Combined Lateral Closing and Medial Opening-Wedge Proximal Humerus Osteotomy in an Adolescent with Extreme Varus Deformity: A Case Report.

CASE: This report describes the case of an athletic 12-year-old boy who presented with a 64° left proximal humeral varus angulation deformity and physeal bar secondary to multiple operations for a proximal humeral metaphyseal cystic lesion and pathologic fracture. Using a combined lateral closing and medial opening-wedge osteotomy, a 68° valgus correction was achieved with excellent clinical and functional outcomes at 16-month follow-up. Forward flexion increased from 120 to 170° preoperatively to postoperatively while abduction improved from 110° preoperatively to 170° postoperatively. CONCLUSION: A combined lateral closing and medial opening-wedge osteotomy of the proximal humerus can successfully treat cases of extreme proximal humerus varus in the growing shoulder where unilateral or dome osteotomies are not suitable.

Long-Term Outcomes at Skeletal Maturity of Combined Pelvic and Femoral Osteotomy for the Treatment of Legg-Calve-Perthes Disease.

Surgical treatment for Legg-Calve-Perthes disease (LCPD) is recommended for older children with moderate to severe disease. We sought to determine whether double osteotomies lead to improved radiologic outcomes compared to reported non-operative outcomes. Patients older than 6 years of age diagnosed with LCPD lateral pillar B or C who were treated with pelvic and femoral osteotomies were included. Radiologic outcomes and leg-length discrepancies were assessed using the Stulberg classification and were compared with the current literature. Fifteen hips in fourteen patients were treated with double osteotomy for LCPD, and seven had lateral pillar C disease (47%). The mean age at surgery was 8.6 years (range, 7.2-10.4) and the mean age at follow-up was 20.2 years (range, 14.2-35.6). At a mean 11.6-year follow-up (range: 6.3-25.2), double osteotomy resulted in 40% of patients having Stulberg I/II scores, 27% having Stulberg III scores, and 33% having Stulberg IV/V scores. The mean leg-length discrepancy was 1.4 cm in lateral pillar C patients compared to 0.8 cm in lateral pillar B patients. Four patients underwent additional surgeries, including two who required total hip arthroplasty. Double osteotomy as an alternative surgical procedure for the treatment of LCPD did not show improved outcomes when compared to historic non-operative cohorts.

Minimum 5-Year Results of Elongation Derotation Flexion Casting for Early Onset Scoliosis: The Story Is Not Over Until Skeletal Maturity.

BACKGROUND: Early conservative treatment for patients with idiopathic infantile scoliosis (IIS) with elongation derotation flexion (EDF) casting and subsequent serial bracing has become widely utilized. However, the long-term outcomes of patients treated with EDF casting are limited. METHODS: We performed a retrospective chart review of all patients who had undergone serial elongation derotation flexion casting and subsequent bracing for scoliosis presenting at a single large tertiary center. All patients were followed for a minimum of 5 years or until surgical intervention. RESULTS: Our study included 21 patients diagnosed with IIS and treated with EDF casting. At a mean 7-year follow-up, 13 of the 21 patients were considered successfully treated with a mean final major coronal curvature of 9 degrees compared to a pretreatment coronal curve of 36 degrees. These patients, on average, began casting at 1.3 years old and spent 1 year in a cast. Patients that did not have substantial improvement began casting at mean 4 years old and remained in a cast for 0.8 years. Three patients initially had substantial improvement with the correction to <20 degrees at a mean age of 7; however, their curves worsened in adolescence with poor brace compliance. All 3 patients will require surgical intervention. Of the patients not successfully treated with casting, 7 required surgery at a mean 8.2 years of age, 4.3 years after initiation of casting. A significant predictor of treatment failure was older age of cast initiation ( P <0.001). CONCLUSIONS: EDF casting can be an effective cure for IIS patients if initiated at a young age with 15 of 21 patients successfully treated (76%). However, 3 patients had a recurrence in adolescence resulting in an overall success rate of only 62%. Casting should be initiated early to maximize the likelihood of treatment success and periodic monitoring should be continued through skeletal maturity as recurrence during adolescence can occur.

Comparison of Fixation Techniques for Lower Extremity Rotationplasty.

