CONCLUSION: Jeune patients should be routinely screened for cervicomedullary stenosis and undergo subsequent prophylactic decompression to minimize or eliminate the development of irreversible neurologic compromise. LEVEL OF EVIDENCE: 4.

Can We Save the Implant: Rib-based Implant Removal Rates and Risk Factors Following Irrigation and Debridement (I&D) Surgery?

BACKGROUND: In the event of a surgical site infection, management includes surgical debridement in an attempt to treat the infection and retain the implant; however they are often unsuccessful in this regard. Although studies have described the incidence of complications, current literature does not have sufficient evidence to provide clear recommendations regarding retention versus removal of implants. This study aims to identify predictive factors associated with the need for implant removal to decrease unnecessary attempts at implant retention. METHODS: A retrospective review of early-onset scoliosis patients at a single institution treated with rib-based vertical expandable prosthetic titanium rib implants who developed infection requiring irrigation and debridement (I&D) due to wound problems including surgical site infection, skin slough, and wound dehiscence. All patients had a minimum of a 2-year follow-up. Univariate and multivariate logistic regression analyses were conducted to determine the odds of implant removal. RESULTS: Fifty-nine of 181 patients (32%) required an I&D due to a wound problem. These patients underwent the initial implant procedure at a mean age of 4.6±3.8 years. In total, 29 patients ultimately underwent implant removal. Significant predictive factors for removal included total number of wound problems, total number of I&Ds, days from identification of wound problem to I&D procedure, days on antibiotics, total number of surgeries, presence of gastrostomy tube, and nonambulatory status (P<0.0001, 0.001, 0.095, 0.093, 0.082, 0.054, and 0.026, respectively). Multiple logistic regression results indicated a total number of wound problems [odds ratio (OR): 6.00, P=0.001], average days from identification of wound problem to I&D (OR: 1.03, P=0.039), and presence of a gastrostomy tube (OR: 5.7, P=0.07) as independent predictors for implant removal. CONCLUSIONS: Data suggests that time from the onset of signs of infection until debridement surgery inversely correlates with the ability to retain the implants. In addition, gastrostomy tube and history of previous wound infections may be predictive clinical factors for implant removal in patients with a rib-based vertical expandable prosthetic titanium rib instrumentation. Such information can be useful for clinicians in deciding on whom to attempt implant retention versus removal when a wound problem presents itself. LEVEL OF EVIDENCE: Level III.

Expert Consensus for Early Onset Scoliosis Surgery.

BACKGROUND: Despite a validated classification system, high-quality multicenter research databases (CSSG/GSSG), and a recent proliferation in publications, early-onset scoliosis (EOS) surgeons have no consensus on standards for surgical treatment. The 21st-century revolution in EOS care has only accelerated, with the arrival of a classification system, magnetically controlled growing rod, nusinersen, and improved nonoperative care (Mehta or Risser casting and compliance-monitored braces). This dizzying pace of change may have outstripped our ability to develop best-practice standards for EOS surgical indications. To learn where consensus is best (and worst) at this moment, we surveyed EOS world thought-leaders on a collection of representative cases. METHODS: A 6-case survey was constructed and sent to 20 EOS world thought-leaders. The cases were selected to be representative of the major treatment categories: idiopathic, neuromuscular, syndromic, congenital, thoracic dysplasia, and spinal muscular atrophy (specifically to assess the impact of nusinersen and parasol deformity on surgical planning). Respondents were queried regarding treatment with specific attention to instrumentation and construct when surgery was selected. Responses regarding surgical timing and technique were analyzed for consensus (defined as >80%). χ analysis was performed to evaluate for differences in treatment preferences based on years of experience. RESULTS: The survey response was 100%. Clinical experience ranged from 8 to 40 years (average 23.9 y). There was no consensus on any case. The greatest variability was on the congenital case; the closest to consensus was on the spinal muscular atrophy case. Three or more approaches were selected for all 6 cases; >4 approaches were selected for 5 cases. There is a trend towards screw fixation for proximal anchors. The management of thoracic dysplasia and parasol deformity is far from consensus. CONCLUSION: The lack of consensus for surgical treatment of 6 representative EOS cases demands a renewed effort and commitment to develop best-practice guidelines based on multicenter outcome data. LEVEL OF EVIDENCE: Level V-Expert Opinion.

