Declining Rates of Legg-Calvé-Perthes Surgery in the United States: National Trends Using the Kids' Inpatient Database and Pediatric Health Information System.

BACKGROUND: In 2004 and 2008 two large prospective, multicenter studies were published which resulted in improved understanding of operative indications for the treatment of Legg-Calvé-Perthes disease (LCPD) based on patient age, disease severity, and resultant radiographic outcomes. The primary aim of this study is to evaluate the trends in surgical management of LCPD in the United States prior, and subsequent to, the publication of these landmark studies. METHODS: Cross-sectional retrospective analysis of US pediatric hospitalizations for the surgical management of LCPD was conducted using the Kids' Inpatient Database from 2000 to 2016. Patients 12 years of age and younger were included who had a primary admission diagnosis of LCPD and a LCPD-related procedure during the hospitalization. Data was subsequently weighted to produce national-level estimates and variables pertaining to patient age group, procedure, demographics, and hospital characteristics were analyzed. In a post hoc analysis, the results of the Kids' Inpatient Database were also corroborated with the Pediatric Health Information System database. RESULTS: A weighted sample of 2786 LCPD surgical admissions met inclusion and exclusion criteria; 11.2% of surgical admissions were patients below 6 years of age, 35.9% were 6 to 8 years of age, and 52.9% were above 8 years of age. There was a significant decrease in admissions for surgical management of LCPD in all age groups over time, however there was no appreciable change in the proportion of LCPD surgical admissions performed among the above 8 to below 12, above 6 to below 8, or below 6 years age groups. Femoral osteotomy remained the most common surgical procedure, while other osteotomy types, including pelvic and unspecified osteotomies involving the hip, decreased over time ( P <0.001). CONCLUSIONS: There is a decreasing rate of hospital admissions for LCPD surgery since 2000, perhaps indicating a decline in incidence of disease. Furthermore, despite evidence supporting LCPD surgical outcomes related to patient age, there has been no change in the proportion of patients undergoing surgery by age group over time. LEVEL OF EVIDENCE: Level III-retrospective study.

A dedicated surgical team for posterior spinal fusion in patients with adolescent idiopathic scoliosis improves OR efficiency.

PURPOSE: Standardized care pathways for adolescent idiopathic scoliosis (AIS) patients undergoing PSF improve clinical outcomes. We hypothesized that having dedicated spine personnel would decrease surgical time and improve clinical outcomes. METHODS: 367 patients with AIS had a PSF within a standardized perioperative care pathway. Cases with 1-3 dedicated spine team members (any combination of circulating nurse, surgical technologist, and anesthesiologist) were compared to teams with none. The impact of individual members was also analyzed. Parametric or non-parametric tests were used for each outcome based on the distribution of the data points. These included one-way ANOVA models, Kruskal-Wallis tests, and Fisher's exact tests. RESULTS: Surgical time and total OR time were significantly decreased with the participation of each additional dedicated team member resulting in 43.86 min less surgical time and 50.8 min less total OR time when three team members were present compared to no team members. If the nurse was a spine member, the surgical time was lower (p = 0.037). If the technologist was a team member, the surgical time and total OR time were lower (p = 0.002 and p = 0.001, respectively). Lastly, if the anesthesiologist was a member of the team, the anesthesia time was lower (p = 0.003). No significant clinical differences were observed. CONCLUSION: Having dedicated surgical team members decreases surgical and total OR time for AIS patients undergoing PSF, and this OR efficiency improves as the dedicated team is more robust. OR surgical teams did not influence clinical outcomes. Hospitals should strongly consider developing surgical teams to improve OR efficiency of PSF cases.

Outpatient Bryant's Overhead Traction Does Not Affect the Rate of Open Reduction or Avascular Necrosis in Developmental Dislocation of the Hip.

