In-hospital post-operative fever after posterior spinal fusion for neuromuscular scoliosis in non-ambulatory cerebral palsy patients: is there value for clinical workup for an isolated fever?

PURPOSE: Children with neuromuscular scoliosis (NMS) resultant to cerebral palsy (CP) are at a heightened risk for complications following surgical treatment. These children have a reported 22-64% rate of post-operative fever development, and additional fever workup has been shown to have limited clinical utility. However, this has yet to be investigated in the setting of an accelerated discharge (AD) pathway. METHODS: A retrospective review of children with non-ambulatory CP treated at 2 centers with posterior spinal fusion (PSF) for NMS was performed. One institution uses a standardized AD post-operative pathway for NMS patients, whereas the second institution had no standard pathway. A post-operative fever was defined as temperature > 38.5 °C. Target outcome variables included the development of a fever as well as re-admission within 90 days of surgery. RESULTS: A total of 122 non-ambulatory children were identified (82% GMFCS V, mean 14.3 ± 3.4 years at surgery). A post-operative fever was documented in 75.4% of patients (N = 92) and all additional culture studies reported negative results. Children admitted to the PICU were more likely to undergo a fever workup (P < 0.001) and more likely to receive additional or extended antibiotic therapy (P < 0.001). Children treated at the AD pathway had a significantly lower rate of PICU admission (P < 0.001). Post-operative PICU admission was associated with a post-operative fever (49.5% vs 25%, P = 0.03). CONCLUSION: Non-ambulatory CP children with NMS undergoing PSF have a 75.4% rate of developing early post-operative fevers. Reflexive fever work-ups provided limited clinical utility while increasing the hospital length of stay and potentially exposing patients to antibiotic-related complications.

Vertebral body tethering for Lenke 1A curves: the lumbar modifier predicts less optimal outcomes.

INTRODUCTION: The addition of the L4 "AR" and "AL" lumbar modifier for Lenke 1A idiopathic scoliosis (IS) has been shown to direct treatment in posterior spinal fusion; however, its utility in vertebral body tethering (VBT) has yet to be evaluated. METHODS: A review of a prospective, multicenter database for VBT in IS was performed for patients with Lenke 1A deformities and a minimum of 2 years follow-up. Patients were categorized by their lumbar modifier (AR vs AL). Less optimal VBT outcome (LOVO) was defined as a final coronal curve > 35°, lumbar adding-on, or revision surgery for deformity progression or adding-on. RESULTS: Ninety-nine patients met inclusion criteria (81% female, mean 12.6 years), with 55.6% being AL curves. Overall, there were 23 instances of tether breakage (23.3%) and 20 instances of LOVO (20.2%). There was a higher rate of LOVO in AR curves (31.8% vs 10.9%, P = 0.01). Patients with LOVO had greater preoperative deformity, greater apical translation, larger coronal deformity on first erect radiographs, and less coronal deformity correction. Failure to correct the deformity < 30° on first erect was associated with LOVO, as was LIV selection short of the last touch vertebra (TV). Independent risk factors for LOVO included AR curves (OR 3.4; P = 0.04) and first erect curve magnitudes > 30 degrees (OR 6.0; P = 0.002). DISCUSSION: There is a 20.2% rate of less optimal VBT following VBT for Lenke 1A curves. AR curves are independently predictive of less optimal outcomes following VBT and require close attention to LIV selection. Surgeons should consider achieving an initial coronal correction < 30 degrees and extending the LIV to at least the TV to minimize the risk of LOVO.

Health-related quality of life and clinical outcomes for magnetically controlled growing rod patients after treatment termination.

