Development of Consensus-Based Best Practice Guidelines for the Peri- and Post-operative Care of Pediatric Patients with Spinal Deformity and Programmable Implanted Devices.

STUDY DESIGN: Modified Delphi consensus study. OBJECTIVE: To develop consensus-based best practices for the care of pediatric patients who have implanted programmable devices (IPDs) and require spinal deformity surgery. SUMMARY OF BACKGROUND DATA: Implanted programmable devices (IPDs) are often present in patients with neuromuscular or syndromic scoliosis who require spine surgery. Guidelines for monitoring and interrogating these devices during the peri-operative period are not available. METHODS: A panel was assembled consisting of 25 experts (i.e., spinal deformity surgeons, neurosurgeons, neuro-electrophysiologists, cardiologists, and otolaryngologists). Initial postulates were based on literature review and results from a prior survey. Postulates addressed the following IPDs: vagal nerve stimulators (VNS), programmable ventriculo-peritoneal shunts (VPS), intrathecal baclofen pumps (ITBP), cardiac pacemakers and implantable cardioverter-defibrillators (ICD), deep brain stimulators (DBS), and cochlear implants. Cardiologist and otolaryngologists participants responded only to postulates on cardiac pacemakers or cochlear implants, respectively. Consensus was defined as ≥80% agreement, items that did not reach consensus were revised and included in subsequent rounds. A total of three survey rounds and one virtual meeting were conducted. RESULTS: Consensus was reached on 39 total postulates across six IPD types. Postulates addressed general spine surgery considerations, use of intraoperative monitoring and cautery, use of magnetically-controlled growing rods (MCGRs), and use of an external remote controller to lengthen MCGRs. Across IPD types, consensus for the final postulates ranged from 94.4-100%. Overall, experts agreed that MCGRs can be surgically inserted and lengthened in patients with a variety of IPDs and provided guidance for the use of intraoperative monitoring and cautery, which varied between IPD types. CONCLUSION: Spinal deformity correction surgery often benefits from the use of intraoperative monitoring, monopolar and bipolar cautery, and MCGRs. Final postulates from this study can inform the peri- and post-operative practices of spinal deformity surgeons who treat patients with both scoliosis and IPDs. LEVEL OF EVIDENCE: V- Expert opinion.

How will early onset scoliosis surgery affect my child's future as a young adult? A follow-up study using patient-reported outcome measures.

PURPOSE: Using patient-reported outcome measures (PROMs), this study was undertaken to determine how well patients with early onset scoliosis (EOS) fare in adulthood. METHODS: Among eight healthcare centers, 272 patients (≥ 18 years) surgically managed for EOS (≥ 5 years) completed the Scoliosis Research Society (SRS)-22r, Functional Assessment of Chronic Illness Therapy-10 (FACIT-Dyspnea-10), and Short Form (SF)-12. Functional and demographic data were collected. RESULTS: The response rate was 40% (108/272). EOS etiologies were congenital (45%), neuromuscular (20%), idiopathic (20%) syndromic (11%), and unknown (4%). All patients scored within normal limits on the FACIT-Dyspnea-10 pulmonary (no breathing aids, 78%; no oxygen, 92%). SF-12 physical health scores and most SRS-22r domains were significantly decreased (p < 0.05 and p < 0.001, respectively) compared with normative values. SF-12 and SRS-22r mental health scores (MHS) were lower than normative values (p < 0.05 and p < 0.02, respectively). Physical health PROMs varied between etiologies. Treatment varied by etiology. Patients with congenital EOS were half as likely to undergo definitive fusion. There was no difference between EOS etiologies in SF-12 MHS, with t scores being slightly lower than normative peers. CONCLUSION: Good long-term physical and social function and patient-reported quality of life were noted in surgically managed patients. Patients with idiopathic EOS physically outperformed those with other etiologies in objective and PROM categories but had similar MHS PROMs. Compared to normative values, EOS patients demonstrated decreased long-term physical capacity, slightly lower MHS, and preserved cardiopulmonary function. LEVEL OF EVIDENCE: Level IV Case Series.

A multicenter evaluation of the time and travel burden on families with children treated for early-onset scoliosis.