BACKGROUND: The efficacy of preliminary traction to increase the likelihood of closed reduction and/or decrease the incidence of avascular necrosis in the management of developmental dysplasia of the hip (DDH) is controversial. We sought to document compliance with and effectiveness of Bryant's outpatient traction in patients with idiopathic DDH. METHODS: Patients presenting between 6 and 24 months of age with idiopathic irreducible DDH were prospectively enrolled in the study. Prereduction outpatient traction was prescribed at participating surgeons' preference and parents' expressed willingness to comply with a traction protocol of at least 14 hours/day for 4 weeks. Traction hours were documented using a validated monitor; parents also reported average daily usage. Rate of successful closed reduction and evidence of capital epiphyseal growth disturbance 1 year' and 2 years' postreduction were documented. RESULTS: Ninety-six patients with 115 affected hips were enrolled. Reliable recorded traction hours were obtained in 31 patients with 36 affected hips. Defining compliance as 14 hours/day average use, 14 of 31 patients (45.2%) were compliant, 2 (6.5%) admitted noncompliance, while 15 (48.2%) claimed to be compliant, but were not. Overall, 68/115 hips (59.0%) were closed reduced. Age at treatment was the only demographic characteristic associated with an increased incidence of closed reduction (11.7 vs. 14.6 mo, P<0.01). Successful closed reduction was achieved in 10/16 hips (62.5%) of compliant patients, 12/20 (60.0%) of noncompliant patients, and 43/72 (59.7%) of no-traction patients. Irregular ossific nucleus development was noted 1-year postindex reduction in 5/16 (31.3%) of complaint-patient hips and 25/92 (27.2%) of noncomplaint and no-traction hips. Distorted proximal femoral epiphysis was noted at 2 years postreduction in 2/15 hips (13.3%) of compliant patients and 15/52 hips (28.8%) in noncompliant and no-traction patients. None of these differences was statistically significant. CONCLUSIONS: Parent-reported use of outpatient traction is unreliable. Four weeks of outpatient overhead Bryant's traction did not affect the rate of closed reduction or avascular necrosis in late-presenting DDH in this cohort. LEVEL OF EVIDENCE: Level II-prospective cohort.

Children's Hospital Ambulatory Response to the 2019 Novel Coronavirus Disease (COVID-19) Pandemic.

The 2019 novel coronavirus disease (COVID-19) pandemic produced an abrupt and near shutdown of nonemergent patient care. Children's National Hospital (CNH) mounted a multidisciplinary, coordinated ambulatory response that included supply chain management, human resources, risk management, infection control, and information technology. To ensure patient access, CNH expanded telemedicine and instituted operational innovations for outpatient procedures. While monthly in-person ambulatory subspecialty visits decreased from 25 889 pre-COVID-19 to 4484 at nadir of the COVID-19 pandemic, telemedicine visits increased from 70 to 13 539. Further studies are needed to assess the impact of innovations in health care delivery and operations that the crisis prompted.

Posterior Tibial Slope is Increased in Patients With Tibial Tubercle Fractures and Osgood-Schlatter Disease.

BACKGROUND: Osgood-Schlatter disease (OSD) and tibial tubercle fractures are pathologies that affect the tibial tubercle apophysis in preadolescents and adolescents. Anatomic alignment of the proximal tibia may explain why some children develop OSD or sustain tibial tubercle fractures and some do not. Recent data has shown an association between posterior tibial slope angle (PTSA) and both OSD and proximal tibia physeal fractures. In this study, we compare radiographic parameters between patients with non-OSD knee pain, knees with OSD, and knees with tibial tubercle fracture to elucidate a difference between these groups. METHODS: Patients treated for OSD, tibial tubercle fractures, and knee pain, from 2012 to 2018, were retrospectively reviewed. Radiographic parameters for each study group included PTSA, anatomic lateral distal femoral angle, anatomic medial proximal tibial angle, patellar articular height, and the distance from the inferior aspect of the patellar articular surface. Caton-Deschamps index was then calculated. Demographic data was collected including age, sex, and body mass index. Demographic and radiographic data was compared using analysis of variance tests, χ2 tests, 2-sample t tests, and multiple linear regression. RESULTS: Two hundred fifty-one knees in 229 patients met inclusion criteria for the study. In all, 76% were male and the average age of the overall cohort was 14 years old. In patients with tibial tubercle fractures, the majority of fractures were Ogden type 3b (65%). After controlling for demographic variability, average PTSA in the fracture cohort was significantly greater than that in the control cohort (ß=3.49, P<0.001). The OSD cohort had a significantly greater posterior slope (ß=3.14) than the control cohort (P<0.001). There was no statistically significant difference between the fracture and OSD cohorts. There was also no difference in Caton-Deschamps index between the 2 study groups when compared with the control group. CONCLUSION: This study demonstrates that patients with tibial tubercle fractures and patients with OSD have an increased PTSA when compared with the control group. This information adds to the body of evidence that increased tibial slope places the proximal tibial physis under abnormal stress which may contribute to the development of pathologic conditions of proximal tibia such as OSD and tibial tubercle fractures. LEVEL OF EVIDENCE: Level III; retrospective comparative study.