PURPOSE: To determine the health-related quality of life (HRQoL) and clinical outcomes of children with early onset scoliosis (EOS) treated with magnetically controlled growing rods (MCGR) followed to definitive fusion (DF). METHODS: A retrospective review of EOS patients treated with MCGR and followed to DF was performed. Outcomes included HRQoL scores, radiographic, clinical, and unplanned returns to the operating room (UPROR) data collected at pre-MCGR implantation, immediately post-MCGR implantation, pre-DF, and post-DF. HRQoL scores were collected at least 6 months post-DF. RESULTS: Twenty-eight patients (57.1% females, mean age at MCGR insertion 7.19 ± 1.5 years, mean pre-MCGR Cobb 64.7° ± 17.6) met inclusion criteria. MCGR treatment resulted in an overall 30.2% improvement in coronal plane deformity following DF. The mean growth rates between MCGR implantation and pre-DF for T1-T12 height and T1-S1 length were 0.33 ± 0.23 mm/month and 0.49 ± 0.28 mm/month, respectively. Of the 28 included patients, 26 (92.9%) experienced at least one UPROR, with a total of 52 surgical complications occurring in the total cohort, representing 1.9 UPROR/patient. Interestingly, there was a decline in scores reported between post-MCGR implantation and the pre-DF time-point (N = 16, 78.2 ± 14.9 vs 69.7 ± 17.8, p = 0.02). These scores recovered post-DF, resulting in an overall unchanged HRQoL when comparing pre-MCGR to post-DF (N = 11, 79.9 ± 15.1 vs 76.7 ± 17.9, p = 0.44). CONCLUSION: While MCGR treatment achieves coronal plane deformity control and facilitates spinal growth, only 7.1% of children experienced a complication-free treatment course when followed to definitive fusion. Patients achieved modest curve correction and spinal growth, while maintaining stable HRQoL outcomes between pre-MCGR and post-DF.

Postoperative CT imaging to characterize fusion in pediatric and adolescent vertebral column resection.

BACKGROUND: Vertebral column resection (VCR) is a powerful corrective technique for the management severe, rigid spinal deformities but does carry a relatively high complications rate. One of the feared complications is pseudarthrosis which places the patient at risk for implant failure. We present a single-center experience with post-operative computed tomography (CT) imaging at the osteotomy site to screen for impending pseudarthrosis. METHODS: A retrospective review of a single surgeon series of posterior-only VCR performed for severe pediatric and adolescent spinal deformities was performed. Demographic, radiographic, and clinical data were collected. Patients underwent postoperative CT imaging at the osteotomy site 6-9 months following VCR with grading of the osteotomy fusion. Patients with impending pseudarthrosis were recommended for prophylactic revision surgery. RESULTS: Thirty-three patients were included (mean age 11.6 ± 4.9 years, 54.5% female), undergoing a mean 1.9 level VCR. Kyphoscoliosis accounted for 75.7% (N = 25/33) of cases with 45.5% of all cases being congenital etiology and 60.6% having at least 1 previous surgery. Postoperative CT imaging was performed in 22 patients at a mean of 7.8 months following VCR. Two patients were identified as having impending pseudarthrosis with one undergoing revision surgery to enhance the posterior fusion, with addition of a third rod while one patient refusing surgery who subsequently developed broken hardware requiring revision surgery. No patient with a stable fusion on CT imaging developed a clinically significant pseudarthrosis. DISCUSSION: Postoperative CT imaging of the osteotomy is useful in screening for impending pseudarthrosis and can aide in decision making for clearance to return to activity or the need for prophylactic intervention following VCR in pediatric and adolescent patients. We advocate that obtaining routine CT imaging of the osteotomy site at 6-9 months may identify potential complications earlier and allow for prophylactic intervention.

Consensus and Equipose in the Management of Military Trainee Femoral Neck Stress Fractures: A Survey of Military Surgeons.

BACKGROUND: Femoral neck stress fractures (FNSFs) are a unique injury pattern not commonly treated in the civilian trauma population; however, it is particularly high with military trainees engaged in basic combat training. To date, no study has surveyed a population of military orthopedic surgeons on treatment preferences for military service members (SMs) with FNSF. QUESTIONS: We aim to evaluate the extent of clinical equipoise that exists in the management of these injuries, hypothesizing that there would be consensus in the factors dictating surgical and non-surgical intervention for FNSF. PATIENTS AND METHODS: A 27-question survey was created and sent to U.S. military orthopedic surgeon members of the Society of Military Orthopaedic Surgeons. The survey was designed in order to gather the experience among surgeons in treating FNSF and identifying variables that play a role in the treatment algorithm for these patients. In addition, seven detailed, clinical vignettes were presented to further inquire on surgeon treatment preferences. Binomial distribution analysis was used to evaluate for common trends within the surgeon's treatment preferences. RESULTS: Seventy orthopedic surgeons completed the survey, the majority of whom were on active duty status in the U.S. Military (82.86%) and having under 5 years of experience (61.43%). Majority of surgeons elected for a multiple screw construct (92.86%), however the orientation of the multiple screws was dependent on whether the fracture was open or closed. Management for compression-sided FNSF involving ≥50% of the femoral neck width, tension-sided FNSF, and stress fractures demonstrating fracture line progression had consensus for operative management. Respondents agreed upon prophylactic fixation of the contralateral hip if the following factors were involved: Complete fracture (98.57%), compression-sided fracture line >75% (88.57%), compression-sided fracture line >50-75% with hip effusion (88.57%), contralateral tension-sided fracture (87.14%), and compression-sided fracture line >50-75% (84.29%). An FNSF < 50% on the contralateral femoral neck or a hip effusion was indeterminate in surgeons indicating need for prophylactic fixation. Majority of surgeons (77.1%) utilized restricted toe-touch weight-bearing for postoperative mobility restrictions. CONCLUSIONS: Consensus exists for surgical and non-surgical management of FNSF by U.S. military orthopedic surgeons, despite the preponderance of surgeons reporting a low annual volume of FNSF cases treated. However, there are certain aspects in the operative and non-operative management of FNSF that are unanimously adhered to. Specifically, our results demonstrate that there is no clear indication on the management of FNSF when an associated hip effusion is involved. Additionally, the indications for surgically treating contralateral FNSF are unclear. LEVEL OF EVIDENCE: IV.

