Cochlear Implantation Outcomes in Pediatric Unilateral Hearing Loss: Impact of Device Use and Direct Input.

OBJECTIVE: To investigate the impact of daily cochlear implant (CI) use on speech perception outcomes among children with unilateral hearing loss (UHL). STUDY DESIGN: Multi-institutional retrospective case series of pediatric patients with UHL who underwent CI between 2018 to 2022. SETTING: Three tertiary children's hospitals. METHODS: Demographics were obtained including duration of deafness and age at CI. Best consonant-nucleus-consonant (CNC) word scores and data logs describing hours of CI usage were assessed postimplantation. Use of direct audio input (DAI) during rehabilitation was recorded. RESULTS: Twenty-seven children were included, with a mean age at CI of 7.8 years. Mean datalogging time was 7.8 ± 3.0 hours/day. 40.7% of children utilized daily DAI. The mean CNC score using the best score during the study period was 34.9%. There was no significant correlation between hours of CI usage and CNC score. There was a significant improvement in CNC score associated with whether the child used DAI during rehabilitation (CNC 50.91% [yes] vs 23.81% [no]), which remained significant when adjusting for age at CI, duration of deafness, and data log hours. CONCLUSION: Unlike children with bilateral hearing loss and CI, children with UHL and CI demonstrate no significant correlation between hours of daily CI usage and CNC scores. However, children who used DAI during postoperative rehabilitation achieved significantly higher CNC scores than those who did not. This suggests that rehabilitation focused on isolated listening with the implanted ear maybe critical in optimizing outcomes with CI in UHL patients.

Glass Ceiling in Hand Surgery: Publication Trends by Gender.

Background: Women are frequently underrepresented across surgical subspecialties and may face barriers to academic advancement. Abstracts presented at American Society for Surgery of the Hand annual meeting (ASSH-AM) highlight some of the top research in hand surgery. We sought to explore differences in abstract characteristics and publication rates based on senior author gender.Though there have been increasing efforts at inclusivity in orthopedic and plastic surgery, women face several barriers to entering the field, publish less frequently, and are underrepresented in leadership positions. Understanding the stages at which discrepancies in research productivity exist may help to address these challenges. Methods: Abstracts from the 2010-2017 ASSH-AMs were reviewed to determine basic characteristics. Author gender was determined through both a search of institutional websites for gender-specific pronouns and inference of gender based on first name. Subsequent full manuscript publications corresponding to the abstracts were identified through a systematic search of PubMed and Google Scholar. Results: A total of 560/620 (90.3%) abstracts from 2010-2017 had an identifiable senior author gender (14.5% female). No differences were noted between male- and female-authored abstracts regarding study design including sample size or level of evidence. Female senior authors were more likely than males to author abstracts focused on pediatrics (19.8% vs 9.4%, p=0.01) and were more likely to collaborate with female first authors (41.3% vs 20.0%, p<0.01). Abstract publication rates were lower for female senior authors versus male senior authors (61.7% vs 74.5%, p=0.02). Conclusion: The number of abstracts with female senior authors had similar representation to the membership proportion of women in the ASSH. There were few differences in abstract characteristics based on senior author gender, though senior authors tend to collaborate with investigators of the same gender. Abstracts authored by females were published 13% less frequently overall, meriting further exploration. Level of Evidence: III.

A Comparison of Motorized and Nonmotorized Scooter Injuries in Pediatric Patients Seen in US Emergency Departments.

