Surgical Treatment of Pediatric Scoliosis: Historical Origins and Review of Current Techniques.

The treatment of scoliosis has been explored and debated in medicine since the first recorded texts. Scoliosis treatment has shifted over time from external modalities, such as traction and bracing, to internal stabilization techniques that leverage surgical advances. Surgical fixation constructs can generally be separated into two different modalities: dynamic vs. static constructs. For skeletally immature individuals with progressive deformities, surgical options range from traditional or magnetically controlled growing rods to vertebral body staples or tethering. For individuals who have reached skeletal maturity, many devices have been developed that provide static length constructs. Understanding the surgical options available is critical for the appropriate management of this varied patient population. With this article, we sought to provide a summary of past and present techniques and devices used in the treatment of scoliosis.

Having Patience With Our Patients: A Key Technique in Cast Saw Burn Prevention.

INTRODUCTION: Although regarded as conservative treatment, casting is not without risk. Injuries may be sustained during application, during cast valving, through the immobilization process, or during cast removal. We developed an experimental model to investigate safe parameters for the appropriate length of time between fiberglass cast application and bivalving for cast saw use. METHODS: A hospital sheet was rolled into a mock "arm" on which short-arm fiberglass casts were formed. An appropriate cast saw technique was used with complete withdrawal of the saw blade from the cast material between cuts. A total of 10 casts were made for control/no vacuum (N = 5) and study/vacuum (N = 5) groups. The temperature of the saw blade was measured at 1-minute increments beginning at 3 minutes after fiberglass submersion in water. A mixed factor analysis of variance assessed differences in temperature change over time between groups with a statistical threshold of P < 0.05. RESULTS: Casts that set for 7 minutes were associated with lower blade temperatures compared with casts that set for 3, 4, 5, and 6 minutes. The average temperature increases for the 3- to 7-minute set times without the use of vacuum were 10.08 (± 1.42), 9.38 (±1.31), 9.32 (±1.85), 8.54 (±2.10), and 5.62°F (±2.42), respectively, and with the use of vacuum, they were 9.40 (±1.14), 8.36 (±1.64), 7.84 (±2.05), 7.30 (±3.14), and 4.82°F (±2.59), respectively. Independent of vacuum use, the change in temperature was significantly different from the maximum temperature (3 minutes) beginning at 7 minutes (all P < 0.043). DISCUSSION: A minimum of 7 minutes of set time for a fiberglass cast before attempting to bivalve using segmented cuts is associated with the smallest increase in temperature of the saw blade. Blade temperature was not affected with the vacuum enabled. Clinicians can demonstrate best practices to minimize the risk of cast saw injuries.

Delayed Postoperative Spinal Cord Injury with Complete Paralysis After Adolescent Idiopathic Surgery: A Case Report.

CASE: We report a 14-year-old girl with adolescent idiopathic scoliosis who experienced bilateral lower extremity paralysis related to postoperative hypotension 10 hours after posterior spinal fusion. She returned to the operating room for spinal cord decompression and hardware removal. Six weeks later, reinstrumentation was performed, and complete neurologic recovery was achieved. CONCLUSION: Delayed presentation of neurologic injury after scoliosis surgery is particularly uncommon. Close postoperative monitoring, with an emphasis on hypotensive etiologies and a low threshold to remove the instrumentation, is essential to rapidly diagnose and treat these catastrophic events.

Allogeneic blood transfusion and AIS surgery: how the NSQIP database can improve patient safety.

PURPOSE: Describe the experience of one institution in modifying allogeneic blood transfusion protocols for AIS surgery in response to the results of ACS-NSQIP-PEDS comparative data in a retrospective cohort study. METHODS: NSQIP data demonstrated that AIS patients at our hospital had a significantly greater risk of ALBT compared to similar institutions (OR 4.1). The ALBT protocol was then revised to initiate transfusion based on Hb/Hct level, clinical hypotension and/or discussion between surgeon and anesthesiologist. A retrospective analysis of perioperative ALBT and autologous cell salvage blood transfusion (CSBT) rates was performed for patients undergoing surgery before (Group A) and after (Group B) the implementation of the revised protocol. RESULTS: Two hundred and ninety patients constituted the study cohort, with 92 patients in Group A and 198 in Group B. Average total blood transfusion (ALBT + CSBT) per patient was significantly lower for Group B than Group A (313 ml vs. 650 ml, p < 0.01). ALBT per patient of Group B was significantly lower than Group A (85 ml vs. 324 ml, p < 0.01). 48% of patients received ALBT in Group A compared to only 18% in Group B. CONCLUSION: Recognition of excessive allogeneic transfusion rates in our institution through comparative data from the ACS-NSQIP-PEDS database resulted in the modification of transfusion parameters that led to a decrease in allogeneic transfusion rates for AIS patients. The current study highlights the value of a large, well-curated surgical database in optimizing clinical protocols and potentially improving overall surgical morbidity.