Increasing soft tissue depth is associated with stalling of magnetically controlled growing rods.

Background: Magnetically controlled growing rods (MCGR) represent the most used implant for the treatment of early onset scoliosis (EOS). These implants lengthen through the application of a remote magnetic field but distraction force generation has been negatively correlated with increasing soft tissue depth. Given the high rate of MCGR stalling, we proposed to investigate the impact of preoperative soft tissue depth on the rate of MCGR stalling at a minimum of 2 years following implantation. Methods: A single-center, retrospective review of prospectively enrolled children with EOS treated with MCGR was performed. Children were included if they had a minimum of 2-years follow-up after implantation and underwent advanced spinal imaging (MRI or CT) preoperatively within a year of implantation. The primary outcome was the development of MCGR stall. Additional measures included radiographic deformity parameters and gain in MCGR actuator length. Results: About 55 patients were identified with 18 having preoperative advanced imaging allowing tissue depth measurement (Mean 5.99 ± 1.9 years, 83.3% female, mean Cobb 68.6 ± 13.8°). At a mean follow-up of 46.1 ± 11.9 months, 7 patients (38.9%) experienced stalling. MCGR stalling was associated with increased preoperative soft tissue depth (21.5 ± 4.4 mm vs. 16.5 ± 4.1 mm; p = .025) and increased BMI (16.3 ± 1.6 vs. 14.5 ± 0.9; p = .007). Conclusions: Greater preoperative soft tissue depth and BMI were associated with the development of MCGR stalling. This data supports previous studies showing that the distraction capacity of MCGR diminishes with increased soft tissue depth. Further research is needed to validate these findings and their implications on the indications for MCGR implantation.

Skeletal Maturity in Legg-Calve-Perthes Disease: Significant Discrepancy Present Between the Hand and the Hip.

BACKGROUND: The concept of delayed skeletal maturity in Legg-Calve-Perthes Disease (LCPD) has been well identified with the Greulich and Pyle (GP) atlas showing 1 to 2 years delay. Recently the optimized Oxford hip skeletal age (Optimized Oxford) system has been developed and shown to have similar accuracy as the GP atlas for assessing skeletal maturity. However, this system has not been used to assess skeletal maturity in LCPD. METHODS: A retrospective review of a prospective, multicenter study of patients with LCPD treated from 1984 to 1991 and followed to skeletal maturity was performed. We identified all patients who had a left-hand radiograph at the time of presentation with an accompanying anteroposterior pelvis radiograph including the contralateral hip. Patients were excluded if their age at presentation fell outside the validated range for the Optimized Oxford system. GP atlas was used to determine bone age using left-hand radiographs and the nonaffected hip radiographs were used to calculate the Optimized Oxford bone age. Skeletal maturity indices were compared with chronological age (CA) to determine the discrepancy between methodologies. RESULTS: A total of 71 patients met inclusion criteria (mean 9.5 ± 1.2 y at presentation, 42.2% females). The mean GP bone age was 1.4 years younger than CA (95% CI: 1.01-1.76 y), with the discrepancy being greater for boys than girls (1.8 vs 0.86 y, P = 0.02). The mean Optimized Oxford bone age was 0.31 years older than CA (95% CI: 0.24-0.38 y) and correlated significantly with CA ( R = 0.97, P < 0.001). There were no sex differences in the Optimized Oxford bone age relative to CA ( P = 0.32). The GP bone age was a mean of 1.7 years younger than the Optimized Oxford bone age (95% CI: 1.35-2.05 y). CONCLUSION: Skeletal maturity assessment in children with LCPD varies according to the utilized maturity system. The Optimized Oxford bone age more closely mirrors the patient's CA and does not correlate with the GP bone age, which reveals a delayed maturation.

