Does Surgeon Level of Expertise Correlate with Patient Outcomes?

Background It is difficult to evaluate the results of surgical techniques as there is inherent variability between surgeons in regard to experience, skill level, and knowledge. Tang suggested a classification system in 2009 in an attempt to standardize surgeon level of expertise, with categories ranging from nonspecialist (Level I) to expert (Level V). This epidemiological analysis of all articles citing Tang's original paper examines if a surgeon's self-reported level of expertise correlates with outcomes and evaluates whether the current definition of Tang level is sufficient to account for expertise bias. Methods In May 2021, all articles citing Tang level of expertise were identified ( N = 222). Articles were included if they described a novel technique and provided author(s)' levels ( n = 205). Statistical analysis was conducted, and p -values less than 0.05 were considered significant. Results The most common specialties reporting Tang level of expertise were orthopaedic surgery (82.9%) and plastic surgery (15.5%). The most common subspecialty was hand surgery. 2020 was the year with the most studies reporting level of expertise (31.7%), followed by 2021 (20.0%) and 2019 (17.1%). The majority of studies (80.5%) reported positive results with their technique, and of these, 63.3% were statistically significant. Level of expertise was not significantly associated with a doctoral degree, type of residency completed, fellowship completion, hand fellowship, author sex, study type, or result significance. Discussion The current Tang classification is both underreported and incomplete in its present state. To account for expertise bias, we recommend all authors report Tang level when describing surgical techniques. Studies with multiple authors should explicitly state the level of each author, as well as a weighted average accounting for the total contribution of each individual.

A Regional Analysis of Hospital Readmissions Following Total Hip and Knee Arthroplasty and the Impact of Medicaid Expansion.

The Hospital Readmissions Reduction Program (HRRP) works to temper nationally rising readmission rates. Total knee arthroplasty (TKA) and total hip arthroplasty (THA) have a 30-day readmission cost burden of $889,300 and $689,400, respectively. No research has compared TKA and THA readmission rates by region and Medicaid expansion status. This study compares THA and TKA readmission rates in the United States by region, Medicaid status, and performance. One-way ANOVAs were conducted to determine the regions with the highest and lowest mean excess readmission ratios (ERRs). An independent t-test compared Medicaid versus non-Medicaid expansion states. Southern hospitals have the highest mean ERR, followed by northeastern, midwestern, and then western hospitals. Although Medicaid expansion states have significantly lower ERRs compared to non-expansion states, Medicaid status alone does not account for regional differences in ERRs after THA and TKA. Regional factors likely confound Medicaid status's effect on readmission rates. (Journal of Surgical Orthopaedic Advances 32(1):005-008, 2023).

Program Directors' Perception of the Role of Personal Statements in the Orthopaedic Surgery Residency Selection Process.

The purpose of this study was (1) to determine how much emphasis is placed on the Personal Statement (PS) by program directors (PDs) and (2) to gain a better understanding of what factors within the PS are considered most important to PDs. An anonymous survey was distributed to PDs at allopathic orthopaedic residency programs in the United States using Survey Monkey (San Mateo, CA). Survey responses were received from 51 of 152 (34%) PDs. Forty-five (88.2%) identified as male, five (9.8%) identified as female, and one (1.9%) chose not to disclose. PDs reported the PS was of average importance, with an average score of 2.82 (range,1-4). Although the PS is still given consideration as part of the overall orthopaedic surgery residency application process, it does not play a major role in determining which applicants will be invited for an interview or how they will be ranked. (Journal of Surgical Orthopaedic Advances 31(2):090-095, 2022).

Prophylactic Radiotherapy for Prevention of Heterotopic Ossification After Periacetabular Fractures: A Review of Efficacy and Associated Conditions.

Prophylactic radiotherapy (XRT) is a commonly used treatment to decrease heterotopic ossification (HO) in patients with traumatic hip injuries. We conducted a retrospective review of patients at risk for HO who underwent XRT. Of the patients reviewed, 27.3% developed radiographic HO, 11.2% developed symptoms, and 2.0% required resection surgery. Patients were divided into primary (n = 71) and secondary prophylaxis (n = 27) cohorts. In the primary group, 25.0% developed radiographic HO, 5.6% developed symptoms, and 0 required surgery. In the secondary cohort, 33.3% of patients developed new radiographic HO, and 25.9% were symptomatic: four had a Brooker score of 3, and three had a score of 4 (p = 0.03), and 7.4% required surgical resection. (Journal of Surgical Orthopaedic Advances 31(2):113-118, 2022).