Demographics and Clinical Presentation of Early-Stage Legg-Calvé-Perthes Disease: A Prospective, Multicenter, International Study.

BACKGROUND: Children with Legg-Calvé-Perthes disease (LCPD) are classically described as small, thin, high-energy children presenting with a painless limp. Epidemiologic studies have historically been retrospective and regional in nature. The purpose of this study was to determine the demographic and clinical features of children presenting in the early stages of LCPD in an international, multicenter cohort. METHODS: Children (6 to 10 years) in the early stages of LCPD (modified Waldenström stage I to IIa) were enrolled in a prospective, multicenter study. Demographic and clinical data at presentation were analyzed. Body mass index percentiles were determined using country-specific growth charts for children in the United States and India, two countries with largest enrollment. Statistical analyses included t-tests and chi-square. RESULTS: A total of 209 children (86% males; mean age 7.9 ± 1.2 years) from 25 centers (six countries) were included. Eight-four percent of children presented with pain with or without a limp. Average pain score at presentation was 3 ± 2 (range 0 to 9), and 63% of children (n = 105) used pain medications. Of these children 65% required medication more than once per week. Thirty percent of children missed school due to pain in the past month, and of those, 74% missed at least 1 day per week. Twenty-nine percent of children from the United States and 20% of children from India were overweight or obese. Nineteen percent reported household smoking. DISCUSSION: This prospective study provides a new international multicenter representation of early LCPD. The frequency of pain and missed school highlights the substantial morbidity and potential social cost and burden for children and families. The prevalence of being overweight/obese in our LCPD cohort was comparable to rates within the pediatric cohort as a whole, and fewer children have a history of smoke exposure than in previous reports. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Ammonia removal from thermal hydrolysis dewatering liquors via three different deammonification technologies.

The benefits of deammonification to remove nitrogen from sidestreams, i.e., sludge dewatering liquors, in municipal wastewater treatment plants are well accepted. The ammonia removal from dewatering liquors originated from thermal hydrolysis/anaerobic digestion (THP/AD) are deemed challenging. Many different commercial technologies have been applied to remove ammonia from sidestreams, varying in reactor design, biomass growth form and instrumentation and control strategy. Four technologies were tested (a deammonification suspended sludge sequencing batch reactor (S-SBR), a deammonification moving bed biofilm reactor (MEDIA), a deammonification granular sludge sequencing batch reactor (G-SBR), and a nitrification suspended sludge sequencing batch reactor (N-SBR)). All technologies relied on distinct control strategies that actuated on the feed flow leading to a range of different ammonia loading rates. Periods of poor performance were displayed by all technologies and related to imbalances in the chain of deammonification reactions subsequently effecting both load and removal. The S-SBR was most robust, not presenting these imbalances. The S-SBR and G-SBR presented the highest nitrogen removal rates (NRR) of 0.58 and 0.56 kg N m-3 d-1, respectively. The MEDIA and the N-SBR presented an NRR of 0.17 and 0.07 kg N m-3 d-1, respectively. This study demonstrated stable ammonia removal from THP/AD dewatering liquors and did not observe toxicity in the nitrogen removal technologies tested. It was identified that instrumentation and control strategy was the main contributor that enabled higher stability and NRR. Overall, this study provides support in selecting a suitable biological nitrogen removal technology for the treatment of sludge dewatering liquors from THP/AD.

