Socioeconomic differences in access to scoliosis care in the pediatric population.

PURPOSE: Adolescent idiopathic scoliosis (AIS) is a common spinal deformity affecting pediatric patients, with up to 10% requiring surgical intervention. Studies have shown disparities in these patients associated with race, ethnicity, and insurance type, but there is limited information on disparities that exist based on geographical parameters. In this study, we aim to explore the disparities in the care for AIS by looking at differences in the rates of readmission, infection, and revision between patients residing in rural and urban environments. METHODS: This is a retrospective cohort study utilizing the Pediatric Health Information System. Pediatric patients that underwent posterior spinal fusion (PSF) for AIS from October 2015 to July 2022 were included. Diagnoses and procedures were identified based on ICD-10 codes and internal tools built into the database. Descriptive statistics were used to summarize the data, including demographics, infection rates, readmission rates, and revision rates. T tests, Chi-squared tests, and logistic regression were used to assess differences between the rural and urban populations. We utilized STATA/SE 15.1 for all data analysis. RESULTS: 15,318 patients were included in the final cohort. Demographics and baseline characteristics were similar between the rural and urban patients, although more rural patients used Medicaid over commercial insurance (41.5% vs. 32.7%, p < 0.01), median household income was lower in rural patients (p < 0.01), and there was a higher proportion of Hispanic patients in the urban patient cohort (13.9% vs. 6.4%, p < 0.01). Complication rates were not significantly different between the urban and rural patient cohorts, although rural patients did have a significantly higher 90-day readmission rate (7.3% vs. 6.1%, p = 0.03) and higher rates of instrumentation removal (7.7% vs. 4.9%, p = 0.01). CONCLUSIONS: The surgical outcomes between rural and urban pediatric AIS patients undergoing PSF are comparable, although 90-day readmission rates and rates of instrumentation removal were higher in rural patients. Insurance status is likely a significant driver for the differences observed in this study. Future research is needed to better understand the reasons for these differences and to develop strategies to improve outcomes. LEVEL OF EVIDENCE: Retrospective cohort study, Level III.

Evaluation and Management of Thoracolumbar Spine Trauma in Pediatric Patients: A Critical Analysis Review.

¼ Pediatric thoracolumbar trauma, though rare, is an important cause of morbidity and mortality and necessitates early, accurate diagnosis and management.¼ Obtaining a detailed history and physical examination in the pediatric population can be difficult. Therefore, the threshold for advanced imaging, such as magnetic resonance imaging, is low and should be performed in patients with head injuries, altered mental status, inability to cooperate with examination, and fractures involving more than 1 column of the spine.¼ The classification of pediatric thoracolumbar trauma is based primarily on adult studies and there is little high-level evidence examining validity and accuracy in pediatric populations.¼ Injury pattern and neurologic status of the patient are the most important factors when determining whether to proceed with operative management.

Assessing Correlations and Demographic Interactions Between PROMIS25 and SRS30 in Pediatric Patients With Spinal Deformity.

INTRODUCTION: Historically, patient-reported outcome measures (PROMs) have been measured using anatomy-specific instruments. However, these instruments may be influenced by the presence of concomitant illnesses not associated with the orthopaedic condition. As such, standardized PROM tool, such as PROMIS25, have been developed to assess patient outcomes. In this study, we aim to compare the correlation and association between 2 common PROMs used for pediatric patients with spinal deformity. METHODS: This study included patients younger than 21 years who were indicated for spinal deformity surgery at our institution. All patients were invited to complete SRS-30 and PROMIS-25 instruments through an automated, electronic patient-reported outcome platform before surgery. Patient demographics were recorded and Spearman correlations were calculated between the various PROMIS and SRS domains. Correlations were compared between different baseline characteristics and demographics using a rho-to-z transformation method. Ceiling and floor effects were also investigated. RESULTS: A total of 207 patients were enrolled in this study. The majority of PROMIS and SRS domains had moderate to strong correlations, with higher correlations observed when each instrument tried to capture the same construct. For example, there was strong correlation between PROMIS raw pain and SRS pain (ρ=-0.86, P<0.01), and PROMIS Depression and SRS Mental Health (ρ=-0.76, P<0.01). Ceiling effects ranged from 1.0 to 16.9% in SRS and 0.5 to 28.5% is PROMIS. Floor effects ranged from 0.5 to 1.5% in SRS and 0.5 to 29.0% in PROMIS. There were significant differences in the correlation between SRS Mental Health and PROMIS Depression when comparing between different sexes (male: ρ=-0.74, female: ρ=-0.59, P=0.04). In addition, there were significant differences in the correlation between SRS Mental Health and PROMIS Anxiety when comparing between different insurance payors (commercial: ρ=-0.86, female: ρ=-0.75, P=0.03). CONCLUSIONS: There is strong correlation between SRS and PROMIS domains in pediatric patients with spinal deformity. These correlations can differ by baseline characteristics and demographics. Providers should consider these differences when interpreting PROMs in diverse patient populations. LEVEL OF EVIDENCE: Level III; Retrospective comparative study.