OBJECTIVES: We sought to characterize and compare trends in pediatric injuries sustained on motorized and nonmotorized scooters across the United States, to assess the use of safety equipment in children presenting with scooter-related injuries, and provide strategies for injury prevention. METHODS: The National Electronic Injury Surveillance System was queried for motorized and nonmotorized scooter-related pediatric injuries from 2014 to 2018 in patients ages 6 to 12 years. Patient demographics, diagnosis, injury location, and narrative of the incident were collected. Bivariate and regression analyses were used to determine demographic and social associations of injury characteristics. RESULTS: An estimated 146,000 (11,452 motorized and 134,548 nonmotorized) injuries occurred in children ages 6 to 12 years over the 5 years. Three of 4 injuries occurred in children younger than 10 years, and most injuries occurred in males (56%).From 2014 to 2018, the nationwide estimated incidence of motorized scooter injuries increased by 112.1%, while that of nonmotorized scooter injuries decreased by 40.3%.Upper extremity injuries were most common with nonmotorized scooters (44.4% of all injuries), while lower extremity injuries were most common with motorized scooters (39.5% of all injuries). Head and neck injuries accounted for 27.4% of nonmotorized scooter injuries and 23.4% of motorized scooter injuries. The number of concussions in motorized scooters increased from 0.4% in 2014 to 2.7% in 2018, while concussions in nonmotorized scooters decreased from 3.5% to 2.7%. Helmets were mentioned in the medical record in 6.6% of the cases. Of these, 60.5% reported no use of helmet at the time of injury. CONCLUSIONS: From 2014 to 2018, the number of motorized scooter injuries increased by 112.1% in the pediatric population ages 6 to 12 years, whereas nonmotorized scooter injuries decreased by 40.3%. In more than 60% of the cases that mentioned a helmet, the child injured was recorded as not wearing a helmet. The rise in pediatric injuries associated with motorized scooters in contrast with the reduction of injuries associated with nonmotorized scooters highlights the need for novel public health policies and interventions promoting helmet use with motorized scooters in the pediatric population.

C-arm contamination of the surgical field: Can contamination be reduced with an intervening drape?

INTRODUCTION: Contamination of the surgical field by the C-arm in orthopaedic procedures is a significant potential source for surgical site infections. The purpose of this study was to explore the utility of a split sheet to aid in prevention of secondary contamination from the C-arm on the C-arm side of the operative field. METHODS: A C-arm and a surgical table were draped by standard techniques. The surgical table was split in thirds: the surgeon's side, the C-arm side of the operative field, and the middle for contamination analysis. Fluorescent powder was used to simulate a contaminant and placed on the C-arm, floor and lower portions of drapes. The C-arm was cycled between PA and Lateral positions. Powder transfer to the field was visualized with a camera under uniform UV light. Photographs were taken to measure fluorescent pixels prior to cycling the C-arm and at 5, 10 and 15 cycles. This protocol was repeated using a split sheet (U-drape) to isolate the C-arm below the operative field. Image J was utilized to calculate differences in the number of pixels brighter than the control image. RESULTS: Using standard draping techniques, there was contamination of the surgical field with the C-arm side of the operative field having the highest level of fluorescent pixels. The number of fluorescent pixels was linearly correlated with the number of PA to Lateral cycles. At the end of 15 cycles, the average number of fluorescent pixels for the intervening draping technique was 2.9 pixels compared to the standard draping technique of 3939 pixels (p = 0.0078). DISCUSSION: The addition of a U-drape between the C-arm and the table results in a statistically significant reduction in surgical field contamination as a result of secondary transfer from the C-arm. LEVEL OF EVIDENCE: II.

Preoperative Opioid Informed Consent and Prescribing Practices in Children Undergoing Orthopaedic Trauma Surgery.

