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.

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.

3D analysis of the preoperative deformity in AIS can be used to guide surgical treatment decisions for selective thoracic fusion

PURPOSE

To identify 3D measures of scoliosis from preoperative imaging that are associated with optimal radiographic outcomes after selective thoracic fusion (STF) for adolescent idiopathic scoliosis (AIS).

METHODS

Subjects with primary thoracic curves (Lenke 1-4, B or C modifiers) fused selectively (L1 or above) who had preoperative 3D reconstructions and minimum 2 years of follow-up were included. An optimal outcome at 2 years was defined as having 4 of 5 parameters previously defined in the literature: (1) lumbar curve < 26º, (2) deformity flexibility quotient < 4, (3) C7-CSVL < 2 cm, (4) lumbar prominence < 5º and (5) trunk shift < 1.5 cm. Univariate and CART analyses were performed to identify preoperative variables associated with achieving an optimal outcome 2 years postoperatively.

RESULTS

Ninety-nine (88F, 11 M) patients met inclusion. Mean age was 15 ± 2 years. Fifty-one subjects (52%) had an optimal outcome. Seven preoperative deformity measures representing smaller thoracolumbar/lumbar deformity in the optimal group were found to be significant on univariate analysis. CART analysis identified the following variables associated with optimal outcomes: difference in apical rotation > 30° = 27% optimal outcomes, difference in apical rotation ≤ 30° and coronal vertebral wedging of lumbar apex > 3° = 46% optimal outcomes, and difference in apical rotation ≤ 30° and coronal vertebral wedging of lumbar apex ≤ 3° = 80% optimal outcomes (p < 0.05).

CONCLUSION

Optimal outcomes after STF were associated with a preoperative difference in apical vertebral rotation in the axial plane less than 30° between thoracic and lumbar curves as well as coronal plane vertebral wedging of the lumbar apical vertebra less than 3°.

Three-dimensional vertebral shape changes confirm growth modulation after anterior vertebral body tethering for idiopathic scoliosis

PURPOSE

To evaluate three-dimensional (3D) vertebra and disk shape changes over 2 years following anterior vertebral body tether (AVBT) placement in patients with idiopathic scoliosis (IS).

METHODS

Patients with right thoracic IS treated with AVBT were retrospectively evaluated. 3D reconstructions were created from biplanar radiographs. Vertebral body and disk height (anterior, posterior, left and right) and shape (wedging angle) were recorded over the three apical segments in the local vertebral reference planes. Changes in height and wedging were measured through 2 years postoperatively. Change in patient height was correlated with changes in the spine dimensions.

RESULTS

Forty-nine patients (Risser 0-3, Sanders 2-4) were included. The mean age was 12.2 ± 1.4 years (range 8-14). The mean coronal curve was 51 ± 10° preoperatively, 31 ± 9° at first postoperative time point and 27 ± 11° at 2-year follow-up (p < 0.001). The mean patient height increased 8 cm by 2 years (p < 0.001). The left side of the spine (vertebra + disc) grew in height by 2.2 mm/level versus 0.7 mm/level on the right side (p < 0.001). This differential growth was composed of 0.5 mm/vertebral level and 1.0 mm/disk level. Evaluation of the change in disk heights showed significantly decreased height anteriorly (- 0.4 mm), posteriorly (- 0.3 mm) and on the right (- 0.5 mm) from FE to 2 years. Coronal wedging reduced 2.3°/level with 1.1°/vertebral level change and 1.2°/disk level. There was no differential growth in the sagittal plane (anterior/posterior height). Patient height change moderately correlated with 3D measures of vertebra + disk shape changes.

CONCLUSIONS

Three-dimensional analysis confirms AVBT in skeletally immature patients results in asymmetric growth of the apical spine segments. The left (untethered) side length increased more than 3 × than the right (tethered) side length with differential effects observed within the vertebral bodies and disks, each correlating with overall patient height change.

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.

Scoliosis Research Society-22r and Ceiling Effects: Limited Capabilities for Precision-Medicine with Adolescent Idiopathic Scoliosis

STUDY DESIGN

Retrospective registry analysis.

OBJECTIVE

To examine predictions of individual Scoliosis Research Society-22r (SRS-22r) questions one year after surgery for adolescent idiopathic scoliosis (AIS).

SUMMARY OF BACKGROUND DATA

A precision-medicine approach to AIS surgery will inform patients of the likelihood of achieving particular results from surgery, specifically individual responses to the SRS-22r questionnaire.

METHODS

A multi-center AIS registry was queried for surgical AIS patients treated between 2002-2020. Preoperative data collected included standard demographic data, deformity descriptive data, and SRS-22r scores. Postoperative 1yr SRS-22r scores were modeled using ordinal logistic regression. . The highest probability was the most likely response. Model performance was examined by c-statistics, where c>.8 was considered excellent. Ceiling effects were measured by the proportion of patients reporting "5" to each question.

RESULTS

3251 patients contributed data to the study; mean age 14.4 (±2.2) yrs, female 2631 (81%), major thoracic coronal curve 53°, mean lumbar 41°. C-statistic values ranged from .6 (poor) to .8 (excellent) evidence of varied predictive capabilities. Q17 ("days off work/school", c = .84, ceiling achieved 75%) and Q15 ("financial difficulties", c = .86, ceiling achieved 82%) had the greatest predictive capabilities while Q11 ("pain medication", c=.73, ceiling achieved 67%), Q10 ("appearance", c=.72, ceiling achieved 35%), and Q19 ("attractive", c=.69, ceiling achieved 37%) performed poorly.

CONCLUSION

Prediction of individual SRS-22r item responses perhaps most germane to AIS treatment was poor. Prediction of less relevant outcomes, where ceiling effects are present, was greater as the models chose "5" for all responses. These ceiling effects may limit discrimination and hamper efforts at personalized outcome predictions.

LEVEL OF EVIDENCE

3.

Intrawound Vancomycin Powder Reduces Delayed Deep Surgical Site Infections Following Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis

STUDY DESIGN

Retrospective.

OBJECTIVE

Evaluate whether the use of vancomycin powder (VP) placed in the surgical site prior to wound closure prevents delayed deep surgical site infections (DDI).

SUMMARY OF BACKGROUND DATA

DDI after posterior spinal fusion (PSF) in adolescent idiopathic scoliosis (AIS) patients remains a significant major complication. The use of VP to prevent acute surgical site infection has been reported but the impact on DDI is unknown.

METHODS

AIS patients treated over the past 20 years with PSF/instrumentation from a large muti-center registry were reviewed. Patients were divided into two groups: intraoperative vancomycin powder placed in the wound (VP) or no antibiotics placed in the wound (NVP). DDI was defined as an infection that occurred >90 days after surgery and required surgical intervention in the operating room. Patients who developed a DDI had secondary verification of VP use or not. Chi square and Kaplan-Meier (K-M) survivorship analyses were used to compare demographics and incident rate of DDI between groups.

RESULTS

4145 cases met inclusion for this study. A total of 43 DDI cases were identified (1.0%). The incidence of DDI for the VP group was 0.2% (4/2111), and 1.9% (39/2034) in the NVP group (P<0.001). Given the difference in follow-up for the 2 groups a Cumulative Survival and Kaplan-Meier analysis revealed the VP group had significantly better "survival" (no DDI) than the NVP group (P<0.001).

CONCLUSION

DDIs are significant, adverse events that can greatly complicate patient recovery after PSF for AIS, including rehospitalization. This study found that patients who received VP intraoperatively were 10 times less likely to develop a DDI than those who did not receive VP. Although other advances/changes in surgical techniques may contribute to the significant decrease in infections found in the more recent VP cohort, VP should be considered as a prophylactic measure.

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.

Pain Medication Use Two Years After Adolescent Idiopathic Scoliosis Fusion Surgery

STUDY DESIGN

Observational case control.

OBJECTIVE

The objective of this study was to evaluate the prevalence of opioid use two years after surgical correction of adolescent idiopathic scoliosis (AIS) and its association with preoperative mental health.

SUMMARY OF BACKGROUND DATA

Studies of opiate use have reported that up to 80% of users began their addiction with misuse of prescription opioids. Identifying opioid use and those at risk in the AIS population is critical for optimal outcomes.

