ATV-Related Trauma in the Pediatric Population.

BACKGROUND: All-terrain vehicles (ATVs) are prevalent in Appalachia and cause significant morbidity and mortality in the pediatric population. This study investigated the injury types and severity in pediatric patients over a 15-year period. METHODS: A retrospective chart review was performed on pediatric ATV-related traumas presenting to our institution from 2005 to 2020. Patients were divided into 3 age groups (0-7, 8-12, and 13-17 y) to evaluate differences in accident demographics, hospitalization, Glasgow Coma Scale, Injury Severity Score, substance use, characterization of orthopaedic and nonorthopaedic injuries, and procedures performed. RESULTS: Inclusion criteria were met by 802 patients. Males represented 71.7% (n=575) and females 28.3% (n=227); the mean age was 12.4 years. The majority (88.5%, n=710) of patients admitted following their accident had a mean stay length of 3.3 days. Of admissions, intensive care unit admission was required by 23.8%, n=191 (mean stay 4.0 d). There were 7 fatalities. The vast majority of accidents occurred between May and September (79.2%, n=635). In patients with documented helmet status, 45% (n=271) were helmeted. Roughly half of all patients (n=393) sustained a fracture (excluding fractures to the head), 370 sustained an injury to the head/face, 129 sustained intra-abdominal/intra-thoracic injuries, and 29 sustained injuries to all 3 systems. The most common fractures involved the forearm (n=98), femur (n=65), and spine (n=59). The most common open fractures were the tibia (n=12), humerus (n=8), and forearm (n=8). The oldest group was more likely than the middle or younger groups to sustain spine ( P <0.0001), pelvis ( P =0.0001), hand ( P =0.0089), and foot ( P =0.0487) fractures. Ethanol testing was positive in 5.0% (n=25) of the oldest group and cannabinoids were present in 6.8% (n=34). The youngest group was significantly more likely to sustain a fracture of the humerus than the middle or older groups ( P <0.0001). Orthopaedic surgical management was required in 24.4% (n=196) of patients. CONCLUSIONS: Pediatric ATV accidents present a significant source of morbidity and mortality. Further intervention is necessary to minimize pediatric ATV injuries. LEVEL OF EVIDENCE: Level IV-Retrospective Case Series.

Surgical Outcomes of Obese Patients With Adolescent Idiopathic Scoliosis From Endemic Areas of Obesity in the United States.

BACKGROUND: Obesity rates continue to rise among children and adolescents across the globe. A multicenter research consortium composed of institutions in the Southern US, located in states endemic for childhood obesity, was formed to evaluate the effect of obesity on pediatric musculoskeletal disorders. This study evaluates the effect of body mass index (BMI) percentile and socioeconomic status (SES) on surgical site infections (SSIs) and perioperative complications in patients with adolescent idiopathic scoliosis (AIS) treated with posterior spinal fusion (PSF). METHODS: Eleven centers in the Southern US retrospectively reviewed postoperative AIS patients after PSF between 2011 and 2017. Each center contributed data to a centralized database from patients in the following BMI-for-age groups: normal weight (NW, 5th to <85th percentile), overweight (OW, 85th to <95th percentile), and obese (OB, ≥95th percentile). The primary outcome variable was the occurrence of an SSI. SES was measured by the Area Deprivation Index (ADI), with higher scores indicating a lower SES. RESULTS: Seven hundred fifty-one patients were included in this study (256 NW, 235 OW, and 260 OB). OB and OW patients presented with significantly higher ADIs indicating a lower SES (P<0.001). In addition, SSI rates were significantly different between BMI groups (0.8% NW, 4.3% OW, and 5.4% OB, P=0.012). Further analysis showed that superficial and not deep SSIs were significantly different between BMI groups. These differences in SSI rates persisted even while controlling for ADI. Wound dehiscence and readmission rates were significantly different between groups (P=0.004 and 0.03, respectively), with OB patients demonstrating the highest rates. EBL and cell saver return were significantly higher in overweight patients (P=0.007 and 0.002, respectively). CONCLUSION: OB and OW AIS patients have significantly greater superficial SSI rates than NW patients, even after controlling for SES. LEVEL OF EVIDENCE: Level III.

