Breaking the Rules in Three Dimensions: What to Expect After a Thoracic-only Fusion With Structural Thoracic and Thoracolumbar Curves.

OBJECTIVE: Despite guidelines to fuse both thoracic and thoracolumbar/lumbar (TH/L) curves in patients with structural curves in both regions, a thoracic-only fusion allows preservation of lumbar motion segments. The purpose of this study was to assess the 2-year postoperative three-dimensional (3D) radiographic and clinical outcomes of patients with double or triple major (thoracic curves >TH/L curves) structural curves who underwent a thoracic-only fusion. METHODS: A prospective adolescent idiopathic scoliosis registry was queried for double or triple major curves undergoing thoracic-only posterior fusion and a minimum 2-year follow-up. 3D reconstructions were generated from bi-planar radiographs. Paired sample t tests were used to assess differences in the coronal, sagittal, and axial planes pre and postoperatively, as well as Scoliosis Research Society Questionnaire-22 scores. Pearson correlations were utilized to identify variables related to spontaneous lumbar derotation. RESULTS: Twenty-two patients met the inclusion criteria. Both thoracic [61 ± 10 degrees to 20 ± 9 degrees ( P < 0.001)] and lumbar curves [41 ± 7 degrees to 22±7 degrees ( P < 0.001)] had significant coronal improvement and T5 to T12 kyphosis improved from 7 ± 14 degrees to 23 ± 8 degrees ( P < 0.001). The thoracic apical translation was significantly improved postoperatively (4.7 ± 1.5 to 0.5 ± 1 cm, P < 0.001), but the lumbar apical translation was unchanged (-1.7 ± 0.6 to -1.7±0.8 cm, P = 0.94). Scoliosis Research Society Questionnaire-22 scores significantly improved by 2 years postoperative. CONCLUSIONS: Unlike the 3D correction observed in nonstructural TH/L curves after thoracic-only fusion, patients with double or triple major curves demonstrated only spontaneous coronal correction of the lumbar curve, whereas the sagittal and axial planes were not significantly improved. These radiographic parameters did not negatively affect subjective or clinical outcomes at minimum 2-year follow-up. LEVEL OF EVIDENCE: Level IV-therapeutic.

Traditional Versus Water-resistant Short Leg Casting: A Randomized Controlled Pilot Study.

INTRODUCTION: We conducted a randomized controlled trial comparing fiberglass short leg casts with traditional cast padding to similar casts with water-resistant cast padding and recorded the opinion of the patient/caregiver and Orthopaedic Technicians (Ortho Techs) that applied and removed the casts. METHODS: Subjects with an injury that would be treated with a short leg cast were enrolled and randomized into a traditional cast or a water-resistant cast. Following cast application, the Ortho Tech that applied the cast completed a questionnaire asking their opinion on ease of application, moldability, padding level, and time taken for application. Following the removal of the study cast, the Ortho Tech that removed the cast completed a questionnaire that included an assessment of skin condition and evidence of the patient poking items inside the cast, as well as their opinion of ease of padding removal, padding durability and longevity, and an overall quality assessment of the cast padding. Following cast removal, the patient (or caregiver) also completed a questionnaire asking for their assessment of comfort, the weight of the cast, itchiness, heat/sweat, smell, and satisfaction. Patients who were treated with an expanded polytetrafluoroethylene cast were also asked about their happiness with the cast's water resistance and asked how long the cast took to dry. RESULTS: Sixty patients were included in this study, thirty in each group. The water-resistant casts took longer to apply than the traditional casts (12.4±4.0 vs. 8.2±3.2 min, P <0.001). The Ortho Techs favored the traditional cast when it came to ease of application ( P <0.001), moldability ( P =0.003), ease of padding removal ( P <0.001), padding durability ( P =0.006), padding longevity ( P =0.005), and their overall impression ( P =0.014). The patients/caregivers responded similarly among the 2 groups for each survey question. CONCLUSIONS: Patients randomized into each cast type tolerated their cast similarly; however, the Ortho Techs involved in this study preferred the traditional cast.

Depression Screening in Pediatric Orthopedic Surgery Clinics and Identifying Patients At-Risk.

BACKGROUND: Up to 25% of youth experience a depressive episode by 18 years of age, leading the US Preventive Services Task Force to recommend depression screening within this population. This study aimed to understand the prevalence of depression identified within pediatric orthopedic clinics compared with primary care clinics after the implementation of a screening program and present data on the prevalence of moderate-severe depression across specific pediatric orthopedic clinics, characterizing and identifying specific populations at higher risk. METHODS: A retrospective review was performed to identify all patients screened using the 2-item and 9-item versions of the Patient Health Questionnaire (PHQ-2/PHQ-9) and the Columbia-Suicide Severity Rating Scale over a 2-year period (October 2018 to January 2021) within pediatric primary care and orthopaedic clinics. Demographic and clinical characteristics were collected. Statistical analysis was performed to compare scores between orthopedic and primary care clinics, as well as between the different pediatric orthopedic subspecialties and included χ 2 test, ANOVA, and logistic regression. RESULTS: There were 32,787 unique adolescent patients screened in primary care clinics, with an additional 14,078 unique adolescent patients screened in orthopaedic clinics, leading to a 30% increase in the overall number of patients receiving depression screening. 5.2% of patients in primary care pediatric clinics screened positive for moderate-severe depression versus 2.0% in pediatric orthopaedic clinics ( P <0.001). 2.7% of primary care patients were at risk of self-harm compared with 0.8% of orthopedic patients ( P <0.001). Within orthopaedic subspecialty clinics, the spine patients were at the highest risk of moderate-severe depression (3.5%), significantly higher than both the sports (1.4%, P =0.006) and patients with acute fracture (1.3%, P <0.001). CONCLUSIONS: This study demonstrates the high incidence of patients screening positive for depression in pediatric and adolescent orthopaedic clinics. By identifying high-risk clinics and patient groups, health care systems can apply a more practical approach and appropriately deploy behavioral health specialists for timely counseling and treatment discussions. LEVEL OF EVIDENCE: Level-III.