Streamlining Postoperative Care After Pediatric Supracondylar Humerus Fractures: Is Follow-up After Pin Removal Routinely Needed?

BACKGROUND: Closed reduction and percutaneous pinning is the standard of care for displaced supracondylar humerus fractures (SCHFs). Although the operative management of SCHFs has achieved good consensus with low complication rates, there remains a paucity of literature on postoperative management. We hypothesized that routine office visits after pin removal can safely be avoided in uncomplicated SCHFs without compromising patient care. METHOD: A retrospective review was conducted to query the electronic medical record for SCHFs, treated with closed reduction and percutaneous pinning. Patients with complicated SCHFs were excluded. Patients were divided into 2 cohorts: follow-up (FU) and nonfollow-up (NFU), depending on the presence or absence of after-pin removal (APR) FU visits. Demographics, surgical variables, number of x-rays, referrals for physical therapy, total FU visits, complications, and clinical events after pin removal up to 3 months were compared. Subgroup analysis was performed according to Gartland fracture types. RESULTS: A total of 179 patients were included in the study, 111 in the FU group and 68 in the NFU group. There were no significant differences found in demographics between the 2 groups. There were no significant differences in complications and APR clinical events between 2 groups (P>0.05). An average of 1.98 additional x-rays were taken APR in FU group. None of the NFU group patients required physical therapy. Excluding patients with pin site infections, 15/108 (13.9%) of FU group patients had >1 APR visits. SUMMARY: For operatively managed uncomplicated SCHFs, patients who do not have routinely scheduled FU APR have no greater incidence of clinical events APR than patients with a scheduled FU. With a detailed discussion including expectations, timeframe for resuming activities, home exercises, and reassurance of the ease of FU if desired, routine FU APR can be safely eliminated after uncomplicated SCHFs in order to streamline postoperative care. LEVEL OF EVIDENCE: Level III.

Extensor Pollicis Longus Tendon Rupture After a Pediatric Distal Radius Fracture: A Case Report and Literature Review.

CASE: A 16-year-old boy underwent closed reduction and pinning of a Salter-Harris II distal radius fracture (DRF). Extensor pollicis longus (EPL) rupture occurred 6 weeks after the injury. Extensor indicis proprius transfer was performed using wide-awake local anesthesia no tourniquet (WALANT) technique. Active thumb range of motion was restored, and the patient returned to all activities, including sports, after 2 months. CONCLUSION: Although delayed attritional EPL rupture after DRF is a well-known complication in adults, this is the first reported case in a truly skeletally immature patient. Awareness of this complication prompts monitoring for prodromal signs and symptoms. The WALANT technique is feasible in selected children.

Impact of Pediatric Subspecialty Training on Perioperative Complications in Adolescent Idiopathic Scoliosis Surgery.

This was a retrospective study of data prospectively collected from 2012 to 2016 from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. The objective was to evaluate the effect of pediatric fellowship training on 30-day perioperative morbidity and mortality following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). Several pathways exist in North America by which physicians acquire the clinical and technical skills to manage AIS surgically. Previous work has noted that surgeons with pediatric fellowship training tend to perform the bulk of pediatric spine surgeries. However, no study has been performed that examines if pediatric fellowship training (PFT) has an impact on early postoperative outcomes. A total of 14,194 AIS surgical patients were identified from the ACS NSQIP database. A cohort receiving isolated PSF was abstracted from this group and separated into 3 groups according to surgeon training: (1) ped+ (with PFT, n=4455); (2) ped-(without PFT, n=325); and (3) ped+match (patients selected from ped+ matched to ped- for age, sex, and fusion levels, n=325). The groups were compared for 30-day perioperative morbidity and mortality. No significant differences were noted for the 3 groups in terms of wound infections, length of hospital stay, readmissions, and unplanned returns to the operating room. Ped+match and ped- groups had no difference in neurologic injury rates. However, the ped+ and ped+match groups had significantly lower rates of blood transfusion and average volume of blood lost compared with the ped- group. Surgeons with pediatric fellowship training have a significantly lower average blood loss volume and blood transfusion rate in PSF for AIS than surgeons without such training. Understanding that different training pathways for surgeons may directly impact operative outcomes invites further examination of surgical education in North America to improve training consistency. [Orthopedics. 2020;43(5):e454-e459.].

The Cost and Educational Experience of Treating Supracondylar Humerus Fractures: A Pilot Analysis on Standardizing Surgical Care.