Pain Medication Disposal Rates After Pediatric Surgery.

OBJECTIVES: To investigate prescription opiate usage, disposal rates, and methods of disposal after pediatric surgery. METHODS: This was a retrospective chart review of patients <18 years of age who underwent a surgical procedure at our institution and were given a postoperative opiate prescription between April 2017 and June 2018. A follow-up phone survey was conducted between 60 and 90 days postoperatively to ask about prescription opiate usage and disposal. RESULTS: A total of 290 patients with a mean age of 9.0 ± 4.7 years (62.8% male) met inclusion criteria. Sixty patients (20.7%) reported using all of their prescription opiate medication, whereas 230 patients (79.3%) did not use all of their pain medication. Of these 230 patients, 141 (61.3%) disposed of their leftover prescription opiates via flushing (56.4%), trash (28.6%), or take-back center (15.0%). At the time of phone survey between 60 and 90 days postoperatively, 88 patients (38.3%) still had leftover pain medication. By 7 days postoperatively, 234 of 290 patients (80.7%) had taken their last prescription opioid. CONCLUSIONS: In our study, 79.3% of patients were overprescribed opiate pain medication after pediatric surgery. Disposal rates at 60 to 90 days for leftover pain medication after pediatric surgery was just >60%. Pediatric patients are often overprescribed prescription opiates after surgery and typically only require a one-week supply of pain medication.

Electronic Medical Record Use and Satisfaction Among Pediatric Orthopaedic Surgeons.

INTRODUCTION: Electronic medical record (EMR) use among pediatric orthopaedic surgeons has evolved substantially within the past decade. In response to the Patient Protection and Affordable Care Act, large hospitals and tertiary pediatric medical centers rapidly acquired and implemented EMRs with uncertainty as to the potential impact on patient care and operational efficiency of subspecialists. This study reviews the background and regulatory framework for Meaningful Use of EMR and assesses the current landscape of EMR utilization by pediatric orthopaedic surgeons. METHODS: In 2015, the Practice Management Committee distributed a survey regarding EMR use and satisfaction to members of the Pediatric Orthopaedic Society of North America. Survey responses from 324 members were used to analyze levels of satisfaction by EMR platform and practice type and to consider drivers of satisfaction or dissatisfaction of end users. RESULTS: Although there were no differences in overall satisfaction based on vendor or practice type, significant differences were noted for 5 specific parameters of satisfaction, including: usefulness of templates, efficiency of practice workflow, information services support, number of logon events, and speed of the system. A user/vendor map is provided to facilitate networking among providers and groups utilizing common EMR platforms to help bring about rational improvements in EMR functionality for the future. CONCLUSIONS: Substantial effort needs to be made to improve subspecialty-specific EMR documentation, order entry, research tools, and clinical workflows to enhance the processes of care for children with orthopaedic conditions in the era of EMR. LEVEL OF EVIDENCE: Level IV.

"Clinical triad" findings in pediatric Klippel-Feil patients.