BACKGROUND: Rotationplasty is a reconstructive, limb-sparing surgery indicated for patients with lower extremity musculoskeletal tumors. The procedure involves rotation of the distal lower extremity to allow the ankle to function as the new knee joint and provide an optimum weight-bearing surface for prosthetic use. Historically there is limited data comparing fixation techniques. The purpose of this study is to compare clinical outcomes between intramedullary nailing (IMN) and compression plating (CP) in young patients undergoing rotationplasty. METHODS: A retrospective review of 28 patients with a mean age of 10±4 years undergoing a rotationplasty for either a femoral (n=19), tibial (n=7), or popliteal fossa (n=2) tumor was performed. The most common diagnosis was osteosarcoma (n=24). Fixation was obtained with either an IMN (n=6) or CP (n=22). Clinical outcomes of patients undergoing rotationplasty were compared between the IMN and CP groups. RESULTS: Surgical margins were negative in all patients. The mean time to union was 24 months (range 6 to 93). There was no difference in the meantime to the union between patients treated with an IMN versus those with a CP (14±16 vs. 27±26 mo, P =0.26). Patients undergoing fixation with an IMN were less likely to have a nonunion (odds ratio: 0.35, 95% confidence interval: 0.03-3.54, P =0.62). Postoperative fracture of the residual limb only occurred in patients undergoing CP fixation (n=7, 33% vs. n=0, 0%, P =0.28). Postoperative fixation complications occurred in 13 (48%) patients, most commonly a nonunion (n=9, 33%). Patients undergoing fixation with a CP were more likely to have a postoperative fixation complication (odds ratio: 20, 95% CI: 2.14-186.88, P <0.01). CONCLUSIONS: Rotationplasty is an option for limb salvage for young patients with lower extremity tumors. The results of this study reveal fewer fixation complications when an IMN can be used. As such, IMN fixation should be considered for patients undergoing a rotationplasty, though equipoise should be shown by surgeons when determining technique.

Does Shorter Time to Treatment of Pediatric Supracondylar Humerus Fractures Impact Clinical Outcomes?

BACKGROUND: Treatment of supracondylar humerus (SCH) fractures within 18 hours of presentation is a tracked quality metric for ranking of pediatric hospitals. This is in contrast with literature that shows time to treatment does not impact outcomes in SCH fractures. We aim to determine whether an 18-hour cutoff for pediatric supracondylar humerus fracture treatment is clinically significant by comparing the complication risks ofpatients on either side of this timepoint. Our hypothesis is that there will be no statistically significant differences based on time to treatment. METHODS: A retrospective review of clinical outcomes was performed for 472 pediatric patients who underwent surgical management of isolated supracondylar humerus fractures between 1997 and 2022 at a single level I pediatric trauma hospital. The cohort was split based on time to surgery (within or ≥18 h from Emergency Department admission). RESULTS: Surgical treatment occurred within 18 hours of arrival in 435 (92.2%) patients and after 18 hours in 37 (7.8%) patients. Mean age was 5.6±2.2 years and 51.5% of patients were female. Gartland fracture classification was type II [n=152 (32.3%)], type III [n=284 (60.3%)], type IV [n=13 (2.8%)], or flexion-type [n=18 (3.8%)]. There were no differences in demographic characteristics or fracture classification between cohorts. Fractures in the ≥18-hour cohort were treated more commonly with 2 pins (62.2% vs. 38.5%, P =0.04). There were no statistically significant differences in open versus closed reduction, utilization of medial pins, or postoperative immobilization between cohorts. We were unable to detect any differences in postoperative complications, including non-union, delayed union, stiffness, malunion, loss of reduction, iatrogenic nerve injury, or infection. This remained true when type II fractures were excluded. CONCLUSIONS: Using an arbitrary time cutoff of <18 hours does not influence clinical outcomes in the surgical treatment of SCH fractures. This held true when type II fractures were excluded. For this reason, we recommend modification to the USNWR guidelines to decrease emphasis on time-to-treatment of SCH fractures. LEVEL OF EVIDENCE: Level III.

Normative Femoral and Tibial Lengths in a Modern Population of Twenty-First-Century U.S. Children.