Spinal Fusion in Pediatric Patients With Low Bone Density: Defining the Value of DXA.

BACKGROUND: Children with medical complexity are at increased risk of low bone mineral density (BMD) and complications after spinal fusion compared with idiopathic scoliosis patients. Our aim was to compare treatments and outcomes of children with medical complexity undergoing spinal fusion in those who had dual-energy x-ray absorptiometry (DXA) scans versus those who did not in an effort to standardize the workup of these patients before undergoing spinal surgery. METHODS: We conducted a retrospective review of patients with low BMD who underwent spinal fusion at a tertiary care pediatric hospital between 2004 and 2016. We consulted with a pediatric endocrinologist to create standard definitions for low BMD to classify each subject. Regardless of DXA status, all patients were given a clinical diagnosis of osteoporosis [at least 2 long bone or 1 vertebral pathologic fracture(s)], osteopenia (stated on radiograph or by the physician), or clinically low bone density belonging to neither category. The last classification was used for patients whose clinicians had documented low bone density not meeting the criteria for osteoporosis or osteopenia. Fifty-nine patients met the criteria, and 314 were excluded for insufficient follow-up and/or not meeting a diagnosis definition. BMD Z -scores compare bone density ascertained by DXA to an age-matched and sex-matched average. Patients who had a DXA scan were also given a DXA diagnosis of low bone density (≤-2 SD), slightly low bone density (-1.0 to -1.9 SD), or neither (>-1.0 SD) based on the lowest BMD Z -score recorded. RESULTS: Fifty-nine patients were analyzed. Fifty-four percent had at least 1 DXA scan preoperatively. Eighty-one percent of DXA patients received some form of treatment compared with 52% of non-DXA patients ( P =0.03). CONCLUSIONS: Patients referred for DXA scans were more likely to be treated for low BMD, although there is no standardized system in place to determine which patients should get scans. Our research highlights the need to implement clinical protocols to optimize bone health preoperatively. LEVEL OF EVIDENCE: Level II-retrospective prognostic study.

Analyzing the Orthopaedic Surgery Personal Statement: Do Residency Applicants See Value in Its Use?

Orthopaedic surgery is one of the most competitive specialties in the residency match. The personal statement (PS) is one component of the application. The significance of the PS to orthopaedic surgery residency applicants is unknown. This study evaluates applicant perceptions of the PS. Applicants to two separate United States orthopaedic residency programs for the 2019-2020 cycle were invited to participate. Survey was distributed via email. Twenty-one percent (204/978) of applicants completed the survey. Most were men (157/204, 77%), and most (125/204, 61%) spent up to 15 hours writing their PS. Many [79.4% (162/204)] believed the PS should continue to be included in the application. Women always edited their PS, while 7.0% (11/ 157) of men did not use any editors. Applicants believe the PS is valuable. The PS is time consuming but allows applicants to communicate details that otherwise may not be included in their application. (Journal of Surgical Orthopaedic Advances 31(1):034-041, 2022).

Expertise of Surgeons Publishing Novel Techniques in the Journal of Wrist Surgery.

Introduction Recent efforts to standardize reporting of surgeon experience in novel technique publications have recommended reporting of Tang level of expertise (LOE). Question/Purpose The aim of this study was to document trends in LOE reporting for novel technique articles published in the Journal of Wrist Surgery and evaluate whether author experience affects novel research outcomes. Methods A total of 261 articles published from 2018 to 2020 were reviewed. Articles describing novel surgical techniques were included and examined for Tang LOE. Author variables were collected online. Results Eight percent (21/261) of articles discussed novel surgical techniques and one reported LOE. Nearly half (47.6%) of articles did not conduct statistical analysis. Four (19.0%) reported insignificant statistical results and 7 (33.3%) reported significant findings. All significant statistical findings were positive. Number of prior related publications by the senior author did not affect new technique result significance ( p = 0.34). Discussion From 2018 to 2020, only one article documented LOE. Authors' variables, including number of prior related publications, were not correlated with significant results in their new publications. This may suggest that an author's established experience in a novel technique, quantified by prior publications on the topic, does not make one more likely to achieve significantly better or worse outcomes in their reviewed Journal of Wrist Surgery study. Conclusions Tang LOE is an important way for readers to classify expertise and should be reported, and potentially modified to better define contributing variables.