BACKGROUND: It has been propagated that patients with Klippel-Feil syndrome (KFS) exhibit "clinical triad" findings (CTFs), known as a short neck, low posterior hairline, and limited cervical range of motion (ROM). However, the literature has noted that up to 50 % of KFS cases may not present with such findings and the reasoning behind such assertions remains speculative. As such, the following study addressed the association between CTFs to that of congenitally-fused cervical segments and other risk factors in KFS patients. METHODS: We conducted a retrospective clinical study based on prospectively collected radiographic data. Thirty-one KFS patients at a single institution were assessed. Radiographs were used to evaluate the location and extent of congenitally-fused segments (spanning the occiput (O) to the first thoracic vertebra (T1)), as well as examining coronal and sagittal cervical alignments based on the Samartzis et al. KFS classification. Clinical records were evaluated to account for the initial clinical assessment of CTFs. Patients were further stratified into two groups: Group 1 included patients noted to have any CTFs, while Group 2 included patients who had no such findings. RESULTS: There were 12 males and 19 females (mean age at initial consultation: 9.7 years). No evidence of any of the CTFs was shown in 35.5 % of patients, whereas 38.7, 16.2 and 9.7 % were determined to have one, two or all three criteria, respectively. Limited cervical ROM was the most common finding (64.5 % of patients). In Group 1, 25 % had a short neck, 30 % a low posterior hairline, and 100 % exhibited limited cervical ROM. Group 1 had a mean of 3.9 fused cervical segments, whereas Group 2 had a mean of 2.5 fused cervical segments (p = 0.028). Age, sex-type, occipitalization and alignment parameters did not significantly differ to Group-type (p > 0.05). In Group 1, based on the Samartzis et al. Types I, II, and III, 16.7, 73.3, and 80.0 % of the patients, respectively, had at least one CTF. CONCLUSIONS: Complete CTFs were not highly associated during the clinical assessment of young KFS patients. However, KFS patients with extensive, congenitally-fused segments (i.e. Samartzis et al. Type III) were significantly more likely to exhibit one of the components of the CTF, which was predominantly a limited cervical ROM. Clinicians managing young pediatric patients should not rely on the full spectrum of CTFs and should maintain a high-index of suspicion for KFS, in particular in individuals that exhibit associated spinal findings, such as congenital scoliosis.

Type of bone graft or substitute does not affect outcome of spine fusion with instrumentation for adolescent idiopathic scoliosis.

STUDY DESIGN: Retrospective cohort analysis. OBJECTIVE: To compare clinical outcomes after spine instrumentation and fusion using 3 different bone grafts in children with adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: Autogenous iliac crest bone graft (AIC) is the "gold standard" to promote fusion in posterior AIS operations, although the morbidity of harvest is a concern. There is limited data comparing outcomes after AIS surgery based on types of bone grafts. METHODS: Children (10-18 yr) with AIS who underwent deformity correction via a posterior approach were identified in the Spinal Deformity Study Group database. All had a minimum of 2-year follow-up. Patients were subdivided into 3 groups based on bone graft used: AIC, allograft, and bone substitute (BS). Clinical data included patient demographics, operative details, postoperative analgesic use, and perioperative complications. Lenke curve type and curve magnitude changes were radiographically analyzed. The Scoliosis Research Society-30 questionnaire was used to assess clinical outcomes. RESULTS: 461 patients met inclusion criteria (girls: 381, boys: 80; average age 14.7 ± 1.7) and consisted of 152 AIC patients (124 girls, 28 boys), 199 allograft patients (167 girls, 32 boys), and 110 BS patients (90 girls, 20 boys). There was no difference in age (P = 0.41) or gender (P = 0.82). The BS group had significantly smaller preoperative curves and shorter operative times. Postoperatively, patients who received BS had significantly longer hospital stays, used higher quantities of patient-controlled intravenous analgesia and used epidurals longer. The AIC group used patient-controlled intravenous analgesia significantly longer. There were no differences between the groups in regards to curve type, number of levels fused, postoperative infections, pseudarthrosis, reoperations for any indication, and Scoliosis Research Society-30 scores at the latest follow-up. CONCLUSION: Outcomes after primary posterior spinal fusion with instrumentation are not influenced by type of bone graft or substitute. LEVEL OF EVIDENCE: 3.

Cervical scoliosis in the Klippel-Feil patient.

