International Orthopaedic Multicenter Study in Fracture Care: Coordinating a Large-Scale Multicenter Global Prospective Cohort Study.

Traditionally, the orthopaedic trauma literature has been dominated by small studies that were largely single-center initiatives. More recently, there has been a paradigm shift toward larger, multicenter studies because the orthopaedic community embraced the concepts of evidence-based medicine and the need for high-quality research to guide clinical practice. The International Orthopaedic Multicenter Study in Fracture Care is a large multicenter international cohort study in musculoskeletal trauma in Africa, Asia, and Latin America. This is the first study of this magnitude within the global orthopaedic trauma community. The International Orthopaedic Multicenter Study in Fracture Care study has provided an opportunity to form new international collaborative relationships and to develop new research capacity and global collaborative relationships that will provide the foundation for future studies in injury prevention and management. LEVELS OF EVIDENCE: IV.

Diagnostic Accuracy of Neuromonitoring for Identification of New Neurologic Deficits in Pediatric Spinal Fusion Surgery.

BACKGROUND: Intraoperative neuromonitoring (IONM) modalities, transcranial motor-evoked potentials (TcMEPs), and somatosensory-evoked potentials (SSEPs) are accepted methods to identify impending spinal cord injury during spinal fusion surgery. Debate exists over sensitivity and specificity of these modalities. Our purpose was to measure the incidence of new neurologic deficits (NNDs) and estimate sensitivity and specificity of IONM modalities. METHODS: Institutional Ethics Board approval was obtained to review charts of patients younger than 22 years undergoing scoliosis surgery from 2007 to 2014 retrospectively. The definition of true-positive patients included two subgroups: (1) patients with an IONM alert, which did not resolve despite the interventions and had a NND postoperatively; or (2) patients with an IONM alert triggering interventions and the alert resolved with no NND postoperatively. Subgroup 2 of the definition is debatable; thus, we performed a multiple sensitivity analysis with three assumptions. Assumption 1: without interventions, all such patients would have experienced NNDs (assumption used in previous studies); Assumption 2: without intervention, half of these patients would have experienced NNDs; Assumption 3: without intervention, none of these of patients would have experienced NNDs. RESULTS: We included 296 patients. Patients with incomplete charts (n = 3), no IONM monitoring (n = 11), and inadequate baseline IONM (n = 7) were excluded. The incidence of NND was 3.7% (95% confidence interval, 2.1%-6.5%). Successful IONM in at least one modality was obtained in 275 patients (92.9%), of whom 268 (97.5%) and 259 (94.2%) had successful baseline TcMEP or SSEP signals, respectively. Fifty-one (17%) patients had IONM alerts, 41 were only TcMEP, 5 were only SSEP, and 5 were in both modalities. After interventions, 42 (82%) patients recovered, 41 had no NND (true-positive under Assumption (1), but one developed a NND (false-negative). Of the 9 patients with no alert recovery, 6 had a NND (true-positive) and 3 did not (false-positives). Of the remaining 224 patients with no alerts, 221 had no NND (true-negatives) and 3 did (false-negatives). Sensitivity was estimated to be 93.5%, 92.2%, and 46.7% for TcMEPs, combination (either TcMEPs or SSEPs), and SSEPs, respectively. Multiple sensitivity analysis demonstrated that sensitivity and specificity vary markedly with different assumptions. CONCLUSION: TcMEPs are more sensitive than SSEP at detecting an impending NND. IONM modalities are highly specific. Both sensitivity and specificity are impacted substantially by assumptions of the impact of interventions on alerts and NND. Properly designed, controlled, multicenter studies are required to establish diagnostic accuracy of IONM in scoliosis surgery.

Traumatic spinal injuries in children at a single level 1 pediatric trauma centre: report of a 23-year experience.

BACKGROUND: With a reported incidence of up to 10% compared to all spinal trauma, spinal injuries in children are less common than in adults. Children can have spine fractures with or without myelopathy, or spinal cord injuries without radiological abnormalities (SCIWORA). METHODS: We retrospectively reviewed the cases of children with spinal injuries treated at a level 1 pediatric trauma centre between 1990 and 2013. RESULTS: A total of 275 children were treated during the study period. The mean age at admission was 12 ± 4.5 years, and the male:female ratio was 1.4:1. Spinal injuries were more common in children of ages 12-16 years, with most injuries among ages 15-16 years. The top 3 mechanisms of spinal injury were motor vehicle-related trauma (53%), sports (28%) and falls (13%). Myelopathy occurred in 12% and SCIWORA occurred in 6%. The most common spine levels injured were L2-sacrum, followed by O-C2. Associated injuries, including head injuries (29%), and fractures/dislocations (27%) occurred in 55% of children. Overall mortality was 3%. Surgical intervention was required in 14%. CONCLUSION: The creation of a pediatric spinal injury database using this 23-year retrospective review helped identify important clinical concepts; we found that active adolescent boys had the highest risk of spine injury, that noncontiguous spine injuries occured at a rate higher than reported previously and that nonaccidental spine injuries in children are underreported. Our findings also emphasize the importance of maintaining a higher index of suspicion with trauma patients with multiple injuries and of conducting detailed clinical and radiographic examinations of the entire spine in children with a known spinal injury.