PURPOSE: Patients who undergo growth-friendly (GF) treatment for early-onset scoliosis (EOS) undergo multiple clinical and surgical encounters. We sought to quantify the associated temporal and travel burden and estimate subsequent cost. METHODS: Four centers in an international study group combined data on EOS patients who underwent surgical GF treatment from 2006 to 2021. Data collected included demographics, scoliosis etiology, GF implant, encounter type, and driving distance. We applied 2022 IRS and BLS data or $0.625/mile and $208.2/day off work to calculate a relative financial burden. RESULTS: A total of 300 patients were analyzed (55% female). Etiologies were: congenital (33.3%), idiopathic (18.7%), neuromuscular (30.7%), and syndromic (17.3%). The average age at the index procedure was 5.5 years. For the 300 patients, 5899 encounters were recorded (average 18 encounters/patient). Aggregate encounter types were 2521 clinical office encounters (43%), 2045 surgical lengthening encounters (35%), 1157 magnetic lengthening encounters (20%), 149 spinal fusions (3%), and 27 spinal fusion revisions (0.5%). When comparing patients by scoliosis etiology or by GF implant type, no significant differences were noted in the total number of encounters or average travel distance. Patients traveled a median round trip distance of 158 miles/encounter between their homes and treating institutions (range 2.4-5654 miles), with a cumulative median distance of 2651 miles for the entirety of their treatment (range 29-90,552 miles), at an estimated median cost of $1656.63. The mean number of days off work was 18 (range 3-75), with an associated loss of $3643.50 in income. CONCLUSION: Patients with EOS averaged 18 encounters for GF surgical treatment. These patients and their families traveled a median distance of 158 miles/encounter, with an estimated combined mileage and loss of income of $5300.

Radiation exposure in multiple hereditary exostoses: A retrospective review.

Background: Exposure to ionizing radiation in patients with Multiple Hereditary Exostoses (MHE) is inevitable and necessary for the diagnosis and treatment of MHE. Radiation exposure has many potentially dangerous consequences, including the increased risk of developing cancer. This is especially concerning in the pediatric patient population since children are more likely to develop adverse effects from radiation than adults. This study aimed to quantify radiation exposure over a five-year period among patients diagnosed with MHE since such information is not currently available in the literature. Methods: Diagnostic radiographs, computed tomography (CT) scans, nuclear medicine studies, and intraoperative fluoroscopy exposures were analyzed for radiation exposure in 37 patients diagnosed with MHE between 2015 and 2020. Results: Thirty-seven patients with MHE underwent 1200 imaging studies, 976 of which were related to MHE and 224 unrelated to MHE. The mean estimated MHE cumulative radiation dose per patient was 5.23 mSv. Radiographs related to MHE contributed the most radiation. Patients from the ages of 10- to 24-years-old received the most imaging studies and exposure to ionizing radiation, especially compared to those under age 10 (P = 0.016). The 37 patients also received a total of 53 surgical-excision procedures, with a mean of 1.4 procedures per person. Conclusions: MHE patients are exposed to increased levels of ionizing radiation secondary to serial diagnostic imaging, with those ages 10-24 years old being exposed to significantly higher doses of radiation. Because pediatric patients are more sensitive to radiation exposure and are at an overall higher risk, the use of radiographs should always be justified in those patients.

Perioperative multimodal analgesic injection for patients with adolescent idiopathic scoliosis undergoing posterior spinal fusion surgery.

PURPOSE: This retrospective cohort study compared postoperative as-needed (PRN) opioid consumption pre and postimplementation of a perioperative multimodal analgesic injection composed of ropivacaine, epinephrine, ketorolac, and morphine in patients undergoing posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). Secondary outcomes include pain score measurements, time to ambulation, length of stay, blood loss, 90-day complication rate, operating room time, nonopioid medication usage, and total inpatient medication cost before and after the initiation of this practice. METHODS: Consecutive patients weighing ≥ 20 kg who underwent PSF for a primary diagnosis of AIS between January 2017 and December 2020 were included. Data from 2018 were excluded to account for standardization of the practice. Patients treated in 2017 only received PCA. Patients treated in 2019 and 2020 only received the injection. Excluded were patients who had any diagnoses other than AIS, allergies to any of the experimental medications, or who were nonambulatory. Data were analyzed utilizing the two-sample t-test or Chi-squared test as appropriate. RESULTS: Results of this study show that compared with 47 patients treated postoperatively with patient-controlled analgesia (PCA), 55 patients treated with a multimodal perioperative injection have significantly less consumption of PRN morphine equivalents (0.3 mEq/kg vs. 0.5 mEq/kg; p = 0.02). Furthermore, patients treated with a perioperative injection have significantly higher rates of ambulation on postoperative day 1 compared with those treated with PCA (70.9 vs. 40.4%; p = 0.0023). CONCLUSION: Administration of a perioperative injection is effective and should be considered in the perioperative protocol in patients undergoing PSF for AIS. LEVEL OF EVIDENCE: Therapeutic Level III.

Definition of Tweener: Consensus Among Experts in Treating Early-onset Scoliosis.

