Closed Reduction Techniques Are Associated With Fewer Complications Than Open Reductions in Treating Moderately Displaced Pediatric Lateral Humeral Condyle Fractures: A Multicenter Study.

INTRODUCTION: Lateral humeral condyle (LC) fractures are the second most common pediatric elbow fractures. Traditionally, displaced fractures have been treated with open reduction although recent studies have demonstrated successful outcomes of closed reduction for similar injuries. This study investigates the outcomes comparing open and closed reduction in a large cohort of children with moderately displaced (Song classification types 1 to 4) lateral humeral condyle fractures. METHODS: Retrospective data from patients aged between 1 and 12 years treated for lateral condyle fractures was collected from 6 academic level 1 trauma centers between 2005 and 2019. Data was collected on patient demographics, radiographic parameters, reduction type, type of hardware fixation, and fracture patterns. Complications recorded include infections, reoperations for nonunion, osteonecrosis, and elbow stiffness. RESULTS: An initial 762 fractures were identified. After excluding Song 5 cases, a total of 480 fractures met inclusion criteria, with 202 (42%) treated with closed reduction and 278 (58%) treated with open reduction. Demographics and injury characteristics were similar across the 2 reduction cohorts. After propensity score matching, delayed healing (52% vs. 28%; OR: 2.88, 95% CI: 1.97-4.22; P<0.0001) and stiffness (22% vs. 10%; OR 2.42, 95% CI: 1.42-4.13; P=0.0012) were significantly higher in the open reduction group. No differences in the rates of infection or nonunion (3% CR and 1% OR) were noted between the 2 groups. CONCLUSION: This study demonstrates that moderately displaced lateral condyle fractures requiring open reduction are more likely to have elbow stiffness and delayed healing when compared with the ones treated with closed reduction. For these reasons, we propose attempting closed reduction techniques as the first line of treatment in moderately displaced lateral humeral condyle fractures (if anatomic articular reduction can be achieved) to attain better patient outcomes.

Using Preference Cards to Support a Thoughtful, Evidence-based Orthopaedic Surgery Practice.

INTRODUCTION: When orthopaedic surgeons begin or relocate their careers, they must communicate effectively about their instrumentation and equipment needs. 'Preference Cards' or 'Pick Lists' are generated by and for individual surgeons at the time of hire and can be updated over time to reflect their needs for common cases. Currently, such decisions are made without formal guidance or preparation. BODY: Surgeons must consider and plan for their operating room needs. Health system and industry factors affect these decisions, as do surgeons' unique interests, preferences, and biases. Orthopaedic surgeons currently face challenges: formal education is deficient in this space, material and reprocessing costs are not transparent, relationships and contracts with industry are complex, and few health systems have mechanisms to support preference card optimization. This complex landscape influences utilization decisions and leaves opportunities for integration, collaboration, and innovation. SUMMARY: Choices about instrument and resource utilization in the OR have wide-reaching impacts on costs, waste generation, OR efficiency, sterile processing, and industry trends. Surgeons and their teams have much to gain by making intentional choices and pursuing both individual and systematic improvements in this space.

Risk Factors for Stiffness After Surgical Treatment of Pediatric Humeral Lateral Condyle Fractures: Results of a Multicenter Study.

INTRODUCTION: Pediatric humeral lateral condyle fractures are the second most common elbow fractures. Their treatment presents challenges due to physeal and intra-articular involvement. Postoperative stiffness is a common concern that can limit limb functionality. This study aims to identify risk factors for postoperative stiffness in a large cohort of these fractures across multiple institutions. METHODS: A large, multicenter retrospective review of medical records from 6 level I trauma centers was conducted. Data from children aged 1 to 12 years with lateral condyle fractures treated between 2005 and 2019 were collected. Elbow stiffness was defined in the present study as having a limited elbow ROM that led to requiring a physical or occupational therapy referral or needing surgical treatment to address stiffness. Relevant patient demographics, fracture characteristics, treatment approaches, and complications were analyzed. RESULTS: Six hundred sixty-five fractures were analyzed. The average patient age was 8.8 years with 21% experiencing stiffness. The stiffness group had older patients, a higher incidence of elbow dislocations, a higher rate of open reduction, and more severe fracture patterns. Multivariate regression analysis identified open reduction, increased age, and concurrent elbow dislocation as significant risk factors for stiffness. Patients with stiffness commonly utilized only physical or occupational therapy (96%), while a small percentage (4%) required surgical interventions. CONCLUSIONS: This study highlights the risk factors for postoperative stiffness in pediatric humeral lateral condyle fractures, namely increased age, concomitant elbow dislocation, and treatment with open reduction. Families of older patients or severe fracture patterns requiring open reduction and those with concurrent elbow instability should be counseled about their increased risk of stiffness. The authors recommend initially attempting a closed reduction in high-risk patients to help mitigate the risk of postoperative stiffness. Early initiation of range of motion exercises may also be beneficial for at-risk patients. LEVEL OF EVIDENCE: Level III: Therapeutic studies-Investigating the results of treatment.