BACKGROUND: The Green-Anderson (GA) leg-length data remain the gold standard for the age-based assessment of leg lengths in children despite their methodologic weaknesses. We aimed to summarize current growth trends among a cross-sectional cohort of modern U.S. children using quantile regression methods and to compare the median femoral and tibial lengths of the modern U.S. children with those of the GA cohort. METHODS: A retrospective review of scanograms and upright slot-scanning radiographs obtained in otherwise healthy children between 2008 and 2020 was completed. A search of a radiology registry revealed 3,508 unique patients between the ages of 2 and 18 years for whom a standard-of-care scanogram or slot-scanning radiograph had been made. All patients with systemic illness, genetic conditions, or generalized diseases that may affect height were excluded. Measurements from a single leg at a single time point per subject were included, and the latest available time point was used for children who had multiple scanograms made. Quantile regression analysis was used to fit the lengths of the tibia and femur and overall leg length separately for male patients and female patients. RESULTS: Seven hundred patients (328 female and 372 male) met the inclusion criteria. On average, the reported 50th percentile tibial lengths from the GA study at each time point were shorter than the lengths in this study by 2.2 cm (range, 1.4 to 3.3 cm) for boys and 2 cm (range, 1.1 to 3.1 cm) for girls. The reported 50th percentile femoral lengths from the GA study at each time point were shorter than the lengths in this study by 1.8 cm (range, 1.1 to 2.5 cm) for boys and 1.7 cm (range, 0.8 to 2.3 cm) shorter for girls. CONCLUSIONS: This study developed new growth charts for femoral and tibial lengths in a modern U.S. population of children. The new femoral and tibial lengths at nearly all time points are 1 to 3 cm longer than traditional GA data. The use of GA data for epiphysiodesis could result in underestimation of expected childhood growth. LEVEL OF EVIDENCE: Prognostic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Predictors of Total Hip Arthroplasty Following Pediatric Surgical Treatment of Developmental Hip Dysplasia at 20-Year Follow-Up.

Long-term outcomes of surgical treatment for pediatric developmental dysplasia of the hip (DDH) are not well defined. The purpose of this study was to report long-term radiographic and clinical outcomes, survivorship free of total hip arthroplasty (THA), and predictors of subsequent THA following childhood treatment of DDH. This study was a single-institution retrospective review of hips treated for DDH with closed or open reduction at a minimum 10-year follow-up. 107 patients (119 hips) were included with a mean patient age of 3.3 years at childhood treatment. At mean 30.5 years follow-up, 24 hips had undergone THA (20%). Mean patient age at time of THA was 33.5 years. None of the hips treated with closed reduction alone required THA, whereas 8 hips treated with open reduction (25%) underwent THA. Hips with patient age > 4 years at the time of treatment had lower survivorship at 35 years follow-up (50% vs. 85%; p < 0.001). Additionally, femoral osteotomy (OR 2.0, p < 0.001), and previous treatment elsewhere (27% vs. 16%; p < 0.01) were associated with subsequent THA. Early referral and appropriate intervention may prove important, as age and prior treatment were predictive of subsequent THA.

Bedside hip aspiration results in decrease in total general anesthesia time in pediatric patients: A multicenter study.

Purpose: The purpose of this study is to compare pediatric hip aspiration in the operating room under general anesthesia or via bedside aspiration under moderate sedation and delineate the anesthetic time required. Methods: A database query conducted at two academic institutions identified all patients under the age of 17 who underwent hip aspiration between 2000 and 2017. At one institution, aspiration was performed in the operating room under general anesthesia. Patients were kept anesthetized until cell count was complete. At the second institution, aspiration was performed in the emergency room at bedside under sedation. The medical record was reviewed for demographic data, hip aspiration results, diagnoses, treatment, and anesthesia time. Results: A total of 233 patients (233 hips) with a mean age of 7.2 years were identified. Seventy-five patients underwent aspiration in the operating room, and 158 patients underwent bedside aspiration. Patients with a negative aspiration averaged 87 min under anesthesia when performed in the operating room and 29 min under sedation when performed at bedside. Patients with a negative aspiration performed in the operating room after 5 pm averaged 99 min under anesthesia, and 73 min under anesthesia when performed between 7 am and 5 pm (p < 0.01). Seventy-eight (49%) patients who underwent bedside aspiration did not require operative intervention and therefore avoided general anesthesia. Conclusion: Pediatric hip aspiration performed in the operating room results in prolonged anesthesia times while synovial fluid is transported and processed. Anesthesia times are significantly longer after 5 pm. Bedside aspiration resulted in significantly less anesthesia exposure, with half of patients undergoing bedside aspiration avoiding general anesthesia altogether. Level of evidence: Level III.