BACKGROUND: The term "Tweener" is colloquially used to refer to early-onset scoliosis (EOS) patients whose age and development make them candidates for multiple surgical options. The purpose of this study was to establish expert consensus on a definition to formally characterize the Tweener population. METHODS: A 3-round survey of surgeons in an international EOS study group was conducted. Surgeons were provided with various patient characteristics and asked if each was part of their definition for Tweener patients. Responses were analyzed for consensus (≥70%), near-consensus (60% to 69%), and no consensus (<60%). RESULTS: Consensus was reached (89% of respondents) for including chronological age in the Tweener definition; 8 to 10 years for females and 9 to 11 years for males. Surgeons agreed for inclusion of Sanders score, particularly Sanders 2 (86.0%). Patients who have reached Sanders 4, postmenarche, or have closed triradiate cartilage should not be considered Tweeners. Bone age range of 8 years and 10 months to 10 years and 10 months for females (12 y for males) could be part of the Tweener definition. CONCLUSIONS: This study suggests that the Tweener definition could be the following: patients with open triradiate cartilage who are not postmenarche and have not reached Sanders 4, and if they have one of the following: Sanders 2 or chronological age 8 to 10 years for females (9 to 11 y for males) or bone age 8 years and 10 months to 10 years and 10 months for females (12 y for males). This definition will allow for more focused and comparative research on this population. LEVEL OF EVIDENCE: Level V-expert opinion.

Interobserver and Intraobserver Agreement are Unsatisfactory When Determining Abstract Study Design and Level of Evidence.

BACKGROUND: Understanding differences between types of study design (SD) and level of evidence (LOE) are important when selecting research for presentation or publication and determining its potential clinical impact. The purpose of this study was to evaluate interobserver and intraobserver reliability when assigning LOE and SD as well as quantify the impact of a commonly used reference aid on these assessments. METHODS: Thirty-six accepted abstracts from the Pediatric Orthopaedic Society of North America (POSNA) 2021 annual meeting were selected for this study. Thirteen reviewers from the POSNA Evidence-Based Practice Committee were asked to determine LOE and SD for each abstract, first without any assistance or resources. Four weeks later, abstracts were reviewed again with the guidance of the Journal of Bone and Joint Surgery (JBJS) LOE chart, which is adapted from the Oxford Centre for Evidence-Based Medicine. Interobserver and intraobserver reliability were calculated using Fleiss' kappa statistic (k). χ2 analysis was used to compare the rate of SD-LOE mismatch between the first and second round of reviews. RESULTS: Interobserver reliability for LOE improved slightly from fair (k=0.28) to moderate (k=0.43) with use of the JBJS chart. There was better agreement with increasing LOE, with the most frequent disagreement between levels 3 and 4. Interobserver reliability for SD was fair for both rounds 1 (k=0.29) and 2 (k=0.37). Similar to LOE, there was better agreement with stronger SD. Intraobserver reliability was widely variable for both LOE and SD (k=0.10 to 0.92 for both). When matching a selected SD to its associated LOE, the overall rate of correct concordance was 82% in round 1 and 92% in round 2 (P<0.001). CONCLUSION: Interobserver reliability for LOE and SD was fair to moderate at best, even among experienced reviewers. Use of the JBJS/Oxford chart mildly improved agreement on LOE and resulted in less SD-LOE mismatch, but did not affect agreement on SD. LEVEL OF EVIDENCE: Level II.

Factors that Influence Acquisition of Lower Extremity Braces in the Pediatric Orthopaedic Population.

BACKGROUND: Lower extremity brace-wear compliance has been studied in pediatrics, but failure to acquire a prescribed brace has not been included. The purpose of this study was to evaluate brace acquisition as a component of brace-wear compliance. METHODS: Records of patients (0 to 21 y) prescribed lower extremity braces from 2017 to 2019 were reviewed. Diagnoses included cerebral palsy, spina bifida, short Achilles tendon, clubfoot, and other. Brace type was categorized as clubfoot foot abduction orthosis, ankle-foot orthosis, knee, hip, or custom/other braces. Brace prescription and acquisition dates were recorded. Insurance was classified as government, private, or uninsured. Patient demographics included age, sex, race, and calculated area deprivation index. RESULTS: Of the 1176 prescribed lower extremity braces, 1094 (93%) were acquired while 82 (7%) were not. The odds ratios (OR) of failure to acquire a prescribed brace in Black and Hispanic patients were 1.64 and 2.71 times that in White patients, respectively (95% confidence interval: 1.01-2.71, P=0.045; 1.23-5.6, P=0.015); in patients without insurance, the OR was 8.48 times that in privately insured patients (95% confidence interval: 1.93-31.1, P=0.007). The ORs of failure to acquire were 2.12 (P=0.003) in patients 4 years or more versus 0 to 3 years, 4.17 (P<0.0001) in cerebral palsy versus clubfoot, and 4.12 (P=0.01) in short Achilles tendon versus clubfoot. There was no significant association between sex or area deprivation index and failure of brace acquisition. CONCLUSIONS: In our cohort, 7% of prescribed braces were not acquired. Black or Hispanic race, lack of insurance, and older age were associated with failure to acquire prescribed braces. Braces prescribed for clubfoot were acquired more often than for cerebral palsy or short Achilles tendon. Brace-wear compliance is an established factor in treatment success and recurrence. This study identified risk factors for failed brace acquisition, a critical step for improving compliance. These results may help effect changes in the current system that may lead to more compliance with brace wear. LEVEL OF EVIDENCE: Level III-retrospective cohort study.