The evolving stall rate of magnetically controlled growing rods beyond 2 years follow-up.

PURPOSE: Magnetically controlled growing rods (MCGR) have become the dominant distraction-based implant for the treatment of early onset scoliosis (EOS). Recent studies, however, have demonstrated rising rates of implant failure beyond short-term follow-up. We sought to evaluate a single-center experience with MCGR for the treatment of EOS to define the rate of MCGR failure to lengthen, termed implant stall, over time. METHODS: A single-center, retrospective review was conducted identifying children with EOS undergoing primary MCGR implantation. The primary endpoint was the occurrence of implant stalling, defined as a failure of the MCGR to lengthen on three consecutive attempted lengthening sessions with minimum of 2 years follow-up. Clinical and radiographic variables were collected and compared between lengthening and stalled MCGRs. A Kaplan-Meier survival analysis was conducted to assess implant stalling over time. RESULTS: A total of 48 children met inclusion criteria (mean age 6.3 ± 1.8 years, 64.6% female). After a mean 56.9 months (range of 27 to 90 months) follow-up, 25 (48%) of children experienced implant stalling at a mean of 26.0 ± 14.1 months post-implantation. Kaplan-Meier survival analysis demonstrated that only 50% of MCGR continue to successfully lengthen at 2 years post-implantation, decreasing to < 20% at 4 years post-implantation. CONCLUSION: Only 50% of MCGR continue to successfully lengthen 2 years post-implantation, dropping dramatically to < 20% at 4 years, adding to the available knowledge regarding the long-term viability and cost-effectiveness of MCGR in the management of EOS. Further research is needed to validate these findings.

Avoiding PICU admission following PSF for neuromuscular scoliosis in non-ambulatory cerebral palsy managed with ERAS protocol.

PURPOSE: Children with neuromuscular scoliosis (NMS) undergoing posterior spinal fusion (PSF) have historically been managed post-operatively in the pediatric intensive care unit (PICU) due to institutional tendencies. This study sought to define risk factors for PICU admission when using an enhanced recovery after surgery (ERAS) pathway. METHODS: A retrospective review of children with non-ambulatory (GMFCS 4 or 5) cerebral palsy undergoing PSF for NMS performed at two institutions by 5 surgeons. Both institutions have a pre-existing ERAS pathway for NMS patients consisting of post-surgical transfer to the hospital floor with early reinstitution of feeding and mobilization. PICU admission is used at the discretion of the surgeon and anesthesiologist rather than by institutional decree. Patient and surgical factors were assessed for risk factors of PICU admission. RESULTS: A total of 103 children were included (84% GMFCS 5, mean 14.52 years (± 3.4 years)). Forty children (38.8%) required postoperative PICU admission. PICU admission was associated with seizure disorder (P = 0.09), pre-existing feeding tube (P = 0.003), tracheostomy (P = 0.03), and modified GMFCS-5 subclassification (P = 0.003). Independent predictors of PICU admission include pre-existing feeding (Odd's ratio = 2.9, P = 0.02) and length of surgery (Odd's ratio = 2.6, P < 0.001), with surgery lasting ≥ 5.0 h having an 82.5% sensitivity and 63.5% specificity (AUC 0.8, P < 0.001) for post-operative PICU admission. CONCLUSION: The majority of children with non-ambulatory cerebral palsy can be successfully managed on the hospital floor following PSF. The extent of central neuromotor impairment is significantly associated with PICU admission along with surgery lasting longer than 5 h.

Impact of surgical treatment on parent-reported health related quality of life measures in early-onset scoliosis: stable but no improvement at 2 years.