The Anterior Modified San Diego Acetabuloplasty Does Not Increase Superior-Anterior Coverage in Patient-Specific 3D-Printed Models.

BACKGROUND: Patients with developmental dysplasia of the hip may require pelvic osteotomies to improve acetabular coverage. The purpose of this study was to compare the changes in acetabular version, tilt, and regional coverage angles following the San Diego acetabuloplasty (SDA), the modified San Diego acetabuloplasty (mSDA), and the Pemberton acetabuloplasty (PA). METHODS: Fourteen patients with developmental dysplasia of the hip and computed tomography (CT) imaging were identified. From CT images, 2 identical pelvises were 3-dimensional-printed for each patient. Bone was printed with rigid material, and cartilage with flexible material. For each model pair, the SDA was performed on one and the PA was performed on the other. CT scans were obtained before and after acetabuloplasties. Next, the bone graft in the SDA model was moved anteriorly, representing the mSDA, and the model was rescanned. Acetabular version, tilt, and coverage angles (posterior, superior-posterior, superior, superior-anterior, and anterior) were calculated. Preoperative to postoperative differences were compared (repeated measures analysis of variance or Wilcoxon signed rank test). The significance was set to P <0.05. RESULTS: The mean age at CT was 5.8±1.2 years (range: 3.9 to 7.5 y). All 3 procedures (SDA, mSDA, and PA) significantly increased acetabular tilt; P <0.045), with a similar change observed for all 3 ( P =0.868). PA was the only procedure to significantly decrease relative acetabular version (6.5±6.5 degrees, preoperative: 12.9±5.3 degrees; P =0.004). Both the SDA and mSDA procedures significantly increased coverage in the superior-posterior octant (SDA: 92.6±9.3 degrees, mSDA: 92.3±9.8 degrees, preoperative: 81.9±9.5 degrees; P <0.02), with a similar percent change among the 2 ( P =1.0). All 3 procedures significantly increased superior coverage ( P <0.04); the increase was similar among the 3 ( P =0.205). The PA was the only procedure to produce a significant increase in coverage in the superior-anterior octant (91.0±16.7 degrees, preoperative: 74.0±12.1 degrees; P =0.005) or the anterior octant (50.7±11.7 degrees, preoperative: 45.8±8.9 degrees; P =0.012). CONCLUSIONS: The SDA and mSDA procedures produced similar postoperative changes, primarily in the superior and superior-posterior acetabular octants. Placing the graft more anteriorly did not increase anterior coverage in the mSDA, and only the PA increased coverage in the superior and superior-anterior acetabular octants.

Three-dimensional assessment of subchondral arc and hip joint coverage angles in the asymptomatic young adult hip.

The primary objective of this study was to develop a custom algorithm to assess three-dimensional (3D) acetabular coverage of the femoral head based on surface models generated from computed tomography (CT) imaging. The secondary objective was to apply this algorithm to asymptomatic young adult hip joints to assess the regional 3D acetabular coverage variability and understand how these novel 3D metrics relate to traditional two-dimensional (2D) radiographic measurements of coverage. The algorithm developed automatically identifies the lateral- and medial-most edges of the acetabular lunate at one-degree intervals around the acetabular rim based on local radius of curvature. The acetabular edges and the center of a best-fit sphere to the femoral head are then used to compute the mean 3D subchondral arc angles and hip joint coverage angles in five acetabular octants. This algorithm was applied to hip models generated from pelvis/hip CT imaging or abdomen/pelvis CT angiograms of 50 patients between 17 and 25 years of age who had no history of congenital or developmental hip pathology, neuromuscular conditions, or bilateral pelvic and/or femoral fractures. Corresponding 2D acetabular coverage measures of lateral center edge angle (LCEA) and acetabular arc angle (AAA) were assessed on the patients' clinical or digitally reconstructed radiographs. The 3D subchondral arc angle in the superior region (58.0 [54.6-64.8] degrees) was significantly higher (p < 0.001) than all other acetabular subregions. The 3D hip joint coverage angle in the superior region (26.2 [20.7-28.5] degrees) was also significantly higher (p < 0.001) than all other acetabular subregions. 3D superior hip joint coverage angle demonstrated the strongest correlation with 2D LCEA (r = 0.649, p < 0.001), while 3D superior-anterior subchondral arc angle demonstrated the strongest correlation with 2D AAA (r = 0.718, p < 0.001). The 3D coverage metrics in the remaining acetabular regions did not strongly correlate with typical 2D radiographic measures. The discrepancy between standard 2D measures of radiographic acetabular coverage and actual 3D coverage identified on advanced imaging indicates potential discord between anatomic coverage and the standard clinical measures of coverage on 2D imaging. As 2D measurement of acetabular coverage is increasingly used to guide surgical decision-making to address acetabular deformities, this work would suggest that 3D measures of acetabular coverage may be important to help discriminate local coverage deficiencies, avoid inconsistencies resulting from differences in radiographic measurement techniques, and provide a better understanding of acetabular coverage in the hip joint, potentially altering surgical planning and guiding surgical technique.