Factors affecting length of stay after posterior spinal fusion for adolescent idiopathic scoliosis.

STUDY DESIGN: Retrospective review of prospectively collected data. OBJECTIVE: Determine factors that influence hospital length of stay after posterior spinal fusion for adolescent idiopathic scoliosis. Standardized care pathways decrease variability in care, improve patient outcomes, and decrease cost. Specifically, global care pathway development using Lean process mapping for patients undergoing posterior spinal fusion for adolescent idiopathic scoliosis (AIS) has been shown to lead to a significant decrease in postoperative length of stay. Assessment of variables that affect length of stay after pathway implementation may identify opportunities for additional process refinement to further decrease postoperative length of stay and improve pathway efficiency. METHODS: A standardized care pathway was implemented at our institution for all patients undergoing posterior spinal fusion for AIS. This pathway was developed using the Lean process mapping technique to create evidence-based protocols for the preoperative, operative, postoperative, and postdischarge care. Patient and care-related variables in these time periods were assessed to determine those factors that significantly affected postoperative length of stay. RESULTS: Preoperative factors associated with a prolonged postoperative length of stay included patient ethnicity (non-Hispanic > Hispanic, p = 0.035) and gender (female > male, p = 0.039). Significant intraoperative factors included longer surgical time (p < 0.001), increased number of fusion levels (p = 0.034), and higher volume of crystalloid administered (p = 0.011). Significant postoperative factors were higher average pain scores on the first postoperative day (p < 0.001) and higher cumulative morphine use (p < 0.001). CONCLUSIONS: Use of a standardized care pathway for the treatment of patients with AIS can decrease postoperative length of stay. Despite a carefully designed pathway, variability persists in aspects of care that can impact length of stay, including surgical efficiency, intraoperative fluid and blood management, and postoperative pain management. Continued process improvement focused on these variables will likely further improve the effectiveness of standardized pathways for patients with AIS. LEVEL OF EVIDENCE: Level III.

Association between perioperative surgical home implementation and transfusion patterns in adolescents with idiopathic scoliosis undergoing spinal fusion.

BACKGROUND: Blood transfusions in patients with adolescent idiopathic scoliosis after fusion have been associated with increased morbidity, mortality, and cost. OBJECTIVE: The aim of this study was to evaluate the association between implementation of blood-conservation strategies within the perioperative surgical home on transfusion rates for patients with adolescent idiopathic scoliosis undergoing spinal fusion. METHODS: Two hundred and thirteen patients (44 preperioperative surgical home, 169 postperioperative surgical home) who underwent posterior spine fusion for adolescent idiopathic scoliosis between 23 June 2014, and 30 July 2017, were enrolled in this case control study. The perioperative surgical home implemented in March 2015 involved evidence-based perioperative interventions to create a standardized clinical pathway including judicious use of crystalloid management, restrictive transfusion strategy, routine use of cell saver, and standardized administration of anti-fibrinolytics. The primary outcome was odds of perioperative transfusion. Secondary outcomes included volumes of crystalloid, albumin, cell saver, packed red blood cells as well as calculated blood loss. Other variables that were documented included antibrinolytic total dose, mean arterial pressure, temperature, laboratory values, intrathecal morphine dosing, and surgical time. Statistical methods included t test and logistic regression. RESULTS: For the postperioperative surgical home, the odds of perioperative transfusion were 0.30 (95% CI 0.13-0.70), as compared to preperioperative surgical home. In terms of secondary outcomes, calculated blood loss was significantly lower in the postperioperative surgical home patients (27.0 mL/kg preperioperative surgical home vs 22.8 mL/kg postperioperative surgical home; mean difference = -0.24 [-0.44, -0.04]). Although no difference was noted in the amount of intraoperative cell saver or albumin administered, a reduction was noted in mean intraoperative crystalloid given postperioperative surgical home (41.4 mL/kg ± 20.4 mL/kg preperioperative surgical home vs 28.0 mL/kg ± 13.7 mL/kg postperioperative surgical home; log mean difference = 0.37 [95% CI 0.21-0.53], P < 0.001). Postperioperative surgical home patients also had a significantly higher temperature nadir (mean difference = -0.47 [95% CI -0.70 to -0.23]; P < 0.001), received a significantly higher total anti-fibrinolytic dose (mean difference = -3939 [95% CI -5364 to -2495]; P < 0.001), and were exposed to shorter surgical times (mean difference = 0.72 [95% CI 0.36-1.09]; P < 0.001). CONCLUSIONS: Implementation of blood-conservation strategies as part of a perioperative surgical home for patients with adolescent idiopathic scoliosis undergoing posterior spine fusion resulted in significant decrease in perioperative blood transfusions.