PURPOSE: The etiology of early-onset scoliosis (EOS) has been shown to significantly influence baseline parent-reported health-related quality of life (HRQoL) measures as assessed by the Early Onset Scoliosis Questionnaire (EOSQ). We sought to assess the influence of distraction-based surgery and scoliosis etiology on EOSQ 2 years following surgical intervention remains unclear. METHODS: A retrospective review of a multi-center prospective EOS database was performed. Children untreated with distraction-based, growth friendly instrumentation for EOS with completed baseline and 2-year post-surgical EOSQ were included. Children were subdivided by curve etiology individually and in combined cohorts (congenital/idiopathic [C/I], neuromuscular/syndromic [NMS]). EOSQ domains and compositive HRQoL score at presentation and 2-year follow-up were compared across C-EOS etiologies. Minimal clinically important difference (MCID) was defined as ≥ 20% change in domain score and compared across etiologies. RESULTS: 150 children with EOS met inclusion criteria (mean 7.09 ± 2.6 years, 58.9% female). There were no differences in EOSQ domains between Congenital vs. Idiopathic nor NM vs. Syndromic etiologies at any timepoint. Combined C/I children demonstrated significantly higher EOSQ scores than combined NMS at initial and 2-years post-treatment. Etiology remained the only independent predictor of 2-year EOSQ composite HRQoL score. Overall, the vast majority of children demonstrated stable HRQoL composite scores, with a trend toward more positive MCID in NMS etiologies. CONCLUSION: EOS etiology remains the most significant influence on EOSQ scores 2 years following surgical intervention. However, the majority of patients, regardless of etiology, maintain stable HRQoL scores suggesting that surgery may only serve to stabilize HRQoL at 2 years.

Effects of distraction-based distal fixation on pelvic parameter development in early onset scoliosis.

PURPOSE: Prior studies have suggested that distraction-based treatment for early onset scoliosis (EOS) may impede the natural development of the sagittal spinal alignment and pelvic parameters. However, to date no study has investigated the effect of distal fixation on pelvic development. METHODS: Ambulatory children with EOS undergoing index distraction-based treatment with distal fixation below T11 were retrospectively reviewed. Patients with distal fixation to the pelvis were identified and compared to children with Spine-based fixation at T12-L5. Radiographic measurements were performed for coronal and sagittal alignment in addition to pelvic parameters (pelvic incidence (PI), pelvic tilt (PT), and sacral slope (SS) and compared at initial presentation, first erect radiograph, and at 2 years following instrumentation. RESULTS: 33 ambulatory children were identified with a minimum of 2-year follow-up (25 female, average 6.59 ± 2.6 years), with 33% (N = 11) instrumented to the pelvis (54.4% female, average 4.42 ± 2.2 years, initial Cobb 76.1°). Children in the pelvis cohort were significantly younger at treatment initiation (P < 0.001). There was no significant difference in PI at the study time periods, however, there was a significant change in PI between presentation and 2-year follow-up with the pelvic fixation demonstrating a mean 12.3° decrease in PI vs a 3.8° increase in the spine-based cohort (P = 0.027). DISCUSSION: Distal fixation to the pelvis in ambulatory children with EOS treated with growth-friendly instrumentation was associated with a mean decrease in PI of 12.3° that developed over the 2-year treatment duration. Further research is needed to investigate the long-term implications of these findings on pelvic and spinal development.

Senior Military Rank Is Associated With Higher Rates of Return to Running and Unrestricted Activity Among Military Servicemembers After Surgical Repair of Patellar Tendon Rupture at 1-Year Follow-up.

Purpose: To evaluate 1-year outcomes in active-duty servicemembers who underwent patellar tendon rupture repair and to identify baseline variables associated with return to activity. Methods: We performed a retrospective review of all active-duty servicemembers undergoing primary patellar tendon rupture repair between 2009 and 2014. All patients had a minimum 12-month follow-up. Demographic variables were recorded, as well as ability to return to impact activities and remain on active-duty status. Rates of recurrent rupture and revision surgery were identified. Univariate analysis was performed to assess relations between outcomes and baseline variables. Results: A total of 123 patients met the inclusion criteria (average age, 33.5 ± 6.6 years; 99% male patients) with a mean follow-up period of 4.3 ± 2.2 years. Whereas 67.4% of patients returned to running at an average of 8.3 months from index surgery, only 42.4% of patients resumed unrestricted occupational function. Higher rates of return to running were observed among patients with senior military rank (P = .046). Senior military rank was also associated with a higher rate of return to unrestricted active-duty status (P = .006). Logistic regression analysis showed an association between postoperative pain (odds ratio [OR], 0.684; 95% confidence interval [CI], 0.56-0.84; P < .001) and return to running, between postoperative pain (OR, 0.77; 95% CI, 0.60-0.98; P = .033) and return to active duty, and between rank (OR, 2.06; 95% CI, 1.04-4.07; P = .037) and return to active duty. Patients who sustained injuries during deployment had a higher rate of recurrent rupture (26.1% vs 9.3%, P = .028). Conclusions: At 1-year follow-up, approximately two-thirds of military servicemembers undergoing primary patellar tendon repair had returned to running after surgery, whereas fewer than one-half returned to full military duty. Younger age and more senior military rank were associated with higher rates of return to running. Additionally, servicemembers of higher rank, particularly officers, had statistically higher rates of return to unrestricted activity. Level of Evidence: Level IV, therapeutic case series.