Defining the Incidence of Residual Acetabular Dysplasia After Successful Reduction With a Harness.

BACKGROUND: The purpose of this study was to evaluate the rate of residual acetabular dysplasia (RAD), defined as an acetabular index (AI) of >90th percentile of age and sex-matched controls, in a cohort of infants successfully treated with the Pavlik harness (PH). METHODS: We retrospectively studied typically developing infants at a single center, with at least 1 dislocated hip, that was successfully treated with a PH and had a minimum of 48 months follow-up. Hip dislocation was defined as <30% femoral head coverage at rest on pretreatment ultrasound or IHDI grade 3 or 4 on the pretreatment radiograph. RESULTS: Forty-six dislocated hips (41 infants) were studied (4 males and 37 females). Brace treatment was initiated at an average age of 1.8 months (range: 2 d to 9.3 mo) and was maintained for an average of 10.2 months (range: 2.3 to 24.9 mo). All hips achieved IHDI grade 1 reduction. Five of 46 hips (11%) had an AI >90th percentile at the conclusion of bracing. Average follow-up was 6.5 years (range: 4.0 to 15.2 y). We found a 30% incidence of RAD (14/46 hips) on final follow-up radiographs. Of these hips, 13/14 (93%) had AI <90th percentile at the end of brace treatment. Comparing children with and without RAD, there were no differences in age at the initial visit or brace initiation, total follow-up, femoral head coverage at the initial visit, alpha angle at the initial visit, or total time in the brace ( P > 0.09). CONCLUSION: In a single-center cohort of infants with dislocated hips treated successfully with a PH, we observed a 30% incidence of RAD at a minimum 4.0-year follow-up. Normal acetabular morphology at the end of brace treatment did not result in normal acetabular morphology at the final follow-up in 13/41 hips (32%). We recommend that surgeons should pay close attention to the year-over-year change in both the AI and AI percentile. LEVEL OF EVIDENCE: Level IV: case series.

Nonoperative Versus Operative Treatment of Type IIA Supracondylar Humerus Fractures: A Prospective Evaluation of 99 Patients.

BACKGROUND: Although current clinical practice guidelines from the American Academy of Orthopaedic Surgeons suggest that Type II and III supracondylar humerus (SCH) fractures be treated by closed reduction and pin fixation, controversy remains as to whether type IIa fractures with no rotation or angular deformity require surgery. The purpose of our study was to prospectively compare radiographic and functional outcomes of type IIa SCH fractures treated with or without surgery. METHODS: Between 2017 and 2019, 105 patients between 2 and 12 years of age presenting with type IIa SCH fractures and without prior elbow trauma, neuromuscular or metabolic conditions, were prospectively enrolled. Ten orthopaedic surgeons managed the patients with 5 preferring surgical treatment and 5 preferring an initial attempt at nonoperative treatment. Patients in the nonoperative cohort were managed with a long-arm cast and close radiographic follow-up. Patients underwent a standardized protocol, including 3 to 4 weeks of casting, bilateral radiographic follow-up 6 months postinjury, and telephone follow-up at 6, 12, and 24 months. RESULTS: Ninety-nine patients met the inclusion criteria (45 nonoperative and 54 operatives). Of the nonoperative patients, 4 (9%) were converted to surgery up to their first clinical follow-up. No differences were identified between the cohorts with respect to demographic data, but patients undergoing surgery had on average 6 degrees more posterior angulation at the fracture site preoperatively (P<0.05). At the final clinical follow-up (mean=6 mo), the nonoperative group had more radiographic extension (176.9 vs 174.4 degrees, P=0.04) as measured by the hourglass angle, but no other clinical or radiographic differences were appreciated. Complications were similar between the nonoperative and operative groups: refracture (4.4 vs 5.6%), avascular necrosis (2.2 vs 1.9%) and infection (0 vs 1.9%) (P>0.05). Patient-reported outcomes at a mean of 24 months showed no differences between groups. CONCLUSION: Contrary to American Academy of Orthopaedic Surgeons guidelines, about 90% of patients with type IIa supracondylar fractures can be treated nonoperatively and will achieve good radiographic and functional outcomes with mild residual deformity improving over time. Patients treated nonoperatively must be monitored closely to assess for early loss of reduction and the need for surgical intervention.

The Reliability of the AO Spine Upper Cervical Classification System in Children: Results of a Multi-Center Study.