Noninvasive Hemoglobin Monitoring for Postoperative Pediatric Orthopaedic Patients: A Preliminary Study.

BACKGROUND: Hemoglobin (Hgb) levels are frequently checked through venipuncture [invasive hemoglobin (iHgb)] in pediatric orthopaedic patients after high blood loss procedures. This needlestick may causes further anxiety and fear in hospitalized children. Noninvasive hemoglobin (nHgb) monitoring has been effectively utilized in the adult intensive care and postoperative total joint arthroplasty setting. nHgb monitoring has not yet been validated in children for routine postoperative Hgb assessment in pediatric orthopaedics. METHODS: In this prospective study, 46 pediatric orthopaedic patients were enrolled who were undergoing surgery and postoperative standard of care iHgb testing. On postoperative day 1, Hgb levels were obtained through venipuncture and nHgb monitor (Pronto-7; Masimo) within a 2-hour period. Patient preferences, iHgb and nHgb values, time to result, and provider preferences were recorded. Cost data were estimated based on the standard Medicare payment rates for lab services versus the cost of nHgb probe. RESULTS: nHgb results were obtained after 1 attempt in 38 patients (83%), after multiple attempts in 7 patients (15%), and could not be obtained in 1 patient. The mean time to obtain nHgb value was significantly shorter than that to obtain iHgb results (1.3±1.5 vs. 40±18.1 min; P <0.0001). The mean nHgb value was significantly higher than the mean iHgb value (11.7±1.5 vs. 10.6±1.1 g/dL, P <0.0001). nHgb exceeded iHgb by 2 g/dL or more in 12 (26%) patients (2.64±0.9 vs. 0.54±0.84 g/dL; P <0.0001). The concordance correlation coefficient between the 2 Hgb methods was 0.59, indicating moderate agreement. Forty-three (93%) of our patients and 34 (74%) of the care providers preferred nHgb over iHgb if results were equivalent. At our institution, the cost per iHgb monitoring is approximately $28 per blood draw as compared with $5 for nHgb monitoring. Interestingly, no patients required postoperative transfusion during the study period, as asymptomatic patients with no cardiac disease are typically observed unless the Hgb is <6. CONCLUSIONS: nHgb monitoring in postoperative pediatric patients overestimated Hgb levels compared with the standard of care methods; however, nHgb had high patient and provider satisfaction and had moderate agreement with iHgb. As no patients required transfusion, postoperative Hgb checks could likely be discontinued in some portion of our population. LEVEL OF EVIDENCE: Level Ib-Diagnostic study.

Vertebral body tethering compared to posterior spinal fusion for skeletally immature adolescent idiopathic scoliosis patients: preliminary results from a matched case-control study.