The Subcapital Femoral Neck Stress Fracture: A Novel Subtype of Compression-sided Stress Fracture-A Report of Three Cases.

Femoral neck stress fractures (FNSFs) are increasingly common, particularly in military training. The usual mode of classifying these injuries is based on the involvement of the compression or tension side of the femoral neck; however, this may oversimplify and fail to address factors such as the orientation of the fracture line. We present a novel subtype of a compression-sided FNSF affecting the subcapital femoral neck and report the treatment outcomes in a military trainee population. A retrospective analysis of patients with a subcapital, compression-sided FNSF was identified from a single U.S. Army basic trainee installation. Radiographic evaluation as well as treatment outcomes associated with the ability to complete military training were reported. A total of three patients with a subcapital compression-sided FNSF were identified in a military trainee population, accounting for 10% of all FNSFs that developed over a 3-month period. Of these individuals, one was treated operatively while the other two were treated non-operatively. Overall, one patient was able to return to and successfully complete military training.

1- vs. 2-year follow-up after posterior spinal fusion for AIS: what additional information is gained?

PURPOSE: Traditionally, 2-year follow-up data have been the established standard for reporting clinical outcomes following spinal deformity surgery. However, previous studies indicate that 2-year follow-up does not represent long-term outcomes. Currently, there is no clear data that demonstrate a difference in outcomes between the 1 and 2 years postoperative time-periods following posterior spinal fusions (PSF) for adolescent idiopathic scoliosis (AIS). METHODS: A multi-center, prospective database was queried for AIS patients treated with PSF. Clinical outcome scores, assessed by SRS-22, coronal and sagittal radiographic parameters were assessed at time periods: 6 months, 1 year, and 2 years post operatively. Complications and reoperation rates were also assessed. Statistical analysis compared outcomes variables across time-points to assess for significant differences. RESULTS: 694 patients (82.6% female, mean age at surgery 14.9 ± 2.13 years) were identified. Between post-operative year 1 and 2, significant difference in SRS-22 domain scores were present for function domain (4.5 vs. 4.6; p < 0.001), mental health domain (4.3 vs. 4.2; p < 0.001), and total domain score (4.4 vs. 4.4; p = 0.03) but were below the minimal clinically important difference threshold. New complication development was significantly higher within the first year following surgery than the 1-2 year follow-up period (p < 0.001) with greater complication severity within the 0-1 year follow-up period (P = 0.03). CONCLUSION: There are no clinically important changes in SRS-22 domain scores between 1 and 2 years following PSF for AIS, with higher complications in the first year following PSF. Two-year follow-up data provide little added clinical information while under-estimating the cumulative complication and reoperation rates at long-term follow-up.

Understanding Noise Exposure During Cast Removal: The Effect of Cast Saw Type and Casting Material.

BACKGROUND: Cast removal can be associated with considerable noise exposure, especially impacting the pediatric patient and provider. Although noise generation from cast saws has been deemed safe by the U.S. Occupational Safety and Health Administration and the U.S. Centers for Disease Control and Prevention standards, there are no current studies on the effects of cast material on noise levels generated. METHODS: A simulated casting model utilizing plaster, fiberglass, and plaster with fiberglass overwrapping was used for experimental testing. Four different casting conditions were tested, with 5 samples in each group. Samples were tested using 2 different cast saws: a standard cast saw and a quiet saw. Each saw was used for 30 seconds of continuous cutting for each sample, measuring peak, mean, and minimum sound levels in decibels with sound level meters. Noise levels were measured at 18, 36, and 72 in (20, 91, and 183 cm) from the saw, comparing saw and cast types against ambient noise and baseline cast-saw noises. Between-group comparisons were performed using univariate analyses. RESULTS: Mean noise generation differed between casting materials, with plaster material demonstrating significantly greater noise levels than fiberglass casts at all distances for each saw type. Increasing fiberglass thickness significantly increased the mean noise levels with standard (18-in distance for 10 and 5 ply: 87.4 and 85.8 dB; p = 0.0004) and quiet cast saws (78.3 and 76.1 dB; p = 0.041. Additionally, the quiet cast saw provided a 5.7 to 10.6 dB reduction in mean and peak noise levels, varying by casting material and distance. CONCLUSIONS: Occupational noise exposure can be mitigated with the use of fiberglass casting material that is not >5 ply in thickness, with a quiet cast saw for removal. The use of a quiet cast saw substantially decreased noise exposure to patients and staff members over standard orthopaedic cast saws.

