Outcomes in Early Versus Delayed Management of Pediatric Femoral Shaft Fractures.

OBJECTIVE: There is a paucity of literature regarding the timing of treatment for pediatric femur fractures. The purpose of this study was to analyze whether early versus delayed management of pediatric femoral shaft fractures would impact outcomes regarding time to union and return to baseline function. METHODS: Pediatric patients presenting with femoral shaft fractures, from January 1, 2010 to January 1, 2021, were identified using the Pediatric Trauma Database at a single Level One Trauma Center and retrospectively reviewed. Demographic information, surgical details, associated injuries, length of follow-up, time to union, and return to baseline function were collected. Patients were then divided into 2 groups; the early intervention group underwent treatment within 24 hours of admission versus the delayed group, which underwent treatment after 24 hours. Patients with neuromuscular disease, pathologic fracture, slipped capital femoral epiphysis, nonambulatory, younger than 6 months old, or had follow-up of <8 weeks posttreatment were excluded. χ 2 and unpaired Student t tests were used to compare outcomes. A P value ≤0.05 was used as the threshold of statistical significance. RESULTS: Of the 169 cases reviewed, 137 met the inclusion criteria. The mean age was 8.0 ± 5.0 (6 mo to 16 y). The average follow-up time was 1.4 ± 1.4 years. Thirty-two (19%) patients did not meet the inclusion criteria and were excluded from the study. One hundred twenty-two (89%) patients were in the early intervention group versus 15 (11%) in the delayed intervention group. There were no statistically significant differences between the early and the delayed arms in regard to time to union, quality of final reduction, and return to baseline function. CONCLUSION: The findings of this study support that the timing of surgical intervention of femoral shaft fractures in the pediatric population is not correlated to time to union and final function. Clinically, prompt treatment of pediatric femoral shaft fractures should not supersede medical methods of resuscitation and likely has no bearing on the final outcome. LEVEL OF EVIDENCE: Level III.

Septic Arthritis of the Pubic Symphysis in a 16-Year-Old Male Adolescent: A Case Report.

CASE: A 16-year-old male adolescent presented with 4 weeks of right-sided hip pain and fever in the setting of recent groin trauma. He was diagnosed with septic arthritis of the pubic symphysis (SAPS) and was treated nonoperatively with antibiotics. Symptoms recurred, and he underwent surgical drainage of the pubic symphysis followed by a prolonged course of antibiotics. Follow-up at 12 months indicated complete symptom resolution. CONCLUSION: This is the ninth reported adolescent case of SAPS. Although the presentation and disease course closely resembled those reported in the literature, this is the only case that required surgical intervention after failed nonoperative management.

Epidemiologic patterns of adolescent idiopathic scoliosis detection and treatment in new york state.

The purpose of this study is to examine the epidemiologic trends of adolescent idiopathic scoliosis (AIS) detection and treatment in New York State (NYS), including disparities in access. The New York Statewide Planning and Research Cooperative System database was reviewed to identify patients who underwent treatment for, or were diagnosed with, AIS from 2008 to 2016. Age determined adolescence; and the surgery date, 3-digit zip code, sex, race, insurance status, institution and surgeon license number were recorded to identify such trends. The geographical distribution was assembled from an NYS shapefile, obtained from the Topologically Integrated Geographic Encoding and Referencing database with analysis performed using tigris R. In total 54 002 patients with AIS, 3967 of whom were surgically treated, were identified for analysis. Diagnoses spiked in 2010. Females were diagnosed and underwent surgical treatment more frequently than males. AIS was diagnosed and treated in white patients more frequently than in black and Asian patients combined. From 2010 to 2013, the patients self-paying for surgical treatment decreased more than other payment modalities. Medium-volume surgeons continually increased the number of cases performed, whereas low-volume surgeons exhibited the opposite pattern. High-volume hospitals had a decrease in the number of cases from 2012 and were overtaken by medium-volume hospitals in 2015. Most procedures are performed within the New York City (NYC) area, though AIS was common in all NYS counties. AIS diagnoses increased after 2010, with fewer patients self-paying for surgery. White patients underwent more procedures than minority patients. Surgical cases were disproportionally performed in the NYC area compared to statewide.

What is New in Pediatric Orthopaedic: Basic Science.

