Socioeconomic Risk Factors for Poor Outcomes of Developmental Dysplasia of the Hip.

OBJECTIVE: To examine the relationship between socioeconomic factors and outcomes of developmental dysplasia of the hip (DDH). STUDY DESIGN: A retrospective review of patients with DDH at a tertiary pediatric hospital from 2003 to 2012 with 2 years minimum follow-up was conducted. The relationship between socioeconomic factors with late presentation, treatment, and outcomes was examined. Socioeconomic factors included insurance status, language, and ethnicity. RESULTS: In total, 188 patients met criteria. Patients with late presentations were more likely to be Hispanic (P = .02). However, public insurance and a non-English language were not associated with late presentation. Hispanic patients (P = .01) and patients with a non-English language (P = .01) had a lower nonoperative treatment success rate. Hispanic patients had more surgical procedures performed than non-Hispanic patients (P = .04). Patients with range of motion limitations were more likely to have public insurance (P = .05) and be Hispanic (P = .04). On multiple logistic regression analysis controlling for late presentation, patients with public insurance had increased odds of range of motion limitations (OR 2.22, P = .04). Patients with public insurance (OR 0.44, P = .04), a non-English primary language (OR 0.30, P < .01), and Hispanic ethnicity (OR 0.37, P = .01) had decreased odds of successful nonoperative treatment. CONCLUSIONS: Public insurance, a non-English language, and Hispanic ethnicity are risk factors for inferior outcomes for DDH. When controlling for late presentation, these were significant risk factors for nonoperative treatment failure.

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.

Sacral Alar Iliac (SAI) Screws Fail 75% Less Frequently Than Iliac Screws in Neuromuscular Scoliosis.

BACKGROUND: Despite recent popularity of sacral alar iliac (SAI) screws for fusion to the pelvis for neuromuscular scoliosis, there are little data regarding the failure rate of this technique compared with traditional modes of iliac fixation. Theoretical advantages of the SAI screws are obviating the need for a rod to iliac screw connector and a lower implant profile. The purpose of this study is to determine whether SAI screws have fewer failures than iliac screws in neuromuscular scoliosis. METHODS: Review of neuromuscular patients treated with posterior spinal fusion with pelvic fixation from 2004 to 2012 with minimum 2-year follow-up was conducted. Medical records and imaging studies were reviewed. Patients were divided into 2 groups based on the type of pelvic fixation (SAI or iliac screws), and implant failures were compared between the groups. RESULTS: A total of 101 patients were reviewed, including 55 patients with iliac screws and 46 patients with SAI screws. Implant failures included: disengagement of the rod to iliac screw connector (10%, 10/101), separation of screw head from screw shaft (4%, 4/101), and set screw disengagement (2%, 2/101). The SAI group had a lower implant failure rate (7%, 3/46) compared with the iliac screw group (24%, 13/55) (P=0.031). Rod to iliac screw connectors failed in 18% (10/55) of patients. There were significantly less surgical revisions in the SAI group (2%, 1/46) for pelvic screw prominence compared with the iliac screw group (11%, 6/55) (P=0.027). CONCLUSIONS: SAI screws had a lower rate of implant failure and revision surgery compared with iliac screws. If rod to screw connector failures are excluded, the failure rate of SAI screws of 6.5% (3/46) is similar to that of iliac screws 5.5% (3/55); therefore, the most important advantage of the SAI technique may be obviating the need for a screw to rod connector. LEVEL OF EVIDENCE: Level III.

Accessory Navicular is Associated With Wider and More Prominent Navicular Bone in Pediatric Patients by Radiographic Measurement.

