Definition of Tweener: Consensus Among Experts in Treating Early-onset Scoliosis.

BACKGROUND: The term "Tweener" is colloquially used to refer to early-onset scoliosis (EOS) patients whose age and development make them candidates for multiple surgical options. The purpose of this study was to establish expert consensus on a definition to formally characterize the Tweener population. METHODS: A 3-round survey of surgeons in an international EOS study group was conducted. Surgeons were provided with various patient characteristics and asked if each was part of their definition for Tweener patients. Responses were analyzed for consensus (≥70%), near-consensus (60% to 69%), and no consensus (<60%). RESULTS: Consensus was reached (89% of respondents) for including chronological age in the Tweener definition; 8 to 10 years for females and 9 to 11 years for males. Surgeons agreed for inclusion of Sanders score, particularly Sanders 2 (86.0%). Patients who have reached Sanders 4, postmenarche, or have closed triradiate cartilage should not be considered Tweeners. Bone age range of 8 years and 10 months to 10 years and 10 months for females (12 y for males) could be part of the Tweener definition. CONCLUSIONS: This study suggests that the Tweener definition could be the following: patients with open triradiate cartilage who are not postmenarche and have not reached Sanders 4, and if they have one of the following: Sanders 2 or chronological age 8 to 10 years for females (9 to 11 y for males) or bone age 8 years and 10 months to 10 years and 10 months for females (12 y for males). This definition will allow for more focused and comparative research on this population. LEVEL OF EVIDENCE: Level V-expert opinion.

Factors that Influence Acquisition of Lower Extremity Braces in the Pediatric Orthopaedic Population.

BACKGROUND: Lower extremity brace-wear compliance has been studied in pediatrics, but failure to acquire a prescribed brace has not been included. The purpose of this study was to evaluate brace acquisition as a component of brace-wear compliance. METHODS: Records of patients (0 to 21 y) prescribed lower extremity braces from 2017 to 2019 were reviewed. Diagnoses included cerebral palsy, spina bifida, short Achilles tendon, clubfoot, and other. Brace type was categorized as clubfoot foot abduction orthosis, ankle-foot orthosis, knee, hip, or custom/other braces. Brace prescription and acquisition dates were recorded. Insurance was classified as government, private, or uninsured. Patient demographics included age, sex, race, and calculated area deprivation index. RESULTS: Of the 1176 prescribed lower extremity braces, 1094 (93%) were acquired while 82 (7%) were not. The odds ratios (OR) of failure to acquire a prescribed brace in Black and Hispanic patients were 1.64 and 2.71 times that in White patients, respectively (95% confidence interval: 1.01-2.71, P=0.045; 1.23-5.6, P=0.015); in patients without insurance, the OR was 8.48 times that in privately insured patients (95% confidence interval: 1.93-31.1, P=0.007). The ORs of failure to acquire were 2.12 (P=0.003) in patients 4 years or more versus 0 to 3 years, 4.17 (P<0.0001) in cerebral palsy versus clubfoot, and 4.12 (P=0.01) in short Achilles tendon versus clubfoot. There was no significant association between sex or area deprivation index and failure of brace acquisition. CONCLUSIONS: In our cohort, 7% of prescribed braces were not acquired. Black or Hispanic race, lack of insurance, and older age were associated with failure to acquire prescribed braces. Braces prescribed for clubfoot were acquired more often than for cerebral palsy or short Achilles tendon. Brace-wear compliance is an established factor in treatment success and recurrence. This study identified risk factors for failed brace acquisition, a critical step for improving compliance. These results may help effect changes in the current system that may lead to more compliance with brace wear. LEVEL OF EVIDENCE: Level III-retrospective cohort study.

Interobserver and Intraobserver Agreement are Unsatisfactory When Determining Abstract Study Design and Level of Evidence.

BACKGROUND: Understanding differences between types of study design (SD) and level of evidence (LOE) are important when selecting research for presentation or publication and determining its potential clinical impact. The purpose of this study was to evaluate interobserver and intraobserver reliability when assigning LOE and SD as well as quantify the impact of a commonly used reference aid on these assessments. METHODS: Thirty-six accepted abstracts from the Pediatric Orthopaedic Society of North America (POSNA) 2021 annual meeting were selected for this study. Thirteen reviewers from the POSNA Evidence-Based Practice Committee were asked to determine LOE and SD for each abstract, first without any assistance or resources. Four weeks later, abstracts were reviewed again with the guidance of the Journal of Bone and Joint Surgery (JBJS) LOE chart, which is adapted from the Oxford Centre for Evidence-Based Medicine. Interobserver and intraobserver reliability were calculated using Fleiss' kappa statistic (k). χ2 analysis was used to compare the rate of SD-LOE mismatch between the first and second round of reviews. RESULTS: Interobserver reliability for LOE improved slightly from fair (k=0.28) to moderate (k=0.43) with use of the JBJS chart. There was better agreement with increasing LOE, with the most frequent disagreement between levels 3 and 4. Interobserver reliability for SD was fair for both rounds 1 (k=0.29) and 2 (k=0.37). Similar to LOE, there was better agreement with stronger SD. Intraobserver reliability was widely variable for both LOE and SD (k=0.10 to 0.92 for both). When matching a selected SD to its associated LOE, the overall rate of correct concordance was 82% in round 1 and 92% in round 2 (P<0.001). CONCLUSION: Interobserver reliability for LOE and SD was fair to moderate at best, even among experienced reviewers. Use of the JBJS/Oxford chart mildly improved agreement on LOE and resulted in less SD-LOE mismatch, but did not affect agreement on SD. LEVEL OF EVIDENCE: Level II.