BACKGROUND: An understanding of musculoskeletal basic science underpins most advancements in the field of orthopaedic surgery. Knowledge of biomechanics, genetics, and molecular pathways is integral to the understanding of the pathophysiology of disease and guides novel treatment options to improve patient outcomes. The purpose of this review is to provide a comprehensive and current overview of musculoskeletal basic science relevant to pediatric orthopaedic surgery. METHODS: Comprehensive Pubmed database searches were performed for all English language articles published between January 2016 and November 2021 using the following search terms: basic science, pediatric orthopaedics, fracture, trauma, spine, scoliosis, DDH, hip dysplasia, Perthes, Legg-Calve-Perthes, clubfoot, and sports medicine. Inclusion criteria focused on basic science studies of pediatric orthopaedic conditions. Clinical studies or case reports were excluded. A total of 3855 articles were retrieved. After removing duplicates and those failing to meet our inclusion criteria, 49 articles were included in the final review. RESULTS: A total of 49 papers were selected for review based on the date of publication and updated findings. Findings are discussed in the subheadings below. Articles were then sorted into the following sub-disciplines of pediatric orthopaedics: spine, trauma, sports medicine, hip, and foot. CONCLUSIONS: With this review, we have identified many exciting developments in pediatric orthopaedic trauma, spine, hip, foot, and sports medicine that could potentially lead to changes in disease management and how we think of these processes. LEVEL OF EVIDENCE: Level V.

Radiation in Adolescent Idiopathic Scoliosis Management: Estimated Cumulative Pre-Operative, Intra-Operative, and Post-Operative Exposure.

Background: Adolescent Idiopathic Scoliosis (AIS) is the most common type of scoliosis affecting adolescents, with approximately 2-4% of children being diagnosed. Crucial to the diagnosis and management are radiographic imaging, which allow physicians to assess and treat - from initial visits through surgical planning and post-operative management. While initial stages require low levels of exposure to radiation, via x-rays, as patients progress in disease severity exposure becomes larger with pre-operative, intra-operative and post-operative CT scans. While many studies have evaluated exposure during AIS treatment, few have assessed the cumulative radiation exposure adolescents receive during their evaluation. The purpose of our study is to complete a comprehensive review on cumulative radiation exposure and determine what stages in AIS treatment expose patients to the highest level of radiation over a duration of 2 years. Methods: A retrospective chart review of 109 AIS cases (29M, 80F), mean age 14.9 ± 2.3 years was completed to assess and quantify each imaging modality used. Employing a radiation detector, each imaging modality was then assessed, and estimated radiation exposures were determined. Statistical analysis was completed utilizing averaged patient exposures during each selected period in AIS management. Results: Mean estimated radiation doses (StDev) were 60.94 mrem (±0.609 mrem) for two x-rays (full-length AP and lateral radiograph of the entire spine), 12.92 mrem (±1.292 mrem) for each fluoroscopy exposure, and 1340.60 mrem (±13.406 mrem) per CT scan. Based on these values, estimated subject exposures were calculated. The total estimated radiation exposure over a 2-year period was 5572.74 mrem (±1428.88 merm) or 2786.37 mrem (±714.43 mrem) per year. Conclusion: The two-year cumulative radiation exposure is below the recommended exposure by Nuclear Regulatory Commission and OSHA. As expected, CT exposure presents the largest radiation exposure to patients with AIS throughout their operative management. Level of Evidence: III, retrospective study.

Clubfoot Cast Simulation Using Pressure Sensors: A Novel Way to Teach the Ponseti Method.

OBJECTIVE: The standard of care in treating congenital clubfoot is the Ponseti method. Resident education of this skill traditionally involves direct casting of patients with attending feedback. With increased clinical time demands, mastery of the skill may not be achievable using direct resident - patient interactions. We describe a novel Ponseti cast simulator using pressure sensors to teach this skill. DESIGN: A novel Ponseti cast simulator was constructed using a standardized model and pressure sensors. A pre-training baseline (trial 1) and post education (trial 2) was made and scored using an objective structured assessment of technical skill (OSATS) checklist. Pressure sensors were placed at the first metatarsal and talar head to record cast forces. SETTING: The study was performed in the Department of Orthopedic Surgery at an academic tertiary care hospital. PARTICIPANTS: Study participants included 6 junior orthopedic residents defined as post-graduate year (PGY) 1 to 3, 6 senior orthopedic residents (PGY 4,5), and a board -certified pediatric orthopedic surgeon to serve as a control. RESULTS: Trial 1 OSATS scores were significantly higher in senior residents (9.7 ± 1.5) than junior residents (5.2 ± 1.2) (p = 0.004). Trial 2 OSATS scores were also significantly higher in senior residents than junior residents: 13.7 ± 1.4 vs. 5.8 ± 1.6 (p = 0.003). Additionally, senior residents significantly improved scores between the first 2 trials 9.7 ± 1.5 vs. 13.7 ± 1.4 (p = 0.003), while junior residents did not 5.2 ± 1.2 vs. 5.8 ± 1.6 (p = 0.4566). In addition, there were no significant differences between junior, and senior resident Trial 1 talar head pressures or first metatarsal pressures, or Trial 2 first metatarsal pressures. CONCLUSIONS: This is the first casting simulation model to use pressure sensors as a way to objectively measure cast application pressure. This simulator may be useful in an orthopedic training programs to teach Ponseti casting.