STUDY DESIGN: Retrospective study. OBJECTIVE: This study addressed in patients with Klippel-Feil syndrome (KFS), the role of congenitally fused cervical patterns, risk factors, and cervical symptoms associated with cervical scoliosis. SUMMARY OF BACKGROUND DATA: KFS is an uncommon condition, characterized as improper segmentation of one or more cervical spine segments with or without associated spinal or extraspinal manifestations. "Scoliosis" is potentially the most common manifestation associated with KFS. However, the role of congenitally fused cervical patterns along with additional potential risk factors and their association with cervical scoliosis, and its relationship with cervical spine-related symptoms remain largely unknown. METHODS: Plain radiographs were utilized to assess the location of congenitally fused cervical segments (O-T1), degree of coronal cervical alignment, and any additional cervical and thoracic spine abnormalities. The classification scheme, as proposed by Samartzis et al of congenitally fused cervical patterns (Types I-III) in KFS patients, was utilized and additional fusion and region-specific patterns were assessed. Patients with coronal cervical alignments of 10° or greater were regarded scoliotic. Patient demographics and the presence of cervical spine-related symptoms were also assessed. RESULTS: Thirty KFS patients were assessed (mean age, 13.5 yr). The mean coronal cervical alignment was 18.7° and scoliosis was noted in 16 patients. Patients that exhibited congenital fusion of the mid and lower cervical spine region, had multiple, contiguous congenitally fused segments (Type III), and associated vertebral malformations (e.g., hemivertebrae) were highly associated with the presence of cervical scoliosis (P < 0.05). Ten patients exhibited cervical spine-related symptoms; however, no statistically significant difference was noted between the presence of symptoms and coronal cervical alignment (P = 0.815) and cervical scoliosis (P = 0.450). CONCLUSION: The study noted a prevalence of cervical scoliosis to occur in 53.3% of young KFS patients. Such patients that exhibited congenital fusion of the mid and lower cervical spine region, had multiple, contiguous congenitally fused segments (Type III), and associated vertebral malformations (e.g., hemivertebrae) were highly associated with the presence of cervical scoliosis. However, in young KFS patients, the presence of cervical scoliosis may not be associated with the manifestation of cervical spine-related symptoms.

Instrumentation constructs in pediatric patients undergoing deformity correction correlated with Scoliosis Research Society scores.

STUDY DESIGN: Data collected prospectively from the Prospective Pediatric Scoliosis Study (PPSS) were analyzed statistically to address the hypothesis that covered specific aspects of treatment and its outcome. OBJECTIVE: To assess and contrast Scoliosis Research Society (SRS) outcome scores for patients assigned to one of three types of spinal instrumentation constructs. The study hypothesis was that the instrumentation strategy that provides the best curve correction will be associated with the best SRS scores. SUMMARY OF BACKGROUND DATA: Surgical treatment of scoliosis has evolved over time using implants and surgical techniques; however, quality of life indicators have not typically been analyzed to assess whether surgery and instrumentation will improve quality of life in pediatric patients. METHODS: Patients were assigned to one of three instrumentation groups depending on the type of construct used. The Scoliosis Research Society's SRS-30 survey was used to measure patient outcomes comparing preoperative results to a 2-year follow-up. RESULTS: Changes in the SRS Pain, Activity, Appearance, Mental, Satisfaction, and SRS Total domains did not differ significantly among instrumentation groups for any time intervals. However, analysis of SRS Pain did show a significant change over time for all instrumentation patterns. The analysis of SRS Activity showed a significant change over time for all instrumentation patterns preoperatively to 2 years postoperatively. Analysis of SRS Appearance showed a significant change over time for all groups but no difference between instrumentation groups. The analysis of SRS Mental based on instrumentation types showed a significant change over time, but only the pedicle screw group's change was statistically significant. Finally, analysis of SRS Satisfaction by instrumentation type showed a statistically significant change over time for all instrumentation patterns. CONCLUSION: There were no statistically significant baseline differences among the three instrumentation construct groups based on mean scores for the six SRS domains. None of the SRS domains had differences among the instrumentation constructs in change scores or significant differences among the instrumentation constructs.

Convex hemiepiphysiodesis: the limits of vertebral stapling.