Pectoralis Major Tendon Tears During Airborne Operations: Are These Injuries Isolated?

INTRODUCTION: Pectoralis major tendon tears are an injury pattern often treated in military populations. Although the majority of pectoralis major tendon tears occur during eccentric loading as in bench press weightlifting, military service members may also experience this injury from a blunt injury and traction force produced by static line entanglement during airborne operations. Although these injuries rarely occur in isolation, associated injury patterns have not been investigated previously. MATERIALS AND METHODS: After obtaining institutional review board approval, medical records were reviewed for all patients who underwent surgical repair of a pectoralis major tendon tear sustained during static line parachuting at a single institution. Radiology imaging, operative notes, and outpatient medical records were examined to determine concomitant injury patterns for each patient identified over a 4-year study period. RESULTS: Twenty-five service members met the study inclusion criteria. All patients underwent presurgical magnetic resonance imaging. Of these 25 service members, 10 (40%) presented with a total of 13 concomitant injuries identified on physical exams or imaging studies. The most common associated injuries were injuries to the biceps brachii and a partial tear of the anterior deltoid. Biceps brachii injuries consisted of muscle contusion proximal long head tendon rupture, proximal short head tendon rupture, partial muscle laceration, and complete muscle transection. Additional concomitant injuries included transection of coracobrachialis, a partial tear of the inferior subscapularis tendon, antecubital fossa laceration, an avulsion fracture of the sublime tubercle, and an avulsion fracture of the coracoid process. CONCLUSIONS: Military static line airborne operations pose a unique risk of pectoralis major tendon tear. Unlike the more common bench press weightlifting tear mechanism, pectoralis major tendon tears associated with static line mechanism present with a concomitant injury in 40% of cases, with the most common associated injury occurring about the biceps brachii. Treating providers should have a high index of suspicion for concomitant injuries when treating pectoralis major tendon tears from this specific mechanism of injury.

To tether or fuse? Significant equipoise remains in treatment recommendations for idiopathic scoliosis.

PURPOSE: Vertebral body tethering (VBT) continues to grow in interest from both a patient and surgeon perspective for the treatment of scoliosis. However, the data are limited when it comes to surgeon selection of both procedure type and instrumented levels. This study sought to assess surgeon variability in treatment recommendation and level selection for VBT versus posterior spinal fusion (PSF) for the management of scoliosis. METHODS: Surgeon members of the Pediatric Spine Study Group and Harms Study Group were queried for treatment recommendations and proposed upper instrumented vertebra (UIV) and lower instrumented vertebra (LIV) selection for PSF and VBT based on 17 detailed clinical vignettes. Responses were subdivided in each clinical vignette according to surgeon experience and treatment recommendations with assessment of intra-rater reliability. Binomial distribution tests were used to establish equipoise, selecting p < 0.10 to indicate the presence of a treatment choice with consensus set > 70% agreement. For treatment choice, responses were assessed first for consensus on the decision to proceed with PSF or VBT. RESULTS: Thirty-five surgeons with varied experience completed the survey with 26 surgeons (74%) completing the second follow-up survey. Overall, VBT was the recommended treatment by 47% of surgeons, ranging by clinical vignette. Consensus in treatment recommendation was present for 6 clinical vignettes including 3 for VBT and 3 for PSF, with equipoise present for the remaining 11. Of the 17 vignettes, 12 demonstrated moderate intra-observer reliability including the 3 consensus vignettes for VBT. Sanders stage ≤ 3 and smaller curve magnitude were related with VBT recommendation but neither age nor curve flexibility significantly influenced the decision to recommend VBT. Surgeons with high VBT volume, ≥ 11 VBT cases/year, were more likely to recommend VBT than those with low volumes (0-10 cases per year (p < 0.0001)). High VBT volume surgeons demonstrated consensus in VBT recommendation for Lenke 5/6 curves (75% mean recommendation). High VBT volume surgeons had a significantly higher VBT recommendation rate for Lenke 1A, 2A curves (71.8% vs 48.0%, p = 0.012), and Lenke 3 curves (62% vs 26.9%, p = 0.023). Equipoise was present for all vignettes in low volume surgeons. In addition, high VBT volume surgeons trended toward including more instrumented levels than low VBT volume surgeons (7.17 vs 6.69 levels). CONCLUSION: Significant equipoise is present among pediatric spine surgeons for treatment recommendations regarding VBT and PSF. Surgeon-, patient-, and curve-specific variables were identified to influence treatment recommendations, including surgeon experience, curve subtype, deformity magnitude, and skeletal maturity. This study highlights the need for continued research in identifying the optimal indications for VBT and PSF in the treatment of pediatric spinal deformity.