Infections After Open Fractures in Pediatric Patients: A Review of 288 Open Fractures.

We reviewed pediatric open fractures treated at a large Level 1 children's trauma center to determine the rate of infection after open fractures, potential risk factors for infection, and the rate of infection caused by antibiotic-resistant organisms. A retrospective review identified 288 open fractures in children 1 to 17 years of age. Post-traumatic infections developed in 24 (8.3%) open fractures. There was no significant association between the development of infection and mechanism of injury (p = 0.33), time to surgical debridement (p = 0.93), or type of empiric antibiotic given (p = 0.66). Infection occurred more frequently in overweight and obese patients (odds ratio = 2.22; 95% confidence interval: 0.93, 5.46, p = 0.07). There was one infection (4.2%) caused by methicillin-resistant staphylococcus aureus (MRSA). The most commonly identified organisms on culture were methicillin-sensitive staphylococcus aureus (n = 3) and pseudomonas (n = 3). Obesity is a significant risk factor for the development of infection after an open fracture in the pediatric population. (Journal of Surgical Orthopaedic Advances 31(2):073-075, 2022).

Hunger Games: Impact of Fasting Guidelines for Orthopedic Procedural Sedation in the Pediatric Emergency Department.

BACKGROUND: Fasting guidelines for pediatric procedural sedation have historically been controversial. Recent literature suggests that there is no difference in adverse events regardless of fasting status. OBJECTIVES: The goal of this study was to examine adverse outcomes and departmental efficiency when fasting guidelines are not considered during pediatric emergency department (PED) sedation for orthopedic interventions. METHODS: Retrospective chart review identified 2674 patients who presented to a level I PED and required procedural sedation for orthopedic injuries between February 2011 and July 2018. This was a level III, retrospective cohort study. Patients were categorized into the following groups: already within American Society of Anesthesiologists (ASA) fasting guidelines on presentation to the PED (n = 671 [25%]), had procedural sedation not within the ASA guidelines (n = 555 [21%]), and had procedural sedation after fasting in the PED to meet ASA guidelines (n = 1448 [54%]). Primary outcomes were length of stay, time from admission to start of sedation, length of sedation, time from end of sedation to discharge, and adverse events. DISCUSSION: There was a significant difference in the length of stay and time from admission to sedation-both approximately 80 min longer in those with procedural sedation after fasting in the PED to meet ASA guidelines (p < 0.001). There was no significant difference among groups in length of sedation or time to discharge after sedation. Adverse events were uncommon, with only 55 total adverse events (0.02%). Vomiting during the recovery phase was the most common (n = 17 [0.006%]). Other notable adverse events included nine hypoxic events (0.003%) and five seizures (0.002%). There was no significant difference in adverse events among the groups. CONCLUSIONS: Length of stay in the PED was significantly longer if ASA fasting guidelines were followed for children requiring sedation for orthopedic procedures. This is a substantial delay in a busy PED where beds and resources are at a premium. Although providing similar care with equivalent outcomes, the value of spending less time in the PED is evident. Overall, adverse events related to sedation are rare and not related to fasting guidelines.

Radiation Reduction Strategies in Pediatric Orthopaedics.

INTRODUCTION: Pediatric orthopaedic patients have the potential for significant radiation exposure from the use of imaging studies, such as computed tomography and bone scintigraphy. With the potential for long-term treatment, such as is required for scoliosis or osteogenesis imperfecta, patients are at even greater risk of radiation-induced carcinogenesis. DISCUSSION: Although an association between radiation and cancer risk is evident, causation is difficult to prove because comorbidities or genetic predispositions may play a role in the higher baseline rates of malignancy later in life. Efforts have been made over the years to reduce exposure using more modern imaging techniques and simple radiation reduction strategies. Educational efforts and clinical practice guidelines are decreasing the rate of computed tomography scan use in pediatrics. Although considerable work is being done on the development of radiation-free imaging modalities, imaging that uses ionizing radiation will, in the near term, be necessary in specific circumstances to provide optimal care to pediatric orthopaedic patients. CONCLUSION: Knowledge of the ionizing radiation exposure associated with commonly used tests as well as radiation-reduction strategies is essential for the optimal and safe care of pediatric orthopaedic patients.