MATERIALS AND METHODS

A query of a multicenter prospective AIS surgical fusion registry was performed to identify patients of all curve types with responses to question 11 on the Scoliosis Research Society-22 questionnaire at two years postoperative. Question 11 asks about pain medication usage for the patient's back with five specific responses: narcotics daily, narcotics weekly or less, non-narcotics daily, non-narcotics weekly/less, or none. Ordinal regression was used to evaluate the association between preoperative Scoliosis Research Society-22 Mental Health (MH) domain scores and two-year postoperative pain medication usage.

RESULTS

A total of 2595 patients who underwent surgery from 2002 to 2019 met inclusion. The average primary curve was 56±12°, average age 14.7±3 years, and 81.5% were female. Forty (1.5%) patients reported utilizing opioids two years after surgery, and a significant difference in preoperative MH scores was observed. Patients taking daily opioids postoperatively had the lowest median preoperative MH score (3.75), followed by non-narcotic group (4), and no medication (4.2, P <0.001). Three patients reporting opioid use postoperatively reported preoperative usage. The rate of two-year postoperative medication use based on the year of surgery demonstrated a small linear decrease in opioid use over time, with a slight increase in nonopioid daily use.

CONCLUSIONS

Less than 2% of patients reported taking opioids for back pain two years after surgical correction of AIS. A lower MH score before surgery may place a patient at increased risk for opioid use two years after surgery. An analysis of the year of surgery suggests that changes in prescription practices over time may be occurring.

LEVEL OF EVIDENCE

4.

Opioid Analgesia Compared with Non-Opioid Analgesia After Operative Treatment for Pediatric Supracondylar Humeral Fractures: Results from a Prospective Multicenter Trial

BACKGROUND

Minimal pain and opioid use after operative treatment for pediatric supracondylar humeral fractures have been previously described; however, opioid-prescribing practices in the United States remain variable. We hypothesized that children without an opioid prescription would report similar postoperative pain compared with children prescribed opioids following closed reduction and percutaneous pinning (CRPP) of supracondylar humeral fractures.

METHODS

Children who were 3 to 12 years of age and were undergoing CRPP for a closed supracondylar humeral fracture were prospectively enrolled in a multicenter, comparative study. Following a standardized dosing protocol, oxycodone, ibuprofen, and acetaminophen were prescribed at 2 hospitals (opioid cohort), and 2 other hospitals prescribed ibuprofen and acetaminophen alone (non-opioid cohort). The children's medication use and the daily pain that they experienced (scored on the Wong-Baker FACES Scale) were recorded at postoperative days 1 to 7, 10, 14, and 21, using validated text-message protocols. Based on an a priori power analysis, at least 64 evaluable subjects were recruited per cohort.

RESULTS

A total of 157 patients were evaluated (81 [52%] in the opioid cohort and 76 [48%] in the non-opioid cohort). The median age at the time of the surgical procedure was 6.2 years, and 50% of the subjects were male. The mean postoperative pain scores were low overall (<4 of 10), and there were no significant differences in pain ratings between cohorts at any time point. No patient demographic or injury characteristics were correlated with increased pain or medication use. Notably, of the 81 patients in the opioid cohort, 28 (35%) took no oxycodone and 40 (49%) took 1 to 3 total doses across the postoperative period. Patients rarely took opioids after postoperative day 2. A single patient in the non-opioid cohort (1 [1%] of 76) received a rescue prescription of opioids after presenting to the emergency department with postoperative cast discomfort.

CONCLUSIONS

Non-opioid analgesia following CRPP for pediatric supracondylar humeral fractures was equally effective as opioid analgesia. When oxycodone was prescribed, 84% of children took 0 to 3 total doses, and opioid use fell precipitously after postoperative day 2. To improve opioid stewardship, providers and institutions can consider discontinuing the routine prescription of opioids following this procedure.

LEVEL OF EVIDENCE

Therapeutic Level II . See Instructions for Authors for a complete description of levels of evidence.

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.

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.

SRS-22r Self-Image After Surgery for Adolescent Idiopathic Scoliosis at 10-year Follow-up

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

To examine SRS-Self Image scores at up to 10 years after surgery for adolescent idiopathic scoliosis (AIS).

SUMMARY OF BACKGROUND DATA

Self-image is complex with implications for surgical and patient-reported outcomes after AIS surgery. Surgically modifiable factors that impact self-image are inconsistently reported in the literature with few longer-term reports. We examined the rate and durability of self-image improvement.

MATERIALS AND METHODS

An AIS registry was queried for patients with up to 10 years of follow-up after AIS surgery. A mixed effects model estimated change in SRS-22 Self Image from baseline to 6 weeks, 1 year, 2 years, 5 years, and 10 years. All enrolled patients contributed data to the mixed effects models. A sub-analysis of patients with 1-year and 10-year follow-up evaluated worsening/static/improved SRS-22 Self Image scores examined stability of scores over that timeline. Baseline demographic data and 1-year deformity magnitude data were compared between groups using parametric and nonparametric tests as appropriate.

RESULTS

Data from 4608 patients contributed data to the longitudinal model; 162 had 1-year and 10-year data. Mean SRS-Self Image improvement at 10-year follow-up was 1.0 (95% CI: 0.9-1.1) point. No significant changes in Self-Image domain scores were estimated from 1-year to 10-year (all P >0.05) postoperative. Forty (25%) patients had SRS-Self Image worsening from 1 year to 10 years, 36 (22%) improved, and 86 (53%) were unchanged. Patients who worsened over 10 years had lower SRS-Self Image at baseline than those unchanged at enrollment (3.3 vs. 3.7, P =0.007). Neither radiographic parameters nor SRS-Mental Health were different at baseline for the enrolled patients.

CONCLUSION

Ten years after surgery, 75% of patients reported similar or better SRS-Self Image scores than one year after surgery. Nearly 25% of patients reported worsening self-image at 10 years. Patients who worsened had lower baseline SRS-Self Image scores, without radiographic or mental health differences at baseline or follow-up.

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.

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.

Prospective evaluation of in situ screw fixation for stable slipped capital femoral epiphysis

PURPOSE

We aimed to determine which variables were associated with persistent symptoms or need for further surgery in patients treated with in situ fixation for stable slipped capital femoral epiphysis. We hypothesized that patients with greater proximal femoral deformity would require revision surgical intervention.

METHODS

We prospectively collected data on stable slipped capital femoral epiphysis patients who underwent in situ screw fixation at a single institution. Demographic and radiographic information, as well as patient-reported outcomes, were collected.

RESULTS

Forty-six patients (54 hips) with an average follow-up of 3.5 years (range: 2.0-8.5) and mean pre-op Southwick slip angle of 40.5° ± 19.4° were studied. We observed one complication following the index procedure (2%). Twelve hips (22%) went on to have a secondary procedure 2.7 ± 2.2 years after the index surgery. Severe slips were 14.8× more likely to undergo a secondary procedure than mild and moderate slips (p < 0.001). We found no correlation between slip severity and patient-reported outcomes (p > 0.6). Hips requiring a secondary procedure had significantly lower Hip disability and Osteoarthritis Outcome scores (76.8 ± 18.4) at final follow-up compared to hips that did not require additional surgery (86.8 ± 15.7) (p = 0.042).

CONCLUSION

With minimum 2-year follow-up, 22% of patients required a secondary surgery. Patient-reported outcomes did not correlate with slip severity, but were found to be significantly higher in slipped capital femoral epiphysis patients that did not require a secondary procedure. Prophylactic treatment of all slip-related cam deformity was not found to be necessary in this prospective cohort. Patients with moderate-to-severe slips may require secondary surgery.

LEVEL OF EVIDENCE

Level II.

Preoperative factors associated with optimal outcomes of selective thoracic fusion at 5 years

PURPOSE

Prior work identified optimal outcomes at 2 years following selective thoracic fusion (STF) for adolescent idiopathic scoliosis (AIS) but it is unclear whether these published predictors represent what is required to achieve an optimal outcome with further time and potential growth. The purpose of this study was to determine the preoperative factors associated with optimal outcome of STF for AIS at 5 years.