Patient similarity network of newly diagnosed multiple myeloma identifies patient subgroups with distinct genetic features and clinical implications.

The remarkable genetic heterogeneity of multiple myeloma poses a substantial challenge for proper prognostication and clinical management of patients. Here, we introduce MM-PSN, the first multiomics patient similarity network of myeloma. MM-PSN enabled accurate dissection of the genetic and molecular landscape of the disease and determined 12 distinct subgroups defined by five data types generated from genomic and transcriptomic profiling of 655 patients. MM-PSN identified patient subgroups not previously described defined by specific patterns of alterations, enriched for specific gene vulnerabilities, and associated with potential therapeutic options. Our analysis revealed that co-occurrence of t(4;14) and 1q gain identified patients at significantly higher risk of relapse and shorter survival as compared to t(4;14) as a single lesion. Furthermore, our results show that 1q gain is the most important single lesion conferring high risk of relapse and that it can improve on the current International Staging Systems (ISS and R-ISS).

Radiation Reduction Strategies in Pediatric Orthopaedics.

INTRODUCTION: Pediatric orthopaedic patients have the potential for significant radiation exposure from the use of imaging studies, such as computed tomography and bone scintigraphy. With the potential for long-term treatment, such as is required for scoliosis or osteogenesis imperfecta, patients are at even greater risk of radiation-induced carcinogenesis. DISCUSSION: Although an association between radiation and cancer risk is evident, causation is difficult to prove because comorbidities or genetic predispositions may play a role in the higher baseline rates of malignancy later in life. Efforts have been made over the years to reduce exposure using more modern imaging techniques and simple radiation reduction strategies. Educational efforts and clinical practice guidelines are decreasing the rate of computed tomography scan use in pediatrics. Although considerable work is being done on the development of radiation-free imaging modalities, imaging that uses ionizing radiation will, in the near term, be necessary in specific circumstances to provide optimal care to pediatric orthopaedic patients. CONCLUSION: Knowledge of the ionizing radiation exposure associated with commonly used tests as well as radiation-reduction strategies is essential for the optimal and safe care of pediatric orthopaedic patients.

Intraobserver and Interobserver Reliability of the Peritubercle Lucency Sign in Slipped Capital Femoral Epiphysis.

BACKGROUND: An area of enlargement of the metaphyseal socket around the epiphyseal tubercle, termed the peritubercle lucency sign, has recently been introduced as a possible predictor of contralateral slipped capital femoral epiphysis in patients with previous unilateral slipped capital femoral epiphysis. This study aimed to assess intraobserver and interobserver reliability for detecting the presence or absence of the peritubercle lucency sign. METHODS: Thirty-five radiographs were presented to 6 fellowship-trained pediatric orthopaedic surgeons on 2 separate occasions 30 days apart, ensuring that the images were shown in a different order on the second exposure. Both times the reviewers recorded whether the peritubercle lucency sign was present or absent in each of the radiographs. Statistical analysis was performed to determine the intraobserver and interobserver reliability. RESULTS: In the intraobserver analysis, percent agreement between the first and second time the radiographs were reviewed varied between 62.9% and 85.7%, for an average intraobserver agreement of 74.8%. κ values for the 6 reviewers varied between 0.34 and 0.716, with an average intraobserver κ value of 0.508. The interobserver percent agreement was 40.0% for the first time the radiographs were reviewed, 42.9% the second time, and the overall interobserver percent agreement was 29%. The interobserver κ value was 0.44 the first time the radiographs were reviewed, 0.45 the second time, and the overall interobserver κ value was 0.45. DISCUSSION: On the basis of our findings, the peritubercle lucency has modest intraobserver and interobserver reliability at best and should be used with other currently used factors, such as age, presence of endocrinopathy, status of triradiate cartilage, posterior sloping angle, and modified Oxford score, in determining the need for prophylactic pinning. Further refinement of the definition of the peritubercle lucency sign may be needed to improve agreement and reliability of the sign. LEVEL OF EVIDENCE: Level III-prognostic study.