Automating Patient-reported Data Collection: Does it Work?

OBJECTIVE: There are several electronic patient-reported outcomes (ePROs) vendors that are being used at institutions to automate data collection. However, there is little known about their success in collecting patient-reported outcomes (PROs) and it is unknown which patients are more likely to complete these surveys. In this study, we assessed rates of PRO completion, as well as determined factors that contributed to the completion of baseline and follow-up surveys. METHODS: We queried our ePRO platform to assess rates of completion for baseline and follow-up surveys for patients from October 2019 to June 2022. All baseline surveys were administered before pediatric orthopaedic procedures, and follow-up surveys were sent at 3 months, 6 months, 1 year, and 2 years after surgery to patients with baseline data. Descriptive statistics were used to summarize the data. Univariate and multivariate analyses were performed to assess differences in patients who did and did not complete surveys. RESULTS: This study included 1313 patients during the study period. Baseline surveys were completed by 66% of the cohort (n = 873 patients). There was a significant difference in race/ethnicity and language spoken in the patients who did and did not complete baseline surveys ( P < 0.01) with lower rates of completion in African American, Hispanic, and Spanish-speaking patients. At least one follow-up was obtained for 68% of patients with baseline surveys (n = 597 patients). There were significant differences in completion rates based on race/ethnicity ( P = 0.03) and language spoken ( P = 0.01). There were lower rates of baseline completion for patients with government insurance in our multivariate analysis (odds ratio: 0.6, P < 0.01). CONCLUSION: Baseline and follow-up PRO data can be obtained from the majority of patients using automated ePRO platforms. However, additional focus is needed on collecting data from traditionally underrepresented patient groups to better understand outcomes in these patient populations. LEVEL OF EVIDENCE: Level III-retrospective cohort study.

Who gets staged surgery in severe pediatric and adolescent spine deformity?

BACKGROUND: There is significant debate regarding the indications of staged surgery for severe adolescent spinal deformity, and the factors associated with the decision to perform staged compared to same-day surgery have not been previously investigated. Thus, the purpose of this study was to determine which factors were most strongly associated with this decision. METHODS: A prospective multicenter registry of adolescent patients with severe spinal deformity was reviewed. Two cohorts were identified: those who underwent a planned staged surgical procedure for deformity correction and those who underwent a same-day procedure. Patients who underwent an unplanned staged procedure secondary to complications during the initial procedure were excluded. Comparisons were made between these cohorts with respect to preoperative patient and radiographic variables to determine which factors were associated with the decision to perform a staged procedure. Surgical data was also compared to evaluate for differences in the intraoperative management of staged versus same-day patients. RESULTS: Two hundred and twenty-nine patients with severe spinal deformities were identified. Forty patients (17%) underwent a planned staged procedure and 189 patients (80%) underwent a same-day procedure. On univariate analysis of preoperative variables, patients who underwent staged surgery had a significantly younger age at surgery, greater major curve magnitude, greater major curve AVT to CSVL, lesser thoracic spine height, greater radiographic trunk shift, and a greater proportion of patients undergoing revision surgery (as opposed to primary correction) compared to those who underwent a planned single-stage procedure. Multivariate logistic regression of pre-operative variables showed that age < 16 years, maximum cobb angle ≥ 120 degrees, major curve AVT to CSVL of ≥ 3.5 cm, and revision surgery were independently associated with the decision to perform a staged procedure. Intraoperatively, patients in the staged cohort more frequently underwent combined anterior and posterior procedures, grade 4 or higher Schwab osteotomies, and had a greater number of levels fused. CONCLUSION: There is substantial variability with respect to the decision to perform surgery for severe adolescent spine deformities in a staged versus same-day fashion. This large analysis of prospectively collected data is the first to describe the factors most strongly associated with the decision to perform a staged procedure and may help guide the surgical decision-making for these patients.