PURPOSE: Direct comparisons between vertebral body tethering (VBT) and posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) are limited. We aimed to evaluate 2-year results of VBT and PSF to report comparative outcomes. METHODS: 26 prospectively enrolled VBT patients were matched 1:1 by age, gender, Risser sign and major curve magnitude with PSF patients. At a minimum 2-year follow-up, surgical results and radiographic outcomes were reviewed. RESULTS: Operative time, anesthesia time, blood loss, and length of stay were significantly lower in the VBT group (< 0.001, p = 0.003, p < 0.001, p < 0.001, respectively). The major curve at 2 years was corrected by 46% in the VBT group vs. 66% in the PSF (p = 0.0004). Success following VBT, defined as no fusion surgery and Cobb angle < 35° at the 2-year follow-up, was seen in 20 VBT patients (77%) (p = 0.0003) and correlated with mean Cobb angle of < 35° on 3-month imaging. 12 VBT patients (46%) showed curve improvement over time, and those patients had significantly lower mean Cobb angle on the 3-month radiograph than non-modulators (23° vs 31°, p = 0.014). At 2 years, cord breakage occurred in five patients (19%). By 2 years, three VBT patients developed complications (2 pleural effusion and 1 overcorrection needing return to OR). In contrast to PSF, growth continued at T1-T12 (mean 13 mm) and over the instrumented levels (mean 10 mm) following VBT, compared to no growth over instrumented segments in the fusion cohort (p = 0.011, p = 0.0001). CONCLUSION: In Sanders stages 3 and 4 patients treated in the USA, Cobb angle < 35° on 3-month imaging was associated with success at the 2-year follow-up. Curve correction was superior in the PSF group with 96% achieving curve correction to < 35° vs. 77% of the VBT patients. Cord breakage was noted in 19% of VBT patients at the 2-year follow-up. Three patients developed complications in both the VBT and PSF cohorts. LEVEL OF EVIDENCE: Level II (prospective study with matched retrospective comparison group).

Tiered Guidelines in a Pediatric Orthopaedic Practice Reduce Opioids Prescribed at Discharge.

BACKGROUND: Data regarding opioid prescribing patterns following pediatric orthopaedic procedures is limited. The aim of this work was to evaluate the effects of tiered guidelines for discharge opioid prescriptions following common pediatric orthopaedic procedures. METHODS: Quality improvement project conducted at a single academic institution. Guidelines for discharge opioid prescriptions were implemented January 2018 and established 4 tiers of increasing invasiveness for 28 common pediatric orthopaedic procedures. Patients who underwent these procedures in 2017 comprised the preguideline cohort (N=258), while patients treated in 2019 comprised the postguideline cohort (N=212). Opioid prescriptions were reported as oral morphine equivalents (OMEs). Univariate tests were performed to assess statistically significant differences before and after implementation of the guidelines. RESULTS: There was a significant decrease in OME prescribed between preguideline and postguideline cohorts (median OME 97.5 vs. 37.5). When analyzed according to procedure tiers, tiers 1, 2, and 4 showed significant decreases in OME prescribed between 2017 and 2019. The rate of no opioids prescribed at discharge increased from 13% to 23% between preguideline and postguideline cohorts. The 30-day refill rate did not significantly change. After implementation of guidelines, 91% of all prescriptions were within the guideline parameters, and there was a significant reduction in prescription variability. In tier 4 procedures, median OME prescribed decreased from 375 preguideline to 188 postguideline, but was associated with greater opioid refills within 30 days of discharge (10.2% preguideline vs. 28.8% postguideline). CONCLUSIONS: Tiered guidelines for discharge opioid prescriptions following pediatric orthopaedic procedures can significantly decrease the quantity of opioids prescribed. Furthermore, we noted excellent adherence and no overall increase in the rates of narcotic refills. Such guidelines may improve pediatric orthopaedists' ability to responsibly treat postoperative pain while limiting the distribution of unneeded opioids. LEVEL OF EVIDENCE: Level IV-quality improvement project.

Flap Reconstruction for Treatment of Pediatric Linear Scleroderma.