CONTEXTE: Les traumatismes médullaires sont moins fréquents chez l'enfant que chez l'adulte, avec une incidence d'au plus 10 % de tous les cas déclarés. Les enfants peuvent subir des fractures de la colonne vertébrale avec ou sans myélopathie, ou un traumatisme médullaire sans anomalie radiologique visible (SCIWORA). MÉTHODES: Nous avons effectué une analyse rétrospective des cas d'enfants atteints d'un traumatisme médullaire admis dans un centre de traumatologie spécialisé en pédiatrie de niveau 1 entre 1990 et 2013. RÉSULTATS: Au total, 275 enfants ont été traités durant la période de l'étude. L'âge moyen au moment de l'hospitalisation était de 12 ± 4,5 ans, et le ratio garçons:filles était de 1,4:1. Les adolescents de 12 à 16 ans formaient le groupe le plus représenté, et l'incidence de traumatisme la plus élevée a été observée chez les jeunes de 15 et 16 ans. Les 3 mécanismes lésionnels les plus fréquents étaient les accidents de la route (53 %), la pratique d'un sport (28 %) et les chutes (13 %). Le taux d'incidence de la myélopathie était de 12 %, et celui du SCIWORA, de 6 %. La section du rachis touchée le plus fréquemment s'étendait de L2 au sacrum, les vertèbres entre l'occiput et C2 arrivant au deuxième rang. Des lésions concomitantes, dont des blessures à la tête (29 %) et des fractures et luxations (27 %), ont été observées chez 55 % des enfants. Le taux global de mortalité était de 3 %. L'intervention chirurgicale a été nécessaire chez 14%. CONCLUSION: La création à partir de cette étude rétrospective d'une base de données sur les traumatismes médullaires chez l'enfant a mis en évidence quelques constatations cliniques dignes d'intérêt : les garçons adolescents actifs présentent le risque le plus élevé de traumatisme médullaire; les lésions médullaires non contiguës surviennent plus fréquemment que ce qui avait été rapporté précédemment; les traumatismes médullaires non accidentels chez l'enfant sont sous-déclarés. Nos conclusions viennent aussi souligner l'importance de maintenir un indice de suspicion élevé dans le cas de patients atteints de lésions multiples et d'effectuer un examen clinique et radiographique détaillé de la totalité de la colonne vertébrale des enfants ayant une lésion médullaire connue.

Development of a Competence-Based Spine Surgery Fellowship Curriculum Set of Learning Objectives in Canada.

STUDY DESIGN: Modified-Delphi expert consensus method. OBJECTIVE: The aim of this study was to develop competence-based spine fellowship curricula as a set of learning goals through expert consensus methodology in order to provide an educational tool for surgical educators and trainees. Secondarily, we aimed to determine potential differences among specialties in their rating of learning objectives to defined curriculum documents. SUMMARY OF BACKGROUND DATA: There has been recent interest in competence-based education in the training of future surgeons. Current spine fellowships often work on a preceptor-based model, and recent studies have demonstrated that graduating spine fellows may not necessarily be exposed to key cognitive and procedural competencies throughout their training that are expected of a practicing spine surgeon. METHODS: A consensus group of 32 spine surgeons from across Canada was assembled. A modified-Delphi approach refined an initial fellowship-level curriculum set of learning objectives (108 cognitive and 84 procedural competencies obtained from open sources). A consensus threshold of 70% was chosen with up to 5 rounds of blinded voting performed. Members were asked to ratify objectives into either a general comprehensive or focused/advanced curriculum. RESULTS: Twenty-eight of 32 consultants (88%) responded and participated in voting rounds. Seventy-eight (72%) cognitive and 63 (75%) procedural competency objectives reached 70% consensus in the first round. This increased to 82 cognitive and 73 procedural objectives by round 4. The final curriculum document evolved to include a general comprehensive curriculum (91 cognitive and 53 procedural objectives), a focused/advanced curriculum (22 procedural objectives), and a pediatrics curriculum (22 cognitive and 9 procedural objectives). CONCLUSION: Through a consensus-building approach, the study authors have developed a competence-based curriculum set of learning objectives anticipated to be of educational value to spine surgery fellowship educators and trainees. To our knowledge, this is one of the first nationally based efforts of its kind that is also anticipated to be of interest by international colleagues.

The 'trampoline ankle': severe medial malleolar physeal injuries in children and adolescents secondary to multioccupant use of trampolines.

The purpose of this study was to describe a series of patients presenting with medial malleolus Salter-Harris types III and IV fractures (MacFarland fractures) related to trampoline use. In total, 11 patients were reviewed retrospectively (mean age: 11.8 years; four boys and seven girls). Salter-Harris type III fractures were more commonly seen (n=7). Undisplaced fractures were more prevalent (n=6). Six children underwent surgical treatment. Average follow-up time was 17.8 months. A medial physeal bar with subsequent growth arrest and ankle deformity was observed in two patients. More than one user was present on the trampoline at the time of the injury in nine of the reported cases. Medial malleolus growth-plate injuries can be seen after trampoline injuries where multiple users were involved. Potential complications including growth arrest can occur.