METHODS

Patients with primary thoracic AIS (Lenke 1-4C curves) who underwent a STF and had minimum 5 years of follow-up were included. Optimal postoperative outcomes for a STF included a deformity-flexibility quotient (DFQ) < 4, lumbar curve < 26°, lumbar correction > 37%, C7-CSVL < 2 cm, lumbar prominence < 5°, and trunk shift < 1.5 cm. These outcomes were used to determine whether adhering to published recommendations for STF increased the likelihood of obtaining an optimal outcome at 5 years, which included: preoperative lumbar curve < 45°, lumbar bend < 25°, apical vertebral translation ratio > 1.2, and thoracic/thoracolumbar Cobb ratio > 1.2.

RESULTS

127 patients met inclusion. A preoperative lumbar curve < 45° was associated with an increased likelihood of achieving three of the optimal outcomes: DFQ < 4, lumbar curve < 26°, and lumbar prominence < 5°. Following the 25° bend rule resulted in two optimal outcomes, while Cobb ratio > 1.2 was only associated with one optimal outcome. AVT > 1.2 was not significantly associated with any optimal outcome measures.

CONCLUSION

This study found that at 5 years, performing a STF when there is a preoperative lumbar Cobb < 45° remained the best guideline for increasing the likelihood of an optimal outcome.

A comparison of cone beam computed tomography, standard computed tomography and plain radiographs in the evaluation of medial epicondyle humerus fractures

The ideal technique to measure medial epicondyle humerus fracture displacement minimizes radiation exposure while maximizing measurement accuracy and reliability. This study compares the radiation exposure and accuracy of displacement measurements of the four-view X-ray examination (XR), computed tomography (CT) and in-clinic cone-beam CT (CBCT). A cadaveric humerus underwent medial epicondyle osteotomy. The fragment was fixed to the humerus at clinically relevant displacements (6 to 18 mm). Dosimeters were placed around the distal humerus and simulating thyroid location. XR, CT and CBCT were performed at each displacement. Four pediatric orthopedists measured the maximum linear displacement on each XR and 3D reconstruction of the CT and CBCT images. Focal (elbow location) and thyroid radiation exposure was compared between modalities. Intra- and interclass correlation coefficients (ICC) for displacement measurements were determined. Mean focal radiation exposures for XR, CT and CBCT were 0.008, 2.061 and 0.478 rad, respectively (P = 0.001). Exposures 10 inches from the elbow for XR, CT and CBCT were 0.001, 0.066 and 0.010 rad, respectively (P = 0.006). At 12 inches, there was no significant difference in exposure between XR and CBCT ( P  = 0.114). Intra- and interobserver reliabilities were excellent for all measures, except lateral x-ray. CBCT and CT had significantly less deviation from the actual displacement compared to XR ( P  < 0.05). In-office CBCT of the elbow exposes patients to significantly less radiation than conventional CT. All X-ray images (except lateral), CT and CBCT had equal reliability in evaluating medial epicondyle fractures, which contrasts with previous evidence.

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.

Telescoping screw fixation compared to traditional in situ screw fixation for slipped capital femoral epiphysis: clinical, radiographic and patient-reported outcomes

This study compares clinical, radiographic and patient-reported outcomes among telescoping and traditional screws for the treatment of slipped capital femoral epiphysis (SCFE). We hypothesized that telescoping screws would prevent slip progression and result in preserved femoral neck growth and improved patient-reported outcomes. Traditional screws were compared to telescoping screws in a 2:1 matched cohort based on age at initial surgery, length of radiographic follow-up and whether or not the hip was pinned prophylactically or as a treatment for SCFE. Neck length and telescoping screw length were measured. The patient-reported outcomes were obtained at routine clinic visits. Total 42 hips were included with a mean follow-up of 24.5 ± 3.3 months. No patients developed avascular necrosis, chondrolysis or needed revision surgical procedures. Telescoping screws increased in length for the entire cohort by a mean of 6.0 ± 4.3 mm. Neck length change was not different in SCFE hips when treated with traditional screws vs. telescoping screws (P = 0.527). However, there was a difference in neck length change between the two groups when comparing prophylactically treated hips (P = 0.001). There were no significant differences in patient-reported outcomes among hips treated with telescoping screws compared to traditional screws. Traditional and telescoping screws are both effective for the treatment of SCFE. Telescoping screws have an advantage when prophylactically treating hips that are at risk of slipping as they don't lead to the coxa breva that is seen with traditional screws. However, both treatment methods had similar patient-reported outcomes.

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.

3-D acetabular morphology of the neuromuscular hip: implications for preoperative planning

The importance of precisely understanding the pathoanatomy of acetabular dysplasia prior to surgical treatment has long been recognized. Acetabuloplasties for neuromuscular hip dysplasia have typically aimed to improve the acetabulum by increasing posterior-superior coverage, as previous three-dimensional (3-D) computed tomography (CT) studies have shown that acetabular dysplasia in neuromuscular hips is primarily in the direction of posterior-superior subluxation or dislocation. The purpose of this study was to identify differences in 3-D morphology between normal hips and dysplastic neuromuscular hips, specifically to identify areas of acetabular deficiency to guide preoperative decision-making. Patients treated for neuromuscular hip dysplasia at a single institution between 2009 and 2017 with a preoperative high-resolution pelvic CT scan (28 hips) were evaluated with custom software to measure acetabular morphology. Acetabuli were divided into equal octants; coverage angles were measured for each octant of interest. Variables were compared with age- and sex-matched normal controls (56 hips). We found a wide range of hip pathology in our study cohort. Five hips had no sectors with abnormal coverage. One hip (4%) was overcovered anteriorly. The remaining pathology was undercoverage located anteriorly [n = 7 (25%)], superiorly [n = 6 (21%)], posteriorly [n = 4 (14%)] or globally [n = 5 (18%)]. Our findings indicate that individual patients with neuromuscular acetabular dysplasia have unique deformities that do not uniformly conform to a specific area of acetabular deficiency. It is imperative to define the specific 3-D acetabular deficiency location and magnitude for accurate preoperative planning. Level of evidence: Level III.

Improving Lower Extremity Casting Quality by Providing an Experienced Assistant in Pediatric Tibia Fractures Managed by Trainees

Background: The value of employing an orthopedic technician or advanced practice provider (OT/APP) to assist trainees during on-call hours has not been assessed. As the third most common pediatric long bone fracture, most tibial fractures can be managed with closed reduction and casting. Purpose: We sought to determine whether clinical outcomes could be positively affected for traumatic childhood tibia fractures by using an experienced OT/APP to aid orthopedic surgery residents with closed reduction and casting. Methods: We performed a retrospective chart review of tibial shaft fractures that occurred between 2010 and January 2017. Fractures undergoing manipulation and closed reduction by orthopedic surgery residents (post-graduate year 2 to 4) in the emergency department were included and differentiated into 2 cohorts: (1) residents who performed the procedure alone and (2) residents who were assisted by an OT/APP. Comparisons in cast quality and treatment success were made using univariate statistics followed by a multivariate Classification and Regression Tree (CART) analysis. Results: Of the 73 patients who met our criteria, 38 received treatment by a resident alone and 35 by a resident assisted by an OT/APP. Evidence to support our hypothesis was found with the resident-alone group "over" padding the casts posteriorly. Univariate analysis demonstrated that the rate of subsequent surgical intervention was more than double in the resident-alone group (31% vs 14%), yet OT/APP castings underwent more wedging at follow-up (17% vs 0%). CART analysis revealed initial fracture severity and lack of OT/APP assistance as predictors of surgical intervention with terminal nodes, in increasing order of risk of requiring surgical intervention: lower translation on sagittal and anteroposterior (AP), lower sagittal translation with greater AP translation, greater sagittal translation with OT/APP assistance, and greater sagittal translation without assistance. The initiation of a cast application-training program in 2015 decreased the need for surgical treatment in the resident-only group (pre-program 38.5% vs post-program 17%), although this was not statistically significant. Conclusion: When residents were assisted by OT/APP with initial tibia closed reduction and casting, subsequent loss of reduction was more likely to be managed with cast wedging; when this assistance was not available, there was a higher rate of fractures needing surgical intervention due, in part, to poor casting technique. The reduction in the rate of surgical intervention after an internal training program was implemented suggests that trainees may improve their casting ability without added help of an experienced assistant. Future study should be performed on distal radius fractures to determine if the presented findings are valid across casting types.

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.