Hunger Games: Impact of Fasting Guidelines for Orthopedic Procedural Sedation in the Pediatric Emergency Department.

BACKGROUND: Fasting guidelines for pediatric procedural sedation have historically been controversial. Recent literature suggests that there is no difference in adverse events regardless of fasting status. OBJECTIVES: The goal of this study was to examine adverse outcomes and departmental efficiency when fasting guidelines are not considered during pediatric emergency department (PED) sedation for orthopedic interventions. METHODS: Retrospective chart review identified 2674 patients who presented to a level I PED and required procedural sedation for orthopedic injuries between February 2011 and July 2018. This was a level III, retrospective cohort study. Patients were categorized into the following groups: already within American Society of Anesthesiologists (ASA) fasting guidelines on presentation to the PED (n = 671 [25%]), had procedural sedation not within the ASA guidelines (n = 555 [21%]), and had procedural sedation after fasting in the PED to meet ASA guidelines (n = 1448 [54%]). Primary outcomes were length of stay, time from admission to start of sedation, length of sedation, time from end of sedation to discharge, and adverse events. DISCUSSION: There was a significant difference in the length of stay and time from admission to sedation-both approximately 80 min longer in those with procedural sedation after fasting in the PED to meet ASA guidelines (p < 0.001). There was no significant difference among groups in length of sedation or time to discharge after sedation. Adverse events were uncommon, with only 55 total adverse events (0.02%). Vomiting during the recovery phase was the most common (n = 17 [0.006%]). Other notable adverse events included nine hypoxic events (0.003%) and five seizures (0.002%). There was no significant difference in adverse events among the groups. CONCLUSIONS: Length of stay in the PED was significantly longer if ASA fasting guidelines were followed for children requiring sedation for orthopedic procedures. This is a substantial delay in a busy PED where beds and resources are at a premium. Although providing similar care with equivalent outcomes, the value of spending less time in the PED is evident. Overall, adverse events related to sedation are rare and not related to fasting guidelines.

Can Pediatric Orthopaedic Surgery be Done Safely in a Freestanding Ambulatory Surgery Center? Review of 3780 Cases.

BACKGROUND: The purpose of this study was to determine the intraoperative and 30-day postoperative complication rates in a large consecutive cohort of pediatric patients who had orthopaedic surgery at a freestanding ambulatory surgery center (ASC). The authors also wanted to identify the rates of same-day, urgent hospital transfers, and 30-day hospital admissions. The authors hypothesized that pediatric orthopaedic procedures at a freestanding ASC can be done safely with a low rate of complications. METHODS: A retrospective review identified patients aged 17 years or younger who had surgery at a freestanding ASC over a 9-year period. Adverse outcomes were divided into intraoperative complications, postoperative complications, need for the secondary procedure, unexpected hospital admission on the same day of the procedure, and unexpected hospital admission within 30 days of the index procedure. Complications were graded as grade 1, the complication could be treated without additional surgery or hospitalization; grade 2, the complication resulted in an unplanned return to the operating room (OR) or hospital admission; or grade 3, the complication resulted in an unplanned return to the OR or hospitalization with a change in the overall treatment plan. RESULTS: Adequate follow-up was available for 3780 (86.1%) surgical procedures. Overall, there were 9 (0.24%) intraoperative complications, 2 (0.08%) urgent hospital transfers, 114 (3%) complications, and 16 (0.42%) readmissions. Seven of the 9 intraoperative complications resolved before leaving the OR, and 2 required return to the OR.Neither complications nor hospitalizations correlated with age, race, gender, or length or type of surgery. There was no correlation between the presence of medical comorbidities, body mass index, or American Society of Anesthesiologists score and complication or hospitalization. CONCLUSIONS: Pediatric orthopaedic surgical procedures can be performed safely in an ASC because of multiple factors that include dedicated surgical teams, single-purpose ORs, and strict preoperative screening criteria. The rates of an emergency hospital transfer, surgical complications, and 30-day readmission, even by stringent criteria, are lower than those reported for outpatient procedures performed in the hospital setting. LEVEL OF EVIDENCE: Level IV-case series.

The Frequency of Mediastinal Injury in Acute Posterior Sternoclavicular Dislocations: A Multicenter Study.