BACKGROUND: Linear scleroderma is a rare connective tissue disease characterized by thickening of the skin due to excess collagen deposit. It is the most frequent type of localized scleroderma in the pediatric population (40%-70%), and it usually affects the extremities and head. Linear scleroderma can cause growth disturbances, extremity length discrepancy, and debilitating joint contractures. The aim of this study was to describe the surgical outcomes of microsurgical flap reconstruction of linear scleroderma in the pediatric population. METHODS: A retrospective review of all children with linear scleroderma was performed at our institution. Patients less than 18 years of age with clinical diagnosis of linear scleroderma and who underwent microsurgical flap reconstruction for correction of their scleroderma were included. Fat grafting procedures were excluded. Patient demographics and surgical outcomes were collected. RESULTS: A total 7 patients underwent microsurgical flap reconstruction for treatment of their linear scleroderma producing debilitating soft tissue contractures and preventing ambulation or elbow extension. Six patients had scleroderma involving the lower extremity and 1 involving the upper extremity. Three anterolateral thigh and 4 latissimus dorsi flaps were performed. The median age at surgery was 7 years (Q1-Q3, 5-11), and the median body mass index was 21.3 kg/m2 (Q1-Q3, 16.5-22.1). The median follow-up was 121.1 months (Q1-Q3, 43.2-187.4). All flaps survived, and no donor site complications were reported. Perioperative complications included wound infection that required debridement (n = 1), immediate postoperative bleeding requiring surgical intervention (n = 1), intraoperative venous congestion (n = 1), and scleroderma recurrence outside the flap (n = 2). When comparing anterolateral thigh and latissimus dorsi flaps, there was no statistically significant difference in the development of surgical complications, number of surgical revisions per patient [median, 4 (Q1-Q3, 4-7) vs 2.5 (Q1-Q3, 1.3, 3), P = 0.0916], or unplanned surgical interventions [median, 0 (Q1-Q3, 0-1) vs 1 (Q1-Q3, 0-1), P = 0.7228]. The reconstruction was successful in improving range of motion in 6 patients, 5 of which reached full weight-bearing. However, all patients had residual limb deformity, and 4 had remaining extremity length discrepancy. CONCLUSIONS: Microsurgical flaps are a good option for functional improvement of severe pediatric linear scleroderma affecting the extremities. However, residual limb deformity is common, and patients are often required to undergo additional surgical revisions.

Trends in Incidence of Adolescent Idiopathic Scoliosis: A Modern US Population-based Study.

BACKGROUND: A successful disease screening strategy requires a high incidence of the condition, efficacy of early treatment, and efficient detection. There is limited population-based data describing trends in incidence of adolescent idiopathic scoliosis (AIS) in the United States and potential role of school screening programs on the incidence of AIS. Thus, we sought to evaluate the incidence of AIS over a 20-year period between 1994 and 2013 using a population-based cohort. METHODS: The study population comprised 1782 adolescents (aged 10 to 18 y) with AIS first diagnosed between January 1, 1994 and December 31, 2013. The complete medical records and radiographs were reviewed to confirm diagnosis and coronal Cobb angles at first diagnosis. Age-specific and sex-specific incidence rates were calculated and adjusted to the 2010 United States population. Poisson regression analyses were performed to examine incidence trends by age, sex, and calendar period. RESULTS: The overall age-adjusted and sex-adjusted annual incidence of AIS was 522.5 [95% confidence interval (CI): 498.2, 546.8] per 100,000 person-years. Incidence was about 2-fold higher in females than in males (732.3 vs. 338.8/100,000, P<0.05). The incidence of newly diagnosed AIS cases with radiographs showing a Cobb angle >10 degrees was 181.7 (95% CI: 167.5, 196.0) per 100,000 person-years. The overall incidence of AIS decreased significantly after discontinuation of school screening in 2004 (P<0.001). The incidence of bracing and surgery at initial diagnosis was 16.6 (95% CI: 12.3, 20.9) and 2.0 (95% CI: 0.5, 3.4) per 100,000 person-years, respectively. CONCLUSIONS: Overall population-based incidence of AIS decreased after school screening was discontinued. However, incidence of patients with a Cobb angle >10 degrees, initiation of bracing and surgery did not change significantly over time. This provides further data to help determine the role of scoliosis screening. LEVEL OF EVIDENCE: Level III.

Is the axial spinal cord classification predictive of intraoperative neurologic alert for pediatric scoliosis patients? An independent retrospective validation study.