BACKGROUND: There is no uniform classification system for traumatic upper cervical spine injuries in children. This study assesses the reliability and reproducibility of the AO Upper Cervical Spine Classification System (UCCS), which was developed and validated in adults, to children. METHODS: Twenty-six patients under 18 years old with operative and nonoperative upper cervical injuries, defined as from the occipital condyle to the C2-C3 joint, were identified from 2000 to 2018. Inclusion criteria included the availability of computed tomography and magnetic resonance imaging at the time of injury. Patients with significant comorbidities were excluded. Each case was reviewed by a single senior surgeon to determine eligibility. Educational videos, schematics describing the UCCS, and imaging from 26 cases were sent to 9 pediatric orthopaedic surgeons. The surgeons classified each case into 3 categories: A, B, and C. Inter-rater reliability was assessed for the initial reading across all 9 raters by Fleiss's kappa coefficient (kF) along with 95% confidence intervals. One month later, the surgeons repeated the classification, and intra-rater reliability was calculated. All images were de-identified and randomized for each read independently. Intra-rater reproducibility across both reads was assessed using Fleiss's kappa. Interpretations for reliability estimates were based on Landis and Koch (1977): 0 to 0.2, slight; 0.2 to 0.4, fair; 0.4 to 0.6, moderate; 0.6 to 0.8, substantial; and >0.8, almost perfect agreement. RESULTS: Twenty-six cases were read by 9 raters twice. Sub-classification agreement was moderate to substantial with α κ estimates from 0.55 for the first read and 0.70 for the second read. Inter-rater agreement was moderate (kF 0.56 to 0.58) with respect to fracture location and fair (kF 0.24 to 0.3) with respect to primary classification (A, B, and C). Krippendorff's alpha for intra-rater reliability overall sub-classifications ranged from 0.41 to 0.88, with 0.75 overall raters. CONCLUSION: Traumatic upper cervical injuries are rare in the pediatric population. A uniform classification system can be vital to guide diagnosis and treatment. This study is the first to evaluate the use of the UCCS in the pediatric population. While moderate to substantial agreement was found, limitations to applying the UCCS to the pediatric population exist, and thus the UCCS can be considered a starting point for developing a pediatric classification. LEVEL OF EVIDENCE: Level III.

Age and CRP Associated With Improved Tissue Pathogen Identification in Children With Blood Culture Negative Osteomyelitis: Results From the CORTICES Multicenter Database.

BACKGROUND: Acute hematogenous osteomyelitis (AHO) is a relatively common condition in children, and identifying the offending pathogen with blood or tissue cultures aids in diagnosis and medical management while reducing treatment failure. Recent 2021 AHO clinical practice guidelines from the Pediatric Infectious Disease Society recommend obtaining routine tissue cultures, particularly in cases with negative blood cultures. The purpose of this study was to identify variables associated with positive tissue cultures when blood cultures are negative. METHODS: Children with AHO from 18 pediatric medical centers throughout the United States through the Children's ORthopaedic Trauma and Infection Consortium for Evidence-based Study were evaluated for predictors of positive tissue cultures when blood cultures were negative. Cutoffs of predictors were determined with associated sensitivity and specificity. RESULTS: One thousand three children with AHO were included, and in 688/1003 (68.6%) patients, both blood cultures and tissue cultures were obtained. In patients with negative blood cultures (n=385), tissue was positive in 267/385 (69.4%). In multivariate analysis, age ( P <0.001) and C-reactive protein (CRP) ( P =0.004) were independent predictors. With age >3.1 years and CRP >4.1 mg/dL as factors, the sensitivity of obtaining a positive tissue culture when blood cultures were negative was 87.3% (80.9-92.2%) compared with 7.1% (4.4-10.9%) if neither of these factors was present. There was a lower ratio of methicillin-resistant Staphylococcus aureus in blood culture-negative patients who had a positive tissue culture 48/188 (25.5%), compared with patients who had both positive blood and tissue cultures 108/220 (49.1%). CONCLUSION: AHO patients with CRP ≤ 4.1 mg/dL and age under 3.1 years are unlikely to have clinical value from tissue biopsy that exceeds the morbidity associated with this intervention. In patients with CRP > 4.1 mg/dL and age over 3.1 years, obtaining a tissue specimen may add value; however, it is important to note that effective empiric antibiotic coverage may limit the utility of positive tissue cultures in AHO. LEVEL OF EVIDENCE: Level III-Retrospective comparative study.

How often does the preoperative plan for freehand pedicle screw placement match the actual surgical execution in adolescent idiopathic scoliosis?