Narrative Review of Complications Following DDH Treatment

BACKGROUND

The purpose of this narrative review was to survey the literature for common complications following treatment of DDH in children less than 4 years old.

METHODS

The Pubmed database was queried. Search result titles were reviewed to identify papers that were pertinent to the topic. Abstracts for these papers were obtained and read, and a subset of these were selected for review of the complete manuscript.

RESULTS

92 manuscripts were reviewed. Residual dysplasia, redislocation, and osteonecrosis are the primary complications of treatment in this age group. In the long term, hips without complications related to DDH treatment tend to do well, although a significant percentage of them will inevitably require joint replacement surgery.

CONCLUSION

Although there is excellent potential for a good outcome when DDH is diagnosed and treated under age 4 years, osteonecrosis continues to be a concern with all treatment methods. A subset of patients from this young cohort will continue to have residual dysplasia or recurrent dislocation requiring return to the operating room.

Nonoperative Management of Femoroacetabular Impingement in Adolescents: Clinical Outcomes at a Mean of 5 Years: A Prospective Study

BACKGROUND

There is a lack of midterm or long-term outcome data on nonoperative management of femoroacetabular impingement (FAI) syndrome in adolescents despite expanding research mostly focused on arthroscopic management.

PURPOSE

To present 5-year outcome data utilizing a nonoperative protocol on a consecutive series of patients presenting to our clinic with FAI syndrome.

STUDY DESIGN

Cohort study, Level of evidence, 2.

METHODS

A total of 100 patients (62% female; mean age 15 years) who presented to the clinic for evaluation of hip pain and had at least 1 hip with a positive impingement sign were prospectively recruited. The management protocol consisted of an initial trial of rest, physical therapy, and activity modification. Patients who remained symptomatic were offered an intra-articular steroid injection. Patients with recurrent symptoms were then offered arthroscopic treatment. Patient-reported outcomes (PROs), including the modified Harris Hip Score (mHHS) and the Nonarthritic Hip Score (NAHS) were then collected at a mean 1, 2, and 5 years after the initial evaluation.

RESULTS

At enrollment, the mean mHHS and NAHS were 69.6 ± 12.9 and 75.5 ± 15.2, respectively. A total of 51 patients (n = 69 hips) were available at a mean 5-year follow-up, with the mean mHHS and NAHS of 89.5 ± 10.8 and 88.1 ± 12, respectively. There was no significant difference in the mHHS or the NAHS between activity modification and physical therapy, injection, or arthroscopic surgery groups at 5-year follow-up (P > .6) and no difference in the proportion of hips meeting the minimal clinically important difference (MCID) for the mHHS based on treatment course (P = .99). There was no significant difference in the mHHS or the NAHS between FAI types at any time point, or in the proportion of hips that met the MCID among FAI types (P = .64). Also, 11 out of 12 hips that required surgery had surgery in less than 2 years. One hip underwent surgery at 5 years after the initial visit. There was no significant drop-off in the mHHS or the NAHS between the 2-year and 5-year time periods (P > .3).

CONCLUSION

Nonoperative management of FAI syndrome is effective in a majority of adolescent patients, with significant improvements in PROs persisting at a mean 5-year follow-up.

Proximal Femur Osteotomy Guided with Patient-Specific 3D Print Technology: A Case Report

CASE

We present a 17-month-old female infant with a left lower extremity infection. After treating the infection, she developed a pathologic femur fracture malunion with a complex femoral deformity. Three-dimensional (3D) patient-specific prints of her affected and unaffected femora were made, and a corrective osteotomy was templated on the prints.

CONCLUSION

By printing the contralateral proximal femur and templating the osteotomy and correction based on the native anatomy of the patient, we were able to simulate the 3D deformity correction and customize an implant to fit the patient's anatomy.

Functional outcomes of unstable ankle fractures with and without syndesmotic fixation in the adolescent population

PURPOSE

The purpose of this study was to compare functional outcomes of adolescents with and without ankle syndesmotic injuries and identify predictors of functional outcome after operative ankle fractures.

METHODS

A retrospective review was conducted on operative adolescent ankle fractures treated between 2009 and 2019 with a minimum of one-year follow-up (mean 4.35 years). Patients who underwent syndesmotic fixation (SF) (n = 48) were compared with operative ankle fractures without syndesmotic injury (n = 63). Functional outcomes were assessed using standardized questionnaires, specifically the Foot and Ankle Ability Measure (FAAM) and Single Assessment Numerical Evaluation.

RESULTS

There were no differences in patient-reported outcomes, rates of return to sport or complications between groups with and without SF. The SF group had a longer tourniquet time (p = 0.04), duration of non-weight-bearing (p = 0.01), more Weber C fibula fractures (p < 0.001), fewer medial malleolus fractures (p = 0.03) and more frequently underwent implant removal (p < 0.0001). Male sex, lower body mass index (BMI) and longer duration of follow-up were significant predictors of a higher FAAM sports score using multivariable linear regression. SF was not a predictor of functional outcome.

CONCLUSION

This study demonstrated that patients that undergo surgical fixation of syndesmotic injuries have equivalent functional outcomes compared to operative ankle fractures without intraoperative evidence of syndesmotic injury. We also identified that male sex, lower BMI and longer duration of follow-up are predictors of a good functional outcome.

LEVEL OF EVIDENCE

III.

3D Characterization of Acetabular Deficiency in Children with Developmental Dysplasia of the Hip

BACKGROUND

The purpose of this study is to determine if a quantitative method can be used to identify differences in 3D morphology between normal and developmentally dysplastic hips and to identify specific areas of undercoverage in children with DDH compared to age- and sex-matched controls.

METHODS

Subjects were included if they were typically developing children with no other underlying conditions affecting their musculoskeletal system and had an available pelvic CT scan (67 hips). Custom software was used to measure standard variables defining acetabular morphology (version, tilt, surface area). Acetabuli were divided into equal octants; coverage angles were measured for each octant of interest. Variables were compared with age- and sex-matched controls (128 hips) using analysis of variance or the Mann-Whitney test.

RESULTS

Hips with DDH were more anteverted compared to normal hips (DDH: 22.6˚, Control: 16.4˚, p < 0.001). The surface area was similar between groups. 28% of hips had a global deficiency, 24% were anteriorly deficient, 19% were laterally deficient, 10% were anteverted (under covered anteriorly and over covered posteriorly), 3% were posteriorly deficient, and 15% of hips had borderline undercoverage. None of the hips in this cohort were found to be retroverted.

CONCLUSIONS

This is the first study to quantify the 3D acetabular deficiency in children with DDH compared to age- and sex-matched controls. We found wide variability in coverage patterns among dysplastic hips. It is imperative to define the specific acetabular deficiency for each individual patient prior to surgical correction.

LEVEL OF EVIDENCE

III - Case-control study.

Use of Metagenomic Next-Generation Sequencing to Identify Pathogens in Pediatric Osteoarticular Infections

BACKGROUND

Osteoarticular infections (OAIs) are frequently encountered in children. Treatment may be guided by isolation of a pathogen; however, operative cultures are often negative. Metagenomic next-generation sequencing (mNGS) allows for broad and sensitive pathogen detection that is culture-independent. We sought to evaluate the diagnostic utility of mNGS in comparison to culture and usual care testing to detect pathogens in acute osteomyelitis and/or septic arthritis in children.

METHODS

This was a single-site study to evaluate the use of mNGS in comparison to culture to detect pathogens in acute pediatric osteomyelitis and/or septic arthritis. Subjects admitted to a tertiary children's hospital with suspected OAI were eligible for enrollment. We excluded subjects with bone or joint surgery within 30 days of admission or with chronic osteomyelitis. Operative samples were obtained at the surgeon's discretion per standard care (fluid or tissue) and based on imaging and operative findings. We compared mNGS to culture and usual care testing (culture and polymerase chain reaction [PCR]) from the same site.

RESULTS

We recruited 42 subjects over the enrollment period. mNGS of the operative samples identified a pathogen in 26 subjects compared to 19 subjects in whom culture identified a pathogen. In 4 subjects, mNGS identified a pathogen where combined usual care testing (culture and PCR) was negative. Positive predictive agreement and negative predictive agreement both were 93.0% for mNGS.

CONCLUSIONS

In this single-site prospective study of pediatric OAI, we demonstrated the diagnostic utility of mNGS testing in comparison to culture and usual care (culture and PCR) from operative specimens.

