Time-Dependent Bacterial Contamination of a Surgical Suction Tip.

Background: No in vitro surgical study has evaluated the time-dependent contamination of surgical suction tips compared with controls. Our purpose was to determine the difference in suction tip bacterial contamination rates between suction-positive and suction-negative tips. Materials and Methods: A matched-pair analysis of the contamination of surgical suction tips over a six-hour period was performed in two clean operating rooms. One suction tip was connected to standard wall suction (suction-positive group), with a matched control tip not connected to wall suction (suction-negative group). At time zero and then at hourly intervals for six hours, the distal 3 cm of suction tips were removed, placed in nutrient broth for 48 hours, then plate cultured. One hundred tips were collected for each time interval. Results: Eighty-two of 700 (11.7%) suction tips had bacterial contamination. Sixty-three (18.0%) of 350 suction-positive tips were contaminated, with 19 (5.4%) of the 350 suction-negative tips contaminated (χ2 = 26.7, p < 0.001). Suction tip contamination was time-dependent with the first significant difference between groups occurring after two hours of continuous suction (χ2 = 4.0, p = 0.04). Contamination rate in the suction-positive group increased significantly after one hour compared with time-zero controls (χ2 = 7.1, p = 0.008). There was no significant difference in frequency of positive cultures over time in the suction-negative group compared with time-zero controls. Conclusions: This is the first controlled laboratory study suggesting a time-dependent increase in positive suction tip cultures. From our data, operating room staff should have an awareness that suction tips represent a potential source of bacterial concentration. We recommend that when not in use, suction tip valves be closed if this feature is available, that hosing be manipulated to cease suction when not needed, that suckers be disconnected from tubing, or that suckers be exchanged at frequent intervals. Doing so may reduce bacterial contamination on the suction tip.

Transiliac-Shortening Osteotomy to Treat Ischial Pressure Injury due to Fixed Pelvic Obliquity: A Case Report.

CASE: A 17-year-old adolescent boy with Gross Motor Function Classification System 5 cerebral palsy and neuromuscular scoliosis underwent posterior spinal fusion and segmental spinal instrumentation from T3 to the pelvis. He developed a right ischial pressure injury a few months postoperatively, which persisted despite nonoperative measures. He subsequently underwent an ipsilateral transiliac-shortening osteotomy 16 months after spinal surgery to treat his residual pelvic obliquity and the ischial pressure injury, which healed completely. At the 1-year follow-up visit, there were no further signs of pressure injury. CONCLUSION: This case report describes transiliac-shortening osteotomy as a viable treatment option for non-healing ischial pressure injuries secondary to fixed pelvic obliquity.

Surgical technique: proximal extension of instrumentation using sublaminar bands for salvage of postoperative proximal junctional failure in pediatric patients.

PURPOSE: Proximal junctional failure is a complication that can occur following posterior spine surgery with instrumentation. The ability to surgically revise this complication is important for the spine surgeon, yet there is little literature on the topic, especially for pediatric patients. METHODS: The technique we describe involves proximal extension of the existing instrumentation using paired levels of sublaminar bands that allows for a smooth transition of forces at the junction of instrumented and non-instrumented regions of the spine. RESULTS: The results of this technique have been promising with a case series demonstrating improved radiographic and clinical outcomes for eight children at a minimum of 1 year follow-up. CONCLUSION: This a reliable, effective, and safe technique for salvage of PJF in children that uses posterior osteotomies and proximal extension of the instrumentation using sublaminar bands, resulting in gradual load sharing correction to restore sagittal balance.

The effect of surgical time on perioperative complications in adolescent idiopathic scoliosis cases. A propensity score analysis.