Don't Throw Away the Handout: Efficacy of Patient Education in Pediatric Orthopaedic Trauma.

BACKGROUND: Printed educational materials (PEMs) have been used for patient education in various settings. The purpose of this study was to determine the readability, understandability, and actionability of trauma-related educational material from the Pediatric Orthopaedic Society of North America (POSNA, Orthokids), as well as determine its efficacy in educating pediatric orthopaedic trauma patients and caregivers. METHODS: The readability, understandability and actionability of PEMs was assessed using the Patient Education materials Assessment Tool (PEMAT). Five reviewers ranging in experience independently evaluated the educational materials. The efficacy of PEMs was assessed prospectively by randomizing patients into 2 groups. The first group (Education) received the OrthoKids educational material related to the patient's fracture. The second group (No Education) did not receive the educational material. At the first follow-up visit, parents/guardians in both groups completed surveys. Statistical analyses included descriptive and univariate statistics. RESULTS: The understandability of PEMs was similar (68% to 74%); however, the educational materials had varying actionability scores ranging from 20% for femoral shaft fractures to 60% for elbow fractures. In total, 101 patients were randomized to assess the efficacy of educational materials (Education=51, No Education=50). There were no significant differences in sex, age, race/ethnicity, and level of education between caregivers in both groups ( P > 0.05). Only 61% (31/51) participants in the Education group reported using the educational material; however, 67% to 68% of participants in either group reported wanting PEMs. Participants in the group that did not receive PEMs were significantly more likely to use the internet to find more information (74% vs. 51%, P < 0.05). CONCLUSIONS: This study suggests that participants that did not receive PEMs were significantly more likely to search the internet for more information. Improving the quality and actionability of educational resources on electronic platforms is needed to improve patient education. A multi-modal approach using PEMs that includes a list of high-quality online sources would likely be most effective in educating pediatric trauma patients and caregivers. LEVEL OF EVIDENCE: I.

Hip Pain in Adolescent Patients.

Hip pain is a common complaint in adolescents. There are several causes for hip pain in this population, with dysplasia and impingement being the most common; however, other conditions such as extra-articular impingement, torsional disorders, labral tears, and osteochondral lesions also require consideration. Many of these conditions are related to underlying anatomic abnormalities and increased activity in this age group. An understanding of the common pathologies of the adolescent hip is integral to the evaluation, diagnosis, and treatment of these patients.

Patient Expectations and Satisfaction in Pediatric Orthopedics.

PURPOSE OF REVIEW: The purpose of the current review is to analyze the current literature regarding the tools available to evaluate patient expectations and satisfaction. There have been an increasing number of tools that have been developed and validated for various orthopedic procedures. Despite the growing number of tools, there are a limited number of tools available for pediatric patients. RECENT FINDINGS: Several tools have been developed in orthopedics to evaluate patient expectations. However, there are no tools that have been validated in the pediatric population. In addition, pediatric patient expectations should be collected in conjunction with parent/caregiver expectations. Although not specifically validated for pediatric patients, there are several tools available that may pertain to pediatric patients including the HSS ACL Expectations Survey, HSS Shoulder Expectations Survey, HSS Knee Surgery Expectations Survey, HSS Foot and Ankle Surgery Expectation Survey, Sunnybrook Surgery Expectations Survey, Musculoskeletal Outcomes Data Evaluation and Management System (MODEMS) Instruments, Quick DASH, and DASH. In terms of patient satisfaction, there are even fewer tools available. Several tools have been developed to evaluate patient satisfaction and five additional tools within orthopedics. Of these tools, there are two that have been validated for pediatric patients: The Swedish Parents Satisfaction Questionnaire and the Scoliosis Research Society-22. There are a growing number of tools to evaluate patient's expectations and satisfaction in the orthopedic literature. Given most of these tools pertain to adult patients, there is a need for further development of tools specifically validated for pediatric patients and their parents/caregivers. Through the measurement of expectations and satisfaction, medical professionals can hope to improve satisfaction and outcomes.