INTRODUCTION: This study sought to examine prescribing practices for pediatric patients undergoing orthopaedic trauma surgery and assess the effect of state-mandated preoperative informed consent for opioids. METHODS: A retrospective single-institution cohort study was done between 2016 and 2018 for surgically managed isolated orthopaedic trauma with cohorting based on the presence of preoperative opioid consent. Analyses examined cohort demographic and procedural factors associated with the number of opioid doses prescribed. RESULTS: A total of 1,793 patients met the study criteria. The proportion of patients prescribed opioids (P = 0.0378) and the number of doses (P < 0.001) were lower in consented patients. Differences were greater among those receiving solution (versus tablets). No cohort differences were observed in refill needs. Nonopioid medications prescribing increased. Multivariate analysis identified multiple factors, including preoperative opioid consent (P = 0.013) associated with fewer prescribed opioid doses. DISCUSSION: After the implementation of preoperative opioid consenting, patients were prescribed fewer opioid doses after pediatric orthopaedic trauma surgery. The increased utilization of nonopioid therapies was also evident. These changes occurred despite a shorter length of hospital stay and without changes in the studied proxies of postoperative pain control. An increased awareness of opioid risks through formal consent discussion may help to facilitate reduced reliance on opioids for children in the postoperative period.

Complex Fracture-Dislocations of the Elbow in the Pediatric Population.

BACKGROUND: Complex fracture-dislocations of the elbow, including terrible triad of the elbow, are serious injuries with guarded outcomes in adults. Although described extensively in adults, little is known about similar complex fracture-dislocations of the elbow in the pediatric population. The purpose of this study was to describe patterns of elbow dislocations with associated fractures in children and report the outcomes of these injuries. METHODS: This was a retrospective review of patients who presented to a level I trauma center from 2007 to 2019 with an elbow dislocation and at least 2 associated fractures. Demographic data, fracture locations, and treatment modality were recorded. Operative reports and radiographs were reviewed to determine clinical outcomes and complications. RESULTS: A total of 26 patients (mean age, 9.8 y) were identified. The majority of patients sustained an elbow dislocation and a medial epicondyle fracture (n=16). The most common third fractures involved the lateral condyle (n=8) or radial neck (n=7). At mean 6.03±3.11 months follow-up, 3 patients lacked ≥10 degrees of extension, and 2 patients lacked ≥15 degrees of flexion. Most patients had a Flynn score of "excellent" (n=20, 76.9%) or "good" (n=2, 7.7%). One patient with significant residual stiffness (>30 degrees flexion contracture) eventually underwent open contracture release. CONCLUSIONS: The most common complex elbow fracture-dislocation pattern in this series was an elbow dislocation with fracture of the medial epicondyle and lateral condyle or radial neck. In contrast to adult terrible triad injuries, most patients had a favorable clinical outcome, with nearly 80% excellent results and a low rate of complications. LEVEL OF EVIDENCE: Therapeutic Level IV-case series.

Does Surgical Experience Decrease Radiation Exposure in the Operating Room?

BACKGROUND: Intraoperative fluoroscopy facilitates minimally invasive surgery, and although it is irreplaceable in terms of intraoperative guidance, it results in substantial radiation exposure to the patient and surgical team. Although the risk of radiation exposure because of equipment factors has been described, there is little known about the impact of surgeon experience on radiation exposure. The aim of this study was to determine whether there is a relationship between years of surgical experience and total dose of radiation used for an archetypal pediatric orthopaedic surgical procedure that requires intraoperative fluoroscopy. METHODS: This was a retrospective cohort study of children undergoing closed reduction and percutaneous pinning for supracondylar humerus fractures at a level I pediatric trauma center. Information pertaining to radiation dosage was gathered including fluoroscopic time, total images acquired, magnification use, and dose area product (DAP). Regression analysis was used to evaluate the effect of surgeon experience on the outcome variables. RESULTS: A total of 759 pediatric patients treated by 17 attending surgeons were included. The median surgeon experience was 8.94 years (interquartile range, 5.9 to 19.8). Increased number of pins was associated with increased DAP (P<0.001) and lower years of experience (P=0.025). There was significantly higher fluoroscopy time in seconds (56.9 vs. 42.1 s, P=0.001), DAP (179.9 vs. 110.3 mGy-cm2, P=0.001), use of magnification (39.5 vs. 31.9 s, P=0.043), and total number of images obtained (74.5 vs. 57.6, P=0.008) in attending surgeons with <1 year of experience compared with those with greater experience. An operator extremity was visible in at least 1 saved image in 263 of 759 (35%) cases. CONCLUSION: Increased surgical experience was significantly associated with decreased fluoroscopy usage, including time, number of images, and dose. Surgeon inexperience increases radiation exposure for patients and staff by over 60% when treating supracondylar humerus fractures. This study clearly identifies methods to reduce radiation exposure, including use of pulsed fluoroscopy instead of continuous fluoroscopy, decreasing use of magnification, removing the operator's extremity from the field, and judicious use and placement of each additional pin. LEVEL OF EVIDENCE: Level III.