STUDY DESIGN: We performed a retrospective chart review of patients with nonadolescent idiopathic scoliosis who underwent open vertebral stapling for treatment of spinal deformity. OBJECTIVE: The objective of this study was to determine the efficacy of vertebral stapling in patients with scoliosis. Measurements included initial deformity correction and maintenance of correction. SUMMARY OF BACKGROUND DATA: Growth modulation has become a topic of interest recently in the spinal deformity literature. It refers to the tethering of growth on one side of the spine to allow for compensatory growth on the contralateral side, and, in theory, correction of scoliosis. Recent studies on endoscopic vertebral stapling have shown promising early results in adolescents with idiopathic scoliosis. Little is known about its applicability in patients with more "malignant" types of scoliosis. METHODS: The medical records and radiographs of 11 children who underwent open vertebral stapling between June 2003 and August 2004 were reviewed. Patients with adolescent idiopathic scoliosis (AIS) were excluded. RESULTS.: Diagnoses included myelodysplasia, congenital scoliosis, juvenile, and infantile idiopathic scoliosis, Marfan syndrome, paralytic scoliosis, and neuromuscular scoliosis. The average age at surgery was 6 + 11 year. All patients were skeletally immature. Preoperative curves averaged 68° (22°-105°). Of the 11, six thoracic curves and five thoracolumbar curves were stapled. Four patients had minor curves, which were not stapled. Initial postoperative radiographs averaged 45° (24°-88°). Average follow-up was 22 month for our series (16-28 month). At final follow-up, scoliosis averaged 69° (36°-107°). Five of the 11 patients have subsequently undergone secondary surgical procedures for progression of scoliosis, including growing rod insertion in three, combined anterior/posterior spinal fusion in another, and bilateral vertical expandable prosthetic titanium rib insertion in a patient with myelodysplasia. Three of the remaining six patients are scheduled for secondary surgery. CONCLUSION: More than half of the patients in our series have undergone or are scheduled to undergo further spinal surgery, at an average of 2 year after anterior vertebral stapling. It is unclear if progression may be related to the young age at surgery, the relatively severe average preoperative curve magnitude, the nature of the underlying scoliosis, or a combination of these.

Patient self-assessment of appearance is improved more by all pedicle screw than by hybrid constructs in surgical treatment of adolescent idiopathic scoliosis.

STUDY DESIGN: A multicenter prospective cohort study. OBJECTIVE: To compare the effect of all pedicle screw versus hybrid constructs on patient self-assessment of appearance after posterior spinal fusion with instrumentation for adolescent idiopathic scoliosis (AIS). This will contribute to future cost-effective analyses on surgical management of AIS. SUMMARY OF BACKGROUND DATA: For surgical management of AIS, the Spinal Appearance Questionnaire (SAQ) and the Scoliosis Research Society outcomes instrument (SRS-30) are reliable surveys of patient satisfaction, but neither tool has been used to assess outcome by implant type. METHODS: Patients received either all pedicle screws or hybrid instrumentation. Self-assessment of appearance pre- and after surgery was measured by SAQ and SRS-30. Statistical significance was evaluated through P values (P < 0.01 in the SAQ, P < 0.05 in the SRS-30) and effect sizes. RESULTS: There were 93 patients in the all pedicle screw cohort and 61 in the hybrid cohort. There were no significant preoperative differences between the cohorts in the SAQ or SRS-30. All pedicle screw patients tended to see more improvement in shoulder level than hybrid patients in 2 separate SAQ questions (P = 0.025, Cohen's D = 0.20; P = 0.013, D = 0.24). The screw patients also tended to have better scores than hybrid patients in the category, "looking better in clothes" (P = 0.017, V = 0.24) at 2 years postoperative. All pedicle screw patients self-reported significant greater improvement than hybrid patients in the SRS-30 Appearance and Mental domains (P = 0.016, ES = 0.038; P = 0.005, ES = 0.051). There were no significant differences between cohorts in age, gender, baseline curve, or major curve magnitude. CONCLUSION: All pedicle screw constructs lead to better self-assessment of appearance in operative treatment of AIS, as determined by SAQ and SRS-30.

Use and outcome of MRI in the surgical treatment of adolescent idiopathic scoliosis.