BACKGROUND: Accessory navicular (AN) is a common anatomic variant that is known to cause medial foot pain. Surgery may be required for excision if conservative measures fail. Often, the medial border of the navicular is excised in addition to the AN during surgery. The purpose of this radiographic study is to determine if the presence of an AN is associated with a wider or more prominent navicular in pediatric patients compared with normal controls. METHODS: This study included pediatric patients who received an initial plain anteroposterior foot radiograph between January 1, 2004 and December 31, 2012 and were between the ages of 10 and 20 years. Feet with an AN were compared with those without, while controlling for age. Male and female patients were analyzed independently. Feet with fractures, deformities, or previous surgeries were excluded. Radiographic measurements included the navicular width and the protrusion of the navicular bone medially. RESULTS: A total of 592 feet were included. An AN was identified in 73 feet. Male patients were analyzed separately from females. Cases with 1 AN bone had similar-sized native navicular bones in the contralateral normal foot compared with controls with 2 normal feet (P>0.05). The presence of an AN was associated with a larger navicular width (male: P=0.02, female: P=0.02) and a larger medial protrusion percent (male: P<0.01, female: P<0.01). Age was controlled for. CONCLUSION: On radiographic examination, feet with an AN had wider native navicular bones that protruded more medially than feet without an AN. LEVEL OF EVIDENCE: Level IV-diagnostic.

Outcomes for Patients With Developmental Hip Dysplasia Who Present After Six Months of Age.

PURPOSE: Late presentation of hip dysplasia persists despite robust screening methods. After 6 months of age, treatment with a hip abduction orthosis becomes challeng-ing, and all other treatment modalities have higher reported rates of complications. METHODS: We performed a retrospective review of all patients from 2003 to 2012 who had the sole diagnosis of de-velopmental hip dysplasia, who presented before 18 months of age, and who had at least 2 years of follow-up. The cohort was then grouped based on their presentation before (BSM) or after (ASM) 6 months of age. The groups were compared for demographics, exam findings, and outcomes. RESULTS: We identified 36 patients with presentation after 6 months and 63 patients who presented before 6 months. Hav-ing a normal newborn hip exam and unilateral involvement were risk factors for late presentation (p < 0.001). Only 6% (2/36) patients in the ASM group were successfully treated non-operatively; the ASM group underwent an average of 1.33 procedures. The odds of utilizing an open reduction for the primary procedure for the late presenting patient was 4.91 times higher than the early presenting group (p = 0.001). Limited hip range of motion, particularly hip external rotation, was the only significantly different out-come (p = 0.03). There was no significance difference in the complications (p = 0.24). CONCLUSION: Management of patients with developmental hip dysplasia presenting after 6 months of age requires more surgical intervention but can result in satisfactory outcomes.

Methicillin-resistant Staphylococcus aureus Swab Results Did Not Change Treatment or Outcome in Pediatric Spinal Fusion Patients.

INTRODUCTION: The aim of this study was to investigate whether preoperative methicillin-resistant Staphylococcus aureus (MRSA) swab results were predictive of surgical site infections (SSIs) in pediatric patients who have undergone spinal fusion. METHODS: We conducted a retrospective chart review of patients who underwent posterior spinal fusion between 2004 and 2014 to determine preoperative MRSA colonization status and SSI rates and organisms. Before October 1, 2012, we administered vancomycin to the patients for infection prophylaxis; beginning October 1, 2012, patients received ceftazidime and Ancef (cefazolin for injection; GlaxoSmithKline). We added powdered vancomycin to all bone grafts. RESULTS: A total of 1,200 patients met inclusion criteria. Of the patients, 2.3% (n = 28 of 1,200) were positive for MRSA, and an SSI developed in 3.1% (n = 37 of 1,200). No significant difference in infection rates was found between patients whose MRSA swab was positive and negative (positive swab = 1 SSI, negative swab = 36 SSIs; P = 0.88). Three SSIs were caused by MRSA. CONCLUSION: The results of a preoperative MRSA nasal swab had no correlation with SSI rates. LEVEL OF EVIDENCE: Level III.

Transfer Time After Acceptance to a Level I Trauma Center.

BACKGROUND: Timely treatment of pediatric orthopaedic emergencies at level I trauma centers is frequently dependent on transfers from neighboring centers. METHODS: Records were collected from our level I trauma center for patients with isolated orthopaedic issues accepted for transfer in 2015. Open fractures, compartment syndrome, septic arthritis, and supracondylar humerus fractures with ecchymosis or neurovascular compromise were emergent. The rush hour was 6 am to 10 am and 3 pm to 7 pm. RESULTS: Ninety-six patients met the inclusion criteria; 19% (18/96) were orthopaedic emergencies and 37% (35/96) occurred during the rush hour. The average time from transfer acceptance to accepting hospital admission was 203 minutes (range, 68 to 584 minutes; SD, 85.8 minutes). The average time from transfer acceptance to departure from the transferring facility was 114 minutes (range, 7 to 391 minutes; SD, 71.9 minutes). There was no correlation between the transfer time and rush hour (P = 0.40), emergent versus nonemergent (P = 0.42), or routed distance from the hospital (P = 0.46). CONCLUSION: The average transfer time exceeded 3 hours and was independent of the distance, the rush hour, or urgency of patient condition. An average 2-hour delay was encountered for patients while leaving a medical facility after acceptance of transfer.