One Affectionate Puppy: A Case of Septic Arthritis Due to Staphylococcus Pseudintermedius.

We describe a case of septic arthritis caused by Staphylococcus pseudintermedius, a common colonizer of dogs that has emerged as a rare human pathogen. Our patient presented with ankle pain and swelling and was treated adequately with cefazolin/cephalexin and arthrotomy. S. pseudintermedius is often misidentified as other coagulase-positive staphylococcal species and has high rates of methicillin and nonpenicillin antibiotic resistance.

Multi-Site Optical Monitoring of Spinal Cord Ischemia during Spine Distraction.

Optimal surgical management of spine trauma will restore blood flow to the ischemic spinal cord. However, spine stabilization may also further exacerbate injury by inducing ischemia. Current electrophysiological technology is not capable of detecting acute changes in spinal cord blood flow or localizing ischemia. Further, alerts are delayed and unreliable. We developed an epidural optical device capable of directly measuring and immediately detecting changes in spinal cord blood flow using diffuse correlation spectroscopy (DCS). Herein we test the hypothesis that our device can continuously monitor blood flow during spine distraction. Additionally, we demonstrate the ability of our device to monitor multiple sites along the spinal cord and axially resolve changes in spinal cord blood flow. DCS-measured blood flow in the spinal cord was monitored at up to three spatial locations (cranial to, at, and caudal to the distraction site) during surgical distraction in a sheep model. Distraction was halted at 50% of baseline blood flow at the distraction site. We were able to monitor blood flow with DCS in multiple regions of the spinal cord simultaneously at ∼1 Hz. The distraction site had a greater decrement in flow than sites cranial to the injury (median -40 vs. -7%,). This pilot study demonstrated high temporal resolution and the capacity to axially resolve changes in spinal cord blood flow at and remote from the site of distraction. These early results suggest that this technology may assist in the surgical management of spine trauma and in corrective surgery of the spine.

Diffuse Correlation Spectroscopy Analysis Implemented on a Field Programmable Gate Array.

Diffusive correlation spectroscopy (DCS) is an emerging optical technique that measures blood perfusion in deep tissue. In a DCS measurement, temporal changes in the interference pattern of light, which has passed through tissue, are quantified by an autocorrelation function. This autocorrelation function is further parameterized through a non-linear curve fit to a solution to the diffusion equation for coherence transport. The computational load for this non-linear curve fitting is a barrier for deployment of DCS for clinical use, where real-time results, as well as instrument size and simplicity, are important considerations. We have mitigated this computational bottleneck through development of a hardware analyzer for DCS. This analyzer implements the DCS curving fitting algorithm on digital logic circuit using Field Programmable Gate Array (FPGA) technology. The FPGA analyzer is more efficient than a typical software analysis solution. The analyzer module can be easily duplicated for processing multiple channels of DCS data in real-time. We have demonstrated the utility of this analyzer in pre-clinical large animal studies of spinal cord ischemia. In combination with previously described FPGA implementations of auto-correlators, this hardware analyzer can provide a complete device-on-a-chip solution for DCS signal processing. Such a component will enable new DCS applications demanding mobility and real-time processing.

Appropriateness of Pediatric Orthopaedic Transfers to a Level 1 Hospital.

OBJECTIVE: To compare a cohort of transferred pediatric orthopaedic patients with orthopaedic patients who primarily presented to a Level 1 pediatric emergency department to identify risk factors for transfer. DESIGN: Retrospective cohort study. SETTING: Level 1 trauma center in New York. PATIENTS: The cohort consisted of patients younger than 18 years who presented to 1 Level 1 pediatric trauma center between January 1, 2013, and December 31, 2013, with an orthopaedic fracture diagnosis code (ICD-9 805.0-839.9). The control group included the patients who presented to that hospital primarily, and the study group included patients who were transferred to that same hospital from another institution. INTERVENTION: Demographic and injury-related data [age, sex, mechanism of injury, location of injury, injury severity score, and insurance status] were collected. MAIN OUTCOME MEASUREMENTS: Regression analysis was performed to assess for predictors of transfer to a Level 1 hospital. Subgroup analysis examined whether transfers were appropriate, based on the type of injury. RESULTS: There were 1064 patients in the nontransfer group and 67 patients in the transfer group. Transferred patients were more likely to have surgery within 24 hours (39.42% vs. 2.63%) and were more likely to have no insurance or Medicaid (50.75% vs. 33.24%). Injury severity score and insurance status were independent predictors for transfer. CONCLUSIONS: This study indicates that injury severity is the primary predictor in deciding to transfer a pediatric patient; however, insurance status may play a role in that decision. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Development of a Saw Bones Model for training pedicle screw placement in scoliosis.