Effectiveness and Sustainability of a Standardized Care Pathway Developed with Use of Lean Process Mapping for the Treatment of Patients Undergoing Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis.

BACKGROUND: Recent changes in health care have begun to shift the industry from a volume-based to a value-based focus. This shift has led to standardized care pathways that decrease care variability, improve outcomes, and decrease cost. Although numerous studies have described standardized pathways for adolescent idiopathic scoliosis (AIS), few have demonstrated sustainability. We report the effectiveness and sustainability of a standardized care pathway for patients undergoing posterior spinal fusion for AIS. METHODS: A standardized care pathway was developed and implemented (in March 2015) at our pediatric hospital for all patients undergoing posterior spinal fusion for AIS. This pathway was developed with use of the Lean process mapping technique to create an evidence-based protocol for preoperative, operative, postoperative, and post-discharge care. The 44 patients managed prior to implementation of the pathway (pre-pathway group) were compared with the 169 patients managed after implementation (post-pathway group). The post-pathway group was divided into 5 cohorts, each representing a 6-month time period. Clinical outcomes (pain scores, medication requirements, transfusions) and efficiency metrics (length of stay) were used to determine pathway sustainability. RESULTS: The pre-pathway group included patients managed in the 8 months prior to implementation (July 2014 to February 2015) and the post-pathway group included patients who underwent surgery from March 2015 to July 2017, divided into 5 cohorts representing 6 months each. Patients in the post-pathway group had lower postoperative pain scores, and used significantly less opioids at each time interval, compared with the pre-pathway group. Perioperative transfusion requirements and postoperative length of stay were significantly lower across all post-pathway cohorts compared with the pre-pathway group. There were no significant differences in clinical results among the 5 post-pathway cohorts. CONCLUSIONS: Implementation of a standardized care pathway developed with use of Lean process mapping demonstrated effective and sustained improvements to the care of patients with AIS, as well as decreased postoperative length of stay. These outcomes have been maintained over 2.5 years, indicating that high-quality care for patients with AIS undergoing spinal fusion can be achieved and sustained with use of a standardized care pathway. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Role of Advanced Imaging in the Diagnosis and Management of Active Legg-Calvé-Perthes Disease.

Since the first description of Legg-Calvé-Perthes disease a century ago, the diagnosis, staging, prognosis, and treatment decisions have been based on plain radiographs. The goal of treatment is prevention of femoral head deformity, yet radiographic prognostic classifications are applied in the fragmentation stage, often after deformity occurs. These classifications are assigned too late in the progression of the disease to maximize the effects of intervention. Thus, alternative mechanisms to determine femoral head involvement earlier in the disease course are warranted. Increasingly, MRI has been used in the study of the disease. Gadolinium-enhanced and diffusion-weighted MRI has shown promising results that correlate with radiographic classifications and the early radiographic outcome. Advanced imaging has improved the assessment of hinge abduction, yet the exact definition remains controversial. The role of imaging in the management of Legg-Calvé-Perthes disease is rapidly evolving. New or refined imaging techniques may eventually allow earlier prognosis and treatment.

Radiographic Resource Utilization in the Initial Referral and Evaluation of Patients With Adolescent Idiopathic Scoliosis.