STUDY DESIGN: Multicenter, prospective, consecutive clinical series. OBJECTIVE.: To report on the use and outcomes of preoperative magnetic resonance imaging (MRI) in a prospective cohort study of 2206 children undergoing posterior spinal fusion and instrumentation for adolescent idiopathic scoliosis. SUMMARY OF BACKGROUND DATA: There is no consensus on the use of MRI in the preoperative evaluation of children with idiopathic scoliosis. Also, there is no consensus on the rate of abnormality and the relevance of abnormality on surgical outcome in so-called "idiopathic" scoliosis. METHODS: We reviewed the first 2206 patients entered consecutively into the Prospective Pediatric Scoliosis Study, a database of children (8-18 years) undergoing operation for scoliosis by pediatric spinal surgeons in the Spinal Deformity Study Group. RESULTS: There were 1812 girls (80.8%) and 394 boys (17.5%). Mean age at operation was 14 years and 3 months. A total of 191 (8.6%) had juvenile idiopathic scoliosis (age ≤ 10 years). A total of 923 patients (41.8%) underwent spine MRI. Ninety-one abnormalities of the spine were detected (9.9% of the 923 screened), of which 39 (4.2%) were neural. There were 26 syringes (66.7% of neural abnormalities and 28.6% of all abnormalities), 12 Chiari malformations (30.7% and 13.2%, respectively), and 1 tethered cord (2.6% and 1.1%, respectively). Fifty-three patients (5.7%) demonstrated abnormalities affecting "other" parts of the spine than the neural elements. Patients undergoing MRI more frequently had a thoracic hyperkyphosis (P < 0.001), had a diagnosis of juvenile idiopathic scoliosis (P < 0.001), had a Risser grade between 0 and 2 (P = 0.022), had a greater curve magnitude (P < 0.001), had three major curves (P < 0.001), were male (P = 0.004), and underwent a combined anterior-posterior surgical approach (P < 0.001). Thoracic hyperkyphosis and juvenile onset were associated with greater chance of neural lesion on MRI of the spine. Incidence of abnormal MRI did not differ significantly by direction of apex, Risser grade, curve magnitude or type, male sex, or body mass index. CONCLUSION: Use of preoperative MRI was 41.8%; 9.9% of patients with so-called "idiopathic" scoliosis had an abnormality on MRI, of which 4.2% were neural anomalies. Of these, syrinx was 66.7%, Chiari was 30.7%, and tethered cord was 2.6%. Significant risk factors for neural abnormality were thoracic hyperkyphosis and juvenile onset. Other characteristics, including apex left thoracic curve, Risser less than or equal to 1, large curve magnitude, triple major curve, male sex, and obesity were not associated with neural abnormality. There were no differences in complication rates between normal and abnormal MRI patients. Our data question the routine use of MRI as a screening tool for adolescent idiopathic scoliosis.

Community-associated methicillin-resistant Staphylococcus aureus in acute musculoskeletal infection in children: a game changer.

BACKGROUND: Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) is a virulent pathogen responsible for an increasing number of invasive musculoskeletal infections in healthy children. The purpose of this study is to characterize the presentation, clinical course, treatment, complications, and long-term morbidity of CA-MRSA musculoskeletal infection in children. METHODS: A retrospective study of children with CA-MRSA musculoskeletal infections from 2 institutions was conducted. RESULTS: The study group included 27 patients. Clinical presentation involved an extremity in 23 of 27 patients. Twelve patients required admission to the intensive care unit. Four of these patients developed acute multisystem failure. Magnetic resonance imaging was obtained in 21 patients and was diagnostic in all. Seven patients developed deep venous thrombosis and septic pulmonary emboli. All patients required surgical intervention, and 16 of 27 required multiple debridements. CONCLUSIONS: CA-MRSA is limb and life threatening. Prompt recognition and treatment are critical. Aggressive surgical drainage/debridement in addition to long-term antibiotics is required. There is significant potential for long-term morbidity despite aggressive management. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Pediatric lateral condyle humeral fractures with and without associated elbow dislocations: a retrospective study.