PURPOSE: To provide a baseline for comparison with future advancements, this study determined the accuracy of preoperative planning of pedicle screw placement using standard radiographs for posterior fusion (PSF) for adolescent idiopathic scoliosis (AIS). METHODS: Ninety-five patients with AIS planned for PSF were prospectively enrolled. Preoperative planning was based upon standard upright posteroanterior and lateral radiographs. The planned number of screws to be placed at each level was recorded. Intraoperatively, all screws were placed by freehand technique. The number of successfully placed screws and the reasons for abandoning screw placement were documented. RESULTS: There were a total of 1783 pedicle screws planned preoperatively. The average planned implant density was 2.0 implants/vertebra. A total of 1723 (96.6%) of the planned screws were placed successfully. Fourteen (0.8%) screws were abandoned after attempted placement (range 0-2 screws/case). Of 241 screws planned in pedicles noted to be "hypoplastic," 13 resulted in the use of a hook or no instrumentation. The placement was not attempted for 49 (range 0-7/case) planned screws due to intraoperative decision-making and a sense that the curve was flexible enough not to require every screw. Three cases (3.2%) required instrumentation of an additional level. CONCLUSIONS: Standard spine radiographs allow for accurate preoperative planning for freehand pedicle screw placement in AIS. Ninety-seven percent of planned screws were placed successfully. The primary reason for deviation from the preoperative plan was intraoperative surgeon decision-making rather than difficulty with screw placement. This study will serve as a baseline when considering the utilization of navigation in PSF for AIS.

Treatment of Hip Instability in Children With Down Syndrome: Keys to Managing a Challenging Problem.

INTRODUCTION: Management of hip instability in children with Down syndrome is a challenging task to undertake for even the most experienced surgeons. As life expectancy of these patients increases, the importance of preserving functional mobility and hip joint stability in order to minimize late hip degeneration and pain has become a priority. The aim of this study is to evaluate the clinical and radiographic outcomes of children with Down syndrome and hip instability who underwent surgical reconstruction with femoral and/or acetabular procedures. METHODS: We performed a retrospective review of all children with Down syndrome age 18 years and younger, who underwent surgical intervention to address hip instability between 2003 and 2017. Data was recorded detailing the patient's demographics, preoperative and postoperative functional status and surgical details. Preoperative and postoperative radiographic analysis was performed as well as 3-dimensional computed tomography scan evaluation, when available. All major and minor complications were recorded and classified using the Severin radiographic classification and the Clavien-Dindo-Sink clinical classification. RESULTS: We studied 28 hips in 19 children that were followed for an average of 4.4 years postsurgical intervention for hip instability. The majority of patients improved in all radiographic parameters. A total of 14 hips (50%) had complications and 9 hips (32%) required a secondary surgery. Of those complications, 2 hips (7%) developed avascular necrosis and 4 hips (14%) developed recurrent instability after the index procedure. Two of these hips had a subsequent anteverting periacetabular osteotomy that produced a stable hip at final follow up. DISCUSSION: Surgical management of hip instability in children with Down syndrome remains challenging. The treating surgeon must have a thorough understanding of the pathoanatomy and design the surgical treatment to meet all of the underlying sources of instability. Combined femoral and acetabular osteotomies plus capsulorrhaphy are often required along with postoperative hip spica immobilization. Although complication and revision surgery rates are high, hip stability and good functional outcomes can be achieved.

Prolonged Brace Treatment Does Not Result in Improved Acetabular Indices in Infantile Dislocated Hips.

BACKGROUND: The Pavlik harness (PH) is commonly used to treat infantile dislocated hips. However, significant variability exists in the duration of brace treatment after successful reduction of the dislocated hip. The purpose of this study was to evaluate the effect of prescribed time in brace on acetabular index (AI) at two years of age using a prospective, international, multicenter database. METHODS: We retrospectively studied prospectively enrolled infants with at least 1 dislocated hip that were initially treated with a PH and had a recorded AI at 2-year follow-up. Subjects were treated at 1 of 2 institutions. Institution 1 used the PH until they observed normal radiographic acetabular development. Institution 2 followed a structured shorter brace treatment protocol. Hip dislocation was defined as <30% femoral head coverage at rest on the pretreatment ultrasound or International Hip Dysplasia Institute (IHDI) grade III or IV on the pretreatment radiograph. RESULTS: Fifty-three hips met our inclusion criteria. Hips from Institution 1 were treated with a brace ×3 longer than hips from institution 2 (adjusted mean 8.9±1.3 vs. 2.6±0.2 mo) (P<0.001). Institution 1 had an 88% success rate and institution 2 had an 85% success rate at achieving hip reduction (P=0.735). At 2-year follow-up, we observed no significant difference in AI between Institution 1 (adjusted mean 25.6±0.9 degrees) compared with Institution 2 (adjusted mean 23.5±0.8 degrees) (P=0.1). However, 19% of patients from Institution 1 and 44% of patients from Institution 2 were at or below the 50th percentile of previously published age-matched and sex-matched AI normal data (P=0.049). Also, 27% (7/26) of hips from Institution 1 had significant acetabular dysplasia (more than 2 SD from the mean), compared with a 22% (6/27) from Institution 2 (P=0.691). We found no correlation between age at initiation of bracing and AI at 2-year follow-up (P=0.071). CONCLUSIONS: The PH brace can successfully treat dislocated infant hips, however, prolonged brace treatment was not found to result in improved acetabular development at 2-year follow-up. LEVEL OF EVIDENCE: Level III.

Practice Variation in the Surgical Management of Children With Acute Hematogenous Osteomyelitis.