Primary Versus Secondary Radiotherapy for Heterotopic Ossification Prevention About the Elbow.

OBJECTIVES: To examine the efficacy and safety of radiotherapy for the prevention of heterotopic ossification (HO) about the elbow. DESIGN: Retrospective chart review. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Two hundred and twenty-nine patients who received prophylactic radiotherapy (XRT) over a 15-year period were identified. Patients were included if they received XRT to the elbow joint and had at least 12 weeks of follow-up after XRT. Fifty-four patients were ultimately included. INTERVENTION: All patients were treated with a single dose of 7 Gy. Ninety-eight percentage of patients received XRT within 24 hours after surgery, and all patients received XRT within 72 hours after surgery. MAIN OUTCOMES MEASUREMENTS: The primary study measures evaluated were the presence or absence of clinically symptomatic HO and the presence of radiographic HO after XRT to the elbow joint. RESULTS: Eighteen patients were treated with XRT after a traumatic injury requiring surgery (primary prophylaxis), and 36 were treated with XRT after excision surgery to remove HO which had already formed (secondary prophylaxis). In the primary cohort, 16.7% developed symptomatic HO after XRT and 11.1% required surgery to resect the heterotopic bone. In the secondary cohort, 11.1% developed symptomatic HO after surgery and XRT and 5.5% required resection surgery. No secondary malignancies were identified. CONCLUSIONS: Our findings suggest that XRT for elbow HO may be safe and effective for both primary and secondary HO. XRT for HO was not shown to be associated with radiation-induced sarcoma in this series, at least in the short term. Further study in a large patient population with extended follow-up is required to better characterize populations at high risk for development of HO and secondary malignancy. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Pediatric injuries related to electric scooter use: a national database review.

Electric scooter (e-scooter) use and resulting injuries have grown exponentially since expansion into ridesharing in 2017. No study has described pediatric e-scooter injuries and focused on their impact in an adolescent cohort. Our primary purpose was to describe the epidemiology of admitted pediatric e-scooter injuries and compare them with existing literature on adults. We queried the National Electronic Injury Surveillance System for e-scooter injuries between 2015 and 2019 in patients 0-18 years old. Injuries caused by an e-scooter to a nonrider were removed. Patients admitted to the hospital were analyzed and weighted national estimates were calculated. A P value of <0.05 was considered significant. Nine hundred and two pediatric patients were treated for an e-scooter injury at an emergency department (ED) between 2015 and 2019. Among those admitted (n = 47), 72.3% were men, and the average age at injury was 11.3 years. Among all injuries (n = 56), the most common diagnosis was fracture (24/56, 42.9%). The 19% (9/47) of patients that experienced polytrauma were significantly older than those with single injuries (P < 0.001). ED admissions grew by 616% from 2017 to 2018. Children experience a greater rate of fractures and polytrauma from e-scooters compared to adults, but fewer facial injuries despite a similar rate of head trauma. The incidence of pediatric head injuries indicates a lack of helmet use similar to adults. Lawmakers should consider bolstering e-scooter regulations to decrease pediatric injuries.

Epiphysiodesis for Leg Length Discrepancy: A Cost Analysis of Drill Versus Screw Technique.

Research has demonstrated similar efficacy of drill epiphysiodesis and percutaneous epiphysiodesis using transphyseal screws for the management of adolescent leg length discrepancy. A cost analysis was performed to determine which procedure is more cost-effective. Patients seen for epiphysiodesis of the distal femur and/or proximal tibia and fibula between 2004 and 2017 were reviewed. A decision analysis model was used to compare costs. Two hundred thirty-five patients who underwent either drill (155/235, 66%) or screw (80/235, 34%) epiphysiodesis were analyzed with an average age at initial procedure of 13 years (range, 8.4 to 16.7 years). There was no significant difference in average initial procedure cost or total cost of all procedures across treatment groups (n = 184). The cost difference between drill and screw epiphysiodesis is minimal. In order for screw epiphysiodesis to be cost-favored, there would need to be a significant decrease in its cost or complication rate. (Journal of Surgical Orthopaedic Advances 30(3):181-184, 2021).