In the pediatric population, lateral condyle fractures are relatively common elbow injuries, but not nearly as common are traumatic elbow dislocations, and these 2 types of injuries in combination are even less common. Our literature search showed only 2 reports on these concomitant injuries. In the study reported here, we evaluated a consecutive series of pediatric patients with lateral humeral condyle fractures with and without elbow dislocation and compared the groups' results.

Fractures and amputations in children and adolescents requiring hospitalization after farm equipment injuries.

BACKGROUND: The majority of farm-related injuries in children are caused by farm machinery. The aim of this study is to report the incidence of children requiring hospitalization for orthopaedic trauma after injury secondary to farm equipment accidents. METHODS: Data for this study were culled from the Kids' Inpatient Database for the years 2000, 2003, and 2006 using the E-code for injuries caused by agricultural machinery to identify the study group. Only those children with fractures (nonskull) and/or amputations were included for analysis. RESULTS: The 3-year study data include 292 children, 88% male, with an average age of 11.9 years. Of the 439 orthopaedic injuries, there were 115 upper extremity, 173 lower extremity, and 96 vertebral, rib, or pelvic fractures, and 55 amputations (34 upper and 21 lower extremity). There were proportionally more closed fractures of the upper extremity in children under the age of 12 years compared with the older children with no difference in rates of other fractures or amputation by age group. CONCLUSIONS: This study provides data on incidence of significant orthopaedic trauma in children in the United States as a result of farm equipment accidents. Most earlier studies have focused on fatality rates or have been limited to a single institution or single state or have been from a non-US population. This study provides pediatric orthopaedists, particularly those practicing in agricultural areas, with injury statistics related to farm equipment injuries that may lead to more and better safety education programs.

Adult outcomes following amputation or lengthening for fibular deficiency.

BACKGROUND: Fibular deficiency results in a small, unstable foot and ankle as well as a limb-length discrepancy. The purpose of this study was to assess outcomes in adults who, as children, had had amputation or limb-lengthening, commonly used treatments for fibular deficiency. METHODS: Retrospective review of existing data collected since 1950 at six pediatric orthopaedic centers identified 248 patients with fibular deficiency who were twenty-one years of age or older at the time of the review. Excluding patients with other anomalies and other treatments (with the excluded group including six who had had lengthening and then amputation), we identified ninety-eight patients who had had amputation or limb-lengthening for the treatment of isolated unilateral fibular deficiency. Sixty-two patients (with thirty-six amputations and twenty-six lengthening procedures) completed several questionnaires, including one asking general demographic questions, the Beck Depression Inventory-II, the Quality of Life Questionnaire, and the American Academy of Orthopaedic Surgeons Lower Limb Questionnaire including the Short Form-36. A group of twenty-eight control subjects completed the Beck Depression Inventory-II and the Quality of Life Questionnaire. RESULTS: There were forty men and twenty-two women. The average age at the time of the interview was thirty-three years. There were more amputations in those with fewer rays and less fibular preservation. Lengthening resulted in more surgical procedures (6.3 compared with 2.4 in patients treated with amputation) and more days in the hospital (184 compared with sixty-three) (both p<0.0001). However, when we compared treatment outcomes we did not find differences between groups with regard to education, employment, income, public assistance or disability payments, pain or use of pain medicine, sports participation, activity restriction, comfort wearing shorts, dislike of limb appearance, or satisfaction with treatment. No patient who had been treated for fibular deficiency reported signs of depression. The only significant difference between treatment groups shown by the Quality of Life Questionnaire was in the scores on the Job Satisfiers content scale, with the amputees scoring better than the patients treated with lengthening (p=0.015). The American Academy of Orthopaedic Surgeons Lower Limb Module did not demonstrate differences in health-related quality of life or physical function. CONCLUSIONS: The patients who were treated with lengthening had started out with more residual foot rays and more fibular preservation than the amputees. They also required more surgical intervention than did those with an amputation. While patients with an amputation spent less of their childhood undergoing treatment, they were found to have a better outcome in terms of only one of seventeen quality-of-life parameters. Both groups of patients who had had treatment of fibular deficiency were functioning at high levels, with an average to above-average quality of life compared with that of the normal adult population.