K-wire Versus Screw Fixation in Displaced Lateral Condyle Fractures of the Humerus in Children: A Multicenter Study of 762 Fractures.

INTRODUCTION: Lateral humeral condyle fractures account for 12% to 20% of all distal humerus fractures in the pediatric population. When surgery is indicated, fixation may be achieved with either Kirschner-wires or screws. The literature comparing the outcomes of these 2 different fixation methods is currently limited. The purpose of this study is to compare both the complication and union rates of these 2 forms of operative treatment in a multicenter cohort of children with lateral humeral condyle fractures. METHODS: This retrospective study was performed across 6 different institutions. Data were retrospectively collected preoperatively and 6 weeks, 3, 6, and 12 months postoperatively. Patients were divided into 2 cohorts based on the type of initial treatment: K-wire fixation and screw fixation. Statistical comparisons between these 2 cohorts were performed with an alpha of 0.05. RESULTS: There were 762 patients included in this study, 72.6% (n=553) of which were treated with K-wire fixation. The mean duration of immobilization was 5 weeks in both cohorts, and most patients in this study demonstrated radiographic healing by 11 weeks postoperatively, regardless of treatment method. Similar reoperation rates were seen among those treated with K-wires and screws (5.6% vs. 4.3%, P =0.473). Elbow stiffness requiring further intervention with physical therapy was significantly more common in those treated with K-wires compared with children treated with screws (21.2% vs. 13.9%, P =0.023) as was superficial skin infection (3.8% vs. 0%, P =0.002), but there was no significant difference in nonunion rates between the two groups (2.4% vs. 1.3%, P =1.000). CONCLUSION: We found similar success rates between K-wire and screw fixation in this patient population. Contrary to previous studies, we did not find evidence that treatment with screw fixation decreases the likelihood of experiencing nonunion. However, given the unique complications associated with K-wire fixation, such as elbow stiffness and superficial skin infection, the treatment with screw fixation remains a reasonable alternative to K-wire fixation in these patients. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Coaching and Surgical Performance.

Surgical coaching is a form of mentoring that can improve surgical performance. While professional athletes have coaching their entire career, other professions, such as medicine, law, and education, are expected to manage their own improvement in performance over their careers. Methods of surgical coaching and the pros and cons of coaching to improve surgical performance and improve patient safety will be presented.

Growth-friendly Spinal Instrumentation in Marfan Syndrome Achieves Sustained Gains in Thoracic Height Amidst High Rates of Implant Failure.

BACKGROUND: There are few reports on the surgical management of early-onset scoliosis (EOS) associated with Marfan syndrome (MFS). Affected patients tend to have more rapid curve progression than those with idiopathic EOS, and their course is further complicated by medical comorbidities. As surgical techniques and implants for growing spines become more widely applied, this study seeks to better delineate the safety and efficacy of growth-friendly spinal instrumentation in treating this population. METHODS: A prospective registry of children treated for EOS was queried for MFS patients treated between 1996 and 2016. Forty-two patients underwent rib-based or spine-based growing instrumentation and were assessed on preoperative, surgical, and postoperative clinical and radiographic parameters including complications and reoperations. Subgroup analysis was performed based on spine-based versus rib-based fixation. RESULTS: Patients underwent their index surgery at a mean age of 5.5 years, when the major coronal curve and kyphosis measured 77 and 50 degrees, respectively. Over half were treated with traditional growing rods. Patients underwent 7.2 total surgical procedures-4.7 lengthening and 1.9 revision surgeries not including conversion to fusion-over a follow-up of 6.5 (±4.1) years. Radiographic correction was greatest at index surgery but maintained over time, with a final thoracic height measuring 23.8 cm. Patients experienced a mean of 2.6 complications over the course of the study period; however, a small group of 6 patients experienced ≥6 complications while over half of patients experienced 0 or 1. Implant failures represented 42% of all complications with infection and pulmonary complications following. CONCLUSIONS: This is the largest report on patients with EOS and MFS. All subtypes of growth-friendly constructs reduced curve progression in this cohort, but complications and reoperations were nearly universal; patients were particularly plagued by implant failure and migration. Further collaborations are needed to enhance understanding of optimal timing and fixation constructs for those with MFS and other connective tissue diseases.