Intraobserver and Interobserver Reliability of the Peritubercle Lucency Sign in Slipped Capital Femoral Epiphysis.

BACKGROUND: An area of enlargement of the metaphyseal socket around the epiphyseal tubercle, termed the peritubercle lucency sign, has recently been introduced as a possible predictor of contralateral slipped capital femoral epiphysis in patients with previous unilateral slipped capital femoral epiphysis. This study aimed to assess intraobserver and interobserver reliability for detecting the presence or absence of the peritubercle lucency sign. METHODS: Thirty-five radiographs were presented to 6 fellowship-trained pediatric orthopaedic surgeons on 2 separate occasions 30 days apart, ensuring that the images were shown in a different order on the second exposure. Both times the reviewers recorded whether the peritubercle lucency sign was present or absent in each of the radiographs. Statistical analysis was performed to determine the intraobserver and interobserver reliability. RESULTS: In the intraobserver analysis, percent agreement between the first and second time the radiographs were reviewed varied between 62.9% and 85.7%, for an average intraobserver agreement of 74.8%. κ values for the 6 reviewers varied between 0.34 and 0.716, with an average intraobserver κ value of 0.508. The interobserver percent agreement was 40.0% for the first time the radiographs were reviewed, 42.9% the second time, and the overall interobserver percent agreement was 29%. The interobserver κ value was 0.44 the first time the radiographs were reviewed, 0.45 the second time, and the overall interobserver κ value was 0.45. DISCUSSION: On the basis of our findings, the peritubercle lucency has modest intraobserver and interobserver reliability at best and should be used with other currently used factors, such as age, presence of endocrinopathy, status of triradiate cartilage, posterior sloping angle, and modified Oxford score, in determining the need for prophylactic pinning. Further refinement of the definition of the peritubercle lucency sign may be needed to improve agreement and reliability of the sign. LEVEL OF EVIDENCE: Level III-prognostic study.

Can Pediatric Orthopaedic Surgery be Done Safely in a Freestanding Ambulatory Surgery Center? Review of 3780 Cases.

BACKGROUND: The purpose of this study was to determine the intraoperative and 30-day postoperative complication rates in a large consecutive cohort of pediatric patients who had orthopaedic surgery at a freestanding ambulatory surgery center (ASC). The authors also wanted to identify the rates of same-day, urgent hospital transfers, and 30-day hospital admissions. The authors hypothesized that pediatric orthopaedic procedures at a freestanding ASC can be done safely with a low rate of complications. METHODS: A retrospective review identified patients aged 17 years or younger who had surgery at a freestanding ASC over a 9-year period. Adverse outcomes were divided into intraoperative complications, postoperative complications, need for the secondary procedure, unexpected hospital admission on the same day of the procedure, and unexpected hospital admission within 30 days of the index procedure. Complications were graded as grade 1, the complication could be treated without additional surgery or hospitalization; grade 2, the complication resulted in an unplanned return to the operating room (OR) or hospital admission; or grade 3, the complication resulted in an unplanned return to the OR or hospitalization with a change in the overall treatment plan. RESULTS: Adequate follow-up was available for 3780 (86.1%) surgical procedures. Overall, there were 9 (0.24%) intraoperative complications, 2 (0.08%) urgent hospital transfers, 114 (3%) complications, and 16 (0.42%) readmissions. Seven of the 9 intraoperative complications resolved before leaving the OR, and 2 required return to the OR.Neither complications nor hospitalizations correlated with age, race, gender, or length or type of surgery. There was no correlation between the presence of medical comorbidities, body mass index, or American Society of Anesthesiologists score and complication or hospitalization. CONCLUSIONS: Pediatric orthopaedic surgical procedures can be performed safely in an ASC because of multiple factors that include dedicated surgical teams, single-purpose ORs, and strict preoperative screening criteria. The rates of an emergency hospital transfer, surgical complications, and 30-day readmission, even by stringent criteria, are lower than those reported for outpatient procedures performed in the hospital setting. LEVEL OF EVIDENCE: Level IV-case series.

Daratumumab in high-risk relapsed/refractory multiple myeloma patients: adverse effect of chromosome 1q21 gain/amplification and GEP70 status on outcome.

Gain of chromosome 1q21 and the gene expression-based GEP70 risk score are established prognostic markers for newly diagnosed Multiple Myeloma (MM) patients. Here we addressed the prognostic impact of these two markers in 81 relapsed/refractory (RR) MM patients treated with the CD38-antibody daratumumab. Fluorescence in situ hybridization for 1q21 was performed at initial presentation, while the GEP70 score was determined at initial presentation and prior to daratumumab treatment. While the GEP70 at initial presentation showed a trend for inferior survival, the GEP70 collected prior to daratumumab treatment was significantly associated with poor outcome (P < 0·05). The worst outcome was seen for patients who were positive for gain(1q) and classified as GEP70 high risk prior to daratumumab [progression-free (PFS) and overall survival (OS) of 0·3 years (95% CI: 0·15-1·4 years) and 0·8 years (95% CI: 0·5-1·9 years) respectively], while the median PFS and OS were not reached by patients without gain(1q) and GEP70 low-risk status. In conclusion, gain(1q) and the GEP70 are powerful prognostic markers for RR MM patients treated with daratumumab, and patients classified as high risk according to these markers experience shorter treatment response.