OBJECTIVE: The purpose of this study was to determine if a Sawbones Scoliosis Model could be used as a simulator to train residents in placing pedicle screws-a complex procedure with a steep learning curve. Surgical simulation, a common tool teaching residents complex procedures in a safe environment, was staged using a Sawbones Scoliosis Model. Ten junior and ten senior residents out of 25 total possible residents (80%) were instructed how to place pedicle screws using the free-hand technique. They were then asked to place them unilaterally from T4 to L4 and were assessed on completion time, accuracy placement accuracy, and overall competency using an objective rating scale. RESULTS: Senior residents had an average time to completion of 38.9 ± 4.7 min vs. junior's 50.1 ± 11.7 min, and a pedicle screw accuracy of 43.6 ± 6.4% vs. junior's 44.4 ± 17.4%. Overall competency scores were similar for both groups; however, senior residents scored higher in the time and motion subdomain. Senior residents had a faster completion time and were more efficient, suggesting greater experience in spine surgery. The low rate of screw accuracy in both groups validates that simulation is a safe way for trainees to learn complex tasks.

Heterotopic Ossification of the Peroneus Brevis Tendon in a Pediatric Patient.

Heterotopic ossification (HO) is abnormal formation of mature lamellar bone in soft tissues. HO is most commonly diagnosed in the setting of localized trauma, which results in improper differentiation of progenitor cells, leading to aberrant tissue formation. In the pediatric population, nongenetic causes of HO have rarely been reported, especially HO involving the tendons of the ankle. We present a case of HO of the peroneus brevis tendon without systemic disease in a pediatric patient. The patient was a 7-year-old female with a normal birth and developmental history who first presented 6 weeks after a right ankle sprain with pain localized to the lateral calcaneus. Prominent swelling and tenderness to palpation were noted over the peroneal tubercle. Radiographic imaging showed dystrophic calcification within the peroneus brevis tendon. After failed conservative management, the heterotopic ossified mass (1.5 × 0.3 cm) was excised from the peroneus brevis tendon. The tendon was primarily repaired. The patient was followed up for 12 weeks postoperatively and achieved full resolution of her pain with a return to normal activity. HO has been theorized to be the result of an imbalance between bone mineralization and demineralization. In the setting of localized trauma, inductive agents have been implicated in pathologic bone formation. In the pediatric population, HO has rarely been diagnosed in the absence of genetic causes. In patients presenting with lateral foot and ankle pain, HO of the peroneal tendons should be considered in the differential diagnosis. In a patient with pain secondary to HO, surgical excision of the heterotopic mass can achieve symptom resolution.

Biomechanical Comparison of Spinopelvic Fixation Constructs: Iliac Screw Versus S2-Alar-Iliac Screw.

STUDY DESIGN: Biomechanical cadaveric study. OBJECTIVE: To compare the biomechanical properties of the iliac and S2-Alar-Iliac (S2AI) screw in a similar spinopelvic fixation construct. SUMMARY OF BACKGROUND DATA: Spinopelvic fixation is used in the correction of pelvic obliquity, high-grade spondylolisthesis, and long spinal fusions. With the development of pedicle screw fixation, the iliac screw has been used as an anchor point to the pelvis. The associated morbidity with this fixation has led to the development of the S2AI screw. Many studies have examined the biomechanical properties of iliac and S2AI screws; however, a direct comparison has not been performed. METHODS: Eight cadaveric spines were instrumented with pedicle screws bilaterally at L5 and S1. Four specimens were further instrumented with iliac screws placed with a starting point at the posterior superior iliac spine, and four specimens were instrumented with S2AI screws placed with a starting point 1 mm inferolateral to the S1 foramen. Screws were connected with 6.35 mm rods. Subfailure testing was performed by loading at 1°/second to a torque of 10 Nm in four directions: left bending, right bending, extension, and flexion. Specimens then underwent a monotonic load to failure under flexion at a rate of 1°/second. RESULTS: There were no significant differences for torsional stiffness in extension, flexion, left bending, or right bending between S2AI and iliac screw constructs. There were no significant differences in S2AI versus iliac screws for failure torque (30.9 ± 12.00 Nm vs. 22.61 ± 6.25 Nm) and yield torque (11.86 ± 0.41 Nm vs. 12.01 ± 1.70 Nm). CONCLUSION: Iliac screws have been associated with increased dissection, wound complications, an additional construct failure point, and hardware prominence. The S2AI screw was developed as an alternative and has been associated with less morbidity. The iliac and S2AI screw demonstrate no statistical difference in stiffness and load-to-failure in a spinopelvic fixation model. LEVEL OF EVIDENCE: Level V.