PURPOSE: We sought to determine whether the axial spinal cord classification by Sielatycki et al. would be associated with increased intraoperative neuromonitoring (IONM) alerts for pediatric scoliosis patients undergoing posterior spinal fusion (PSF) surgery. METHODS: Children less than age 19 with scoliosis undergoing PSF were retrospectively reviewed. Axial-T2 MRI of the thoracic apex was reviewed for spinal cord/CSF architecture as described by Sielatycki et al.: Type 1-circular cord with visible CSF, Type 2-circular cord but no visible CSF at apical concavity, and Type 3-cord deformed with no intervening CSF. Intraoperative neuromonitoring reports, operative records and preoperative radiographs were reviewed. RESULTS: 90 patients met the inclusion criteria. Rate of neurologic events was Type 1: 2% (1/41 patients), Type 2: 14.3% (4/28), Type 3: 57.1% (12/21) (Type 1 vs 2 p = 0.06; Type 1 vs 3 p < 0.0001; Type 2 vs 3 p = 0.0017). Three patients with a Type 3 cord awoke with significant deficits. In comparison to Type 1 cords, Type 3 and Type 2 spinal cords were associated with increased coronal and total deformity angular ratios (Type 1 vs 3 p = 0.035 and 0.0054 respectively; Type 1 vs 2 p = 0.042 and 0.03 respectively). There was no difference in gender, diagnosis category, age at surgery, Cobb angle or kyphosis between the three groups. CONCLUSION: The axial spinal cord classification correlated with IONM alerts and greater severity of spinal deformity in pediatric scoliosis patients. LEVEL OF EVIDENCE: IV, retrospective cohort study.

Characteristics and reoperation rates of paediatric tarsal coalitions: a population-based study.

PURPOSE: Tarsal coalitions are congenital fusions of two or more tarsal bones and can lead to foot pain and stiffness. Few studies examine the long-term reoperation rates following paediatric tarsal coalition surgery. METHODS: A population-based database, linking medical records at all medical centres to capture the entire medical history of the full population of a Midwest county, was used to identify tarsal coalitions in children between 1966 and 2018. Records were reviewed for clinical data, surgical records and followed up to identify any subsequent surgical interventions. RESULTS: A total of 58 patients (85 coalitions) were identified; 46 calcaneonavicular (CN) coalitions, 30 talocalcaneal (TC) coalitions and nine other coalitions (seven talonavicular, one naviculocuboid, one naviculocuneiform). In all, 46 coalitions were treated surgically (43 coalition resections, three arthrodeses) and 39 were treated nonoperatively. Patients treated surgically were less likely to report ongoing symptoms at final follow-up compared with patients managed nonoperatively (33% versus 67%; p = 0.0017). With a median 14.4 years (interquartile range 9.3 to 19.7) follow-up, there was an overall re-operation rate of 8.7% (4/46). Differences in reoperation rates by initial surgery (resection versus arthrodesis; p = 0.2936), coalition type (CN versus TC versus Other; p = 0.6487) or composition (osseous versus fibrocartilaginous; p = 0.29) did not reach statistical significance. CONCLUSION: This is the first population-based study demonstrating the durability of surgical management of tarsal coalitions in a paediatric population. At final follow-up, patients treated surgically are less likely to report persistent symptoms compared with patients managed nonoperatively. Long-term reoperation rates appear to be low (8.7%). LEVEL OF EVIDENCE: III.

Intercalary Allograft Reconstruction of the Proximal Tibia With and Without a Free Fibula Flap in Pediatric Patients.

BACKGROUND: Limb salvage of the proximal tibia can be difficult due to the growth potential of and functional demands of the pediatric patients. Multiple reconstruction techniques exist, however, the ideal form of reconstruction is yet to be elucidated. The purpose of the current study is to evaluate outcomes in patients with an intercalary resection of the proximal tibia reconstructed with an allograft with or without a free vascularized fibula flap (FVF). METHODS: Seventeen pediatric patients (9 males, 8 females) underwent lower extremity limb salvage with the use of intercalary cadaveric allograft at a mean age of 12±4 years. The most common diagnoses were osteosarcoma (n=6) and Ewing sarcoma (n=6). Patients were reconstructed with an allograft alone (n=6) or supplemented with an FVF (n=11). RESULTS: All surviving patients had at least 2 years of clinical follow-up, with the mean follow-up of 12±7 years. The mean time to union of the allograft was 11±4 months, with 6 patients requiring additional bone grafting. There was no difference in the need for an additional bone graft (odds ratio=1.14, P=1.0) between patients with an FVF and those without. Four patients underwent an amputation, all with an allograft alone, due to disease recurrence (n=2) and due to infection (n=2). As such, there was a higher 10-year overall limb-salvage rate when the allograft was combined with an FVF compared with an allograft alone (100% vs. 33%, P=0.001). At last follow-up, the mean Mankin and Musculoskeletal Tumor Society rating was 86%, with a higher mean score in patients reconstructed with an FVF (94% vs. 70%, P=0.002). CONCLUSION: Use of an intercalary allograft supplemented with an FVF to reconstruct the proximal tibia provides a durable means of reconstruction with an excellent functional outcome following oncologic proximal tibia resection in a pediatric population. LEVEL OF EVIDENCE: Level III-therapeutic level.