Scheuermann Kyphosis: Current Concepts and Management.

PURPOSE OF REVIEW: Scheuermann's kyphosis (SK) is a developmental deformity of the spine that affects up to 8% of children in the US. Although, the natural progression of SK is noted to be gradual over years, severe deformity can be associated with significant morbidity. Thorough clinical examination and interpretation of relevant imaging help differentiate and confirm this diagnosis. Treatment includes both operative and nonoperative approaches. The purpose of this article is to provide an updated overview of the current theories of its pathogenesis, as well as the principles of diagnosis and treatment of SK. RECENT FINDINGS: Although a definitive, unified theory continues to be elusive, numerous reports in the past decade provide insight into the pathophysiology of SK. These include alterations in mechanical stress and/or hormonal disturbances. Candidate genes have also been identified to be linked to the inheritance of SK. Updates to nonoperative treatment include the effectiveness of dedicated exercise programs, as well as the types and duration of orthotic treatment. Advances in surgical technique can be observed with a trend toward a posterior-only approach, with supporting evidence for careful evaluation of both the sagittal and coronal planes to determine fusion levels in order to avoid postoperative junctional pathologies. SK is an important cause of structural or rigid kyphosis. It can lead to significant morbidity in severe cases. Treatment is based on curve magnitude and symptoms. Nonoperative treatment consists of physical therapy in symptomatic patients, and bracing can be added for skeletally mature patients. Operative management can be considered in patients with large, progressive, and symptomatic deformity. Future studies can benefit from a focused investigation into patient-reported outcomes after undergoing appropriate treatment.

Variations in the Management of Closed Salter-Harris II Distal Tibia Fractures.

BACKGROUND: There are no formal practice guidelines for the surgical management of closed, Salter-Harris (SH) II distal tibia fractures. The purpose of this study was to survey the indications for operative and nonoperative management of this injury across pediatric tertiary care centers. METHODS: We surveyed pediatric orthopedic surgeons at 20 tertiary care level-1 pediatric trauma centers. Surgeons were provided with 16 clinical scenarios that varied based on patient age and sex, and highlighted the following surgical indications: translation <3 mm, translation ≥3 mm, sagittal plane angulation >5 degrees, and coronal plane angulation >5 degrees. Each case's scenario and radiographs after closed reduction were presented in a randomized manner. Consensus was defined as 80% agreement, and descriptive statistics were used to summarize the results. RESULTS: In total, 33 of 37 surgeons completed the survey (89% response rate). All surgeons took trauma call at a level-1 pediatric trauma center and had an average of 8.8 years (SD: 6.5 y) of experience. Consensus was reached in 4 of 16 scenarios. Specifically, nonoperative management was recommended for all scenarios showing <3 mm of translation after closed reduction. The majority of surgeons recommended operative management in scenarios showing coronal plane angulation after closed reduction, but none of these scenarios reached consensus. There was a near-equal split in operative and nonoperative management in 8 of 16 scenarios. These scenarios showed ≥3 mm translation after closed reduction and sagittal plane angulation after closed reduction. Surgeons with 6 to 10 years in practice were the most likely to recommend surgery, especially in the case of >5 degrees coronal plane angulation postreduction ( P <0.05). CONCLUSIONS: There is considerable variation regarding the indications for operative and nonoperative management of closed, SHII distal tibia fractures. Consensus was reached for nonoperative management in patients with <3 mm of translation after closed reduction; however, with greater deformity consensus regarding optimal treatment was unable to be achieved. The variation in the management of distal tibia SHII fractures is significant, suggesting that perhaps clinical equipoise exists between operative and nonoperative management. LEVEL OF EVIDENCE: V.

Pediatric Heterotopic Ossification: A Comprehensive Review.