Do Patient-specific or Fracture-specific Factors Predict the Development of Acute Compartment Syndrome After Pediatric Tibial Shaft Fractures?

BACKGROUND: Tibial shaft fractures are the most common injuries preceding acute compartment syndrome (ACS), so it is important to understand the incidence of and risk factors for ACS after pediatric tibial shaft fractures. The purposes of this study were to determine the rate at which ACS occurs and if any patient or fracture characteristics are significantly associated with developing ACS. METHODS: All patients aged 5 to 17 years treated for a tibial shaft fracture at a level 1 pediatric trauma center, a level 1 adult trauma center, and an outpatient orthopaedic practice between 2008 and 2016 were retrospectively identified. Demographics, mechanisms of injury, and fracture characteristics were collected from the medical records. Radiographs were reviewed by study authors. ACS was diagnosed clinically or by intracompartmental pressure measurement. Univariable analysis was performed using the Fisher exact test for nominal variables and simple logistic regression for continuous variables. Multivariable analysis was performed using stepwise logistic regression. RESULTS: Among 515 patients with 517 tibial shaft fractures, 9 patients (1.7%) with 10 (1.9%) fractures developed ACS at a mean age of 15.2 years compared with a mean age of 11 years in patients without ACS (P=0.001). One patient with bilateral tibial fractures developed ACS bilaterally. Age greater than 14 years (P=0.006), higher body mass index (P<0.001), motorcycle or motor vehicle accidents (P=0.034), comminuted and segmental tibial shaft fractures (P<0.001), ipsilateral fibular fracture (P=0.002), and associated orthopaedic injuries (P=0.032) were all significantly more common in the ACS group. CONCLUSIONS: ACS developed in 1.7% of the patients with tibial shaft fractures in this retrospective study-a rate significantly lower than previously reported. Age greater than 14 years, higher body mass index, motor vehicle or motorcycle accidents, comminuted or segmental fracture pattern, ipsilateral fibular fracture, and associated orthopaedic injuries are all significantly associated with its development. LEVELS OF EVIDENCE: Level III-retrospective comparative study.

Concurrent Ipsilateral Tibial Shaft and Distal Tibial Fractures in Pediatric Patients: Risk Factors, Frequency, and Risk of Missed Diagnosis.

BACKGROUND: The purpose of this study was to determine the frequency of concurrent ipsilateral distal tibial fractures with tibial shaft fractures in the pediatric population; to identify patient and fracture characteristics that increase the likelihood of a concurrent fracture; and determine if any of these concurrent distal tibial fractures were missed on initial radiographic examination. METHODS: Retrospective chart review was done to identify patients 5 to 17 years old who were treated for a tibial shaft fracture at a large, Level 1 free-standing children's hospital and an outpatient orthopaedic practice between 2008 and 2016. Patient and fracture characteristics were recorded. RESULTS: Of 517 fractures (515 patients), 22 (4.3%) had concurrent ipsilateral distal tibial fractures: 11 triplane, 5 medial malleolar, 3 bimalleolar, and 2 Tillaux (Salter-Harris III) ankle fractures, and 1 Salter-Harris II distal tibial fracture. Age was the only patient characteristic significantly associated with a second, more distal fracture: patients with both fractures were older (12.7 y) than those with an isolated tibial shaft fracture (11 y). There was no difference in the rate of distal tibial fractures between high-energy and low-energy mechanisms of injury and no differences in the rate of open injuries or the presence of a fibular fracture. Patients with a tibial shaft fracture at the junction of the middle and distal thirds were significantly more likely to have a concurrent distal tibial fracture; oblique and spiral fracture patterns were more frequent in the group with concurrent distal tibial fractures than in the isolated tibial shaft fracture group. CONCLUSIONS: In our series, 36% of the concurrent distal tibial fractures were not diagnosed until chart review for this study, which suggests the need for ankle-specific imaging in certain patients. We recommend ankle-specific imaging when an oblique or spiral tibial shaft fracture is located at the junction of the middle and distal thirds of the tibia or in patients in whom a distal tibial fracture is suspected because of pain, swelling, or bruising. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

The Frequency of Mediastinal Injury in Acute Posterior Sternoclavicular Dislocations: A Multicenter Study.