BACKGROUND: Posterior spinal instrumentation and fusion (PSIF) for adolescent idiopathic scoliosis (AIS) can be lengthy and complication-ridden. The aim of this study was to evaluate the effect of surgical time on perioperative complications in this procedure when controlling for confounding variables with propensity score analysis. METHODS: This was an IRB-approved review of electronic health records from 2010 to 2019 at a single tertiary care children's hospital. Patients undergoing PSIF were grouped into "short" (< 6 h) or "long" (≥ 6 h) surgical time groups. Outcome measures were estimated blood loss (EBL), cell saver transfusions, packed red blood cell (pRBC) transfusions, length of stay (LOS), intraoperative monitoring (IOM) alerts, hematocrit, ICU transfer, neurologic loss, surgical site infection, and 90-day readmissions. We controlled for age, sex, BMI, curve severity, number of segments fused, and surgeon factors. RESULTS: After propensity score matching there were 113 patients in each group. The short surgical time group had lower EBL (median 715, IQR 550-900 vs median 875, IQR 650-1100 cc; p < 0.001), received less cell saver blood (median 120, IQR 60-168 vs median 160, IQR 97-225 cc; p = 0.001), received less intraoperative pRBCs (median 0, IQR 0-0 vs median 0, IQR 0-320, p = 0.002), had shorter average LOS (4.8 ± 1.7 vs 5.4 ± 2.5 days; p = 0.039), and fewer IOM alerts (4.3% vs 18%, p = 0.003). CONCLUSIONS: Patients with shorter surgical times had less blood loss, received less transfused blood, had a shorter LOS, and fewer IOM alerts compared to patients with longer surgical times. Surgical times < 6 h may have safety and efficacy advantages over longer times. LEVEL OF EVIDENCE: III.

BrAIST-Calc: Prediction of Individualized Benefit From Bracing for Adolescent Idiopathic Scoliosis.

STUDY DESIGN: Prospective multicenter study data were used for model derivation and externally validated using retrospective cohort data. OBJECTIVE: Derive and validate a prognostic model of benefit from bracing for adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: The Bracing in Adolescent Idiopathic Scoliosis Trial (BrAIST) demonstrated the superiority of bracing over observation to prevent curve progression to the surgical threshold; 42% of untreated subjects had a good outcome, and 28% progressed to the surgical threshold despite bracing, likely due to poor adherence. To avoid over-treatment and to promote patient goal setting and adherence, bracing decisions (who and how much) should be based on physician and patient discussions informed by individual-level data from high-quality predictive models. MATERIALS AND METHODS: Logistic regression was used to predict curve progression to <45° at skeletal maturity (good prognosis) in 269 BrAIST subjects who were observed or braced. Predictors included age, sex, body mass index, Risser stage, Cobb angle, curve pattern, and treatment characteristics (hours of brace wear and in-brace correction). Internal and external validity were evaluated using jackknifed samples of the BrAIST data set and an independent cohort (n=299) through estimates of discrimination and calibration. RESULTS: The final model included age, sex, body mass index, Risser stage, Cobb angle, and hours of brace wear per day. The model demonstrated strong discrimination ( c -statistics 0.83-0.87) and calibration in all data sets. Classifying patients as low risk (high probability of a good prognosis) at the probability cut point of 70% resulted in a specificity of 92% and a positive predictive value of 89%. CONCLUSION: This externally validated model can be used by clinicians and families to make informed, individualized decisions about when and how much to brace to avoid progression to surgery. If widely adopted, this model could decrease overbracing of AIS, improve adherence, and, most importantly, decrease the likelihood of spinal fusion in this population.

2015-2021 Industry Payments to Pediatric Orthopaedic Surgeons: Analysis of Trends and Characteristics of Top-earning Surgeons.

BACKGROUND: Analysis of industry payments to pediatric orthopaedic surgeons last occurred in 2017. We investigated payments to pediatric orthopaedic surgeons from 2015 to 2021 to understand surgeon characteristics associated with increased industry payments. METHODS: Open Payments Database datasets from 2015 to 2021 were queried for nonresearch payments to pediatric orthopaedic surgeons. Annual aggregates and subcategories were recorded. For surgeons receiving payments in 2021, the Hirsch index (h-index), gender, and US census division were found using the Scopus database, Open Payments Database, and online hospital profiles, respectively. χ 2 , Fisher exact, Mann-Whitney U , and t tests were used to compare surgeons in the top 25%, 10%, and 5% payment percentiles to the bottom 75%, 90%, and 95%, respectively. RESULTS: Payments rose 125% from 2015 to 2021. Education, royalties, and faculty/speaker increased most, while travel/lodging, honoraria, charitable contributions, and ownership interest decreased. Only royalties increased from 2019 to 2021. In 2021, of 419 pediatric orthopaedic surgeons receiving industry payments, men received greater median aggregate payments than women ($379.03 vs. $186.96, P =0.047). There were no differences in gender proportions between the top 75% and bottom 25% ( P =0.054), top 10% and bottom 90% ( P =0.235), and top 5% and bottom 95% ( P =0.280) earning comparison groups. The h-index was weakly positively correlated with industry payments ( rs =0.203, P <0.001). Mean h-indices in the 75th ( P <0.001, 95% CI: 2.62-7.65), 90th ( P =0.001, 95% CI: 3.28-13.03), and 95th ( P =0.005, 95% CI: 4.25-21.11) percentiles were significantly higher. Proportions of surgeons from the Middle Atlantic and West South Central in the 90th ( P =0.025) and 95th percentiles ( P =0.033), respectively, were significantly lower compared to all other regions. A higher proportion of surgeons from the Pacific were placed in the 90th ( P =0.004) and 95th ( P =0.024) percentiles. CONCLUSIONS: Industry payments to pediatric orthopaedic surgeons rose from 2015 to 2021. Most categories fell from 2019 to 2021, which may be related to the SARS-CoV-19 pandemic. In 2021, though gender was not related to aggregate payment percentile, location in select US census divisions and h-index was. LEVEL OF EVIDENCE: Level II-Retrospective study.