Site-specific Surgical Site Infection Rates for Rib-based Distraction.

BACKGROUND: Implantable rib-based distraction devices have revolutionized the treatment of children with early onset scoliosis and thoracic insufficiency syndrome. Unfortunately, the need for multiple skin incisions and repeated surgeries in a fragile patient population creates considerable infection risk. In order to assess rates of infection for different incision locations and potential risk factors, we generated a prospectively collected database of patients treated with rib-based distraction devices. METHODS: We analyzed a cohort of patients with thoracic insufficiency syndrome from various etiologies that our institution treated with rib-based distraction devices from 2013 to 2016. Surgery type (implantation, expansion, revision/removal), and surgeon adjudicated surgical site infection (SSI) were collected. For this study, we developed a novel, rib-based distraction device surgical site labeling system in which incisions could be labeled as either proximal or distal surgical exposure areas. Treating surgeons documented the operative site, procedure, and SSI site in real-time. RESULTS: A total of 166 unique patients underwent 670 procedures during the study period, producing 1537 evaluable surgical sites; 1299 proximal and 238 distal. Patients were 6.81±4.0 years of age on average. Forty-seven procedures documented SSIs (7.0%), while 40 (24.1%) patients experienced an infection. Analysis showed significant variation in the rate of infection between implantation, and expansion, and revision procedures, with implantation procedures having the highest infection rate at 13.1% (P<0.01). Infections occurred more frequently at distal sites than proximal ones (P=0.02). CONCLUSIONS: Our novel, surgeon-entered, prospective quality improvement database has identified distal surgical sites as being at higher risk for SSI than proximal ones. Further, rib-based distraction device implantation procedures were identified as being at a greater risk for SSI than expansion or revision procedures. We believe this data can lead to improved prevention measures, anticipatory guidance, and patient care. LEVEL OF EVIDENCE: Level II-prognostic study.

Approaching Unusual Pediatric Distal Humerus Fracture Patterns.

Pediatric distal humerus fractures are common, and numerous variations can occur depending on patient's age, position of the extremity at the time of injury, and energy of impact. Classic injury patterns include the flexion/extension supracondylar humerus, medial epicondyle, lateral condyle, and the transphyseal distal humerus. We describe our treatment philosophy for pediatric elbow fractures and how these principles were applied to some unusual fractures that presented to our institution.

Pediatric T-Condylar Humerus Fractures: A Systematic Review.

BACKGROUND: The pediatric T-condylar humerus fracture is different from its adult counterpart, and its rarity makes general consensus for treatment algorithms difficult to define. Pediatric orthopaedic surgeons tend to think of this fracture as a supracondylar humerus fracture with intra-articular extension. The transition age at which this injury resembles the adult distal humerus fracture and less so the pediatric supracondylar humerus fracture with intra-articular extension is unclear. The goal of this study is to synthesize the literature and identify factors associated with good and poor outcomes of these problematic injuries in children and adolescents. METHODS: We searched EMBASE, COCHRANE, and Medline computerized literature databases from the earliest date available in the database to 2014 using the following search term including variants and pleural counterparts: pediatric T-condylar humerus fracture. A final database of individual patients was assembled from the literature. Outcomes were rated using the method described by Jarvis and colleagues. Where possible the Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association classification was used to stratify outcomes. Univariate and multivariate statistical tests were applied to the assembled database to assess differences in outcomes. RESULTS: Patients with a triceps-splitting approach had improved Jarvis outcome scores compared with the other operative approaches as well as the best arc of motion at follow-up. In addition, 6/25 triceps split patients were 10 years old or younger compared with 3/38 Bryan-Morrey patients and 0/23 osteotomy patients. No patients with Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association C3 fractures were treated with a triceps-splitting approach. When an articular approach was used, the Morrey Slide led to similar range of motion and functional outcomes as an olecranon osteotomy (P=0.616). However, the olecranon osteotomy resulted in more approach-related complications (P<0.001). An approach-related complication was associated with a poor outcome in 42% of cases. CONCLUSIONS: Pediatric T-condylar humerus fractures requiring an open approach may benefit from less invasive approaches such as the triceps split approach where the fracture pattern allows. Younger children are more amenable to less invasive means of fracture reduction and fixation. If an articular reduction is required, the aggregated literature suggests that the Morrey slide offers equivalent results to the olecranon osteotomy but with fewer approach-related complications. An olecranon osteotomy can be considered in cases of articular comminution. LEVEL OF EVIDENCE: Level IV-therapeutic.