Surgically Treated Femoral Neck Stress Fractures Are Likely to Result in Military Separation During Basic Combat Training.

BACKGROUND: Femoral neck stress fractures are a common condition affecting military service members, most noticeably during basic combat training. Previous studies have investigated the risk factors for femoral neck stress fracture development in basic trainees and outcomes associated with treatment; however, few studies have focused on operatively treated femoral neck stress fracture in the military trainee. Doing so would be important not only for the military, but also providers caring for athletes, such as distance runners, who have a heightened risk for femoral neck stress fracture development. QUESTIONS/PURPOSES: (1) What proportion of US Army trainees completing basic combat training at Fort Jackson, SC, USA, who undergo surgery for femoral neck stress fracture during basic training subsequently leave military service because of the injury? (2) What factors are related to the patient or the fracture are associated with a higher likelihood of military separation? (3) What factors on the initial MRI are associated with progression of the stress fracture extent? METHODS: A retrospective study of a longitudinally maintained database of stress injuries involving basic combat trainees from a single military post was reviewed over a 3-year period. Inclusion criteria included basic trainees undergoing surgery for a femoral neck stress fracture between January 2018 and June 2020 with a minimum of 1-year follow-up. Surgery was indicated for service members with complete and tension-sided femoral neck stress fractures and those with high risk compression-sided stress fractures, generally representing fractures involving more than 50% of the femoral neck width. Over the study period, 57 service members (51% [29 of 57] women with a mean age of 24 years) underwent surgery for a femoral neck stress fracture, and all 57 had a minimum of 1-year follow-up. Identified service members underwent independent data collection including injury and radiographic parameters based on chart and imaging review. Documented fracture line progression on repeat imaging was present in 39% of service members, with a mean fracture line progression of 55% of the femoral neck width. Service members were subdivided based upon the ability to return to military service at 1 year. Univariate analysis was performed using patient and injury variables to identify factors associated with the ability to return to military service. RESULTS: Overall, 58% (33 of 57) of service members who had a femoral neck stress fracture treated surgically underwent military separation. A higher proportion of service members who demonstrated fracture line progression leading to surgical treatment remained in the military (58% [14 of 24] versus 30% [10 of 33]; odds ratio 0.3 [95% confidence interval (CI) 0.1 to 0.9]; p = 0.03). With the numbers available, we found no other patient- or fracture-related variables associated with military separation, although we suspect we may have been underpowered on some of these comparisons, in particular gender (61% [20 of 33] of individuals separated after surgery for this injury were women compared with 38% [9 of 24] who were retained; OR 2.6 [95% CI 0.9 to 7.56]; p = 0.09). The extent of osseous edema on T1-weighted imaging in association with a hip effusion demonstrated a significant positive correlation with final fracture percentage (r = 0.62; p = 0.003). CONCLUSION: Military service members with a femoral neck stress fracture initially managed nonoperatively but with progression of the fracture line requiring surgical intervention were more likely to return to military duties and complete basic combat training, suggesting that early diagnosis of femoral neck stress fractures may be associated with better functional recovery after surgical treatment. Additionally, the extent of the osseous edema on initial MRI T1-weighted imaging sequences may help predict the final extent of femoral neck stress fractures on repeat imaging. Further investigations should incorporate patient-reported outcomes and further explore factors associated with fracture progression and the inability to return to active duty or sport. LEVEL OF EVIDENCE: Level III, therapeutic study.