Concave rod first vs. convex rod first in AIS instrumentation with differential rod contouring: computer modeling and simulations based on ten AIS surgical cases.

PURPOSE: To assess biomechanical differences between AIS instrumentations using concave vs. convex rod first. METHODS: Instrumentations of ten AIS patients were simulated first with major correction maneuvers using the concave rod then with convex rod. Correction maneuvers were concave/convex rod translation, followed by apical vertebral derotation and then convex/concave rod translation. The concave/convex rods were 5.5/5.5 and 6.0/5.5 mm diameter Co-Cr and contoured to 35°/15°, 55°/15°, 75°/15° and 85°/15°, respectively. RESULTS: Differences in simulated thoracic Cobb angle (MT), thoracic kyphosis (TK) and apical vertebral rotation (AVR) were less than 5° between the two techniques; mean bone-screw force difference was less then 15N (p > 0.1). Increasing differential contouring angle from 35°/15° to 85°/15°, the MT changed from 14 ± 7° to 15 ± 8°, AVR from 12 ± 4° to 6 ± 5°, TK from 23 ± 4° to 42 ± 4°, and bone-screw forces from 159 ± 88N to 329 ± 170N (P < 0.05). Increasing the concave rod diameter from 5.5 to 6 mm, the mean MT correction improvement for both techniques was less than 2°, the AVR correction was improved by 2°, the TK increased by 4° and bone-screw force increased by about 25N (p < 0.05). CONCLUSION: There was no significant difference in deformity corrections and bone-screw forces between the two techniques. Increasing differential contouring angle and rod diameter improved AVR and TK corrections with no significant effect on the MT Cobb angle. Although this study simplified the complexity of a generic surgical technique, the main effects of a limited number of identical steps were replicated for each case in a systematic manner to analyze the main first-order effects.

Biomechanical analysis of rod contouring in posterior spinal instrumentation and fusion for 3D correction of adolescent idiopathic scoliosis.

PURPOSE: To biomechanically evaluate 3D corrective forces and deformity correction attributable to key parameters of rod contouring in posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). METHODS: Computerised patient-specific biomechanical models of six AIS cases were used to simulate PSF and evaluate the effects of 5.5-mm cobalt-chrome rod contouring angle (concave-convex angles: 30°-15°, 45°-15° and 60°-15°), length (spanning 4 and 7 vertebrae), and apex location (T7, T9). 3D correction and bone-implant forces were computed and analysed. RESULTS: By increasing the concave rod contour from 30° to 60°, thoracic kyphosis (TK) increased from 18° ± 2° (15°-19°) to 24° ± 2° (22°-26°), apical vertebra rotation (AVR) correction increased from 41% (SD8%) to 66% (SD18%) whilst the main thoracic curve (MT) correction decreased from 68% (SD6%) to 56% (SD8%). With a contouring length of 4 vs. 7 vertebrae, the resulting TK, AVR and MT corrections were 22° ± 1° (19°-26°) vs. 19° ± 10° (15°-22°), 57% (SD18%) vs. 50% (SD26%) and 59% (SD1%) vs. 69% (SD35%), respectively. With the rod contouring apex at T7 (vs. T9), AVR corrections were 69% (SD19%) vs. 44% (SD9%), with no significant difference in TK and MT corrections, and with comparatively 67% of screw pull-out forces. Corrective forces were more evenly shared with fixation on 7 vs. 4 vertebrae. CONCLUSION: Rod contouring of a greater angulation, over a shorter portion of the rod, and more centred at the apex of the main thoracic curve apex improved AVR correction and allowed greater restoration of TK, but resulted in significantly higher screw pull-out forces and came at the expense of less coronal plane correction.