BACKGROUND: Acute posterior sternoclavicular dislocations (APSCD) are rare injuries that historically have prompted concern for injury to the great vessels and other mediastinal structures from initial trauma or subsequent treatment, resulting in the recommendation that a thoracic or vascular surgeon be present or available during operative treatment. The objectives of the study were to characterize the demographic, clinical, and radiographic characteristics of a large series of APSCDs in skeletally immature patients and to describe the rate and nature of any vascular or mediastinal complications that occurred during treatment. METHODS: Following Institutional Review Board approval, records of consecutive patients under 25 years of age treated for APSCD were collected from each of 6 participating centers. Only acute injuries (sustained fewer than 10 days before presentation) were included. Patient demographics, injury mechanism, associated mediastinal injuries, and need for thoracic/vascular surgery were recorded. Mediastinal structures injured or compressed by mass effect were specifically characterized by review of preoperative computed tomography imaging. RESULTS: Review identified 125 patients with a mean age of 14.7 years; 88% were male. APSCD most commonly resulted from a sporting injury (74%) followed by falls from standing height (10%) and high-energy motor vehicle trauma (10%). The most common finding on cross-sectional imaging was compression without laceration of the ipsilateral brachiocephalic vein (50%). Eleven patients had successful closed reduction, and 114 (90%) had open reduction and internal fixation, with 25 failed or unstable closed reductions preceding open treatment. There were no vascular or mediastinal injuries during reduction or fixation that required intervention. CONCLUSIONS: In this multicenter series of 125 APSCDs no injuries to the great vessels/mediastinal structures requiring intervention were identified. Although more than half of patients had evidence of extrinsic vascular compression at the time of injury, careful open reduction of acute injuries can be safely performed. Although vascular injuries following APSCD seem to be quite rare, vascular complications can be catastrophic. Treating providers should consider these data and their own institutional resources to maximize patient safety during the treatment of APSCD. LEVEL OF EVIDENCE: Level III-therapeutic case control study.

Minimum 5-Year Follow-up on Graduates of Growing Spine Surgery for Early Onset Scoliosis.

INTRODUCTION: After discontinuation of growth friendly (GF) surgery for early onset scoliosis, patients undergo spinal fusion or continued observation. This last planned treatment is colloquially called "definitive" treatment, conferring these patients as "graduates" of a growing program. The 5-year radiographic and clinical outcomes of this cohort are unknown. METHODS: An international pediatric spine database was queried for patients from a GF program (spine or rib-based) with minimum 5-year follow-up from last planned surgery (GF or spinal fusion). Radiographs and charts were reviewed for main coronal curve angle and maximum kyphosis as well as occurrence of secondary surgery. RESULTS: Of 580 graduates, 170 (29%) had minimum 5-year follow-up (37% male). Scoliosis etiology was congenital in 41 (24%), idiopathic 36 (21%), neuromuscular 51 (30%), and syndromic 42 (25%). Index surgery consisted of spine-based growing rods in 122 (71%) and rib-based distraction in 48 (29%). Mean age at index surgery was 6.8 years, and patients underwent an average of 5.4 lengthenings over an average of 4.9 years (range, 6 mo to 11 y). Last planned treatment was at an average age of 11.8 years (range, 7 to 17 years). Last planned treatment consisted of spinal fusion in 114 patients, 47 had growing implants maintained, 9 had implants removed. Average follow-up was 7.3 years (range, 5 to 13 y).When compared from postdefinitive treatment to 2-year follow-up, there was noted progression of the coronal curve angle (46±19 to 51±21 degrees, P=0.046) and kyphosis (48±20 to 57±25 degrees, P=0.03). However, between 2 and 5 years, no further progression occurred in the coronal (51±21 to 53±21 degrees, P=0.26) or sagittal (57±25 to 54±28 degrees, P=0.93) planes. When stratified based on etiology, there was no significant coronal curve progression between 2- and 5-year follow-up. When comparing spinal fusion patients to those who had maintenance of their growing construct, there was also no significant curve progression.Thirty-seven (21%) underwent at least 1 (average, 1.7; range, 1 to 7) revision surgery following graduation, and 15 of 37 (41%) underwent 2 or more revision surgeries. Reason for revision was implant revision (either GF or spinal fusion) in 34 patients, and implant removal in 3. On an average, the first revision was 2.5 years after the definitive treatment plan (range, 0.02 to 7.4 y). In total, 15 of 37 (41%) revisions occurred over 2 years following the final decision for treatment plan, and 7 of 37 (19%) occurred 5 or more years after the definitive treatment.Patients who underwent spinal fusion as a definitive treatment strategy were more likely to undergo revision surgery (27%) than patients who had their GF implants maintained (11%) (P=0.04). CONCLUSIONS: Five years following "graduation" from growing surgery for early onset scoliosis, there is progression of curve magnitude in both the coronal and sagittal planes up to 2 years, with no further progression at 5 years. A total of 21% of patients undergo at least 1 revision surgery, and average time to revision surgery is over 2 years from last planned surgery. Risk of revision surgery was higher in patients who underwent a spinal fusion as their definitive treatment strategy. LEVEL EVIDENCE: Level III-retrospective comparative. TYPE OF EVIDENCE: Therapeutic.