Comparison of Percentile Weight Gain of Growth-Friendly Constructs in Early-Onset Scoliosis.

STUDY DESIGN: Multicenter retrospective cohort. OBJECTIVE: To compare improvement in nutritional status seen in early-onset scoliosis (EOS) patients following treatment with various growth-friendly techniques, especially in underweight patients (<20th weight percentile). BACKGROUND: Thoracic insufficiency resulting from EOS can lead to severe cardiopulmonary disease. In this age group, pulmonary function tests are often difficult or impossible to perform. Weight gain has been used in prior studies as a proxy for improvement and has been demonstrated following VEPTR and growing rod implantation. In this study, we aim to analyze weight gain of EOS patients treated with four different spinal implants to evaluate if significant differences in weight percentile change exist between them. METHODS: Retrospective review of patients treated surgically for EOS was performed from a multicenter database. Exclusion criteria were index instrumentation at >10 years old and <2 years' follow-up. RESULTS: 287 patients met the inclusion criteria and etiologies were as follows: congenital = 85; syndromic = 79; neuromuscular = 69; and idiopathic = 52. Average patient age at surgery was 5.41 years, with an average follow-up of 5.8 years. Preoperatively, 55.4% (162/287) fell below the 20th weight percentile. There was no significant difference in preoperative weight between implants (p = .77), or diagnoses (p = .25). Among this group, the mean change in weight percentile was 10.5% (range: -16.7% to 88.7%) and all implant groups increased in mean weight percentile at final follow-up. There were no significant differences in weight percentile change between the groups when divided by implant type (p = .17). CONCLUSIONS: Treatment of EOS with growth-friendly constructs resulted in an increase in weight percentile for underweight patients (<20th percentile), with no significant difference between constructs. LEVEL OF EVIDENCE: Level III.

Removal of Infected Posterior Spinal Implants: Be Prepared to Transfuse.

STUDY DESIGN: Single-center retrospective review of spinal deformity patients undergoing removal of infected posterior spinal fusion implants over a 10-year period. OBJECTIVE: To evaluate the intraoperative blood loss and perioperative complications of implant removal in posterior spinal fusions. SUMMARY OF BACKGROUND DATA: To our knowledge, no studies examine blood loss or complications associated with removal of infected spinal implants in spinal deformity. METHODS: A retrospective review of 28 consecutive cases of infected posterior spinal fusion implant removal from 2003 to 2012 was performed. Exclusion criteria were patients with ≤6 levels of instrumentation, a partial removal of implants or a bleeding disorder. RESULTS: The average estimated blood loss was 465 mL (range 100-1,505 mL). Average estimated blood volume was 3,814 mL (range 1,840-9,264 mL). The average percentage of estimated blood loss was 14.2% (range 1.9%-43.5%). On postoperative labs obtained at the conclusion of the procedure, there was an average loss in hematocrit of 6.6 from preoperative values. Seventy-one percent of patients (20/28) received a blood transfusion; 39% (11/28) of these received a transfusion intraoperatively and 54% (15/28) received a transfusion postoperatively. Forty-six percent of patients (13/28) experienced an associated medical complication in the postoperative period. Among these 13, there were 16 total complications, with the most common being seizures (4/16), pneumonia (2/16), and sepsis (2/16). Average hospital stay was 14 days (range 4-52). CONCLUSION: Seventy-one percent of patients undergoing removal of infected spinal implants received a blood transfusion. We recommend having blood products available when removing posterior spinal instrumentation >6 levels. Patients and families should be counseled on the high risk of complications and expected hospital stay in these cases. LEVEL OF EVIDENCE: Level III.