Diagnosis and Treatment of Idiopathic Congenital Clubfoot.

Idiopathic congenital clubfoot is the most common serious musculoskeletal birth defect in the United States and the world. The natural history of the deformity is to persist into adult life with a significant decrease in function and quality of life. The Ponseti method (serial casting, Achilles tenotomy, and bracing of the clubfoot) has become the most effective and accepted treatment of children born with clubfoot worldwide. The treatment is successful, particularly when the Ponseti-trained practitioner (often a pediatric orthopedic surgeon), the primary care clinician, and the family work together to facilitate success. An important factor in the ultimate success of the Ponseti method is parental understanding of the bracing phase. There is a very high rate of recurrent deformity when bracing is not done properly or is stopped prematurely. The importance of positive education and support for the parents to complete the entire treatment protocol cannot be overstated. The goal of treatment is a deformity-free, functional, comfortable foot. Ponseti clubfoot programs have been launched in most countries throughout the world, including many countries with limited resources. Ultimately, the goal is that every infant born with a clubfoot will have access to care with the Ponseti method. This clinical report is intended for medical practitioners who are involved in the care of pediatric patients with clubfoot. Understanding the standard of care will help these practitioners to care for patients and their families.

Musculoskeletal Education: An Assessment of the Value of the American Academy of Pediatrics Musculoskeletal Boot Camp Course in Improving Clinical Confidence of Pediatricians Managing Common Musculoskeletal Conditions.

In 2016, the American Academy of Pediatrics Section on Orthopaedics established an annual Musculoskeletal (MSK) Boot Camp course to fill the gaps in MSK knowledge, performance, and outcomes for pediatricians and primary care doctors. A standardized one-day curriculum of key MSK topics was developed including short lectures, hands-on workshops, debates, live webinars, and Q&A sessions. A survey was created to evaluate attendee confidence related to diagnosing 20 common MSK conditions in children and adolescents at the beginning and end of the course. Confidence in diagnosing the conditions was gauged using a 6-point Likert-type scale. A two-sample t test was used to compare overall confidence score pre- and post-seminar. In addition, each subtopic was analyzed. The average pre-seminar confidence score was 3.92 versus 4.86 post-seminar. All categories demonstrated a statistically increased confidence score post-seminar (P < .0001). Live MSK continuing education for pediatricians is effective in improving confidence in clinical practice.

An intraoperative laterally placed distractor for gradual load sharing correction of severe spastic neuromuscular spinal deformity.

PURPOSE: To analyze the overall deformity correction for severe neuromuscular scoliosis using laterally placed intra-operative distraction and compare to those receiving standard surgical technique. METHODS: This was a retrospective, IRB-approved, cohort study of patients with GMFCS 4 or 5 spastic cerebral palsy with neuromuscular scoliosis, age greater than 10 years, who underwent posterior spinal fusion from 2007 to 2019. All patients had vectored cervical traction with Gardner-Wells tongs, with hips flexed in a relative sitting position. The study cohort underwent intraoperative, laterally placed correction using a distractor placed between two upper ribs and the ipsilateral greater trochanter while the control cohort did not. The 24 study patients were compared to 22 control patients. RESULTS: Preoperative comparisons identified significant differences in Cobb angle, preoperative flexibility, and pelvic obliquity with the study group having larger, stiffer deformities with greater obliquity. There were no differences in pre-operative sagittal plane deformity. Mean post-operative upright Cobb angle correction was 67.3° ± 14.8° in the study and 55.3° ± 9.9° in the control group, representing a 66% and 60% correction, respectively. No neurological or other complications were noted from the use of this technique. CONCLUSION: The use of a laterally placed distraction device from upper ribs to ipsilateral greater trochanter allowed gradual lateral un-bending of large stiff neuromuscular spine deformities with greater correction than that of standard technique. In this small series, the technique allowed load-sharing during correction, with hips remaining in a functional sitting position, and without neurological complications. LEVEL OF EVIDENCE: Level III-retrospective cohort study.