BACKGROUND: Acute posterior sternoclavicular dislocations (APSCD) are rare injuries that historically have prompted concern for injury to the great vessels and other mediastinal structures from initial trauma or subsequent treatment, resulting in the recommendation that a thoracic or vascular surgeon be present or available during operative treatment. The objectives of the study were to characterize the demographic, clinical, and radiographic characteristics of a large series of APSCDs in skeletally immature patients and to describe the rate and nature of any vascular or mediastinal complications that occurred during treatment. METHODS: Following Institutional Review Board approval, records of consecutive patients under 25 years of age treated for APSCD were collected from each of 6 participating centers. Only acute injuries (sustained fewer than 10 days before presentation) were included. Patient demographics, injury mechanism, associated mediastinal injuries, and need for thoracic/vascular surgery were recorded. Mediastinal structures injured or compressed by mass effect were specifically characterized by review of preoperative computed tomography imaging. RESULTS: Review identified 125 patients with a mean age of 14.7 years; 88% were male. APSCD most commonly resulted from a sporting injury (74%) followed by falls from standing height (10%) and high-energy motor vehicle trauma (10%). The most common finding on cross-sectional imaging was compression without laceration of the ipsilateral brachiocephalic vein (50%). Eleven patients had successful closed reduction, and 114 (90%) had open reduction and internal fixation, with 25 failed or unstable closed reductions preceding open treatment. There were no vascular or mediastinal injuries during reduction or fixation that required intervention. CONCLUSIONS: In this multicenter series of 125 APSCDs no injuries to the great vessels/mediastinal structures requiring intervention were identified. Although more than half of patients had evidence of extrinsic vascular compression at the time of injury, careful open reduction of acute injuries can be safely performed. Although vascular injuries following APSCD seem to be quite rare, vascular complications can be catastrophic. Treating providers should consider these data and their own institutional resources to maximize patient safety during the treatment of APSCD. LEVEL OF EVIDENCE: Level III-therapeutic case control study.

Minimum 5-Year Follow-up on Graduates of Growing Spine Surgery for Early Onset Scoliosis.

INTRODUCTION: After discontinuation of growth friendly (GF) surgery for early onset scoliosis, patients undergo spinal fusion or continued observation. This last planned treatment is colloquially called "definitive" treatment, conferring these patients as "graduates" of a growing program. The 5-year radiographic and clinical outcomes of this cohort are unknown. METHODS: An international pediatric spine database was queried for patients from a GF program (spine or rib-based) with minimum 5-year follow-up from last planned surgery (GF or spinal fusion). Radiographs and charts were reviewed for main coronal curve angle and maximum kyphosis as well as occurrence of secondary surgery. RESULTS: Of 580 graduates, 170 (29%) had minimum 5-year follow-up (37% male). Scoliosis etiology was congenital in 41 (24%), idiopathic 36 (21%), neuromuscular 51 (30%), and syndromic 42 (25%). Index surgery consisted of spine-based growing rods in 122 (71%) and rib-based distraction in 48 (29%). Mean age at index surgery was 6.8 years, and patients underwent an average of 5.4 lengthenings over an average of 4.9 years (range, 6 mo to 11 y). Last planned treatment was at an average age of 11.8 years (range, 7 to 17 years). Last planned treatment consisted of spinal fusion in 114 patients, 47 had growing implants maintained, 9 had implants removed. Average follow-up was 7.3 years (range, 5 to 13 y).When compared from postdefinitive treatment to 2-year follow-up, there was noted progression of the coronal curve angle (46±19 to 51±21 degrees, P=0.046) and kyphosis (48±20 to 57±25 degrees, P=0.03). However, between 2 and 5 years, no further progression occurred in the coronal (51±21 to 53±21 degrees, P=0.26) or sagittal (57±25 to 54±28 degrees, P=0.93) planes. When stratified based on etiology, there was no significant coronal curve progression between 2- and 5-year follow-up. When comparing spinal fusion patients to those who had maintenance of their growing construct, there was also no significant curve progression.Thirty-seven (21%) underwent at least 1 (average, 1.7; range, 1 to 7) revision surgery following graduation, and 15 of 37 (41%) underwent 2 or more revision surgeries. Reason for revision was implant revision (either GF or spinal fusion) in 34 patients, and implant removal in 3. On an average, the first revision was 2.5 years after the definitive treatment plan (range, 0.02 to 7.4 y). In total, 15 of 37 (41%) revisions occurred over 2 years following the final decision for treatment plan, and 7 of 37 (19%) occurred 5 or more years after the definitive treatment.Patients who underwent spinal fusion as a definitive treatment strategy were more likely to undergo revision surgery (27%) than patients who had their GF implants maintained (11%) (P=0.04). CONCLUSIONS: Five years following "graduation" from growing surgery for early onset scoliosis, there is progression of curve magnitude in both the coronal and sagittal planes up to 2 years, with no further progression at 5 years. A total of 21% of patients undergo at least 1 revision surgery, and average time to revision surgery is over 2 years from last planned surgery. Risk of revision surgery was higher in patients who underwent a spinal fusion as their definitive treatment strategy. LEVEL EVIDENCE: Level III-retrospective comparative. TYPE OF EVIDENCE: Therapeutic.

Establishing Consensus on the Best Practice Guidelines for Use of Halo Gravity Traction for Pediatric Spinal Deformity.