PURPOSE OF REVIEW: The purpose of this review is to provide a comprehensive analysis of heterotopic ossification (HO) in pediatric patients, including an in-depth examination of the risk factors associated with this condition, current prophylactic measures, and available management strategies. RECENT FINDINGS: HO is a medical disorder in which bone tissue inexplicably develops in soft tissues such as muscles and tendons. It involves the formation of mature, lamellar bone in extra-skeletal soft tissue, and its formation is influenced by oxygen tension, pH, the availability of micronutrients, and mechanical stimulation. HO has many cellular origins, with the most common theory being multipotent cells in local tissue. The diagnosis of HO is typically made based on exam, radiographs, and CT. Management includes both prophylactic nonsurgical options and surgical resection for severe or recalcitrant cases. The review highlights the incidence, risk factors, and management strategies associated with HO in pediatric patients. HO is a rare condition in children, with severe neurologic injury being the most common cause. Pediatric patients most commonly develop HO following severe neurologic injury, followed by trauma and surgery. Current prophylactic measures, include nonsteroidal anti-inflammatory drugs and radiation therapy though limited literature on their use in the pediatric population exists. For recalcitrant symptomatic cases, wide surgical resection can be considered but has a higher risk profile and associated morbidity. This review highlights the need for further pediatric specific research to inform guidelines and management strategies for this debilitating condition.

Rates and Factors Associated With Hardware Removal in Physeal Ankle Fractures: Analysis of the Pediatric Health Information System.

Background: Ankle fractures are among the most common physeal fractures in children. When surgical management is warranted, subsequent hardware removal remains controversial. This study was designed to determine rates of hardware removal in patients with physeal ankle fractures and identify risk factors for removal. Procedure data was utilized to compare rates of subsequent ankle procedures in patients with hardware removed and hardware retained. Methods: We conducted a retrospective cohort study utilizing data from the Pediatric Health Information System (PHIS) for the years 2015 through 2021. We longitudinally followed patients treated for distal tibia physeal fractures to determine the rates of hardware removal and subsequent ankle procedures. Patients with open fractures or polytrauma were excluded. We used univariate, multivariate, and descriptive statistics to characterize the rates of hardware removal, identify factors associated with removal, and assess the rates of subsequent procedures. Results: This study included 1008 patients who underwent surgical management of a physeal ankle fracture. The mean age at index surgery was 12.6 years with an SD of 2.2 years, and 60% of patients identified as male. Two hundred forty-two patients (24%) had their hardware removed at an average time of 276 days (range, 21-1435 days) following index surgery. Patients with Salter Harris III (SH-III) or Salter Harris IV (SH-IV) fractures had hardware removed more often than patients with Salter-Harris II (SH-II) fractures (28.9% vs 11.7%, P < .01). Four-year rates of subsequent ankle procedures are similar between patients with hardware removed and hardware retained. Conclusion: The rate of hardware removal in children with physeal ankle fractures is higher than previously reported. Patients of younger age, higher income, and with fractures involving the epiphysis (SH-III and SH-IV) are more likely to undergo hardware removal. Level of Evidence: Level III, retrospective study.

Rib-to-spine and rib-to-pelvis magnetically controlled growing rods: does the law of diminishing returns still apply?