INTRODUCTION: The dangers of radiation exposure in children have been well studied, with assessment of adolescent idiopathic scoliosis (AIS) documented as having the potential for notable patient exposure. The purposes of this study were to evaluate a consecutive series of patients referred to a tertiary care pediatric hospital for AIS and to assess the type and quality of imaging obtained before referral for specialist evaluation. METHODS: We performed a prospective study of consecutive patients referred over a 6-month period to a pediatric orthopaedic practice at a large, free-standing, urban children's hospital for evaluation of AIS. We assessed prereferral radiographic exposure, evaluating the utilization and adequacy of these radiographs. RESULTS: Of a total of 131 patients enrolled in the study, 79 had received radiographs before the visit; of these, only 59 patients (75%) brought the previously obtained radiographs to the specialist consultation, and 45 patients (76%) of this subset were found to be adequate for evaluation of AIS. Of the total cohort, 56 patients (43%) required repeat radiographs because of missing or inadequate radiographs. DISCUSSION: We found a large number of missing or inadequate radiographs, leading to repeat radiation exposure in this cohort. Improvements in the utilization of radiographs before orthopaedic referral could decrease unnecessary patient radiation exposure.

Quantifying the performance of a hybrid anion exchanger/adsorbent for phosphorus removal using mass spectrometry coupled with batch kinetic trials.

Increasingly stricter phosphorus discharge limits represent a significant challenge for the wastewater industry. Hybrid media comprising anionic exchange resins with dispersions of hydrated ferric oxide nanoparticles have been shown to selectively remove phosphorus from wastewaters, and display greater capacity and operational capability than both conventional treatment techniques and other ferric-based adsorbent materials. Spectrographic analyses of the internal surfaces of a hybrid media during kinetic experiments show that the adsorption of phosphorus is very rapid, utilising 54% of the total capacity of the media within the first 15 min and 95% within the first 60 min. These analyses demonstrate the importance of intraparticle diffusion on the overall rate in relation to the penetration of phosphorus. Operational capacity is a function of the target effluent phosphorus concentration and for 0.1 mg P L-1, this is [Formula: see text], which is 8-13% of the exhaustive capacity. The adsorbed phosphorus can be selectively recovered, offering a potential route to recycle this important nutrient. The main implication of the work is that the ferric nanoparticle adsorbent can provide a highly effective means of achieving a final effluent phosphorus concentration of 0.1 mg P L-1, even when treating sewage effluent at 5 mg P L-1.

Age-Based Normative Measurements of the Pediatric Pelvis.

OBJECTIVES: Pediatric pelvic trauma is associated with high rates of morbidity and mortality. Current classifications do not take into account age-dependent quantitative differences of the pediatric pelvis making accurate diagnosis of pathologic diastasis of the pubic symphysis, sacroiliac (SI) joints, and triradiate cartilage difficult. The purpose of this study was to establish age-based normative values for the width of the pubic symphysis, SI joints, and the triradiate cartilage of the pediatric pelvis. METHODS: All computed tomographic (CT) scans of the abdomen and pelvis from patients between the ages 2 and 16 years over a 3-year period at a single institution were evaluated. Patients were excluded if the CT was performed as part of a trauma evaluation or for a history of neuromuscular disease or spinopelvic instrumentation. A total of 821 CT were included. The width of pubic symphysis, right and left SI joints, and each limb of the triradiate cartilages was measured using the PACS digital measurement tool. Left and right measurements of the SI joints and triradiate cartilage were combined and reported together. RESULTS: From age 2 to 16 years, the average widths of the SI joint and pubic symphysis decreased from 3.11 to 1.80 mm and 5.55 to 3.69 mm, respectively. The average widths of the 3 limbs of the triradiate cartilage also slightly decreased from age 2 until closure: ilioischial, iliopubic, and ischiopubic cartilages decreasing from 3.72 to 2.74 mm, 4.42 to 3.52 mm, and 3.08 to 2.97 mm, respectively. CONCLUSIONS: This study demonstrates an age-dependent decrease in width of the pubic symphysis and left and right SI joints. By contrast, the widths of the triradiate cartilage remain relatively stable until closure. We believe that these age-based normative values will aid in future diagnosis of pathologic diastasis of these areas of the pediatric pelvis.