INTRODUCTION: The surgical indications to manage children with acute hematogenous osteomyelitis (AHO) remain poorly defined. The purpose of this study was to identify if practice pattern variation exists in the surgical management of pediatric AHO among tertiary pediatric medical centers across the United States. A secondary purpose was to evaluate variables that may impact the rate of surgical intervention among these institutions. METHODS: Children with AHO were retrospectively analyzed between January 1, 2010, and December 31, 2016, from 18 pediatric medical centers throughout the United States. The rates of surgery were identified. Admission vitals, labs, weight-bearing status, length of stay, and readmission rates were compared between those who did and did not undergo surgery. Multivariate regression and classification and regression tree analyses were performed to identify the variables that were associated with surgical intervention. RESULTS: Of the 1003 children identified with AHO in this retrospective, multicenter database, 619/1003 (62%) were treated surgically. Multivariate analysis revealed institution, inability to ambulate, presence of multifocal infection, elevated admission C-reactive protein, increased admission platelet count, and location of the osteomyelitis were significant predictors of surgery (P<0.01). Patients who underwent surgery were more than twice as likely to have a recurrence or readmission and stayed a median of 2 days longer than those who did not have surgery. In the classification and regression tree analysis, 2 distinct patterns of surgical intervention were identified based on institution, with 12 institutions operating in most cases (72%), regardless of clinical factors. A second cohort of 6 institutions operated less routinely, with 47% receiving surgery overall. At these 6 institutions, patients without multifocal infection only received surgery 26% of the time, which increased to 74% with multifocal infection and admission erythrocyte sedimentation rate >37.5 mm/h. CONCLUSIONS: This study is the first to objectively identify significant differences in the rates of surgical management of pediatric AHO across the United States. Variation in the surgical management of AHO appears to be driven primarily based on institutional practice. Twelve institutions operated on 72% of patients, regardless of the severity of disease, indicating that the institution custom or dogma may drive the surgical indications. Six institutions relied more on clinical judgment with significant variability in rates of surgical intervention (26% vs. 74%), depending on the severity of the disease. Surgical intervention is associated with increased recurrence, readmission, and hospital length of stay. As a result of these findings, it is essential to prospectively study the appropriate surgical indications and measure the outcomes in children with pediatric AHO. LEVEL OF EVIDENCE: Level III.

Best Practice Guidelines for Surgical Site Infection in High-risk Pediatric Spine Surgery: Definition, Prevention, Diagnosis, and Treatment.

BACKGROUND: Prior "best practice guidelines" (BPG) have identified strategies to reduce the risk of acute deep surgical site infection (SSI), but there still exists large variability in practice. Further, there is still no consensus on which patients are "high risk" for SSI and how SSI should be diagnosed or treated in pediatric spine surgery. We sought to develop an updated, consensus-based BPG informed by available literature and expert opinion on defining high-SSI risk in pediatric spine surgery and on prevention, diagnosis, and treatment of SSI in this high-risk population. MATERIALS AND METHODS: After a systematic review of the literature, an expert panel of 21 pediatric spine surgeons was selected from the Harms Study Group based on extensive experience in the field of pediatric spine surgery. Using the Delphi process and iterative survey rounds, the expert panel was surveyed for current practices, presented with the systematic review, given the opportunity to voice opinions through a live discussion session and asked to vote regarding preferences privately. Two survey rounds were conducted electronically, after which a live conference was held to present and discuss results. A final electronic survey was then conducted for final voting. Agreement ≥70% was considered consensus. Items near consensus were revised if feasible to achieve consensus in subsequent surveys. RESULTS: Consensus was reached for 17 items for defining high-SSI risk, 17 items for preventing, 6 for diagnosing, and 9 for treating SSI in this high-risk population. After final voting, all 21 experts agreed to the publication and implementation of these items in their practice. CONCLUSIONS: We present a set of updated consensus-based BPGs for defining high-risk and preventing, diagnosing, and treating SSI in high-risk pediatric spine surgery. We believe that this BPG can limit variability in practice and decrease the incidence of SSI in pediatric spine surgery. LEVEL OF EVIDENCE: Not applicable.

Three-dimensional analysis of spinal deformity correction in adolescent idiopathic scoliosis: comparison of two distinct techniques.

PURPOSE: To compare 3D postoperative deformity correction using two distinct commonly utilized techniques for the treatment of adolescent idiopathic scoliosis (AIS). METHODS: AIS patients with major thoracic (Lenke 1-2) curves at two sites who underwent deformity correction via posterior spinal instrumented fusion using one of two distinct techniques were retrospectively reviewed. Patients were matched 1:1 between sites for Lenke type (95% Lenke 1) and follow-up time. The "band site" performed posteromedial translation using thoracic sublaminar bands and 5.5-mm rods. The "screw site" performed spine derotation using differential rod contouring with pedicle screws and 5.5-mm rods. 3D measures of deformity from spinal reconstructions were compared between sites. RESULTS: Preoperatively, the groups had similar thoracic curve magnitudes (band, 55 ± 12° vs. screw, 52 ± 10°; p > 0.05); the "screw site" had less T5-T12 kyphosis (2 ± 14° vs. 7 ± 12°, p = 0.05) and greater thoracic apical rotation (- 19 ± 7° vs. - 14 ± 8°, p = 0.007). Postoperatively, the "screw site" had greater percent correction (61% vs. 76%, p < 0.001) and kyphosis restoration (p = 0.002). The groups achieved a similar amount of apical derotation (p = 0.9). The "band site" used cobalt chromium rods exclusively; the "screw site" used cobalt chromium (3%) and stainless steel (97%; p < 0.001). The "band site" performed significantly longer fusions. CONCLUSIONS: Significant variations were found between two commonly utilized techniques in AIS surgery, including rod material, correction mechanisms, and fusion levels. Significantly, a greater 3D deformity correction of the coronal and sagittal planes was observed at the "screw site" compared to the "band site", but with no difference in axial plane correction.