Evaluation of Outcomes Before and After Implementation of a Standardized Postoperative Care Pathway in Pediatric Posterior Spinal Fusion Patients.

BACKGROUND: Standardized pathways decrease variability and improve outcomes and safety. PURPOSE: The article aims to evaluate outcomes of a standardized postoperative care pathway compared with individual surgeon preference. METHODS: A review of patients prestandardization and poststandardization was performed. Patients between the ages of 10-21 years with adolescent idiopathic scoliosis (ICD-9 code 737.30) admitted to the hospital for posterior spinal fusion (CPT code 22630) were included in the study. The prestandardization group (25 patients) was enrolled from April 1, 2010, through March 30, 2011, and the poststandardization group (25 patients) from April 1, 2014, to March 30, 2015. Exclusion criteria were renal disease, epilepsy, neurological disorder, or postoperative complications that led to change in routine care including ileus or fever greater than 102 °F. Data were analyzed using the Wilcoxon signed rank test, with significance set at p < .001. RESULTS: The length of stay (p = .0166), time to ambulation (p < .0001), patient-controlled analgesia use (p < .0001), and postoperative time to resumption of regular diet (p < .0001) were all significantly decreased in the poststandardization group. There were no complications or readmissions in either group. CONCLUSION: The standardized pathway resulted in shorter length of stay, decreased narcotic use, decreased time to regular diet, and decreased time to ambulation with no increase in complication rates.

Prospectively collected surgeon indications for discontinuation of a lengthening program for early-onset scoliosis.

INTRODUCTION: At some point after children with early-onset scoliosis (EOS) undergo implantation of a distraction construct to control deformity and promote growth, a decision is made to discontinue lengthening. The purpose of this study was to evaluate surgeon indications for discontinuation of a lengthening program and to evaluate patient outcomes. METHODS: As a part of a multicenter database, surgeons prospectively completed a questionnaire at the completion of growth-friendly treatment. Surgeon indications for discontinuation included patient age, pain/functional status, implant status, and spinal deformity parameters. Patient demographics, scoliosis type, deformity parameters, and length of time in a growing program were queried. Patients were treated with a final fusion or observation, and rate of secondary surgeries was analyzed. RESULTS: Questionnaires were completed on 121 patients (61% female). EOS etiology was 31% neuromuscular, 43% congenital, 16% idiopathic, and 10% syndromic. Average age at initiation of growing program was 6.8 ± 3.1 years, and average age at discontinuation was 12.7 ± 2.5 years. The most commonly cited indications for discontinuation of a lengthening program included bone age/skeletal maturity (n = 46), patient age (n = 33), and diminishing returns with expansions (n = 33). A larger coronal Cobb angle was found in patients who underwent definitive fusion (65°) when compared with continued observation (55°, p = 0.001). Twenty-nine (24%) patients were initially treated with observation after completion of a growing construct. In this subgroup, at a minimum of 2 years' (average 3.8 years') follow-up, 26/29 (90%) patients remained stable with observation alone; whereas, three (10%) underwent delayed final fusion surgery. CONCLUSIONS: The most common surgeon-cited indications for discontinuation of a lengthening program in EOS patients are skeletal maturity and patient age. The majority of patients (76%) underwent definitive spinal fusion after discontinuation of a lengthening program; whereas, those treated with observation alone had a survivorship of 90% at a minimum follow-up of two years.

Do Patient-specific or Fracture-specific Factors Predict the Development of Acute Compartment Syndrome After Pediatric Tibial Shaft Fractures?