Treatment of hip subluxation in skeletally mature patients with cerebral palsy.

Hip subluxation is common in children with spastic cerebral palsy. Most physicians favor intervention to treat hip subluxation in skeletally immature patients with cerebral palsy. However, treatment in skeletally mature patients with cerebral palsy is controversial. The goal of this study was to evaluate radiographic and clinical outcomes after hip reconstruction in skeletally mature patients with cerebral palsy. The authors performed a retrospective review of all skeletally mature patients (n=20) with cerebral palsy who underwent hip surgery for subluxation at the authors' institution between 2005 and 2011. Charts were reviewed for demographic characteristics, procedure, follow-up, and complications. Acetabular index, migration index, and neck-shaft angle were measured on preoperative and most recent radiographs. Average follow-up was 2.2 years. Average migration index for the entire group improved from 57% to 20% (P<.0001). Of patients who had all radiographic abnormalities addressed at surgery (varus derotational femoral osteotomy for neck-shaft angle >135°, open reduction for migration index >50%, and acetabular osteotomy for acetabular index >25°), 91% had a final migration index of less than 25%. In patients who did not have all radiographic abnormalities addressed, 33% had a migration index of less than 25% at final follow-up. No intraoperative complications occurred; however, 13 patients had at least 1 postoperative complication. Hip subluxation in skeletally mature patients with cerebral palsy is difficult to treat and is associated with a high incidence of complications. The likelihood of a successful outcome appears to be related to the appropriateness of the surgical procedure. When all radiographic abnormalities were addressed during surgery, a successful radiographic outcome at final follow-up was much more likely than when intervention was less comprehensive.

Selective removal of phosphate from wastewater using hydrated metal oxides dispersed within anionic exchange media.

Hydrated ferric oxide (HFeO), hydrated zirconium oxide (HZrO) and hydrated copper oxide (HCuO) were immobilized within a microporous anion exchange resin (IRA-400), forming hybrid media for enhanced phosphate removal from aqueous systems. Empirical data from batch kinetic trials fitted the pseudo second order mechanism for chemical adsorption and each media was rate limited by intraparticle diffusion overall. These models were also used to predict the adsorption rate constants and the equilibrium adsorption capacities, which ranged from 26.51 to 30.44 mgP g(-1), and from 24.15 to 27.90 mgP g(-1) of media for the calculated and experimental capacities, respectively. The phosphate adsorption behavior by the hybrid materials fit both the Langmuir and Freundlich adsorption isotherms (R(2)>0.94), and the maximum adsorption capacities were 111.1 mgP g(-1) for HFeO, 91.74 mgP g(-1) for HZrO and 74.07 mgP g(-1) for HCuO. The effect of competing ions such as sulfate reduced these capacities to 18.52 mgP g(-1) for HFeO and 18.97 mgP g(-1) for HZrO. Despite this decrease, HFeO was capable of reducing the phosphate in a real wastewater matrix by 83%, and the HZrO media was able to reduce it by 86%, suggesting that such hybrid media have the potential for application at full scale.

Segmental metadiaphyseal humeral bone loss in pediatric trauma patients: a case series.

BACKGROUND: The management of posttraumatic bone loss is complicated and often requires complex reconstructive procedures. No options exist that are specific to the treatment of the growing skeleton that has intercalary bone loss. We have observed reconstitution of the humerus in 2 cases that have precluded extensive management. METHODS: Two pediatric patients sustained traumatic injuries to the upper extremities, including humeral bone loss, and are presented after spontaneous reconstitution of the segmental bone loss. RESULTS: With treatment restricted to soft-tissue injury and bone stabilization with external fixation, both patients demonstrated radiographic healing of humeral segmental bone loss. Both patients were thought to have a partially intact periosteal sleeve. They have returned to sporting activities with mild loss of function. CONCLUSIONS: In certain pediatric injuries, spontaneous healing of segmental bone defects can occur. This response may obviate the need for complex, interventional procedures. LEVELS OF EVIDENCE: Level IV-case series.