Return to Golf Following Cervical and Lumbar Spinal Fusion: A Systematic Review.

BACKGROUND: There is a paucity of literature about return to play (RTP) for golf protocols following cervical and lumbar fusions. The timing of return to this sport is a common question among patients. The aim of this review was to analyze and report the current protocols for RTP following cervical and lumbar spinal fusion. METHODS: A systematic search was conducted using the following databases: MEDLINE, PubMed, Web of Science, Scopus, and Google Scholar. A 3-step, multiauthor screening process was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Inclusion criteria included peer-reviewed and published prospective, case-control, cohort, case series, or review articles. Studies had to pertain to RTP for golf following instrumented cervical or lumbar spinal fusion to be included. RESULTS: Three articles met inclusion criteria: 2 retrospective survey-based cohort studies and 1 survey-based case series study. All studies included a minimum of 1 year of follow-up. Of patients, 71.6% (n = 51) were able to RTP following surgery; 54.3%-80% were able to RTP at a similar or improved level of play as preoperatively. Postoperative pain reduction was noted in 2 articles. CONCLUSIONS: Most golfers are able to RTP within 12 months following cervical or lumbar spinal fusion. Patients generally reported decreased lower back pain and leg pain postoperatively. Following cervical or lumbar fusion, many golfers are able to RTP at the same or an increased frequency compared with preoperatively.

Trends in Leadership at Pediatric Orthopaedic Fellowships.

BACKGROUND: Pediatric orthopaedic fellowship directors (FDs) have a valuable impact on the education of trainees and future leaders in the field. There is currently no research on the characteristics of pediatric orthopaedic FDs. METHODS: Programs were identified using the Pediatric Orthopaedic Society of North America fellowship directory. Operative, nonoperative, and specialty programs were included. Data was collected through Qualtrics survey, e-mail, telephone, and online searches. Variables included demographics (age, sex, race/ethnicity), Hirsch index (h-index) as a measure of research productivity, graduate education, residency and fellowship training, years of hire at current institution and as FD, and leadership roles. RESULTS: Fifty-five FDs were identified. The majority (49/55, 89%) were male and 77% (27/35) were Caucasian. The mean age at survey was 51.1±8.2 years. The mean h-index was 17.2. Older age correlated with higher h-index (r=0.48, P=0.0002). The average duration from fellowship graduation to FD appointment was 9.6±6.7 and 6.9±6.1 years from institutional hire. Sixteen FDs (29%) had additional graduate level degrees. Almost all (52/55, 95%) FDs completed orthopaedic surgery residencies and all graduated fellowship training. Twenty-nine percent (16/55) completed more than 1 fellowship. Most FDs (51/55, 93%) completed a fellowship in pediatric orthopaedic surgery. Ten FDs (18%) completed pediatric orthopaedic surgery fellowships that included spine-specific training. One-third of all current FDs were fellowship-trained at either Boston Children's Hospital (9/55, 16%) or Texas Scottish Rite Hospital for Children (9/55, 16%). CONCLUSIONS: Pediatric orthopaedic FDs are typically early-career to mid-career when appointed, with a strong research background. Nearly a third completed additional graduate degrees or multiple fellowships. Although male dominated, there are more female FDs leading pediatric orthopaedic programs compared with adult reconstruction, trauma, and spine fellowships. As fellowships continue to grow and diversify, this research will provide a baseline to determine changes in FD leadership.

Variability in Antibiotic Treatment of Pediatric Surgical Site Infection After Spinal Fusion at A Single Institution.