Randomized controlled trial of energy healing effects on pain and anxiety in AIS posterior surgery: a pilot study

OBJECTIVES

Energy healing (EH) is a part of the diverse group of Complementary and Alternative Medicines (CAM). The purpose of this study was to evaluate the effects of EH therapy prior to and following posterior surgical correction for adolescent idiopathic scoliosis (AIS) compared to controls.

METHODS

Patients were prospectively randomized to one of two groups: standard operative care for surgery (controls) vs. standard care with the addition of three EH sessions. The outcomes included visual analog scales (VAS) for pain and anxiety (0-10), days until conversion to oral pain medication, and length of hospital stay. For the experimental group, VAS was assessed pre- and post-EH session.

RESULTS

Fifty patients were enrolled-28 controls and 22 EH patients. The controls had a median of 12 levels fused vs. 11 in the EH group (p = 0.04). Pre-operative thoracic and lumbar curve magnitudes were similar (p > 0.05). Overall VAS pain scores increased from pre- to post-operative (p < 0.001), whereas the VAS anxiety scores decreased immediately post-operative (p < 0.001). The control and pre-EH assessments were statistically similar. Significant decreases in VAS pain and anxiety scores from pre to post-EH assessment were noted for the EH group. Both groups transitioned to oral pain medication a median of 2 days post-operative (p = 0.11). The median days to discharge was four in the controls and three in the EH group (p = 0.07).

CONCLUSION

In this pilot study, EH therapy resulted in a decrease in patient's pre-operative anxiety. Offering this CAM modality may enhance the wellbeing of the patient and their overall recovery when undergoing posterior surgical correction for AIS.

LEVEL OF EVIDENCE

Therapeutic Level II.

Prevalence of trochlear dysplasia in infants evaluated for developmental dysplasia of the hip

PURPOSE

The purpose of this study was to define the incidence of trochlear dysplasia in an infant cohort being screened for developmental dysplasia of the hip (DDH).

METHODS

Newborns screened for DDH that were evaluated with ultrasound for the presence of trochlear dysplasia were retrospectively reviewed. The sulcus angle and trochlear depth were measured. Based on previous work, trochlear dysplasia was defined as a sulcus angle of > 159°. Our newborn cohort was then analyzed to identify potential risk factors for trochlear dysplasia.

RESULTS

A total of 383 knees in 196 infants were studied. In total, 52% were referred for breech intrauterine positioning and 21% were ultimately diagnosed with DDH and had treatment initiated with a Pavlik harness. Of the entire cohort, 8% of knees were deemed to have trochlear dysplasia. Breech patients were found to have a flatter sulcus angle than those that were not breech (149.5° (sd 7.2°) versus 147.9° (sd 7.5°); p = 0.028). Similarly, a shallower trochlear depth was identified in breech patients versus non-breech patients (1.6 mm (sd 0.4) versus 1.8 mm (sd 0.4); p = 0.019). Those with trochlear dysplasia (as defined by sulcus angle > 159°) did show a smaller alpha angle (i.e. more dysplastic hip) as compared with those without trochlear dysplasia (59.2° (sd 10.2°) versus 65.9° (sd 7.5°); p < 0.001). Hips with DDH were 2.4-times more likely to have knees with trochlear dysplasia (95% confidence interval 1.1 to 5.3).

CONCLUSION

Ultrasound screening of newborn knees reveals that trochlear dysplasia is relatively common in breech babies with DDH.

LEVEL OF EVIDENCE

III.

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.

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.

3D cone-beam tomosynthesis provides axial imaging of the spine with lower radiation compared to computed tomography

STUDY DESIGN

Three imaging techniques were compared using porcine spines.

OBJECTIVES

To compare image acquisition time, radiation exposure, pedicle width measurement, assessment of screw breach, and image artifact between cone-beam tomosynthesis (CBT) single mode, CBT dual mode (stereotactic CBT), and computed tomography (CT) imaging with and without spinal implants. CT is the standard for axial imaging of orthopedic procedures. CBT technology is being developed, allowing real-time intraoperative imaging and 3D surgical guidance. CBT may deliver useful axial imaging quicker with less radiation than current technologies.

METHODS

Six porcine spines were instrumented with bilateral pedicle screws at six levels connected with 5.5 mm rods. Dosimeters were attached to four surfaces of spines. CT, CBT single and CBT dual images were acquired pre-implant and post-implant. Image acquisition and 3D reconstruction times were recorded. Pedicle widths were measured before and after instrumentation. Screw medial breaches were graded (0: no breach, 1: < 2 mm, 2: 2-4 mm, 3: > 4 mm). Artifact and/or distortion of each image was ranked (0 = none, 1 = mild, 2 = moderate, 3 = large). Image acquisition and reconstruction times, radiation dose, pedicle width, screw breach and artifact were compared between techniques.

RESULTS

Total image acquisition and reconstruction times of CBT was significantly less (single: 9.9 ± 0.2 s, p < 0.001; dual: 60.0 ± 8.7 s, p < 0.001) than CT (250.3 ± 36.7 s). CBT had significantly less radiation exposure than CT (CT: 0.7 ± 0.1 rad, single: 0.03 ± 0.02 rad, dual: 0.07 ± 0.03 rad; p < 0.001). No difference in pedicle width change pre-implant to post-implant was found (CT: p = 0.449, single: p = 0.430, dual: p = 0.528). Pedicle width (pre-implant: p > 0.5, post-implant: p > 0.9) and pedicle width change (p > 0.4) was similar amongst all techniques. Breach assessment was not different between groups (p = 0.257). CBT images had consistently lower artifact grades than CT.

CONCLUSIONS

Although CBT axial image quality appeared subjectively inferior to CT, it enabled consistent assessment of pedicle width and screw breach, at half time and 10× lower radiation exposure. With continued refinements, CBT technology may allow for adequate intra-operative axial imaging using low radiation exposure.

Ligamentum Teres Transfer During Medial Open Reduction in Patients with Developmental Dysplasia of the Hip

BACKGROUND

The ligamentum teres (LT) is believed to have a number of functions, including a role in hip stability, nociception, proprioception, vascular supply to the femoral head, and synovial fluid circulation. The LT is often excised in the process of performing a medial open reduction (MOR) of the hip. We sought to conduct a retrospective review of hips undergoing a MOR for dislocated infantile developmental dysplasia of the hip (DDH) to compare clinical and radiographic outcomes for patients with and without LT reconstruction.

METHODS

We performed a retrospective review of 38 hips treated with MOR with or without LT reconstruction with minimum two-year follow-up. Radiographic outcomes were determined using the Severin score. Information regarding avascular necrosis (AVN), concomitant surgical procedures, repeat dislocation, subsequent surgery, limp, pain, and range of motion symmetry was recorded.

RESULTS

Eighteen hips that underwent MOR with LT reconstruction were compared to 20 hips that underwent MOR without LT reconstruction. Mean follow up for this cohort was 70.1 months (median: 61.8; Range: 24.2 to 182.2 months). The group with LT reconstruction had an 11% rate of AVN, the group without LT reconstruction had a 15% rate of AVN (p=1.0) No hips in either group re-dislocated or had pain at final follow up. Two hips (5%) had a limp at most recent follow up, all were in the group that did not receive a LT reconstruction (p=0.488). Three hips (17%) in the LT reconstruction group and one hip (5%) in the other group had asymmetrical hip range of motion at final follow up (p=0.328).

CONCLUSION

This study offers preliminary data to suggest that ligamentum teres reconstruction is a safe procedure that can minimize the risk for subluxation or re-dislocation that can occur within the post reduction hip spica cast. Although in this study, the patients who did not have LT reconstruction had a similar re-dislocation rate, we believe that ligamentum teres preservation is a useful adjunct to medial open reduction, especially in centers that may only treat occasional cases or have less experience in applying an excellent hip spica cast.Level of Evidence: III.

Elastic Intramedullary Nailing of Pediatric Both-Bone Forearm Fractures

Background

Elastic intramedullary nailing of both-bone pediatric forearm fractures is used to treat unstable fractures that fail conservative management with closed reduction and casting, open injuries, or injuries with neurovascular compromise.