Closed reduction and percutaneous pinning (CRPP) for supracondylar humeral fractures (SCHF) comprised considerable surgical volume in pediatric orthopaedics. Limited reports are available on how standardization of the surgical care affects the cost and trainee's learning experience. Methods: Cost analysis was performed by chart review with the billing department in a university teaching hospital. The association of cost with perioperative variables was determined by univariate and multivariable analyses. The educational experience was acquired by questionnaires completed by seven attending surgeons and 22 orthopaedic trainees. Results: Fifty-one patients were included, revealing the hospital charge of $6,345 per CRPP case. Most of the cost comprised OR time (67%) and anesthesia time (13%). The attending surgeon and fracture type were independently associated with anesthesia time. Standardization of care was perceived for better learning experience and cost saving. Conclusion: Efforts in the standardization of SCHF surgical care can improve cost saving and trainees' learning experience.

Skeletally Immature Patients With Adolescent Idiopathic Scoliosis Curves 15°-24° Are at High Risk for Progression.

STUDY DESIGN: Retrospective review. OBJECTIVES: To evaluate the incidence of adolescent idiopathic scoliosis (AIS) curve progression and brace prescription in skeletally immature patients (Risser 0 to Risser 1) with curves 15°-24°. SUMMARY OF BACKGROUND DATA: Many skeletally immature patients with mild AIS ask about the likelihood of curve progression. No studies have answered these questions. METHODS: The charts and radiographs of 302 consecutive patients with curves 15°-24° at initial visit, Risser 0 to Risser 1, were reviewed until skeletal maturity (≥Risser 4) or surgery. Curves averaged 19.1° ± 2.9° at initial visit. The Risser grade was 0 in 247 patients (82%) and 1 in 55 patients (18%). Patients who were Risser 0 were compared with those who were Risser 1, curves 15°-19° were compared with curves 20°-24°. RESULTS: The majority of patients demonstrated curve progression ≥5° (65%). Patients who were Risser 0 did not progress significantly more than patients who were Risser 1 (10° vs. 8°) (p = .22). Patients with curves 20°-24° did not progress significantly more than patients with curves 15°-19° (10° vs. 9°) (p = .65). CONCLUSIONS: Curve progression for small curves (15°-19°) is similar to curves between 20° and 24°. Close observation or perhaps early intervention for these patients is necessary. These data may suggest a paradigm shift to earlier brace initiation and call for early treatment in small curves. LEVEL OF EVIDENCE: Level II.

Physical Activity among Navajo Cancer Survivors: A Qualitative Study.

Physical activity (PA) may improve quality of life and survival among cancer survivors; however, little is known about Navajo cancer survivor PA. We evaluated Navajo cancer survivor PA habits, barriers, and preferences through focus groups and interviews (n = 32). Transcripts were coded in NVivo and major themes summarized by consensus. Survivor exercise guidelines were largely unknown, but movement, resilience and life balance were valued. Most participants reported at ≥1 mode of current PA (n = 24; 71% walking, 46% work/homesteading). Barriers to PA included treatment side effects, limited access to programs, fear of "over doing it," and family/friends encouraging rest. Preferences for PA varied.

Comparison of S2-Alar and traditional iliac screw pelvic fixation for pediatric neuromuscular deformity.

BACKGROUND CONTEXT: Many pelvic fixation options exist for posterior spinal fusion of pediatric neuromuscular scoliosis, including standard iliac screws (SISs) or a more recently introduced S2-Alar (S2A) technique. However, little data exist comparing the clinical and radiographic outcomes of these techniques. PURPOSE: This study aimed to dentify differences in clinical and radiographic outcomes for pediatric neuromuscular scoliosis patients treated with SIS or S2A pelvic fixation. STUDY DESIGN/SETTING: This was a retrospective cohort study at a pediatric orthopedic clinic. PATIENT SAMPLE: Patients aged 8-19 years undergoing posterior spinal fusion to the pelvis for neuromuscular scoliosis using SIS or S2A technique, with Gross Motor Function Classification System (GMFCS) Level 4 or 5 were included. OUTCOMES MEASURES: Postoperative complication rates associated with pelvic fixation method were the outcome measures. METHODS: Charts and radiographs were reviewed for demographics, intra- and postoperative course, levels of instrumentation, operative correction, and implant failure (IF). Postoperative complications were classified according to the Accordion scale. RESULTS: We studied 50 patients (28 SIS, 22 S2A) aged 14.0±2.8 years and an average follow-up of 3.5±1.7 years. The average number of levels fused was 16.5±1.1 with an average curve correction of 48°±21° postoperatively. A significant difference in radiographic IF rates was noted between SIS and S2A groups (57% vs. 27%, p=.02). No difference was noted between groups for frequency or severity of postoperative complications, inclusive of wound infections. Subgroup analysis demonstrated equivalent IF rates when comparing the S2A group with the SIS group with cross-links. CONCLUSIONS: The S2A group generally demonstrated improved rates of radiographic IF compared with the SIS group, but the rates became equivalent when a cross-link was added to an SIS construct. Further, no difference in postoperative complication rates were identified between SIS and S2A groups.