Variability in length of stay following neuromuscular spinal fusion.

BACKGROUND: Patients with neuromuscular scoliosis (NMS) who undergo posterior spinal fusion (PSF) often have long, protracted hospital stays because of numerous comorbidities. Coordinated perioperative pathways can reduce length of hospitalization (LOH) without increasing complications; however, a subset of patients may not be suited to rapid mobilization and early discharge. METHODS: 197 patients with NMS underwent PSF at a single hospital by two surgeons with a post-operative care pathway emphasizing early mobilization, rapid transition to enteral feeds, and discharge prior to first bowel movement. Average LOH was 4.9 days for all patients. Patients were divided into quartiles (< 3 days, 3-5 days, 5-7 days, > 7 days) based on their LOH, and their charts were retrospectively reviewed for preoperative, intraoperative, and postoperative factors associated with their LOH. RESULTS: Age at surgery, gender, the need for tube feeds, and specific underlying neuromuscular disorder were not significant predictors of LOH; however, severely involved cerebral palsy (CP) patients (GMFCS 4/5) were more likely to have extended stays than GMFCS 1-3 patients (p = 0.02). Radiographic predictors of LOH included major coronal Cobb angle (p = 0.002) and pelvic obliquity (p = 0.02). Intraoperative predictors included longer surgical times, greater numbers of levels fused and need for intraoperative or postoperative blood transfusion (p < 0.05). The need for ICU admission and development of a pulmonary complication were significantly more likely to fall into the extended LOH group (p < 0.05). CONCLUSIONS: Several variables have been identified as significant predictors of LOH after PSF for NMS in the setting of a standardized discharge pathway. Patients with smaller curves and less complex surgeries were more amenable to accelerated discharge. Conversely, patients with severe CP with large curves and pelvic obliquity requiring longer surgeries with more blood loss may not be ideal candidates. These data can be used to inform providers' and families' post-operative expectations. LEVEL OF EVIDENCE: Therapeutic Level III.

Use of an Accelerated Discharge Pathway in Patients With Severe Cerebral Palsy Undergoing Posterior Spinal Fusion for Neuromuscular Scoliosis.

BACKGROUND: Implementation of a coordinated multidisciplinary postoperative pathway has been shown to reduce length of stay after posterior spinal fusion (PSF) for adolescent idiopathic scoliosis. This study sought to compare the outcomes of nonambulatory cerebral palsy (CP) patients treated with PSF and cared for using an accelerated discharge (AD) pathway with those using a more traditional discharge (TD) pathway. METHODS: A total of 74 patients with Gross Motor Function Classification System (GMFCS) class 4/5 CP undergoing PSF were reviewed. Thirty consecutive patients were cared for using a TD pathway, and 44 patients were subsequently treated using an AD pathway. The cohorts were then evaluated for postoperative complications and length of stay. RESULTS: Length of stay (LOS) was 19% shorter in patients managed with the AD pathway (AD 4.0 days [95% CI 2.5-5.5] vs. TD 4.9 days [95% CI 3.5-6.3], p = .01). There was no difference between groups with respect to age at surgery, GMFCS class, preoperative curve magnitude, pelvic obliquity, kyphosis, postoperative curve correction, fusion to the pelvis, or length of fusion between groups. Length of stay remained significantly shorter in the AD group by 0.9 days when controlling for estimated blood loss (EBL) and length of surgery. Complication rates trended lower in the AD group (33% AD vs. 52% TD, p = .12), including pulmonary complications (21% AD vs. 38% TD, p = .13). There was no significant difference in wound complications, return to the operating room, or medical readmissions between groups. CONCLUSIONS: Adoption of a standardized postoperative pathway reduced LOS by 19% in nonambulatory CP patients. Overall, complications, including pulmonary, trended lower in the AD group. Early discharge appears to be possible in this challenging patient population. Although the AD pathway may not be appropriate for all patients, the utility of the AD pathway in optimizing care for more routine PSF for this patient subset appears to be worthwhile. LEVEL OF EVIDENCE: Level III, therapeutic.