Description

Small incisions are used to enter the medullary canal of the distal end of the radius and proximal part of the ulna, avoiding injury to the adjacent physis. The elastic nail is advanced to the fracture site under fluoroscopic guidance. The fracture is reduced with traction and manipulation, and the nail is passed across the fracture site to stabilize the forearm.

Alternatives

Closed reduction and casting is the mainstay of treatment in most pediatric forearm fractures. If conservative treatment fails, these fractures can be surgically managed with elastic intramedullary nails or with plate and screw fixation.

Rationale

Elastic intramedullary nailing of pediatric forearm fractures provides a minimally invasive alternative to treat unstable fractures that fail closed reduction and casting. It has been shown to be a reliable method of achieving anatomic union with excellent function of the injured upper extremity in most patients with very few complications related to the surgery^1-3.

Expected Outcomes

We advise patients that in >90% of children treated with this technique, we achieve anatomic union with excellent wrist and elbow function. Usually, the nails can be removed 6 to 12 months after the procedure. Complications related to infection, nonunion, malunion, compartment syndrome, and neurovascular compromise are rare^1-3.

Important Tips

Position the patient and fluoroscopy machine to allow easy access to the elbow and wrist throughout the procedure.Use a sharp-pointed awl to access the medullary canal without injuring the adjacent physes of the distal end of the radius or proximal part of the ulna.Contour the radial implant to allow easy passage and to establish the anatomic radial bow.Traction and direct manual pressure can be used to reduce the fractured fragments to allow passage of the implants across the fracture site.A small open reduction of the fracture site should be performed after ≥3 failed attempts at obtaining a closed reduction.The nails should be cut so that they can be buried subcutaneously but easily accessed for later removal without injuring the adjacent physes.

Three-dimensional analysis of the sagittal profile in surgically treated Lenke 5 curves in adolescent idiopathic scoliosis

STUDY DESIGN

Retrospective.

OBJECTIVES

To determine how the pre- and postoperative three-dimensional (3D) sagittal profiles of Lenke 5 curves in idiopathic scoliosis patients compare to unaffected controls. Prior research evaluating the sagittal plane of Lenke 5 (thoracolumbar/lumbar) curves in 2D suggests that the major curve is hypolordotic.

METHODS

Patients with Lenke 5 curves treated with thoracolumbar/lumbar posterior fusion who had biplanar radiography (with 3D reconstruction) preoperatively (Pre) and 2+ years postoperatively (PO2Y) were included. A cohort of similarly aged controls (C) without spinal pathology was identified. The following 3D sagittal measurements were compared both pre- and postoperatively to controls: T1-T10, T10-L3, L3-S1, and pelvic incidence (PI). Kyphosis is designated by positive values, and lordosis by negative values.

RESULTS

Nineteen Lenke 5 patients and 125 controls were included. Preoperatively, Lenke 5 patients were hypokyphotic relative to controls from T1 to T10 (30° ± 13° vs. 42° ± 9°, p < 0.001) and hyperlordotic from T10 to L3 (- 26° ± 15° vs. - 13° ± 12°, p < 0.001). Lenke 5 spines were less lordotic from L3 to S1 (- 41° ± 9° vs. - 47° ± 7°, p = 0.004). PI was similar between groups (Lenke 5 Pre: 48° ± 13°, C: 46° ± 10°, p = 0.49). Postoperatively, the area of principal deformity (T10-L3) remained hyperlordotic (PO2Y: - 23° ± 10° vs. C: - 13° ± 12°, p < 0.001). The proximal and distal uninstrumented segments demonstrated spontaneous sagittal correction, becoming similar to controls: T1-T10 (PO2Y: 41° ± 12° vs. C: 42° ± 9°, p = 0.421) and L3-S1 (PO2Y: - 48° ± 9° vs. C: - 47° ± 7°, p = 0.56).

CONCLUSION

When measured in 3D, Lenke 5 curves were more lordotic than controls in the periapical region of the major coronal curve. Posterior correction improved sagittal alignment, including spontaneous sagittal correction of the unfused segments. However, ~ 10° of hyperlordosis persisted in the instrumented/fused T12-L3 segment. Intraoperative correction strategies should take this preoperative increase in 3D sagittal deformity into account during rod contouring as well as compression/distraction to restore more normal sagittal alignment.

LEVEL OF EVIDENCE

III.

Assessment of three-dimensional acetabular coverage angles

The purpose of this article is to report the inter- and intra-observer reliability of a computerized objective technique to quantify patient-specific acetabular morphology. We describe the use of and provide the software code for a technique to better define the location and magnitude of acetabular pathology. We have developed software code that allows the end user to obtain detailed measurements of the acetabulum using traditional computed tomography data. We provide the code and detailed instructions on how to use it in this article. The methodology was validated by having an unbiased observer (that was not involved in this project but has been trained in this software measurement methodology) to perform the entire acquisition, reconstruction and analysis procedure and compare their measurements to the measurements of one of the authors. The author then repeated the procedure 2 months later to determine intra-observer reliability. Inter- and intra-observer reliability for version, tilt, surface area and total acetabular coverage angles ranged from an intra-class correlation coefficient of 0.805 to 0.997. The method provided in this manuscript gives a reproducible objective assessment of three-dimensional (3D) acetabular morphology that can be used to assist in the diagnosis of hip pathology and to compare the morphological parameters of subjects with and without hip pathology. It allows a surgeon to understand the 3D shape of each individual’s acetabulum, share these findings with patients and their parents to demonstrate the magnitude and location of the clinical abnormality and perform patient-specific surgical corrections to optimize the shape and coverage of the hip.

Quality improvement in post-operative opioid and benzodiazepine regimen in adolescent patients after posterior spinal fusion

STUDY DESIGN

Prospective, quality-improvement.

OBJECTIVES

To evaluate pain management following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) and Scheuermann's Kyphosis (SK) determine the optimal opioid and benzodiazepine prescription amounts, and implement a multimodal post-operative pain regimen. The incidence of prescription opioid abuse is increasing in the United States. Orthopedic spine surgeons often prescribe large quantities of opioids post-operatively for pain control. Previous efforts on pain control have focused on in-patient post-operative regimens after PSF.

METHODS

Between 2/1/17 and 5/30/18 patients with AIS or SK were sent home with pain diaries after discharge to document daily narcotic, benzodiazepine, non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen and gabapentin use following PSF. Diaries were collected at the 4 week post-operative visit. Data from two cohorts were reviewed: pre-intervention and post-intervention. Our prescription intervention went into effect 9/1/17.

RESULTS

Twenty-four (30%) patients returned pain diaries. The pre-intervention cohort consisted of 12 patients (7 female; 5 males; 14.9 years (range 12-19)). Patients were prescribed on average 80 × 5 mg tabs (26-140) of oxycodone but used on average 45 tabs (12-129) over an average of 17.5 days (9-33). They were prescribed an average of 30 × 2 mg tabs (0-150) of diazepam, used on average 4.8 (0-105) tabs over 12.5 (5-25) days. The post-intervention cohort consists of 12 patients (9 female; 3 male; 14.8 years (12-19)). They were prescribed on average 50 × 5 mg tabs (35-80) of oxycodone, used 20.5 (0-39.5) tabs over 8.5 days (3-16). They were prescribed on average 18 × 2 mg tabs of diazepam (0-43), used 5.4 tabs (0-19) over 10 days (5-14).

CONCLUSIONS

This analysis has directly impacted clinical practice. Prescribed opioid and benzodiazepine doses have been decreased by over 50%, and more resources are being directed towards determining the disparity between the amount of medications prescribed and consumed in our post-operative patients.