BACKGROUND: Recent focus on surgical site infections (SSIs) after posterior spine fusion (PSF) has lowered infection rates by standardizing perioperative antibiotic prophylaxis. However, efforts have neglected to detail antibiotic treatment of SSIs. Our aim was to document variability in antibiotic regimens prescribed for acute and latent SSIs following PSF in children with idiopathic, neuromuscular, and syndromic scoliosis. METHODS: This study included patients who developed a SSI after PSF for scoliosis at a pediatric tertiary care hospital between 2004 and 2019. Patients had to be 21 years or younger at surgery. Exclusion criteria included growing rods, staged surgery, and revision or removal before SSI diagnosis. Infection was classified as acute (within 90 d) or latent. Clinical resolution of SSI was measured by return to normal lab values. Each antibiotic was categorized as empiric or tailored. RESULTS: Eighty subjects were identified. The average age at fusion was 14.7 years and 40% of the cohort was male. Most diagnoses were neuromuscular (53%) or idiopathic (41%).Sixty-three percent of patients had an acute infection and 88% had a deep infection. The majority (54%) of subjects began on tailored antibiotic therapy versus empiric (46%). Patients with a neuromuscular diagnosis had 4.0 times the odds of receiving initial empiric treatment compared with patients with an idiopathic diagnosis, controlling for infection type and time (P=0.01). Ninety-two percent of patients with acute SSI retained implants at the time of infection and 76% retained them as of August 2020. In the latent cohort, 27% retained implants at infection and 17% retained them as of August 2020. CONCLUSIONS: Patients with acute infections were on antibiotics longer than patients with latent infections. Those with retained implants were on antibiotics longer than those who underwent removal. By providing averages of antibiotic duration and lab normalization, we hope to standardize regimens moving forward and develop SSI-reducing pathways encompassing low-risk patients. LEVEL OF EVIDENCE: Level III.

Surgical Correction of Scoliosis in Children with Severe Congenital Heart Disease and Palliated Single Ventricle Physiology.

STUDY DESIGN: Case series. OBJECTIVE: In this study we focus on this group, and describe the largest cohort to date of single ventricle patients undergoing surgical correction of scoliosis at a single institution. SUMMARY OF BACKGROUND DATA: Outcomes of spinal surgery for patients with congenital heart disease (CHD) have evolved and most affected patients have uncomplicated procedures. The risk of perioperative complications remains highest in patients with single ventricle ("Fontan") physiology. METHODS: We reviewed patients with single ventricle CHD and operative scoliosis repair over a 25-year span. Patients who had undergone a Fontan, bidirectional Glenn, and/or Kawashima procedure before operative scoliosis repair were included. Patients were excluded if they lacked preoperative cardiac care and/or sufficient medical history at our institution. RESULTS: Twenty-three patients were included. The average age at surgery was 13.6 years (range, 5-23). Seventy percent of the cohort was female (16/23). The majority of patients underwent a Fontan before scoliosis surgery (20/23, 87%). Patients without intraoperative tranexamic acid (TXA) had a 67% complication rate (8/12) versus 36% (4/11) in those with intraoperative TXA (P = 0.29). There was a significant difference in estimated blood loss by weight (cc/kg) between non-TXA and TXA patients (P = 0.016). Twelve patients experienced complications (52%), all of which occurred postoperatively. There were no deaths, cerebrovascular events, adverse perioperative cardiac or hemodynamic complications, or wound infections. Using the Clavien-Dindo-Sink classification for postoperative complications, four patients had serious adverse events, including one permanent neurologic deficit. CONCLUSION: Spinal surgery for scoliosis has been performed in selected patients with single ventricle physiology at a single institution without mortality for 25 years. Operative blood loss may be reduced by routine use of TXA. Complications occur most commonly in the postoperative period, and can include pleural effusion.Level of Evidence: 4.

Changing practice patterns: the impact of a cost analysis project on surgeons' preference for treatment of pediatric displaced humeral lateral condyle fractures.

A 2012 publication regarding the surgical management of pediatric lateral humeral condyle fractures (PLHCF) found that leaving pins exposed produced an average savings of $3442 per patient compared to burying pins, with fewer complications. The primary objective of this present study was to determine the impact of this cost analysis on surgeons' treatment preferences at the same hospital. The secondary aim was to verify that leaving pins exposed continued to be a cost-effective and safe treatment strategy. We reviewed all PLHCF treated with open reduction and internal fixation at our institution between 2004 and 2017. The Clavien-Dindo Classification was used to grade complications. Variations in treatment course were evaluated using a chi-squared test to compare the proportions of buried and exposed pins, pre- and postcost analysis report publication. Two hundred forty-eight patients were included. The mean age was 5.9 years (range 1-12 years). In 174 (70%) cases, the pins were buried and in the remaining 30% the pins were exposed. Between 2004 and 2012, the majority of pins were buried (90%) compared to between 2013 and 2017, when the majority of pins were exposed (62%) (P < 0.001). There was no difference detected in complication rate (P = 0.75) or complication severity (P = 0.61) across groups. The demonstrated cost-effectiveness of exposing the pins in the treatment of PLHCF has had a statistically significant impact on surgeon behavior at our institution. Publishing cost analysis research can change physician practice to improve quality, safety and value of care delivery.