BACKGROUND: Although halo gravity traction (HGT) has been used to treat children with severe spinal deformity for decades, there is a distinct lack of high-quality evidence to speak to its merits or to dictate ideal manner of implementation. In addition, no guidelines exist to drive research or assist surgeons in their practice. The aim of this study was to establish best practice guidelines (BPG) using formal techniques of consensus building among a group of experienced pediatric spinal deformity surgeons to determine ideal indications and implementation of HGT for pediatric spinal deformity. METHODS: The Delphi process and nominal group technique were used to formally derive consensus among leaders in pediatric spine surgery. Initial work identified significant areas of variability in practice for which we sought to garner consensus. After review of the literature, 3 iterative surveys were administered from February through April 2018 to nationwide experts in pediatric spinal deformity. Surveys assessed anonymous opinions on ideal practices for indications, preoperative evaluation, protocols, and complications, with agreement of 80% or higher considered consensus. Final determination of consensus items and equipoise were established using the Nominal group technique in a facilitated meeting. RESULTS: Of the 42 surgeons invited, responses were received from 32, 40, and 31 surgeons for each survey, respectively. The final meeting included 14 experts with an average 10.5 years in practice and average 88 annual spinal deformity cases. Experts reached consensus on 67 items [indications (17), goals (1), preoperative evaluations (5), protocols (36), complications (8)]; these were consolidated to create final BPG in all categories, including statements to help dictate practice such as using at least 6 to 8 pins under 4 to 8 lbs of torque, with a small, tolerable starting weight and reaching goal weight of 50% TBW in ∼2 weeks. Nine items remained items of equipoise for the purposes of guiding future research. CONCLUSIONS: We developed consensus-based BPG for the use and implementation of HGT for pediatric spinal deformity. This can serve as a measure to help drive future research as well as give new surgeons a place to begin their practice of HGT. LEVEL OF EVIDENCE: Level V-expert opinion.

Pediatric Femoral Shaft Fractures: A Multicenter Review of the AAOS Clinical Practice Guidelines Before and After 2009.

BACKGROUND: To determine if the AAOS clinical practice guidelines (CPG) for the treatment of pediatric femoral shaft fractures (2009) changed treatment, we analyzed pediatric femoral shaft fractures at 4 high-volume, geographically separated, level-1 pediatric trauma centers over a 10-year period (2004 to 2013). METHODS: Consecutive series of pediatric femoral shaft fractures (ages, birth to 18 y) treated at the 4 centers were reviewed. Treatment methods were analyzed by age and treatment method for each center and in aggregate. RESULTS: Of 2646 fractures, 1476 (55.8%) were treated nonoperatively and 1170 fractures operatively. Of the operative group, flexible intramedullary nails (IMN) were used for 568 patients (21.5%), locked intramedullary nails (LIMNs) for 309 (11.7%), and plating for 188 (7.1%). In total, 105 fractures were treated with external fixation or skeletal traction. Analysis before and after the CPG publication revealed a significant increase in the use of interlocked IMNs in patients younger than 11 years (0.5% before, 3.8% after; P<0.001). Over the same time period there was an increase in surgical management, regardless of technique, for patients younger than 5 years (6.4% before, 8.4% after; P=0.206). There were considerable differences in treatment among centers: 74% of fractures treated with plating were from a single center (center A), which also contributed 68% of patients younger than 5 years treated with plating; center B had the highest rate (41%) of flexible IMN in children younger than 5 years; center C had the highest rate (63%) of LIMN in children younger than 11 years; and center D treated the fewest patients outside the CPG guidelines. CONCLUSIONS: Following publication of the AAOS CPG, there was a significant increase in the use of LIMNs in patients younger than 11 years old and a trend toward surgical treatment in patients younger than 5 years. The considerable variability among centers in treatment methods and adherence to the CPG highlights the need for further outcome studies to better define optimal treatment methods and perhaps update the AAOS CPG guidelines. LEVEL OF EVIDENCE: Level III-therapeutic.

Pediatric Sports Medicine, A New Subspeciality in Orthopedics: An Analysis of the Surgical Volume of Candidates for the American Board of Orthopaedic Surgery Part II Certification Exam Over the Past Decade.