Evaluation of the Three-Dimensional Translational and Angular Deformity in Slipped Capital Femoral Epiphysis

The purpose of this study was to quantify three-dimensional translational and angular deformity (defined as theta) present at the proximal femoral physis in slipped capital femoral epiphysis (SCFE), and to use theta to differentiate between SCFE hips, contralateral unaffected hips, and normal hips by comparing to the current gold standard measure of the Southwick slip angle (SSA). 3DCT reconstructions of the pelvis and femur in SCFE patients and normal adolescents were obtained and pelvic position was standardized. The center point and direction vector of the femoral epiphysis was determined. The femoral neck axis was defined. The angle between the femoral neck axis and epiphysis vector defined the 3D angle of deformity (theta). The 3D translation of the femoral epiphysis, measured as a percentage of femoral neck diameter, was measured in three planes. The average theta angle was significantly greater in SCFE hips (46.5 ± 24.3°) compared with control (13.7 ± 6.4°) or normal (11.7 ± 3.7°) hips (p < 0.001). There was no significant difference in theta angle between control and normal hips (p = 0.468). Theta angle correlated strongly with SSA (r_s  = 0.737, p < 0.001). Statement of clinical significance: The proximal femoral deformity in patients with slipped capital femoral epiphysis can be defined by measuring displacement of the epiphysis in all three dimensions in relation to the femoral neck axis. This information can be used in epiphyseal reorientation surgery to ensure anatomic reduction. The similarity between control and normal hips may argue against the thought that there is pre-existing deformity in a pre-slip condition of unaffected contralateral hips in SCFE patients. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:1081-1088, 2020.

Functional Outcomes of Tillaux and Triplane Fractures with 2 to 5 Millimeters of Intra-Articular Gap

BACKGROUND

The treatment of transitional ankle fractures (Tillaux and triplane) is often dictated by the amount of displacement at the articular surface. Although >2 mm is a common indication for operative management, this practice has not been strongly supported by either the pediatric or adult literature. The purpose of this study was to determine whether operative treatment of transitional fractures with 2 to 5 mm of intra-articular gap leads to superior functional outcomes compared with cast management.

METHODS

A retrospective review of all patients treated for distal tibial fractures at a single institution between 2009 and 2017 was conducted. Computed tomographic images obtained after closed reduction were reviewed to identify patients with 2 to 5 mm of displacement (either gap or step-off) at the articular surface of the tibial plafond. Complications were classified according to the modified Clavien-Dindo system. Only patients with functional outcome data (Foot and Ankle Ability Measure [FAAM]) at a minimum of 2 years after treatment were included. Two multivariable linear regression models were developed using backward stepwise regression with either the FAAM Sports score or the Single Assessment Numerical Evaluation (SANE) Sports score as the dependent variables.

RESULTS

Fifty-seven patients (34 with triplane fractures and 23 with Tillaux fractures) with a mean follow-up of 4.5 years (range, 2.0 to 9.2 years) met inclusion criteria. Thirty-four patients were treated operatively, and 23 patients were treated with closed reduction and cast application. Nonoperative treatment, greater intra-articular gap, and presence of a grade-III complication were associated with worse functional outcomes in both multivariable regression models. A gap after closed reduction remained a negative predictor of functional outcome even in patients who were treated operatively. Patients who were treated nonoperatively and had ≤2.5 mm of gap had a significantly higher mean SANE Sports score at 90% than those patients with >2.5 mm of gap at 75% (p = 0.03).

CONCLUSIONS

In Tillaux and triplane fractures with 2 to 5 mm of gap at the tibial plafond, a greater gap after closed reduction, nonoperative treatment, and complications were negative predictors of functional outcome at a mean follow-up of 4.5 years. Surgical management likely conveys the greatest functional benefit when the intra-articular gap exceeds 2.5 mm.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Femoral derotational osteotomy level does not effect resulting torsion

PURPOSE

The purpose of this study was to assess the effect on femoral torsion by rotational osteotomies at three different levels as measured in 3D using both the mechanical and the anatomic axes.

METHODS

Ten cadaveric lower extremities underwent femoral osteotomies perpendicular to the anatomic axis (AA) at three levels: subtrochanteric, mid-diaphyseal and supracondylar. Parallel pins were placed, one in each femur segment. Computed tomography (CT) was acquired in post-osteotomies neutral position, then post-external rotation of the femur at each osteotomy level. Femurs were returned to neutral rotation between imaging exams. Using 3D CT reconstructions, custom software calculated femoral torsion (angle between the femoral neck axis and the posterior condylar axis in the transverse plane) and pin angle between segments, reoriented to both the mechanical axis (MA) and the AA. Pin angle and torsion change were compared for the three osteotomy locations (regression analysis and ANOVA performed).

RESULTS

Two specimens were omitted (inadequate imaging); the remaining eight donors were 55-90 years old (mean: 64 ± 15 years), CT confirmed no bony defects. All three levels of osteotomy demonstrated significant correlations between the amount of rotation at the osteotomy (pin angle change) and the resulting change in femoral torsion (R square range 0.658-0.847). No significant differences were found between osteotomy level in torsion (MA:p = 0.285, AA:p = 0.156) or in pin angle (MA:p = 0.756, AA:p = 0.753).

CONCLUSIONS

Performing a corrective rotational osteotomy orthogonal to the AA achieves the desired effect on MA regardless of location. This suggests that a surgeon's osteotomy level choice may be based on other risks/benefits of the various techniques.

Spinal rod gripping capacity: how do 5.5/6.0-mm dual-diameter screws compare?

STUDY DESIGN

Biomechanical comparative study.

OBJECTIVE

To evaluate pedicle screw gripping capacity from five suppliers, comparing single-diameter (S-D) systems using 5.5-mm-diameter rods to dual-diameter (D-D) systems accepting 5.5- and 6.0-mm-diameter rods with both cobalt chromium (CoCr) and titanium alloy (Ti) rods. D-D systems have become increasingly prevalent; however, these systems theoretically may compromise spinal rod gripping, particularly when a smaller-diameter rod is used within a D-D pedicle screw.

METHODS

D-D pedicle screw systems from three suppliers (accepting 5.5- and 6.0-mm-diameter, Ti and CoCr rods), and S-D systems from two suppliers (accepting 5.5-mm-diameter, Ti and CoCr rods) were tested on an MTS MiniBionix machine. Axial load was applied in line with the rod to measure axial gripping capacity (AGC), and torsional load was applied to measure torsional gripping capacity (TGC) for each rod material and diameter. AGC and TGC were compared between D-D and S-D constructs, suppliers, rod diameters, and materials with subsequent classification and regression tree (CART) analysis.

RESULTS

5.5-mm rods within D-D screws were no weaker than 5.5-mm rods in S-D systems for AGC (dual > single, p = 0.043) and TGC (p = 0.066). As a whole, D-D systems had greater AGC than S-D systems (p = 0.01). AGC differed between suppliers (p < 0.001). No rod diameter (p = 0.227) or material (p = 0.131) effect emerged. With CART analysis, Supplier was the most significant predictor for greater AGC. As a whole, D-D systems had greater TGC than S-D systems (p = 0.008). TGC differed between suppliers (p < 0.001). Rod diameter was a significant predictor of higher TGC (6.0 > 5.5 mm, p = 0.002). CoCr rods had greater TGC than Ti (p < 0.001). CART analysis revealed that Supplier and CoCr material were significant predictors for increased TGC.

CONCLUSIONS

Despite 30%-70% variability in gripping capacity due to rod supplier and material, overall D-D pedicle screw systems had similar AGC and TGC as S-D systems.

LEVEL OF EVIDENCE

N/A.

Predicting epiphyseal stability of slipped capital femoral epiphysis with preoperative CT imaging

BACKGROUND

We analyzed preoperative CT scans of hips with slipped capital femoral epiphysis (SCFE) for characteristics that could be predictive of intraoperative epiphyseal stability and developed a set of imaging criteria for stable and unstable SCFE. We then compared this grading system with the Loder classification.

METHODS

We reviewed preoperative CT imaging to develop a SCFE stability classification system. Three orthopaedic surgeons used the classification system to grade stability on a series of SCFE hips. Kappa was used to evaluate intra- and interobserver reliability among the observers. A series of SCFE hips treated with open procedures in which intraoperative stability was determined under direct visualization was evaluated. Intraoperative stability was compared with stability ratings as determined by the CT classification system and the Loder classification system.

RESULTS

Interobserver reliability among our three observers was κ = 0.823 (95% confidence interval (CI) 0.414 to 1.0; p < 0.001). Intraobserver reliability was κ = 0.901 (95% CI 0.492 to 1.31; p < 0.001). In all, 27 hips were used in the comparison of intraoperative stability with the Loder and CT classification systems. CT-predicted stability exhibited 78% concordance with intraoperative stability. The sensitivity and specificity of CT-predicted stability was 75% and 82%, respectively, versus Loder sensitivity of 69% and specificity of 91%.