The Variability of Pelvic Obliquity Measurements in Patients with Neuromuscular Scoliosis.

Pelvic obliquity (PO), or pelvic alignment in the coronal plane, is an important radiographic parameter to indicate fusion levels and judge success of scoliosis correction in patients with neuromuscular scoliosis. There are multiple commonly used techniques to measure PO that have good to excellent interrater and intrarater reliability, but these different methods yield inconsistent values when used on the same radiograph. This study evaluates the inconsistency in the magnitude of PO measurements for patients with neuromuscular scoliosis among 5 common measurement techniques. METHODS: Radiographs of 63 patients with neuromuscular scoliosis were evaluated by 5 raters. Each rater measured PO on each radiograph using the Osebold, O'Brien, Allen and Ferguson, Lindseth, and Maloney techniques. Patients were divided into 2 cohorts based on coronal balance or imbalance. Interrater and intrarater analyses were performed using a 2-way random effects model to calculate absolute agreement. The mean difference in PO between all possible pairs of the techniques was compared using a 2-tailed t test. RESULTS: The Maloney and Osebold techniques demonstrated excellent interrater reliability, and the Maloney, Osebold, and O'Brien techniques demonstrated excellent intrarater reliability. Significant differences in PO measurement were found in 6 of the 10 comparisons for the balanced spines and 8 of the 10 comparisons for the unbalanced spines. Variability in measurement was captured by best-fit lines, which demonstrated greater dispersion between the means for the Osebold and Maloney techniques in the unbalanced spines than in the balanced spines. CONCLUSIONS: To our knowledge, this study is the first to evaluate mean differences in magnitude of PO among common measurement techniques while accounting for coronal imbalance. Although there is no gold standard for measuring PO, the Maloney and Osebold techniques are the most consistent. This study suggests that those 2 techniques can be used interchangeably when the spine is coronally balanced, but the Osebold technique becomes more inconsistent than the Maloney technique when coronal imbalance exceeds 2 cm. CLINICAL RELEVANCE: This information is relevant to surgeons using PO to plan fusion levels and striving for objective ways to judge correction intraoperatively as well as for researchers compiling PO data from multiple centers or studies.

Could have tethered: predicting the proportion of scoliosis patients most appropriate for thoracic anterior spinal tethering.