Does Shorter Time to Treatment of Pediatric Femur Shaft Fractures Impact Clinical Outcomes?

BACKGROUND: Annual rankings by US News and World Report are a widely utilized metric by both health care leaders and patients. One longstanding measure is time to treatment of femur shaft fractures. Hospitals able to provide at least 80% of pediatric patients with an operating room start time within 18 hours of admission to the emergency department score better as part of the overall pediatric orthopaedic ranking. Therefore, it is important to determine whether the 18-hour treatment time for pediatric femur shaft fractures is a clinically meaningful metric. METHODS: A retrospective review of clinical outcomes of 174 pediatric patients (aged below 16 y) with isolated femur shaft fractures (Injury Severity Score=9) was conducted from 1997 to 2017 at a single level I pediatric trauma center. The 2 comparison groups were patients receiving fracture reduction within 18 hours of emergency department admission (N=87) or >18 hours (N=87). RESULTS: Patient, injury, and surgical characteristics were similar between the 2 groups. Both groups had a similar mean age (treatment <18 h=7.5 y; treatment >18 h=8.1 y). Patients who received treatment within 18 hours were more often immobilized postoperatively (70.1% vs. 53.5%; P=0.0362) and had a shorter median hospital length of stay (2 vs. 3 d; P=0.0047). There were no statistically significant differences in any outcomes including surgical site infection, time to weight-bearing (treatment <18 h mean=48.1 d vs. 52.5 d), time to complete radiographic fracture healing (treatment <18 h mean=258.9 d vs. 232.0 d), decreased range of motion, genu varus/valgus, limb length discrepancy, loss of reduction, or persistent pain. CONCLUSIONS: Treatment of pediatric femur shaft fractures within 18 hours does not impact clinical outcomes. National quality measures should therefore use evidence-based metrics to help improve the standard of care. LEVEL OF EVIDENCE: Therapeutic level III.

Predictors of cost for posterior spinal fusion in adolescent idiopathic scoliosis.

STUDY DESIGN: Single-center retrospective review of pediatric patients who underwent posterior spinal fusion for adolescent idiopathic scoliosis (AIS). OBJECTIVE: To determine what clinical and operative factors influence inflation-adjusted hospital costs of posterior spine fusion surgery for AIS. With rising healthcare costs and the advent of bundled payments, it is essential understand the predictors of costs for surgical procedures. We sought to determine the components of hospital costs for AIS posterior spine fusion surgery using standardized, inflation-adjusted, line-item costs for services and procedures. METHODS: The study population comprised 148 AIS patients who underwent spinal fusion surgery at a large tertiary care center between 2009 and 2016. Data on medical characteristics, curve type, curve magnitude, number of screws and the number of levels was collected through manual chart review of X-rays and medical records. Hospital costs from admission until discharge were retrieved from an institutional database that contained line-item details of all procedures and services billed during the hospital episode. Bottom-up microcosting valuation techniques were used to generate standardized inflation-adjusted estimates of costs and standard deviations in 2016 dollars. RESULTS: Mean cost of AIS surgery was $48,058 ± 9379. Physician fees averaged 15% of the total cost ($7045 ± 1732). Implant costs and surgical/anesthesia/surgeon's fees accounted for over 70% of the hospital costs. Mean number of screws was 16 ± 4.5, mean number of levels fused was 11.2 ± 2.2, and the mean implant density (screws per level fused) was 1.45 ± 0.35. On multivariate analysis, the number of screws per level fused, number of levels fused, curve magnitude and length of stay were all significantly associated with hospital costs (p < 0.01). CONCLUSIONS: Bundled payments for AIS surgery should include adjustments for number of levels fused and curve size. Areas for cost savings include further reduction in implant costs, shortening length of stay, and reducing intraoperative costs. LEVEL OF EVIDENCE: III.