The World Health Organization's action plan on the road traffic injury pandemic: is there any action for orthopaedic trauma surgeons?

Road traffic crash-related death, injury, and chronic disability continue to be a major worldwide burden to drivers, pedestrians, and users of mass transit, especially in low- and middle-income countries (LMIC). Projections predict worsening of this burden, and while motorization of LMIC increases exponentially, a corresponding improvement in prehospital and acute in-hospital trauma care has not been seen. The WHO now has 2 programs that address different elements of this challenge, namely, the Violence and Injury Prevention department (prevention) and the Emergency and Essential Surgical Care project (treatment). Activities of Violence and Injury Prevention have included developing guidelines for prehospital and essential trauma care, whereas activities of the Emergency and Essential Surgical Care have included developing the Integrated Management of Emergency and Essential Surgical Care toolkit and a textbook, "Surgical Care at the District Hospital." Organized surgical institutions in high-income countries-trauma associations, university departments, surgical nongovernmental organizations, etc.-can benefit from the infrastructure and tools the WHO has developed to better address the deficits in surgical services to improve the equitable distribution of surgical care services and resources to LMIC.

The Otto Aufranc Award. On the etiology of the cam deformity: a cross-sectional pediatric MRI study.

BACKGROUND: Femoroacetabular impingement (FAI) has been recognized as a common cause of hip pain as well as a cause of hip arthritis, yet despite this, little is known about the etiology of the cam morphology or possible risk factors associated with its development. QUESTIONS/PURPOSES: The purposes of our study were to determine when the cam morphology associated with FAI developed in a cross-sectional cohort study of pediatric patients pre- and postphyseal closure using MRI and whether increased activity level during the period of physeal closure is associated with an increased likelihood that the cam deformity will develop. METHODS: Alpha angles were measured at the 3 o'clock (anterior head-neck junction) and 1:30 (anterosuperior head-neck junction) positions in both hips with a cam deformity defined as an alpha angle ≥ 50.5° at the 3 o'clock position. Forty-four volunteers (88 hips) were studied: 23 with open physes (12 females, mean age 9.7 years; 11 males, age 11.7 years) and 21 with closed physes (five females, age 15.2 years; 16 males, age 16.2 years). Daily activity level using the validated Habitual Activity Estimation Scale was compared for patients in whom cam morphology did and did not develop. RESULTS: None of the 23 (0%) patients prephyseal closure had cam morphology, whereas three of 21 (14%, p = 0.02; all males) postclosure had at least one hip with cam morphology. Daily activity level was higher (p = 0.02) for patients with the cam morphology (7.1 hours versus 2.9 hours). Mean alpha angles at the 3 o'clock head-neck position were 38° (95% confidence interval [CI], 37.2°-39.1°) in the open physes group and 42° (95% CI, 40.16°-43.90°) in the closed physes group; at the 1:30 head-neck position, they were 45° (95% CI, 44.0°-46.4°) in the open physes group and 50° (47.9°-52.3°) in the closed physes group. CONCLUSIONS: The fact that cam morphology was present exclusively in the closed physeal group strongly supports its development during the period of physeal closure with increased activity level as a possible risk factor.

Pediatric noncontiguous spinal injuries: the 15-year experience at a level 1 trauma center.

STUDY DESIGN: Retrospective review. OBJECTIVE: To determine the incidence and clinical characteristics of noncontiguous spinal injuries (NCSI) in a pediatric population. The secondary objective is to identify high-risk patients requiring further imaging to rule out NCSI. SUMMARY OF BACKGROUND DATA: NCSI can add significant complexity to the diagnosis, management, and outcome of children. There is very little in the pediatric literature examining the nature, associated risk factors, management, and outcomes of NCSI. METHODS: All children up to 18 years of age with a spinal injury, as defined by International Classification of Diseases, Ninth Revision codes, at one pediatric trauma hospital were included (n = 211). Data for patient demographics, mechanism of injury, spinal levels involved, extent of neurological injury and recovery, associated injuries, medical complications, treatment, and outcome were recorded. RESULTS: Twenty-five (11.8%) of 211 patients had NCSI, with a median age of 13.0 years (interquartile range = 8-15). The most common pattern of injury was a double thoracic noncontiguous injury. Sixteen percent of the cases of NCSI were initially missed, with no clinical deterioration due to missed diagnosis. Associated injuries occurred in 44% of patients with NCSI. Twenty-four percent of patients with multiple NCSI had a neurological injury compared with 9.7% in patients with single-level or contiguous injuries (P = 0.046). CONCLUSION: There is a high incidence of children with multiple NCSI who are more likely to experience neurological injuries compared with patients with single-level or contiguous spinal injuries. Patients with a single-level spinal injury on existing imaging with an associated neurological injury should undergo at least plain films of the entire spine to exclude noncontiguous injuries. In patients without neurological injury and a single spinal fracture, radiography showing at least 4 levels above and below the fracture should be performed. All children with spinal injury should have associated injuries carefully excluded.