PURPOSE: The Law Of Diminishing Returns (LODR) has been demonstrated for traditional growing rods, but there is conflicting data regarding the lengthening behavior of Magnetically Controlled Growing Rods (MCGR). This study examines a cohort of patients with early-onset scoliosis (EOS) with rib-to-spine or rib-to-pelvis-based MCGR implants to determine if they demonstrate the LODR, and if there are differences in lengthening behaviors between the groups. METHODS: A prospectively collected multicenter EOS registry was queried for patients with MCGR with a minimum 2-year follow-up. Patients with rib-based proximal anchors and either spine- or pelvis-based distal anchors were included. Patients with non-MCGR, unilateral constructs, < 3 lengthenings, or missing > 25% datapoints were excluded. Patients were further divided into Primary-MCGR (pMCGR) and Secondary-MCGR (sMCGR). RESULTS: 43 rib-to-spine and 31 rib-to-pelvis MCGR patients were included. There was no difference in pre-implantation, post-implantation and pre-definitive procedure T1-T12 height, T1-S1 height, and major Cobb angles between the groups (p > 0.05). Sub-analysis was performed on 41 pMCGR and 19 sMCGR rib-to-spine patients, and 31 pMCGR and 17 sMCGR rib-to-pelvis patients. There is a decrease in rod lengthenings achieved at subsequent lengthenings for each group: rib-to-spine pMCGR (rho = 0.979, p < 0.001), rib-to-spine sMCGR (rho = 0.855, p = 0.002), rib-to-pelvis pMCGR (rho = 0.568, p = 0.027), and rib-to-pelvis sMCGR (rho = 0.817, p = 0.007). Rib-to-spine pMCGR had diminished lengthening over time for idiopathic, neuromuscular, and syndromic patients (p < 0.05), with no differences between the groups (p > 0.05). Rib-to-pelvis pMCGR neuromuscular patients had decreased lengthening over time (p = 0.01), but syndromic patients had preserved lengthening over time (p = 0.65). CONCLUSION: Rib-to-spine and rib-to-pelvis pMCGR and sMCGR demonstrate diminished ability to lengthen over subsequent lengthenings.

Erratum: Rates of readmission and reoperation after operative management of midshaft clavicle fractures in adolescents.

[This corrects the article on p. 1001 in vol. 12, PMID: 35036342.].

Rate of Refracture After Removal of Hardware in Pediatric Femur Fractures.

PURPOSE: Both flexible intramedullary nails (FINs) and plate osteosynthesis are commonly used for the treatment of femoral shaft fractures in pediatric patients. The purpose of this study is to determine the refracture rate after hardware removal in pediatric femur fractures. METHODS: This is a retrospective cohort study that utilized the Pediatric Health Information System database to determine the number of pediatric patients ages 4 to 10 who underwent surgical fixation of a femur fracture and subsequent hardware removal between the years 2015 and 2019. All patients had a minimum of a 2-year follow-up to assess for refracture. Patients with metabolic bone disease, neuromuscular conditions, bone fragility disorders, nutritional deficiencies, and pathologic fractures were excluded. RESULTS: Of the total, 2805 pediatric patients with 2881 femoral shaft fractures who underwent FIN (48.4%), plate fixation (36.1%), splinting/casting (14.9%), or external fixation (0.6%) were included. The mean age of patients with index fracture was 7.2 years (SD, 2.1) and 69% were males. Eight hundred eighty patients (60%) in the FIN group had their hardware removed compared with 693 patients (68%) in the plate fixation group ( P = 0.07), at an average of 287 ± 191 days versus 320 ± 203 days ( P = 0.03). Refracture occurred in 13 patients (1.5%) who had their hardware retained and in 21 patients (1.4%) who had their hardware removed ( P = 0.732). Among 65% of patients who underwent hardware removal, refracture occurred in 7 patients with FIN (0.8%) and 14 patients with plate fixation (2.2%) ( P = 0.04). Refracture occurred within 365 days from hardware removal in 1 patient with FIN (0.1%) and 7 patients with plate fixation (1%) ( P = 0.01). In logistic regression, patients with FIN fixation had lower odds of refracture after hardware removal compared with plate fixation (adjusted odds ratio: 0.39; 95% CI: 0.15-0.97). Age and payor status did not reach statistical significance in multivariate analysis. CONCLUSIONS: The rate of refracture after hardware removal for pediatric patients with a femoral shaft fracture was similar between patients with hardware retained and removal. However, patients with FIN had a lower rate of refracture AFTER hardware removal compared with plate fixation. This information can be helpful for advising families regarding the risks of refracture after hardware removal. LEVEL OF EVIDENCE: Level IV-retrospective cohort study.

Prolonged Length of Stay and Readmissions Following In Situ Pinning of Slipped Capital Femoral Epiphysis An Analysis of Incidence and Predictive Factors.