Iliac screw instrumentation to the pelvis in children with neuromuscular and syndromic scoliosis. No lateral connectors and respect sagittal balance.

STUDY DESIGN: One-center retrospective cohort study. BACKGROUND: Compared to the traditional iliac screw technique, the modified iliac screw technique has a lower rate of distal implant failure in the treatment of neuromuscular scoliosis patients with pelvic obliquity. However, the reasons for decreased failure with the modified iliac screw technique are controversial. QUESTIONS/PURPOSES: (1) Is distal implant failure, as evident by implant breakage or disconnection, more likely to occur in patients receiving the traditional iliac screw technique (PSIS) compared to the modified S2AI (MODS2) technique? (2) After controlling for relevant confounding variables, are there other identifiable risk factors for distal implant failure? METHODS: We identified patients who underwent pelvic screw fixation by three pediatric spine surgeons from January 2007 to July 2017. Based on the starting point of the iliac screws, patients were divided into two groups. Group 1 consisted of PSIS fixation with an offset connector. Group 2 consisted of modified S2AI fixation without an offset connector. Demographic, operative, and radiographic data were obtained. RESULTS: Cobb angle, lumbar lordosis, and pelvic obliquity were not significantly different between the two groups. Overall distal implant failure was 40/100 (40%) and significant between Group 1 PSIS 29/53 (55%) and Group 2 MODS2 11/47 (23%) (p = 0.002). No other complications were significant. Three risk factors were identified with implant failure: high pelvic incidence (17-fold increase, 95% confidence interval [CI] = 5.5 to 53.1, p < 0.001), high angle rod contour (3.8-fold increase, 95% CI = 1.2 to 11.9, p = 0.023), and use of an offset connector (3.2-fold increase, 95% CI = 1.0 to 10.3, p = 0.049). Failure did not correlate with the use of a cross-link, iliac screw diameter, or screw density. Revision surgery related to distal implant failure did not significantly differ between the two groups. CONCLUSIONS: Compared to the use of an offset connector with PSIS fixation, MODS2 fixation had a lower rate of implant failure. Sagittal balance parameters, namely pelvic incidence and angle of rod bend, were the major risk factors for implant failure. LEVEL OF EVIDENCE: III.

Anaphylaxis after injecting a hemostatic agent containing gelatin into vertebral bone under pressure-a warning.

STUDY DESIGN: Case series. PURPOSE: The use of topical hemostatic agents is common in spinal deformity surgery. While beneficial, emerging case data shows gelatin-containing agents causing intra-operative complications. We present two patients who developed anaphylaxis after injection of these gelatin-containing hemostatic agents into the vertebral body using manual pressure. In the literature, while anaphylactic reactions associated with the use of animal-derived gelatin has been implicated; the risk of injecting these products into the closed vascular cavity of the vertebral body with subsequent embolization into systemic circulation bears emphasis. This report is to meant to make the surgical team aware of the risks of injecting hemostatic agents using manual pressure into the vertebral body and to highlight a plausible mechanism for the phenomenon. METHODS: Two children with spinal deformity undergoing posterior spinal fusion procedures with the use of gelatin-containing hemostatic agents injected into the vertebral body through the pedicle are described. RESULTS: Both patients had gelatin-containing hemostatic agent solution injected under manual pressure through the vertebral pedicle to prevent excessive bleeding. Anaphylaxis occurred soon thereafter, resulting in emergent cessation of the surgery and initiation of medical resuscitation. In both cases, tryptase levels obtained just after the event were elevated. CONCLUSION: Patients with an allergy to or prior history of exposure to zoologic products undergoing spine surgery may be at risk of anaphylaxis if the gelatin-containing hemostatic agent is injected under manual pressure into the closed space of the vertebral body. This allows rapid entry into the venous circulation. We recommend that the surgeon perform a thorough history of a patient's allergies and use extreme caution when injecting these topical hemostatic products into the vertebral body. LEVEL OF EVIDENCE: IV.

Operative time in adolescent idiopathic scoliosis surgery: a need for a standard definition.