BACKGROUND: Posterior spinal fusion (PSF) has proven to be a safe, reliable technique to treat spinal deformities in adolescents. In recent early reports, vertebral body tethering (VBT) is showing promise as a method to modulate growth, driving scoliosis correction, while offering the potential added benefit of maintaining some flexibility in the instrumented segment. With recent FDA humanitarian device exemption (HDE) approval, VBT is poised to become more widely available as a treatment for a subset of current PSF candidates. Our aim was to use approved criteria from a recent FDA IDE to determine who could have been tethered in the years preceding approval. METHODS: A retrospective analysis was performed of patients with idiopathic scoliosis treated with PSF or VBT at a large pediatric spine center from 1/1/2016 to 6/25/2019. Tethering indications followed the criteria outlined by an ongoing FDA IDE: age 8-16, Sanders bone age ≤ 4, primary thoracic curve between 35° and 60°, and lumbar curve < 35°. Risser sign and triradiate cartilage status were also employed to ascertain skeletal maturity in the absence of Sanders score. RESULTS: Of the 359 patients (78.6% female) who underwent PSF or VBT for idiopathic scoliosis, 75 (20.9%) met IDE criteria for VBT (57 had PSF and 18 had VBT). 284 were not appropriate for thoracic VBT: 77 (21.4%) had a non-thoracic primary curve, 80 (22.3%) were too mature at presentation, 36 (10.0%) had a lumbar curve > 34°, 9 (2.5%) had a main thoracic curve out of range, and 1 had a proximal thoracic curve > 40°. 81 patients (22.6%) had multiple exclusionary criteria. CONCLUSIONS: After decades with a successful treatment for AIS (PSF), we are at an inflection point: VBT is conditionally approved by the FDA as an HDE device, unleashing more widespread use. Many pediatric spine surgeons will want to know what proportion of PSFs will someday be VBTs. If FDA IDE criteria are used to ensure that a VBT candidate has an appropriate maturity stage and scoliosis deformity pattern, 20.9% of our 359 surgical range patients would have qualified for thoracic VBT. LEVEL OF EVIDENCE: Level III.

Anterior Cruciate Ligament Injury Incidence in Adolescent Athletes: A Systematic Review and Meta-analysis.

BACKGROUND: The incidence of anterior cruciate ligament (ACL) injuries among adolescent athletes is steadily increasing. Identification of the highest risk sports for ACL injuries by sex and competitive setting (ie, practice vs match) is important for targeting injury prevention programs. PURPOSE: To identify the risk of ACL injuries in adolescent athletes by sport, sex, and setting across a variety of common US and international sports. STUDY DESIGN: Meta-analysis. METHODS: Essentially, 3 online databases (PubMed, Embase, and Cochrane Library) were searched for all studies of ACL injuries per athlete-exposure (AE) or hours of exposure in adolescent athletes. Injuries were then pooled and incidence rates (IRs) reported per 1000 AEs or hours of exposure, with the relative risk (RR) of injuries calculated for sex-comparable sports. IRs per competitive setting (match vs practice) were also calculated. RESULTS: A total of 1235 ACL injuries over 17,824,251 AEs were identified (IR, 0.069 [95% CI, 0.065-0.074]), with 586 of these injuries in girls across 6,986,683 AEs (IR, 0.084 [95% CI, 0.077-0.091]) versus 649 injuries in boys over 10,837,568 AEs (IR, 0.060 [95% CI, 0.055-0.065]). Girls had a higher overall rate of ACL injuries (RR, 1.40 [95% CI, 1.25-1.57]), with the most disproportionate risk observed in basketball (RR, 4.14 [95% CI, 2.98-5.76]). The risk of ACL injuries by sex was highest in girls' soccer (IR, 0.166 [95% CI, 0.146-0.189]) and boys' football (IR, 0.101 [95% CI, 0.092-0.111]). ACL injuries were over 8 (RR, 8.54 [95% CI, 6.46-11.30]) and 6 (RR, 6.85 [95% CI, 5.52-8.49]) times more likely to occur in a match versus a practice setting for female and male athletes, respectively. CONCLUSION: The risk of ACL injuries overall approached nearly 1 per 10,000 AEs for female athletes, who were almost 1.5 times as likely as male athletes to suffer an ACL injury across all adolescent sports. A multisport female athlete was estimated to have a nearly 10% risk of ACL injuries over her entire high school or secondary school career. Specifically, male and female adolescents playing soccer, basketball, lacrosse, and football appeared at particular risk of injuries, a finding that can be used to target an injury intervention.

Characteristics and Hospital Costs of Spica Cast Treatment of Non-accidental-related Diaphyseal Femoral Fractures in Children Before Walking Age.