Valve or No Valve: A Prospective Randomized Controlled Trial of Casting Options for Pediatric Forearm Fractures.

The purpose of this study was to determine the rate of cast-related complications when using split or intact casts. A total of 60 patients aged 3 to 13 years with closed shaft or distal third radius and ulna fractures requiring reduction were recruited for this study. Patients underwent closed reduction under sedation and were placed into a long-arm fiberglass cast with 1 of 3 modifications: no valve, univalve, or bivalve. Patients were followed to 6 weeks after reduction or surgical treatment if required. The frequency of neurovascular injury, cast saw injury, unplanned office visits, and cast modifications, the need for operative intervention, and pain levels through the follow-up period were recorded. The results showed no incidents of compartment syndrome or neurovascular injury. Additionally, there were no differences between complications associated with cast type (P=.266), frequency of cast modifications (P=.185), or subsequent need for surgical stabilization (P=.361). Therefore, cast splitting following closed reduction of low-energy pediatric forearm fractures does not change clinical outcomes with respect to neurovascular complications, cast modifications, pain levels, or the need for repeat reduction. Consideration should be given to minimizing cast splitting after reduction of low-energy pediatric forearm fractures for practice efficiency and to potentially decrease saw-related injury. [Orthopedics. 2017; 40(5):e849-e854.].

Poor Utility of Gonadal Shielding for Pediatric Pelvic Radiographs.

Plain pelvic radiographs are commonly used for a variety of pediatric orthopedic disorders. Lead shielding is typically placed over the gonads to minimize radiation exposure to these sensitive tissues. However, misplaced shielding can sabotage efforts to protect patients from excessive radiation exposure either by not covering radiosensitive tissues or by obscuring anatomic areas of interest, prompting repeat radiographic examinations. The goal of this study was to determine the incidence of misplaced shielding for pelvic radiographs obtained for pediatric orthopedic evaluation. Children 8 to 16 years old who had an anteroposterior or frog lateral pelvic radiograph between 2008 and 2014 were included. A total of 3400 patients met the inclusion criteria, and 84 boys and 84 girls were randomly selected for review. For both boys and girls, the percentage of incorrectly positioned or missing shields was calculated. Chi-square testing was used to compare the frequency of missing or incorrectly placed shields between sexes and age groups. Pelvic shields were misplaced in 49% of anteroposterior and 63% of frog lateral radiographs. Shielding was misplaced more frequently for girls than for boys on frog lateral radiographs (76% vs 51%; P<.05). Pelvic bony landmarks were often obscured by pelvic shielding, with a frequency of 7% to 43%, depending on the specific landmark. The femoral head and acetabulum were obscured by shielding in up to 2% of all images. The findings suggest that accepted pelvic shielding protocols are ineffective. Consideration should be given to alternative protocols or abandonment of this practice. [Orthopedics. 2017; 40(4):e623-e627.].

Complementary and Integrative Medicine at Mayo Clinic.

Complementary and alternative medicine (CAM) has gained acceptance throughout the industrialized world. The present study was performed to provide information about the use of CAM at Mayo Clinic, an academic medical center in Northern Midwest of the US. We retrospectively reviewed the electronic medical records of 2680 patients visiting the CAM program at Mayo Clinic, Rochester, between 1 July 2006 and 31 March 2011. Services provided included acupuncture, massage, integrative medical consultations and executive stress management training. Data including age, gender, race, diagnosis and the number of treatment/consultation sessions were collected to describe the use of CAM in our institute over the last several years. It was found that the mean (standard deviation) age of patient was 52.6 (15.5) years. Of those, 73.1% were female and 26.9% were male. Most patients were white. The number of patients referred to CAM increased significantly from 2007 to 2010. The three most common diagnostic categories were back pain (12.9%), psychological disorders (11.8%), and joint pain (9.6%). Back pain was the most common diagnosis for patients receiving acupuncture, and fibromyalgia was the most common for patients receiving massage therapy. Psychological disorders (i.e., stress) were the major diagnosis referred to both integrative medical consults and executive stress management training. These results suggest that the diseases related to pain and psychological disorders are the main fields of CAM use. It also shows the increasing trend of the use of CAM at an academic medical center in the US.

Reinforcing a spica cast with a fiberglass bar.

Hip spica casting is used in the treatment of femur fractures and hip dysplasia in children 1 to 6 years old. A bar connecting the legs of the cast has been shown to improve cast integrity and assist in patient transport. We present a simple and low-cost technique that can be used to create a connecting bar and that can be performed with readily available casting materials.