Plate Versus Lag Screw Only Fixation of Unstable Ankle Fractures Involving the Fibula in Adolescent Patients.

BACKGROUND: Plate fixation has been the traditional technique for fracture repair of unstable ankle injuries with an associated lateral malleolus fracture. Recently, biomechanical and clinical data have demonstrated lag screw only fixation to be an effective alternative to plate fixation in the adult population. This comparison has yet to be studied in the adolescent or pediatric population. The objective of this study was to compare lag screw only fixation with traditional plating for lateral malleolus fractures in adolescents. METHODS: A retrospective review was conducted of 83 adolescents with unstable oblique lateral malleolus fractures treated at a single pediatric level-1 trauma center between 2011 and 2019 with a minimum clinical follow-up until fracture union. Patients were divided into 2 surgical groups: (1) plate fixation (n=51) or (2) lag screw fixation (n=32). Radiographic and clinical outcomes and complications were measured in both groups. RESULTS: All patients in both groups achieved our primary outcome measure of fracture union without loss of reduction. The mean surgical time for subjects treated with a plate was 15 minutes longer (64 vs. 49 min) (P=0.001) and these patients were 3.8 times more likely to have symptomatic implants (P<0.044) than subjects treated with screws. Approximately 50% of the cohort was available by phone for patient-reported outcomes at a mean follow-up of 50 months. The mean Single Assessment Numerical Evaluation scores, Foot and Ankle Ability Measure Activities of Daily Living scores, Foot and Ankle Ability Measure sports scores, and return to sports rates were similar (92 vs. 93, 98.2 vs. 98.1, 93.2 vs. 94.0, 95% vs. 86%, respectively; P>0.05) between the 2 treatment methods. CONCLUSIONS: Lag screw only fixation is a safe and effective procedure for noncomminuted, oblique fibula fractures in the adolescent population as demonstrated by equivalent fracture healing rates without loss of reduction and similar outcome scores. Given these comparable results with the additional benefits of shorter surgical time and less symptomatic implants, lag screw only fixation should be considered as a viable treatment alternative to traditional lateral plating in the adolescent population. LEVEL OF EVIDENCE: Level III.

Three-dimensional Analysis of Acetabular Morphology and Orientation in Patients With Slipped Capital Femoral Epiphysis.

BACKGROUND: Previous studies analyzing the acetabuli in patients with slipped capital femoral epiphysis (SCFE) have not definitively addressed the relationship between SCFE and acetabular shape. Femoral head overcoverage and acetabular version are thought to contribute to SCFE. The purpose of this study was to determine the acetabular morphology and orientation in hips with SCFE and compare them with normally developing children. METHODS: Pelvic computed tomography (CT) images of patients with SCFE were compared with pelvic CTs of patients without orthopedic abnormalities (normal controls). Three-dimensional (3-D) reconstructions were created from each CT examination. Custom software uniformly aligned the pelvis then determined acetabular measures from the reconstructions including acetabular version, acetabular tilt, articular surface area, and acetabular coverage angle measured in a radial manner dividing the acetabulum into octants. RESULTS: Two-hundred forty-four hips were included (53 SCFE, 31 unaffected contralateral hips in patients with SCFE, and 160 controls). The acetabular version was similar among SCFE hips, unaffected contralateral hips, and normal controls (P=0.48). Control hips had higher acetabular tilt than SCFE-affected hips (P=0.01) and unaffected contralateral hips (P=0.04). The acetabular surface area was higher in SCFE-affected hips compared with controls (P<0.05). SCFE-affected hips and the unaffected contralateral hips in patients with SCFE had increased acetabular coverage compared with controls in all 5 acetabular octants. CONCLUSIONS: Contrary to some previous studies, the authors did not find the acetabulum to be retroverted in patients with SCFE compared with controls. Both affected and unaffected hips of patients with SCFE have decreased acetabular tilt. Acetabular surface area is higher in hips with SCFE compared with normal controls, and both the SCFE-affected hips and unaffected hips had increased acetabular coverage compared with controls in all 5 octants of the acetabulum. The shared morphology of affected and unaffected hips in patients with SCFE suggests that their acetabular anatomy may predispose them to slip. LEVEL OF EVIDENCE: Level III.

What's New in Pain Management for Pediatric Orthopaedic Surgery.