CONCLUSION

The CT evaluation method provided is easy to use and can help to improve the accuracy in determining preoperative epiphyseal stability, which may lead to improved treatment outcomes for this population.

LEVEL OF EVIDENCE

III.

Obesity Is Associated With Increased Thoracic Kyphosis in Adolescent Idiopathic Scoliosis Patients and Nonscoliotic Adolescents

STUDY DESIGN

Retrospective comparative cohort study.

OBJECTIVE

To compare radiographic parameters between adolescents with a greater body mass index (BMI) percentile to underweight individuals.

SUMMARY OF BACKGROUND DATA

Increased BMI percentile has been associated with increased complications after surgical correction of adolescent idiopathic scoliosis (AIS). However, association between BMI percentile and preoperative sagittal plane alignment has not been evaluated. The purpose of this study was to evaluate the effect of BMI percentile on sagittal alignment in AIS patients compared with nonscoliotic adolescents.

METHODS

Posterior-anterior and lateral spinal radiographs of 1,551 AIS patients with a thoracic major curve (Lenke 1-4) and 70 nonscoliotic adolescent patients were compared. BMI percentile was determined based on age and sex, and patients were divided into four categories: underweight (<5th percentile), normal-weight (5th-85th percentile), overweight (85th-95th percentile), and obese (≥95th percentile).

RESULTS

Coronal plane deformity magnitude was not significantly different between the 4 categories of AIS patients (p = .51). Increased BMI percentile was associated with increased thoracic kyphosis globally (T2-T12: p < .005) as well as segmentally (T2-T5: p < .001; T5-T12: p < .001) in patients with AIS. This was also true in obese adolescents without spinal deformity (p < .04). Lumbar lordosis, pelvic incidence, and pelvic tilt were not significantly different between AIS patients in the four BMI percentile categories (p > .07). Pelvic incidence was significantly greater in AIS patients compared with nonscoliotic adolescents (54 ± 13 vs. 46 ± 11; p = .01).

CONCLUSION

Increased BMI percentile is associated with increased thoracic kyphosis in AIS patients and nonscoliotic adolescents. Excess weight may reduce anterior vertebral growth. AIS patients have an increased pelvic incidence compared with nonscoliotic adolescents; however, this variable is not influenced by body mass. These relationships should be taken into account when planning sagittal plane deformity correction or considering neuro axis disorders (also associated with increased kyphosis) in patients with scoliosis.

LEVEL OF EVIDENCE

Level II.

A three-dimensional analysis of scoliosis progression in non-idiopathic scoliosis: is it similar to adolescent idiopathic scoliosis?

PURPOSE

To evaluate the three-dimensional (3D) characteristics of spine deformity in patients with non-idiopathic scoliosis compared with those observed in patients with adolescent idiopathic scoliosis (AIS).

METHODS

A retrospective chart review was conducted to identify patients with non-idiopathic scoliosis. Twenty-eight patients with neural axis (NA) abnormalities (Chiari 1, syrinx) and 20 patients with connective tissue disorder (CTD) (Marfan's, Beal's, Ehlers-Danlos syndrome, mixed) were identified. The 3D parameters of the coronal, sagittal, and axial plane were compared with 284 AIS patients with a similar range of coronal deformity.

RESULTS

The average coronal curve was similar between all three groups (AIS 48 ± 15°, CTD 43 ± 22°, and NA 49 ± 18°; p = 0.4). The NA patients had significantly greater 3D thoracic kyphosis (20 ± 18° vs 10 ± 15°, p = 0.001) and less thoracic apical vertebral rotation (- 5 ± 18° vs - 12 ± 10°, p = 0.003) when compared with AIS. The CTD group's 3D thoracic kyphosis (p = 0.7) and apical vertebral rotation (p = 0.09) did not significantly differ from AIS. Significant negative correlations were found in all three groups between thoracic kyphosis and coronal curve magnitude (AIS r = - 0.49, CTD r = - 0.772, NA r = -0.677, all p < 0.001).

CONCLUSIONS

Scoliotic patients with NA abnormalities have a more kyphotic, less-rotated 3D profile than patients with AIS, while scoliosis patients with CTD have 3D features similar to AIS. Irrespective of the underlying diagnosis, however, greater scoliotic curves were associated with a greater loss of intersegmental kyphosis, suggesting a similar biomechanical pathophysiology for curve progression.

What Factors Are Associated With Kyphosis Restoration in Lordotic Adolescent Idiopathic Scoliosis Patients?

STUDY DESIGN

Review of a prospective adolescent idiopathic scoliosis (AIS) multicenter registry.

OBJECTIVE

To evaluate predictors of surgical thoracic kyphosis restoration in AIS patients with lordotic preoperative thoracic sagittal profiles.

SUMMARY OF BACKGROUND DATA

Prior work on kyphosis-producing techniques has yielded mixed findings and has focused on the sagittal plane in 2D.

METHODS

A validated formula to predict 3D T5-T12 sagittal alignment using standard 2D measures was applied in a cohort of 1614 Lenke 1-4 patients treated with posterior instrumentation using 5.5-mm-diameter rods. Patients with 3D kyphosis 1 standard deviation (12.2°) below the mean (5.3°) were identified as the study cohort. Predictors of 3D T5-T12 kyphosis at two years were evaluated using univariate analysis followed by Classification and Regression Tree (CART).

RESULTS

There were 134 patients identified. All had preoperative 3D T5-T12 kyphosis of <-7°. The average 3D kyphosis was -13° ± 5° preoperatively and 20° ± 7° at two years (p < .001). The thoracic coronal curve improved from 62° ± 12° to 21° ± 8° at two years (p < .001). Of 15 variables analyzed, multivariate CART analysis identified only surgeon as a predictor of 2-year kyphosis. Two surgeon groups were identified by CART which included those who restored more kyphosis versus those who restored less. Subsequent analysis demonstrated significant differences between groups in the rate of Ponte osteotomies used (p < .023), stainless steel versus cobalt chromium rods (p < .001), and segmental screw fixation (p < .001).

CONCLUSION

Kyphosis restoration in patients with preoperative lordosis in the thoracic sagittal plane is possible. In this analysis, there was not one single technique identified as being solely responsible for the ability to restore kyphosis. The most predictive factor identified was the surgeon performing the correction, which is likely a reflection of focus on deformity correction in three planes, as well as a combination of methods used to restore kyphosis.

LEVEL OF EVIDENCE

Level III, therapeutic.

Rigid segmental cervical spine instrumentation is safe and efficacious in younger children

PURPOSE

The utilization of cervical spine instrumentation in the young pediatric patient is not well reported. This study presents outcomes and complications of cervical spine instrumentation in patients who underwent cervical spine fusion surgery before age 10.

METHODS

Radiographic and clinical data were collected on all patients who underwent cervical spine surgery with instrumentation at a single institution between January 1, 2006, and March 31, 2015. Patients were ≤ 10 years of age at the time of surgery with any cervical spine deformity/injury diagnosis. Patient demographics, details on cervical spine diagnosis, procedural data, imaging data, and postoperative follow-up data were collected.

RESULTS

Twenty children met the criteria and were included in the study with a mean follow-up of 10.6 months (3 months-2 years). Initial indication for cervical spine correction surgery included deformity (7 cases), trauma (6 cases), instability (3 cases), stenosis (2 cases), rotary subluxation (1 case), and infection (1 case). Fifteen cases were treated with adult 3.5-mm cervical spine instrumentation, 3 with wiring (1 sublaminar and 2 spinous process), and 2 with cannulated screws. Postoperative immobilization included 16 halo fixation, 3 collars, and 1 CTO. Overall, there were five complications related to the surgery. Two patients who had wiring (1 sublaminar and 1 spinous process) developed a non-union and required revision surgery (1 with cannulated screws and 1 with 3.5-mm segmental cervical spine instrumentation). One patient developed a postoperative infection that required incision and drainage. Five patients developed superficial pin infections for their halo. Two deformity patients experienced neurological complications that were likely unrelated to the cervical instrumentation.

CONCLUSIONS

Rigid segmental fixation can be safe and efficacious when used in pediatric cervical spine patients. Whether used with halo or orthosis, patients experience minimal to no complications from the instrumentation and achieve successful fusion. Cervical spine wiring had a high risk of non-union requiring revision surgery. The incidence of wound infection was low with one in 20 cases.