BACKGROUND: In situ pinning is one of the primary treat-ments for slipped capital femoral epiphysis (SCFE) in pedi-atric patients, many of whom have multiple comorbidities. Despite the fact that SCFE pinning is a frequently performed procedure in the United States, little is known regarding sub-optimal postoperative outcomes in this patient population. The purpose of this study was thus to identify the incidence, perioperative predictors, and specific causes of prolonged hospital length of stay (LOS) and readmissions following fixation. METHODS: The 2016-2017 National Surgical Quality Im-provement Program database was employed to identify all patients undergoing in situ pinning of a SCFE. Significant variables, such as demographics, preoperative comor-bidities, birth history, operative characteristics (length of surgery and inpatient and outpatient procedure), and postop-erative complications were collected. The primary outcomes of interest were prolonged LOS (defined as exceeding the 90th percentile, or 2 days) and readmission within 30 days following the procedure. The specific reason for readmission was recorded for each patient. Bivariate statistics followed by binary logistic regression modeling were employed to explore the relationship between perioperative variables and prolonged LOS and readmissions. RESULTS: A total of 1,697 patients underwent pinning, with a mean age of 12.4 years. Of these, 110 (6.5%) experienced a prolonged LOS and 16 (0.9%) were readmitted within 30 days. The most common causes of readmission related to the initial treatment were hip pain (n = 3) followed by postop-erative fracture (n = 2). Surgery on an inpatient basis (OR = 3.64; 95% CI: 1.99-6.67; p < 0.001), history of seizure disorder (OR = 6.79; 95% CI: 1.55-29.7; p = 0.01), and longer operative time (OR = 1.03; 95% CI: 1.02-1.03; p < 0.001) were significantly associated with prolonged LOS. CONCLUSIONS: The majority of readmissions following SCFE pinning were due to postoperative pain or fracture. Patients presenting with medical comorbidities and un-dergoing pinning as an inpatient were at increased risk of experiencing a prolonged LOS.

Return to the Operating Room for Unplanned Pin Removal After Percutaneous Pinning of Supracondylar Humerus Fractures: A Retrospective Review.

BACKGROUND: Pin migration is a common complication associated with closed reduced and percutaneous pinning (CRPP) of supracondylar humerus fractures (SCHF) in children. Though this complication occurs frequently, little work has been done to elicit circumstances surrounding this complication. The purpose of this study was to evaluate patients with SCHF treated with percutaneous pins who needed to return to the operating room for pin removal. METHODS: This was a multicenter study involving children treated at 6 pediatric tertiary care centers between 2010 and 2020. Retrospective chart review was performed to identify children aged 3 to 10 years of age with a diagnosis of a SCHF. Current Procedural Terminology (CPT) codes were used to identify patients who underwent CRPP of their injuries. CPT codes for deep hardware removal requiring procedural sedation or anesthesia were used to identify patients who needed to return to the operating room for hardware removal. RESULTS: Between 2010 and 2020, 15 out of 7862 patients who were treated for SCHF at our 6 participating study centers experienced pin migration requiring a return to the operating room for pin removal, yielding a complication rate of 0.19%. Twelve (80%) of these injuries were Wilkins modification of the Gartland classification Type III, while the remaining injuries were Type II. 2-pin fixation constructs were used in nine (60%) children; 3-pin fixation constructs were used in 6 (40%) children. Pin migration was noted 23.2±7.0 days postoperatively at clinic follow-up. Four patients were noted to have multiple pins buried at follow-up. Four patients required 1-centimeter incisions for exposure of the buried pins, while surgeons were able to remove the buried pin with just a needle driver and blunt dissection in the remainder of patients. CONCLUSIONS: Pin migration is a common complication of closed reduction and percutaneous pinning of SCHF. There is variation in pin site management to prevent migration in the absence of underlying risk factors. LEVEL OF EVIDENCE: Level III.

Factors associated with subsequent surgery after septic arthritis of the knee in children.