BACKGROUND: Tibial shaft fractures are the most common injuries preceding acute compartment syndrome (ACS), so it is important to understand the incidence of and risk factors for ACS after pediatric tibial shaft fractures. The purposes of this study were to determine the rate at which ACS occurs and if any patient or fracture characteristics are significantly associated with developing ACS. METHODS: All patients aged 5 to 17 years treated for a tibial shaft fracture at a level 1 pediatric trauma center, a level 1 adult trauma center, and an outpatient orthopaedic practice between 2008 and 2016 were retrospectively identified. Demographics, mechanisms of injury, and fracture characteristics were collected from the medical records. Radiographs were reviewed by study authors. ACS was diagnosed clinically or by intracompartmental pressure measurement. Univariable analysis was performed using the Fisher exact test for nominal variables and simple logistic regression for continuous variables. Multivariable analysis was performed using stepwise logistic regression. RESULTS: Among 515 patients with 517 tibial shaft fractures, 9 patients (1.7%) with 10 (1.9%) fractures developed ACS at a mean age of 15.2 years compared with a mean age of 11 years in patients without ACS (P=0.001). One patient with bilateral tibial fractures developed ACS bilaterally. Age greater than 14 years (P=0.006), higher body mass index (P<0.001), motorcycle or motor vehicle accidents (P=0.034), comminuted and segmental tibial shaft fractures (P<0.001), ipsilateral fibular fracture (P=0.002), and associated orthopaedic injuries (P=0.032) were all significantly more common in the ACS group. CONCLUSIONS: ACS developed in 1.7% of the patients with tibial shaft fractures in this retrospective study-a rate significantly lower than previously reported. Age greater than 14 years, higher body mass index, motor vehicle or motorcycle accidents, comminuted or segmental fracture pattern, ipsilateral fibular fracture, and associated orthopaedic injuries are all significantly associated with its development. LEVELS OF EVIDENCE: Level III-retrospective comparative study.

Concurrent Ipsilateral Tibial Shaft and Distal Tibial Fractures in Pediatric Patients: Risk Factors, Frequency, and Risk of Missed Diagnosis.

BACKGROUND: The purpose of this study was to determine the frequency of concurrent ipsilateral distal tibial fractures with tibial shaft fractures in the pediatric population; to identify patient and fracture characteristics that increase the likelihood of a concurrent fracture; and determine if any of these concurrent distal tibial fractures were missed on initial radiographic examination. METHODS: Retrospective chart review was done to identify patients 5 to 17 years old who were treated for a tibial shaft fracture at a large, Level 1 free-standing children's hospital and an outpatient orthopaedic practice between 2008 and 2016. Patient and fracture characteristics were recorded. RESULTS: Of 517 fractures (515 patients), 22 (4.3%) had concurrent ipsilateral distal tibial fractures: 11 triplane, 5 medial malleolar, 3 bimalleolar, and 2 Tillaux (Salter-Harris III) ankle fractures, and 1 Salter-Harris II distal tibial fracture. Age was the only patient characteristic significantly associated with a second, more distal fracture: patients with both fractures were older (12.7 y) than those with an isolated tibial shaft fracture (11 y). There was no difference in the rate of distal tibial fractures between high-energy and low-energy mechanisms of injury and no differences in the rate of open injuries or the presence of a fibular fracture. Patients with a tibial shaft fracture at the junction of the middle and distal thirds were significantly more likely to have a concurrent distal tibial fracture; oblique and spiral fracture patterns were more frequent in the group with concurrent distal tibial fractures than in the isolated tibial shaft fracture group. CONCLUSIONS: In our series, 36% of the concurrent distal tibial fractures were not diagnosed until chart review for this study, which suggests the need for ankle-specific imaging in certain patients. We recommend ankle-specific imaging when an oblique or spiral tibial shaft fracture is located at the junction of the middle and distal thirds of the tibia or in patients in whom a distal tibial fracture is suspected because of pain, swelling, or bruising. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Flexible intramedullary nailing of femoral shaft fractures: closed versus open reduction.

Children's femoral shaft fractures are commonly treated with flexible intramedullary nailing after closed or open reduction, but there is little information concerning indications for open reduction. The purpose of this study was to determine radiographic and clinical features likely to lead to open reduction before flexible intramedullary nailing. Record review identified 158 femoral shaft fractures treated with flexible intramedullary nailing. In addition to patient demographics and mechanism of injury, data obtained included surgeon name, estimated blood loss, type of reduction, type and diameter of nail, type of operating table, the use of percutaneous reduction techniques or supplemental casting, time to and duration of surgery, total time in operating room, and time to union. Fracture ratios were calculated based on established radiographic protocol. Of 158 fractures, 141 were treated with closed reduction and 17 with open reduction. The anteroposterior fracture index (1.3 ± 0.4, P = 0.0007), surgeon (P = 0.002), and flattop operating table (0.05) were associated with open reduction. Smaller lateral diameter of bone at the fracture site, transverse fracture, and surgeon were all found to be independent risk factors for open reduction; patient characteristics, including age, sex, and BMI, did not seem to influence the choice of open reduction. Fractures with a lower fracture index or pattern resembling a transverse fracture rather than oblique or spiral had an increased risk of converting to an open reduction. Surgeon preference and use of flattop tables also had a significant influence on how the fracture was treated.