BACKGROUND: Improving pain control and decreasing opioid prescription and usage continue to be emphasized across both pediatric and adult populations. The purpose of this review is to provide a comprehensive assessment of recent literature and highlight new advancements pertaining to pain control in pediatric orthopaedic surgery. METHODS: An electronic search of the PubMed database was performed for keywords relating to perioperative pain management of pediatric orthopaedic surgery. Search results were filtered by publication date for articles published between January 1, 2015 and December 1, 2020 and yielded 404 papers. RESULTS: A total of 32 papers were selected for review based upon new findings and significant contributions in the following categories: risk factors for increased opioid usage, opioid overprescribing and disposal, nonpharmacologic interventions, nonsteroidal anti-inflammatory drugs, peripheral nerve blocks, spine surgery specific considerations, surgical pathway modifications, and future directions. CONCLUSIONS: There have been many advances in pain management for pediatric patients following orthopaedic surgery. Rapid recovery surgical care pathways are associated with shorter length of stay and improved pain control in pediatric spine surgery. Opioid overprescribing continues to be common and information regarding safe opioid disposal practices should be routinely provided for pediatric patients undergoing surgery. LEVEL OF EVIDENCE: Level IV-literature review.

Reliability of Low-dose Biplanar Radiography in Assessing Pediatric Torsional Pathology.

BACKGROUND: Low-dose biplanar radiographs (LDBRs) significantly reduce ionizing radiation exposure and may be of use in evaluating lower extremity torsion in children. In this study, we evaluated how well femoral and tibial torsional profiles obtained by LDBR correspond with 3-dimensional (3D) computed tomography (CT) and magnetic resonance axial imaging (MRI) in pediatric patients with suspected rotational abnormalities. METHODS: Patients who had both LDBR and CT/MRI studies performed for suspected lower extremity rotational deformities were included. Unlike previous publications, this study focused on patients with lower extremity torsional pathology, and bilateral lower extremities of 17 patients were included. CT/MRI torsion was measured using the Reikerås method, after conversion to 3D reconstructions. The LDBRs were deidentified and sent to the software division of EOS imaging, who created 3D reconstructions and evaluated each reconstruction for the torsional quantification of the femurs and tibiae. These imaging modalities were compared using correlation statistics and Bland-Altman analyses. RESULTS: The mean age of the cohort was 12.1±1.7 years old. Torsional values of the femur were significantly lower in LDBRs versus 3D CT/MRIs at 17.7±15.1 and 23.3±17.3, respectively (P=0.001). Torsional values of the tibia were similar in LDBRs versus 3D CT/MRIs at 23.6±10.6 and 25.3±11.2, respectively (P=0.503). There was a good intermodality agreement between LDBR and 3D CT/MRI torsional values in the femur (intraclass correlation coefficient=0.807) and tibia (intraclass correlation coefficient=0.768). Bland-Altman analyses showed a fixed bias with a mean difference of -5.6±8.8 degrees between femoral torsion measurements in LDBRs versus 3D CT/MRIs (P=0.001); 15% (5/34) of femurs had a clinically significant measurement discrepancy. Fixed bias for LDBR measurements compared with 3D CT/MRIs for the tibia was not observed (P=0.193), however, 12% (4/34) of tibias had a clinically significant measurement discrepancy. CONCLUSION: Although we found strong correlations between torsional values of the femur and tibia measured from LDBRs and 3D CT/MRIs, torsional values of the femur produced from LDBRs were significantly lower than values obtained from 3D CT/MRIs with some notable outliers. LEVEL OF EVIDENCE: Level III.

Functional Outcomes of Unstable Ankle Fractures in Adolescents.

BACKGROUND: The purpose of this study was to describe the functional outcomes and complications of unstable supination external rotation (SER) and pronation external rotation (PER) ankle fractures in adolescents. A secondary outcome was to compare functional outcomes of SER stage IV injuries that were treated definitively with closed reduction and cast application to a similar group of minimally displaced fractures treated with open reduction and internal fixation (ORIF). METHODS: A retrospective review of adolescents aged 10 to 18 years with unstable ankle fractures treated at a single institution between 2009 and 2017 was conducted. All patients had functional outcomes data from the Foot and Ankle Ability Measure obtained at a minimum of 1-year follow-up. RESULTS: In total, 67 adolescents (41 SER, 26 PER) were included (mean follow-up: 52.3±24.8 mo). A total of 56 were treated with ORIF and 11 were closed reduced and casted. No patients treated nonsurgically had a loss of reduction and none required subsequent surgical intervention. Preoperative radiographic predictors of syndesmotic injury (>6 mm of tibiofibular clear space or <2 mm of tibiofibular overlap) were not sensitive and only moderately specific predictors of intraoperative syndesmotic injury. There was no difference in functional outcome between the 11 SER stage IV fractures treated nonoperatively and a group of minimally displaced SER injuries treated with ORIF. Patients with open or partially open physes had better functional outcomes. Patients with syndesmotic injuries, medial malleolus fractures, or fracture-dislocations were not associated with lower functional outcome scores in our adolescent cohort. CONCLUSIONS: Unstable SER and PER injuries in adolescents have favorable functional outcomes at intermediate-term follow-up, though a minority continue to have impaired ankle function. Minimally displaced SER stage IV injuries with near anatomic alignment after closed reduction can be successfully treated with continued closed management, and have no difference in functional outcomes compared with similar injuries treated with ORIF. LEVEL OF EVIDENCE: Level III.