BACKGROUND: Fractures are one of the most common presentations of child abuse second only to soft tissue damage, with ∼60% of fractures being femur, humerus or tibia fractures. Although studies have shown increased health care costs associated with nonaccidental trauma (NAT), there is little data regarding the cost of NAT-associated fractures compared with accidental trauma (AT) related fractures. The purpose of this study was to consider the economic burden of NAT related femoral fractures compared with AT femoral fractures. METHODS: We performed a retrospective study of children under the age of one with femoral fractures treated with a spica cast at a Level 1 Pediatric Trauma Center between 2007 and 2016. Variables included age, sex, length of hospital stay, and estimated total billing cost obtained from this hospital's billing department. In addition, fracture site (mid-shaft, distal, proximal, and subtrochanteric) and pattern were assessed. RESULTS: Sixty children with a mean age of 7 months were analyzed. NAT was suspected in 19 cases (31.7%) and confirmed in 9 (15%) before discharge. Two groups were analyzed: the NAT group included suspected and confirmed cases of abuse (28) and the AT group contained the remaining 32 cases. There was no significant difference in the demographics between these 2 groups. Children in NAT group had a longer length of stay compared with AT group (78.9 vs. 36.7 h, P<0.001). Overall consumer price index-adjusted hospital costs were $24,726 higher for NAT group compared with AT group (P=0.024), with costs of laboratory workup, radiology, and nonorthopaedic physician fees being the top 3 components contributing to the increased costs. CONCLUSIONS: The overall incidence of NAT was 46.6% in children presenting with femoral fracture under 1 year of age. The overall hospital cost of treating fractures in the NAT group was 1.5 times higher than the AT group, with imaging charges the most significant contributor to cost difference. LEVEL OF EVIDENCE: Level III-retrospective review.

Where Have All the Fractures Gone? The Epidemiology of Pediatric Fractures During the COVID-19 Pandemic.

BACKGROUND: During the COVID-19 pandemic, public health measures to encourage social distancing have been implemented, including cancellation of school and organized sports. A resulting change in pediatric fracture epidemiology is expected. This study examines the impact of the COVID-19 pandemic on fracture incidence and characteristics. METHODS: This is a retrospective cohort study comparing acute fractures presenting to a single level I pediatric trauma hospital during the COVID-19 pandemic with fractures during a prepandemic period at the same institution. The "pandemic" cohort was gathered from March 15 to April 15, 2020 and compared with a "prepandemic" cohort from the same time window in 2018 and 2019. RESULTS: In total, 1745 patients presenting with acute fractures were included. There was a significant decrease in the incidence of fractures presenting to our practice during the pandemic (22.5±9.1/d vs. 9.6±5.1/d, P<0.001). The presenting age for all fractures decreased during the pandemic (7.5±4.3 vs. 9.4±4.4 y, P<0.001) because of decreased fracture burden among adolescents. There were also a decrease in the number of fractures requiring surgery (2.2±1.8/d vs. 0.8±0.8/d, P<0.001). During the pandemic, there was an increase in the proportion of injuries occurring at home (57.8% vs. 32.5%, P<0.001) or on bicycles (18.3% vs. 8.2%, P<0.001), but a decrease in those related to sports (7.2% vs. 26.0%, P<0.001) or playgrounds (5.2% vs. 9.0%, P<0.001). There was no increase in time-to-presentation. Patients with distal radius torus fractures were more likely to receive a velcro splint during the pandemic (44.2% vs. 25.9%, P=0.010). CONCLUSIONS: Pediatric fracture volume has decreased 2.5-fold during the COVID-19 pandemic, partially because of cessation of organized sports and decreased playground use. In endemic regions, lower trauma volume may allow redeployment of orthopaedic surgeons and staff to other clinical arenas. Given the rising proportion of bicycling injuries, an emphasis on basic safety precautions could improve public health. An observed increase in the prescription of velcro splints for distal radius fractures highlights an opportunity for simplified patient care during the pandemic. LEVEL OF EVIDENCE: Level III.