BACKGROUND: Pediatric orthopaedic surgery has become increasingly subspecialized over the past decade. The purpose of this study was to analyze the volume of pediatric sports medicine cases performed by surgeons applying for the American Board of Orthopaedic Surgeons (ABOS) Part II certification exam over the past decade, comparing caseloads according to the type(s) of fellowship completed. METHODS: The ABOS database was reviewed for all surgeons applying for the ABOS Part II certification exam from 2004 to 2014. Fellowship training of the candidates was recorded as Pediatrics, Sports, and Dual-Fellowship (fellowship in both Pediatrics and Sports). All other candidates were categorized as "Other". A total of 102,424 pediatric cases (patients below 18 years) were reviewed to identify sports medicine cases performed by CPT code. Multiple linear regression and Mann-Whitney U tests were used to determine trends in case volume overall and according to fellowship training for all patients, patients ≥13 and patients <13. One-way ANOVA testing was used to compare multiple means followed by multiple post hoc comparisons using a Tukey all pairwise approach using SPSS. RESULTS: A total of 14,636 pediatric sports medicine cases were performed. There was an increase in the number of sports medicine cases performed in patients <13 (117.5±31.8 from 2004-2009 to 212.4±70.1 from 2010-2014, P=0.035; r=0.743, P=0.0007). The number of Pediatrics (r=0.601, P=0.005), Sports (r=0.741, P=0.0007) and Dual-Fellowship candidates increased (r=0.600, P=0.005) from 2004-2014. Dual-Fellowship surgeons performed 21.4% of pediatric sports medicine cases in 2014 when compared to 2.1% in 2004 (919% increase). As a group, the number of pediatric sports cases performed by Dual-Fellowship (r=0.630, P=0.004) and Sports (r=0.567, P=0.007) candidates has increased, while the number performed by "Other" candidates has decreased (r=0.758, P=0.0005). Per surgeon, Dual-Fellowship candidates performed a greater number of pediatric sports cases per collection period (36.5±9.18) than Pediatrics (6.71±0.94), Sports (5.99±0.46), and "Other" (1.21±0.15, P<0.0001 for each) candidates from 2004 to 2014. CONCLUSIONS: Over the past decade operative sports injuries have increased in children with a similar increase in the number of orthopedic surgeons specializing in pediatric sports medicine. On a per surgeon basis, these dual fellowship-trained candidates have performed on average five times the number of pediatric sports medicine cases compared to all other ABOS Part II candidates. These trends may point towards the development of a new subspecialty of pediatric sports medicine among orthopedic surgeons. LEVEL OF EVIDENCE: Level IV-Retrospective Database Review.

Pulseless Supracondylar Humerus Fracture With Anterior Interosseous Nerve or Median Nerve Injury-An Absolute Indication for Open Reduction?

BACKGROUND: Optimal management for a pulseless supracondylar humerus fracture associated with anterior interosseous nerve (AIN) or median nerve injury is unclear. The purpose of this study was to determine the incidence of pulseless supracondylar humerus fractures associated with AIN or median nerve injury, to assess open versus closed surgical management, to determine factors associated with the need for neurovascular intervention, and to report the outcome. METHODS: A retrospective review was performed at 4 pediatric trauma hospitals on all patients who sustained a Gartland III or IV supracondylar humerus fracture with the combination of absent distal palpable pulses and AIN or median nerve injury between 2000 and 2014. Choice of treatment, details regarding preoperative and postoperative exam findings, follow-up course, and outcome were recorded. RESULTS: A total of 71 patients met inclusion criteria; 52 patients (73%) underwent closed reduction (CR); 19 patients (27%) underwent open reduction (OR) and early antecubital fossa exploration. The index procedure of CR plus percutaneous pinning was sufficient treatment in 50 (of 52, 96%) patients with only 2 requiring reoperation. One patient developed compartment syndrome approximately 9 hours after CRPP (13.5 h after time of injury) and underwent emergent fasciotomies. Of the 19 patients who underwent OR and early exploration, 6 needed vascular procedures, 5 required detethering of entrapped surrounding fibrous tissues. Forty patients were diagnosed with median nerve palsy versus 31 diagnosed with AIN palsy. There was no significant difference between patients presenting with median nerve versus AIN palsy, with similar rates of need for OR (10/40; 25% vs. 9/31; 29%), rate of compartment syndrome (3/40; 7.5% vs. 3/31; 9.7%), need for reoperation (4/40; 10% vs. 6.5%), and ultimate resolution of nerve palsy (4/36; 20.1% vs. 3/30; 10%). Compartment syndrome developed in 6 (of 71, 8.5%) patients and was associated with poor perfusion status on presentation and delayed time from injury to surgery. In patients with at least 3-month neurological follow-up, 59 (of 61, 97%) patients had complete resolution of nerve palsy. CONCLUSIONS: Although previous authors have suggested a pulseless SCH fx with an associated AIN or median nerve injury should be treated with exploration and OR, 70% (50/71) of the patients in this series were treated with a CR. In this series, both AIN and median nerve palsies among patients presenting with pulseless extremity and Gartland III or IV SCH fracture, offer similar rates of OR, risk of compartment syndrome, and resolution of nerve palsy. LEVEL OF EVIDENCE: Level IV.

Orthopaedic Care for Children: Who Provides It? How Has It Changed Over the Past Decade? Analysis of the Database of the American Board of Orthopaedic Surgery.