Our objective is to report and define 'operative time' in adolescent idiopathic scoliosis (AIS) posterior spinal fusion surgeries. Documenting key times during surgery are important to compare operative risks, assess learning curves, and evaluate team efficiency in AIS surgery. 'Operative time' in literature has not been standardized. Systematic review was performed by two reviewers. Keywords included operative time, duration of surgery, and scoliosis. One thousand nine hundred six studies were identified, 1092 duplicates were removed and 670 abstracts were excluded. Of the 144 articles, 67 met inclusion and exclusion criteria. Studies were evaluated for number of patients, operative time, and definition of operative time. Meta-analysis was not performed due to confounders. Of the 67 studies (6678 patients), only 14 (1565 patients) defined operative time, and all specified as incision to closure. From these 14 studies, the median operative time was 248 minutes (range 174-448 minutes). In the 53 studies (5113 patients) without a definition, one study reported time in a non-comparable format, therefore, data were analyzed for 52 studies (5078 patients) with a median operative time of 252 minutes (wider range 139-523 minutes). A clear standardized definition of operative or surgical time in spine surgery does not exist. We believe that operative time should be clearly described for each published study for accurate documentation and be defined from incision time to spine dressing completion time in order to standardize study results. Level of evidence: IV.

Twenty-two Years of Pediatric Musculoskeletal Firearm Injuries: Adverse Outcomes for the Very Young.

BACKGROUND: Firearm injuries are a significant cause of morbidity and mortality for children in the United States. The purpose of this study is to investigate the 22-year experience of pediatric firearm-related musculoskeletal injuries at a major pediatric level 1 hospital and to analyze the risk of adverse outcomes in children under 10 years of age. METHODS: An institutional review board-approved, retrospective cohort analysis was conducted on pediatric firearm-related musculoskeletal injuries at our institution from 1995 to 2017. A total of 189 children aged 0 to 18 years were identified using International Classification of Diseases, 9th Revision/10th Revision codes, focusing on musculoskeletal injuries by firearms. Exclusion criteria were primary treatment at an outside hospital, isolated nonmusculoskeletal injuries (eg, traumatic brain injury), and death before orthopaedic intervention. Two cohorts were included: age below 10 years and age 10 years and above. Primary outcome measure was a serious adverse outcome (death, growth disturbance, amputation, or impairment). Standard statistical analysis was used for demographic data, along with linear mixed models and multivariable logistic regression for adverse outcome. RESULTS: Of the 189 children, 46 (24.3%) were below 10 years of age and 143 (75.7%) were 10 years and above. Fifty-two (27.5%) of the total group had an adverse outcome, with 19 (41.3%) aged below 10 years and 33 (23.1%) aged 10 years and above (P=0.016). Adverse outcomes were 3 deaths, 17 growth disturbances, 7 amputations, and 44 impairments. For those below 10 years of age, rural location (P=0.024), need for surgical treatment (P=0.041), femur injury (P=0.032), peripheral nerve injury (P=0.006), and number of surgeries (P=0.022) were associated with an adverse outcome. CONCLUSIONS: Over one fourth of survivors of musculoskeletal firearm injuries had an adverse outcome. Children 10 years and above represent the majority of firearm injuries in our population; however, when injured, those below 10 years are more likely to have an adverse outcome. LEVEL OF EVIDENCE: Level III.

Treatment of type III supracondylar humerus fractures: adherence and limitations of American Academy of Orthopedic Surgeons Appropriate Use Criteria App.

The American Academy of Orthopedic Surgeons (AAOS) published Appropriate Use Criteria (AUC) in 2014 to aid physicians in the management of pediatric supracondylar humerus fractures. AUC should be evaluated in real practice, and if necessary modified based on identified problems. This study compares AAOS AUC recommendations with actual treatment performed in a cohort of patients treated for type III supracondylar humerus fractures. Medical record review of patients treated for type III supracondylar humerus fractures at our hospital from 2009 to 2016. Criteria required by the AAOS AUC were collected and entered into the AAOS AUC web-based application to determine the 'appropriateness' and score of each treatment. These were compared with the actual treatment the patient received. Over the study period, 585 patients (mean age: 6.5 years, 51% male, 49% female) were treated for type III supracondylar humerus fractures. Of the 585 cases, 561 (95.9%) were classified as 'appropriate', 24 (4.1%) as 'maybe appropriate', and 0 (0%) as 'rarely appropriate'. Of the 'maybe appropriate' cases there was a significant decrease in the proportion that deviated from the AUC over time (P = 0.0076). The main reasons for deviation were that an open reduction was performed due to difficulty with closed reduction (75% of deviations) or the surgery was not performed emergently (25% of deviations). The vague definition of 'emergent' and not allowing for open reduction if needed are limitations of the AUC that should be clarified or improved by the AAOS.