Effect of Different Distal Fixation Augmentation Methods on the Pullout Strength of Fassier-Duval Telescoping Rods.

Antegrade telescoping rods have been introduced for use in pediatric patients with osteogenesis imperfecta (OI) to decrease the incidence of long-bone fractures and to correct and prevent deformities. Recent studies have documented failures of telescoping intramedullary rods due to inadequate distal fixation. The purpose of this study was to evaluate the pullout strength of distal fixation of the telescoping rod with and without synthetic calcium phosphate or polymethylmethacrylate (PMMA) augmentation. Four sets of 6 telescoping distal fixation rods were fixed according to standard insertion technique into an open-cell rigid-foam synthetic bone block simulating OI bone. The groups tested were as follows: control (no augmentation), 0.75 mL of PMMA-augmented, 0.75 mL of PMMA-rescued (stripped distal fixation, then resecured after PMMA augmentation), and 0.75 mL of bioabsorbable-calcium phosphate (CP)-augmented. All rods were tested to failure. The peak load was recorded. Average pullout strengths were as follows: control, 20±6.6 N; PMMA, 125±16.8 N; PMMA-rescued, 137±11.9 N; bioabsorbable-CP, 81±10.3 N. All augmented groups had significantly higher pullout strength compared with the control (P<.001). The PMMA and PMMA-rescued groups failed at the PMMA/bone interface, whereas the bioabsorbable-CP group failed at the cement/rod interface. All augmented constructs improved pullout strength by at least 400% compared with the control. Bioabsorbable cement may be less detrimental to the physis if pullout still occurs despite augmentation due to its mode of failure. This study provides biomechanical evidence to support the further in vivo investigation of either PMMA or bioabsorbable cement augmentation to improve pullout strength of distal telescoping rod fixation.

Do Intraoperative LIV-Tilt and Disk Angle Remain Stable at 2-year Follow-up Compared With Upright Radiographs in Patients With Idiopathic Scoliosis?: A Retrospective Cohort Study.

STUDY DESIGN: This study was a retrospective chart and radiographic review. OBJECTIVE: The aim of this study was to determine if lowest instrumented vertebra (LIV) tilt and disk wedging measured intraoperatively correlated to their respective values on standing radiographs at intermediate follow-up. SUMMARY OF BACKGROUND DATA: No guidelines exist regarding an acceptable intraoperative LIV-tilt. MATERIALS AND METHODS: After IRB approval, a consecutive series of patients with adolescent idiopathic scoliosis (AIS) and structural lumbar curves treated with posterior spinal fusion (PSF) at a single institution between 2007 and 2010 was identified. A total of 163 patients with AIS underwent PSF during this time period. Seventeen patients had fusion of structural lumbar curves with adequate imaging and a minimum 2-year follow-up. The LIV-tilt and disk angle below the LIV was measured on the preoperative standing, intraoperative supine fluoroscopy and postoperative standing radiographs, and coronal balance was measured on the preoperative and postoperative standing radiographs using a standardized method separately by 2 authors. RESULTS: The curve distribution was as follows: Lenke 3 (29%), Lenke 5 (47%), and Lenke 6 (24%). There was agreement on radiographic measurements between the 2 authors with a correlation coefficient of 0.98 for coronal balance, 0.91 for LIV-tilt, and 0.65 for disk angle. LIV-tilt improved from 19.4 degrees preoperatively to 3.6 degrees intraoperatively. At minimum 2-year follow-up, LIV had on average progressed to 8.6 degrees. The disk angle improved from 5.4 degrees preoperatively to 2.5 degrees intraoperatively. This improvement was maintained at 2 years (2.8 degrees). Coronal balance also improved during the postoperative period from 17.9 mm immediately following surgery to 11.1 mm at the last follow-up. CONCLUSIONS: Compared with prone intraoperative fluoroscopic images, disk wedging below LIV remains stable at 2 years postsurgery on standing radiographs in patients with AISundergoing PSF, including structural lumbar curves, whereas LIV-tilt improvement is not maintained. Intraoperative fluoroscopy provides a reliable prediction of disk wedging below LIV, 2 years after surgery on standing radiographs.