Why Irrigate for the Same Contamination Rate: Wound Contamination in Pediatric Spinal Surgery Using Betadine Versus Saline.

BACKGROUND: The risk of surgical site infection in pediatric posterior spine fusion (PSF) is up to 4.3% in idiopathic populations and 24% in patients with neuromuscular disease. Twenty-three percent of pediatric PSF tissue cultures are positive before closure, with a higher rate in neuromuscular patients. Our primary aim was to evaluate the feasibility of a complete randomized controlled trial to study the efficacy of surgical site irrigation with povidone-iodine (PVP-I) compared with sterile saline (SS) to reduce the bacterial contamination rate before closure in children undergoing PSF. METHODS: One hundred seventy-five subjects undergoing PSF were enrolled in a multicenter, single-blind, pilot randomized controlled trial. We recruited patients at low-risk (LR) and high-risk (HR) for infection 3:1, respectively. Before closure, a wound culture was collected. Nonviable tissues were debrided and the wound was soaked with 0.35% PVP-I or SS for 3 minutes. The wound was then irrigated with 2 L of saline and a second sample was collected. RESULTS: One hundred fifty-three subjects completed the protocol. Seventy-seven subjects were allocated to PVP-I (18 HR, 59 LR) and 76 to SS (19 HR, 57 LR). Cultures were positive in 18% (14/77) of PVP-I samples (2 HR, 12 LR) and in 17% (13/76) of SS samples (3 HR, 10 LR) preirrigation and in 16% (12/77) of PVP-I samples (5 HR, 7 LR) and in 18% (14/76) of SS samples (4 HR, 10 LR) postirrigation. Eight percent (3/37) HR subjects (1 PVP-I, 2 SS) experienced infection at 30 days postoperative. No LR subjects experienced infection. CONCLUSIONS: Positive cultures were similar across treatment and risk groups. The bacterial contamination of wounds before closure remains high regardless of irrigation type. A complete randomized controlled trial would be challenging to adequately power given the similarity of tissue positivity across groups. LEVEL OF EVIDENCE: Level II-pilot randomized controlled trial.

Diagnosing and treating native spinal and pelvic osteomyelitis in adolescents.

STUDY DESIGN: Retrospective case series. OBJECTIVES: To describe how pediatric patients with spinal and pelvic osteomyelitis are diagnosed and treated and assess the diagnostic value of magnetic resonance imaging (MRI), needle aspiration biopsy (NAB), and blood cultures in this population. Spinal and pelvic osteomyelitis de novo are uncommon in children and minimal literature exists on the subject. Research has shown that NAB and blood cultures have variable diagnostic yield in adult native osteomyelitis. At our institution, there is no standard protocol for diagnosing and treating pediatric spinal and pelvic osteomyelitis de novo. METHODS: All diagnoses of spinal and pelvic osteomyelitis at a pediatric tertiary care center from 2003 to 2017 were reviewed. Patients aged 0-21 at diagnosis were included. Patients with osteomyelitis resulting from prior spinal operations, wounds, or infections and those with chronic recurrent multifocal osteomyelitis were eliminated. All eligible patients' diagnoses were confirmed by MRI. RESULTS: 29 patients (18 men, 11 women) met the inclusion criteria. The median age at diagnosis was 11 years old (range 1-18). More than half of all cases (17/29, 59%) affected the lumbar spine. The most common symptoms were back pain (20/29, 69%), fever (18/29, 62%), hip pain (11/29, 38%), and leg pain (8/29, 28%). The majority of NABs and blood cultures performed were negative, but of the positive tests Staphylococcus aureus was the most prevalent bacteria. 86% (25/29) had an MRI before a diagnosis was made and 72% (13/18) had an NAB performed post-diagnosis. CONCLUSIONS: MRI is a popular and helpful tool in diagnosing spinal osteomyelitis de novo. NAB cultures are often negative but can be useful in determining antibiotic treatment. LEVEL OF EVIDENCE: Level IV.