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.

Pediatric Orthopaedists Are Not Immune: Characterizing Self-reported Burnout Rates Among POSNA Members.

BACKGROUND: There are no published data characterizing burnout rates for pediatric orthopaedic surgeons. The primary purpose of this study was to identify the rates of self-reported personal and team burnout among members of the Pediatric Orthopaedic Society of North America (POSNA). A secondary aim was to determine whether specific demographic variables were more likely to be associated with self-reported burnout. METHODS: During its 2018 annual meeting, the POSNA Wellness Taskforce launched a web-based survey in which members were asked to respond to 2 previously validated questions related to personal and team burnout. The survey was distributed by a closed POSNA membership e-mail list and responses were analyzed anonymously. Descriptive statistics were calculated. Pearson χ testing was used to analyze differences in burnout rates as a function of age and sex. RESULTS: A total of 615 POSNA members completed the survey, a 47% response rate. Overall, 38% reported personal burnout and 46% reported team burnout. Women were more likely to report both personal (P<0.001) and team burnouts (P<0.005). Members aged 40 to 59 years were more likely to report personal burnout, irrespective of sex (P<0.001). Members aged 50 to 59 years were more likely than those in other age groups to report team burnout (P<0.001). There was no significant association found between the presence of burnout and either race, ethnicity, LGBTQ status, or educational background. CONCLUSIONS: As a group, pediatric orthopaedists report moderately high rates of both personal and team member burnout. Individual-specific factors such as age and sex may play an important role in determining one's risk for experiencing burnout. Recognizing that burnout affects a significant minority of POSNA members is a crucial first step. LEVEL OF EVIDENCE: Level III.

The amount of surgical correction of the main thoracic curve is the best predictor of postoperative clinical shoulder balance in patients with Adolescent Idiopathic Scoliosis.

PURPOSE: This study sought to analyze factors that predict postoperative shoulder balance based on clinical photography. METHODS: Based on inclusion criteria, 132 AIS patients were selected. Age, sex, and BMI of each patient were recorded. The following parameters were recorded from radiographs: clavicle angle, T1 tilt, the upper instrumented vertebra (UIV), lowest instrumented vertebra (LIV) thoracic kyphosis, lumbar modifier, preoperative and postoperative proximal thoracic Cobb angle, preoperative and postoperative main thoracic Cobb angle, and preoperative and postoperative thoracolumbar Cobb angle, if applicable. Two spine surgeons independently assigned the photographs shoulder balance grades based on the WRVAS (1-2 = Acceptable, 3-5 = Unacceptable). Surgeons were blinded as to whether the photographs were taken preoperatively or postoperatively. The shoulders were also graded as right high, left high, or balanced. RESULTS: Of all variables analyzed, only main thoracic Cobb angle correction (MTCAC) showed a statistically significant relationship with postoperative shoulder balance (p = 0.01). Odds of having unacceptable shoulder balance increase by 21% for every 5° increase in MTCAC (Adjusted OR = 1.21, 95% CI 1.015-1.452). The odds of unbalanced shoulders are 4.7 times higher for patients whose MTCAC is 40° or more (p = 0.001). Inter-rater reliability was excellent (k =0 .7). Intra rater reliability was perfect for Surgeon 1 (kappa = 1.0) and showed substantial agreement for Surgeon 2 (kappa = 0.8) CONCLUSIONS: Greater correction of main thoracic Cobb angle predicts unacceptable postoperative shoulder balance with 40° of correction signifying a major dichotomy between acceptable and unacceptable.

The Burden of Pediatric Musculoskeletal Diseases Worldwide.

Global burden of disease (GBD) refers to the economic and human costs resulting from poor health. The disability-adjusted life year is a measure of life lost from premature death and life not lived at 100% health. Surgery has long been neglected in the distribution of resources for global health. Because of years of life lived with a disability and the large proportion of children in a population, pediatric musculoskeletal conditions early in life can contribute to the GBD. Fortunately, the World Health Organization has recently promoted essential surgical services through its Emergency and Essential Surgical Care Project and Global Initiative.