BACKGROUND: Septic arthritis of the knee in children is a challenging problem. Surgical debridement is an established treatment, but there is a paucity of literature on long-term prognosis. AIM: To determine the rates and factors associated with return to surgery (RTS) and readmission after index surgical debridement for septic arthritis of the knee in children. METHODS: This is a retrospective cohort study that utilizes data from the Healthcare Cost and Utilization Project (HCUP). We included patients between ages 0 to 18 years that underwent surgical debridement for septic arthritis of the knee between 2005 and 2017. Demographic data included age, gender, race, hospital type and insurance type. Clinical data including index admission length of stay (LOS) and Charlson Comorbidity Index (CCI) were available from the HCUP database. Descriptive statistics were used to summarize the data and univariate and multivariate analyses were performed. RESULTS: Nine-hundred thirty-two cases of pediatric septic knee were included. This cohort was 62.3% male, with mean age of 9.0 (± 6.1) years. Approximately 46% of patients were white and approximately half had Medicaid insurance. Thirty-six patients (3.6%) required RTS at a minimum of 2 year after index surgery, and 172 patients (18.5%) were readmitted at any point. The mean readmission LOS was 11.6(± 11.3) d. Higher CCI was associated with RTS (P = 0.041). There were no significant associations in age, gender, race, insurance type, or type of hospital to which patients presented. Multivariate analysis showed that both increased CCI (P = 0.008) and shorter LOS (P = 0.019) were predictive of RTS. CONCLUSION: Septic arthritis of the knee is an important condition in children. The CCI was associated with RTS at a minimum of 2 years after index procedure. No association was found with age, gender, race, insurance type, or hospital type. Shorter LOS and CCI were associated with RTS in multivariate analysis. Overall, risk of subsequent surgery and readmission after pediatric septic knee arthritis is low, and CCI and shorter LOS are predictive of RTS.

Indications and Efficacy of Halo-Gravity Traction in Pediatric Spinal Deformity: A Critical Analysis Review.

¼: Halo-gravity traction (HGT) is a well-established technique for correcting severe spinal deformity in pediatric patients. ¼: HGT induces soft-tissue relaxation and gradually lengthens the spine, and it can be used preoperatively and intraoperatively. ¼: It is typically indicated for spinal deformity over 90° in any plane and medical optimization. ¼: There are several complications associated with the use of HGT, and it is critical to follow a protocol and perform serial examinations to minimize this risk.

Intraoperative Antibiotic Use in Patients With Early-onset Scoliosis: Current Practices and Trends.

BACKGROUND: Best Practice Guidelines (BPGs) regarding antibiotic prophylaxis in early-onset scoliosis (EOS) patients were published in September 2019. Recommendations included using intravenous cefazolin and topical vancomycin for all index procedures, plus gram-negative coverage for neuromuscular patients. Guideline adherence is unknown. This study aimed to characterize antibiotic prophylaxis at the time of index growth-friendly procedures and assess changes in practice patterns over time. MATERIALS AND METHODS: This retrospective review of data collected through a multicenter study group included EOS patients undergoing index growth-friendly procedures between January 2018 and March 2021, excluding revisions, lengthenings, and tetherings. Demographics, clinical measurements, intraoperative antibiotics, and 90-day complications were recorded. Descriptive and univariate statistics were utilized. Antibiotic prophylaxis from April 2018 through September 2019 and October 2019 through March 2021 were compared with evaluate change after BPG publication. RESULTS: A total of 562 patients undergoing growth-friendly procedures were included. The most common scoliosis types included neuromuscular (167, 29.7%), syndromic (134, 23.8%), and congenital (97, 17.3%). Most index procedures involved magnetically controlled growing rods (417, 74%) followed by vertical expandable prosthetic titanium rib or traditional growing rods (105, 19%). Most patients received cefazolin alone at index procedure (310, 55.2%) or cefazolin with an aminoglycoside (113, 20.1%). Topical antibiotics were used in 327 patients (58.2%), with most receiving vancomycin powder. There was increased use of cefazolin with an aminoglycoside after BPG publication (16% vs. 25%) ( P =0.01). Surgical site infections occurred in 12 patients (2.1%) within 90 days of index procedure, 10 pre-BPGs (3%), and 2 post-BPGs (0.9%), with no significant difference in surgical site infection rate by type of antibiotic administered ( P >0.05). CONCLUSIONS: Historical variability exists regarding antibiotic prophylaxis during index growth-friendly procedures for EOS. There continues to be variability following BPG publication; however, this study found a significant increase in antibiotic prophylaxis against gram-negative bacteria after BPG publication. Overall, greater emphasis is needed to decrease variability in practice, improve compliance with consensus guidelines, and evaluate BPG efficacy. LEVEL OF EVIDENCE: Level III-retrospective.