Don't You Wish You Had Fused to the Pelvis the First Time: A Comparison of Reoperation Rate and Correction of Pelvic Obliquity.

STUDY DESIGN: A multicenter retrospective study. OBJECTIVE: The aim of this study was to compare pelvic obliquity correction and reoperation rate in neuromuscular scoliosis patients who had their pelvis included in a posterior spinal fusion (pelvic fusion, PF) at their index procedure versus revision procedures. SUMMARY OF BACKGROUND DATA: There is limited information on outcomes specific to fusing to the pelvis for neuromuscular scoliosis in a revision operation versus index surgery. METHODS: Charts and radiographs were reviewed of patients with PF for neuromuscular scoliosis from January 2003 to August 2015 at four high-volume pediatric spine centers with >2 year follow-up. RESULTS: Two hundred eighty-five patients met inclusion criteria; 271 had PF done at index surgery and 14 had PF done during revision surgery. Before index procedure, there were no significant differences in Cobb angle (P = 0.13). Before PF, there was no difference in pelvic obliquity (P = 0.26). At the time of fusion to the pelvis, estimated blood loss (P = 0.23) and operative time (P = 0.43) did not differ between index and revision groups. Percent correction in pelvic obliquity was similar for both groups (P = 0.72). Overall, 69 patients had complications requiring return to the operating room. Excluding the revision surgery for inclusion of the pelvis for the revision group, there was still a lower reoperation rate with index PF (22.9%, n = 62/271) than revision PF (50.0%, n = 7/14) (P = 0.02). Implant failures were significantly higher in the revision group (index = 7.4%, 20/271; revision = 42.9%, 6/14; P < 0.001). CONCLUSION: PF at the index spinal fusion led to similar correction of pelvic obliquity with approximately half the reoperation rate compared with PF at a revision surgery. Operative time and blood loss were similar between index and revision spinal fusion. LEVEL OF EVIDENCE: 4.

Improving perioperative care for adolescent idiopathic scoliosis patients: the impact of a multidisciplinary care approach.

The complex nature of the surgical treatment of adolescent idiopathic scoliosis (AIS) requires a wide variety of health care providers. A well-coordinated, multidisciplinary team approach to the care of these patients is essential for providing high-quality care. This review offers an up-to-date overview of the numerous interventions and safety measures for improving outcomes after AIS surgery throughout the perioperative phases of care. Reducing the risk of potentially devastating and costly complications after AIS surgery is the responsibility of every single member of the health care team. Specifically, this review will focus on the perioperative measures for preventing surgical site infections, reducing the risk of neurologic injury, minimizing surgical blood loss, and preventing postoperative complications. Also, the review will highlight the postoperative protocols that emphasize early mobilization and accelerated discharge.

Radiation exposure in the young level 1 trauma patient: a retrospective review.

Computed tomography (CT) has become an increasingly popular and powerful tool for clinicians managing trauma patients with life-threatening injuries, but the ramifications of increasing radiation burden on individual patients are not insignificant. This study examines a continuous series of 337 patients less than 40 years old admitted to a level 1 trauma center during a 4-month period. Primary outcome measures included number of scans; effective dose of radiation from radiographs and CT scans, respectively; and total effective dose from both sources over patients' hospital stays. Several variables, including hospital length of stay, initial Glasgow Coma Scale score, and Injury Severity Score, correlated with greater radiation exposure. Blunt trauma victims were more prone to higher doses than those with penetrating or combined penetrating and blunt trauma. Location and mechanism of injury were also found to correlate with radiation exposure. Trauma patients as a group are exposed to high levels of radiation from X-rays and CT scans, and CT scans contribute a very high proportion (91.3% ± 11.7%) of that radiation. Certain subgroups of patients are at a particularly high risk of exposure, and greater attention to cumulative radiation dose should be paid to patients with the above mentioned risk factors.