Intrathecal Anomalies in Presumed Infantile Idiopathic Scoliosis: When Is MRI Necessary?

STUDY DESIGN: Retrospective review. OBJECTIVE: To determine the rate of abnormal magnetic resonance imaging (MRI) findings in patients with presumed infantile idiopathic scoliosis (IIS) and the rate of neurosurgical intervention in those patients, and to develop a guideline concerning when to obtain an MRI. SUMMARY OF BACKGROUND DATA: The reported rate of intrathecal anomalies associated with presumed IIS varies in the literature (12% to 50%). Conclusions have led to conflicting recommendations concerning when an MRI is indicated. METHODS: After appropriate internal review board approval, the authors retrospectively reviewed the medical records of patients from a single institution meeting the inclusion criteria: presumed idiopathic curve with a magnitude of ≥20°, age <36 months at diagnosis, normal neurologic examination, and presentation between 2002 and 2010. The authors reviewed the MRI findings, whether neurosurgical intervention took place, and the orthopedic treatment course (observation, brace, cast, or surgery). RESULTS: A total of 56 patients were identified and reviewed; 43 had had an MRI. Seven of 43 patients were found to have an anomaly (16.2%). A fatty filum was identified in 2 patients, a syrinx in 3, Chiari I malformation in 2, and a tethered cord in 1 (this patient also had a syrinx). Two of the 7 patients required neurosurgical intervention (28%). Patients who did not have an MRI were statistically younger, had smaller Cobb angles, and required less orthopedic treatment. CONCLUSIONS: The incidence of intrathecal anomalies (16.2%) at the authors' institution was similar to previously published reports; however, the need for neurosurgical intervention was significantly lower in this study (28%). For younger patients with small curves (<30°) who do not require orthopedic treatment, MRI under sedation can be delayed or avoided. Clinical judgment should be the determinant for whether to use MRI when evaluating patients with presumed IIS.

Treatment of femoral lengthening-related knee stiffness with a novel quadricepsplasty.

BACKGROUND: Knee stiffness is common after femoral lengthening. Certain patients require a quadricepsplasty when therapy does not improve flexion. A small subset of such patients may also have obligate patellar dislocation with knee flexion due to contracture of the extensor mechanism. We describe our surgical approach for both clinical situations and our outcomes in a pediatric population. METHODS: Six patients, 2 with obligate patellar dislocation, were reviewed (9% of our femoral lengthening population). Indications for surgery included persistent symptomatic restriction of flexion after at least 3 months of therapy or obligate lateral patellar dislocation with knee flexion. Knee range of motion and clinical strength were assessed. Four patients were available for gait analysis and concentric quadriceps strength testing by isokinetic dynamometer. Patient satisfaction was surveyed by questionnaire. RESULTS: All patients had full flexion before lengthening. The mean length gained (by circular external fixation and/or intramedullary motorized nail) was 10.7 cm. The mean age at the time of quadricepsplasty was 16 years. The average active flexion preoperatively was only 48 degrees. Two patients with obligate patellar dislocation and relatively good knee flexion inflated the average preoperative knee flexion. Although both had knee flexion to 100 degrees, the patella dislocated with flexion beyond 30 degrees. At follow-up (mean, 6.2 y) active flexion averaged 120 degrees (P<0.004). All patients had 5/5 clinical strength and no significant quadriceps lag. No patients had patellar instability postoperatively. Isokinetic dynamometer revealed an average weakness of 63% compared with the nonoperative quadriceps. Gait analysis indicated patients had near-normal gait patterns. All patients were satisfied and would pursue the same treatment. CONCLUSIONS: Our quadricepsplasty can significantly increase knee flexion and treat obligate patellar dislocation in the setting of extension contracture after femoral lengthening when nonoperative measures fail. LEVEL OF EVIDENCE: Level IV.