30-day readmission after pediatric upper extremity surgery: Analysis of the NSQIP database.

PURPOSE: To determine the incidence and risk factors of complications, reoperations and 30-day unplanned readmission after pediatric upper extremity surgery. METHODS: Retrospective analysis of the 2013 National Surgery Quality Improvement Program pediatric database to identify procedures that met the CPT code of a primary upper extremity procedure. A univariate and multivariate analysis was performed to identify patient- and surgery-related risk factors for complications, reoperations and 30-day unplanned readmissions. RESULTS: Upper extremity pediatric surgeries have low complication (1.70%), reoperation (0.5%) and readmission rates (0.78%). Procedures requiring reoperation, inpatient procedures, and those complicated by surgical site infection were more likely to be readmitted. Patients with complex medical histories such as cardiac disease, gastrointestinal disease, pulmonary disease, or a central nervous system disorder were more likely to be readmitted. CONCLUSIONS: Pediatric upper extremity surgery is safe and associated with low complication and readmission rates. Algorithms focusing on decreasing surgical site infection and optimizing complex pediatric medical problems may limit or further decrease complication and readmission rates. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic III.

The Utility of Digital Tomosynthesis to the Practicing Orthopaedic Trauma Surgeon: A Case Series.

OBJECTIVE: To document the role of digital tomosynthesis (DTS) in the evaluation and treatment of orthopaedic trauma patients. DESIGN: Retrospective case series. SETTING: Level 1 trauma center with nonunion referral patient population. PARTICIPANTS: Four orthopaedic trauma patients with musculoskeletal injuries. INTERVENTION: Three revision surgical procedures and 1 conservative treatment for patients with periprosthetic fractures or nonunions. RESULTS: DTS successfully visualized 2 nonunions, 1 refracture, and 1 arthrodesis. MAIN OUTCOME MEASURE: Documented fracture or nonunion on imaging. CONCLUSIONS: DTS has the potential to be of significant value in the detection and follow-up of fractures. LEVEL OF EVIDENCE: Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Medial Epicondyle Fractures in Children and Adolescents: Shifting Care from General Hospitals to Children's Hospitals?

OBJECTIVES: To determine if there is a shift in the treatment of children with medial epicondyle fractures toward children's hospitals, and to explore potential confounders of any observed effect. STUDY DESIGN: The Healthcare Cost and Utilization Project Kids' Inpatient Database was used to examine the epidemiology of medial epicondyle fractures, particularly with attention to whether they were admitted to a general hospital or a children's hospital (defined as free-standing children's hospitals, specialty children's hospitals, and children's units within general hospitals). Age and insurance payer status were also collected and evaluated as potential confounders. RESULTS: The proportion of medial epicondyle hospital discharges from children's hospitals increased (from 29%-46%; P < .001), and the proportion of discharges from general hospitals declined over the study period (from 71%-42%; P < .001). Age and insurance payer status both remained consistent throughout the study period and did not contribute to this finding. CONCLUSIONS: This study demonstrates an increase in the proportion of discharges for pediatric medial epicondyle fractures from children's hospitals. Although this finding is likely multifactorial, it may represent increasing subspecialization and increasing medical liability when treating children. Children's hospitals should identify those conditions which will continue to increase in number and consider constructing clinical pathways in order to optimize delivery of care and resource utilization.