BACKGROUND: The field of orthopaedic surgery has subspecialized over the past decade with an increasing number of graduates of orthopaedic residency programs entering fellowship training. The number of graduates from pediatric orthopaedic fellowships has also increased over the past decade. We hypothesize as the number of pediatric orthopaedic fellowship graduates has increased, the proportion of orthopaedic cases completed by pediatric surgeons in comparison with adult surgeons has also increased. We have used the database of the American Board of Orthopaedic Surgery (ABOS) to analyze the trends in who is providing the orthopaedic care for children. METHODS: Procedure logs of applicants for ABOS part II certification from 2004 to 2014 were collected and pediatric cases were used for this study. Applicants were divided into pediatric orthopaedic surgeons and adult orthopaedic surgeons based on the self-declared subspecialty for part II examination. CPT codes were used to place the cases into different categories. Descriptive and statistical analysis were performed to evaluate the change in the practice of pediatric orthopaedics over the past decade. RESULTS: ABOS part II applicants performed 102,424 pediatric cases during this period. In total, 66,745 (65%) cases were performed by nonpediatric surgeons and 35,679 cases (35%) by pediatric surgeons. In total, 82% of the pediatric cases were done by adult surgeons in 2004 which decreased to 69% in 2009 and to 53% in 2014 (r=0.8232, P=0.0019). In pediatric sports medicine, pediatric orthopaedic surgeons performed 7% of the cases in 2004 which increased to 14% in 2009 and to 28% in 2014 (300% increase from 2004). Pediatric surgeons also increased their share of pediatric trauma cases. In total, 12% of lower extremity trauma cases were attended by pediatric surgeons in 2004 compared with 47% in 2014 (235% increase from 2004). In upper extremity trauma, pediatric surgeons increased their share of the cases from 12% in 2004 to 43% in 2014 (175% increase from 2004). CONCLUSIONS: Over the past decade, pediatric orthopaedic specialists are caring for an increasing share of pediatric cases. Pediatric trauma, pediatric spine, and pediatric sports medicine have seen the greatest increase in the percentage of cases performed by pediatric orthopaedic surgeons. LEVEL OF EVIDENCE: Level III.

The Role of Computed Tomography and Magnetic Resonance Imaging in the Diagnosis of Pediatric Thoracolumbar Compression Fractures.

BACKGROUND: Because of concerns about radiation exposure, some centers consider magnetic resonance imaging (MRIs) the preferred imaging modality for pediatric thoracic and/or lumbar compression fractures. The purpose of this study was to evaluate the sensitivity of computed tomography (CT) and MRI in diagnosing thoracolumbar compression fractures and the utility of MRI in their management. METHODS: Retrospective review identified 52 patients aged 0 to 18 years with 191 thoracic and/or lumbar compression fractures who had both CT and MRI during the initial trauma evaluation. The decision to perform CT and/or MRI was made by the attending pediatric spine surgeon. In all cases the CT scan was performed before the MRI. All imaging studies were reviewed by a board-certified pediatric radiologist and attending pediatric spine surgeon. RESULTS: Only 10 patients (19%) had a single-level injury. Of 42 with multiple compression fractures, 34 (81%) had fractures in contiguous levels, and 8 had noncontiguous injuries. Comparing CT and MRI, there was complete agreement in the number and distribution of fractures in 23 patients (44%). MRI identified additional levels of fracture in 15 patients (29%); 14 (27%) had fewer levels fractured on MRI than CT. Only one patient (2%) had fractures seen on MRI after a normal CT scan. Complete correlation between CT and MRI was seen in 59% (17/29) of patients aged 11 to 18 years, compared with 26% (6/23) of patients younger than 11. CONCLUSIONS: In pediatric patients with mild thoracic or lumbar compression fracture(s), CT scan demonstrates a high sensitivity in determining the presence or absence of a fracture compared with MRI. Although some variability exists between the 2 modalities in the exact number of spinal levels involved, the definitive treatment and outcome were not changed by the addition of MRI. The information that may be obtained from an MRI must be weighed against the increased time and expense of the study, as well as the risks associated with sedation when necessary. LEVEL OF EVIDENCE: Level II-diagnostic study.

Pediatric Patients with Spondylolysis Have High Rates of Vitamin-D Deficiency.

The objective of this study was to document the 25-hydroxyvitamin D status of patients with a confirmed diagnosis of spondylolysis to determine if these patients have increased rates of vitamin D deficiency. After confirming the diagnosis of spondylolysis, patients were prospectively enrolled in this study. A total of 39 patients (30 male, 9 female) with a mean age of 14.9 years and a mean BMI of 22.9 had vitamin D levels drawn after imaging confirmed the diagnosis of spondylolysis. The mean 25-hydroxyvitamin D level was 26 ng/ml. Only 9 patients (23.1%) were considered to have normal vitamin D levels > 32 ng/ml. An additional 22 patients (56.4%) had insufficient values of 20 to 32 ng/ml, and 8 patients (20.5%) had vitamin D deficiency with values <20 ng/ml. Pediatric patients presenting with spondylolysis, regardless of race or age, have high rates of 25-hydroxyvitamin D deficiency. (Journal of Surgical Orthopaedic Advances 28(4):257-259, 2019).