Occipital Plate Fixation in the Pediatric Population.

BACKGROUND: Occipital plate fixation has been shown to improve outcomes in cervical spine fusion. There is a paucity of literature describing occipital plate fixation, especially in the pediatric population. The authors reviewed a case series of 34 patients at a pediatric hospital who underwent cervical spine fusion with occipital plate fixation between 2003 and 2016. This study describes how occipital plates aid the cervical spine union in a case series of diverse, complex pediatric patients. METHODS: Our orthopaedic database at our institution was queried for patients undergoing an instrumented cervical spine procedure between 2003 and 2016. Medical records were used to collect diagnoses, fusion levels, surgical technique, and length of hospitalization, neurophysiological monitoring, complications, and revision procedures. RESULTS: Thirty-four patients met the inclusion criteria. The mean age was 10.9 years (range, 3-21 y). Indications for surgery included cervical instability, basilar invagination, and os odontoideum. These indications were often secondary to a variety of diagnoses, including trisomy 21, Klippel-Feil syndrome, and rheumatoid arthritis. The mean length of hospitalization was 10 days (range, 2 to 80 d). There were no cases of intraoperative dural leak, venous sinus bleeding from occipital screw placement, or implant-related complications. Postoperative complications included 2 cases of nonunion. Eight patients (24%) had follow-up surgery, only 3 (9%) of which were instrumentation revisions. Both patients with nonunion had repeat occipitocervical fixation procedures and achieved union with revision. CONCLUSIONS: Occipital plate fixation was successful for pediatric cervical spine fusion in this diverse cohort. The only procedure-related complication demonstrated was delayed union or nonunion and implant loosening (4/34, 12%) and there were no plate-related complications. This novel case series shows that occipital plate fixation is safe and effective for pediatric patients with complex diagnoses. LEVEL OF EVIDENCE: Level IV-case series.

Use of recombinant human bone morphogenetic protein for revision cervical spine fusion in children with Down syndrome: a case series.

OBJECTIVE: Patients with trisomy 21 (Down syndrome; DS) often have atlantoaxial instability (AAI), which, if severe, causes myelopathy and neurological deterioration. Children with DS and AAI who undergo cervical spine fusion have a high rate of nonunion requiring revision surgery. Recombinant human bone morphogenetic protein-2 (rhBMP-2) is a TGF-ß growth factor that is used to induce bone formation in spine fusion. Although previous studies in the adult population have reported no reduction in pseudarthrosis rates with the use of rhBMP-2, there is a lack of literature in the pediatric DS population. This study describes the use of rhBMP-2 in children with DS and AAI during revision to treat nonunion. METHODS: A retrospective review of a cervical spine fusion database (n = 175) was conducted. This database included all cervical spine fusions using modern instrumentation at the authors' institution from 2002 to 2019. Patients with DS who underwent a revision utilizing rhBMP-2 were included in the study. The number of prior fusions, use of rhBMP-2 in fusions, length of stay, halo use, and surgical data were collected. Postoperative complications and length of follow-up were also recorded. RESULTS: Eight patients (75% female) met the inclusion criteria. The average age at revision with rhBMP-2 was 11 years (range 3-19 years). All patients were diagnosed with nonunion after an initial cervical fusion. All revisions were posterior fusions of C1-2 (n = 2) or occiput to cervical (n = 6). All revisions included implant revisions, iliac crest bone grafting, and rhBMP-2 use. One patient required irrigation and debridement of an rhBMP-induced seroma. Another patient required return to the operating room to repair a dural tear. There were no neurological, infectious, airway, or implant-related complications. Revision utilizing rhBMP-2 achieved fusion in 100% (n = 8) of patients. The average length of follow-up was 42.6 months. All patients demonstrated solid fusion mass on the last radiograph. CONCLUSIONS: This is the first case series reporting the successful use of rhBMP-2 to facilitate cervical spine fusion in patients with DS after previous nonunion. In addition, few rhBMP-2-related postoperative complications occurred.