Assessment of Gross Motor Skills in Ponseti-treated Children With Idiopathic Clubfoot at 3 Years Old: Insights from the Peabody Developmental Motor Scale 2.

BACKGROUND: Congenital talipes equinovarus, or clubfoot, can lead to lifelong functional impairments, including diminished gross motor skills (GMS), if left untreated. The Ponseti method corrects idiopathic clubfoot through casting and bracing. Given the importance of GMS in childhood development, this technique must be optimized to support childhood and long-term health outcomes. This study examined immediate posttreatment GMS in 3-year-old children treated with Ponseti, hypothesizing that they would perform on par with their nonclubfoot peers. METHODS: Data from 45 children (33 to 46 mo of age) treated for idiopathic clubfoot were analyzed. The Peabody Developmental Motor Scales, 2nd edition, was used to assess GMS, and logistic regression identified factors influencing Gross Motor Quotient (GMQ) scores. RESULTS: Approximately half (n=22) of the patients exhibited below-average GMS (11th to 25th percentile), with 11 scoring below the 10th percentile. Initial deformity severity, gender, and cast numbers did not impact GMQ. Repeat percutaneous tenotomy was associated with lower GMQs. Brace compliance significantly reduced odds of low GMQs by up to 80%. Age at testing and additional surgery were also linked to below-average and poor GMQs. CONCLUSIONS: GMS appeared to be impaired in almost half of the 3-year-old patients treated for idiopathic clubfoot, so our hypothesis was disproven. Repeat percutaneous tenotomy was associated with lower GMS, necessitating future recognition of patients who might be at risk of relapse. Brace noncompliance emerged as a significant risk factor, emphasizing early identification of these patients and education for their parents. This study offers a benchmark for clinicians and parents, but research on long-term outcomes is needed. LEVEL OF EVIDENCE: Level II, prospective cohort study.

Accelerated Protocols in Adolescent Idiopathic Scoliosis Surgery.

Adolescent idiopathic scoliosis (AIS) is the most common form of scoliosis. Treatment depends on the degree of curvature, skeletal maturity, and age of the patient. Once the curve reaches 50 degrees, posterior spinal fusion (PSF) is necessary to stabilize the spine and prevent further progression of the curve. PSF causes significant trauma to the tissues and often results in significant pain postoperatively. The purpose of this article is to provide the audience with a review of preoperative, intraoperative, and postoperative pain control with an accelerated protocol in patients with AIS undergoing PSF.

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.

Prospective, Randomized Ponseti Treatment for Clubfoot: Orthopaedic Surgeons Versus Physical Therapists.

BACKGROUND: Clubfoot is a common congenital foot deformity in children. The Ponseti method of serial casting has become the standard of care in clubfoot treatment. Clubfoot casting is performed in many centers by both orthopaedic surgeons and physical therapists (PTs); however, direct comparison of outcomes and complications of this treatment between these providers is limited. This study prospectively compared the outcomes of patients with clubfoot treated by these 2 groups of specialists. METHODS: Between January 2010 and December 2014, all patients under the age of 12 months with a diagnosis of clubfoot were included. Patients were randomized to an orthopaedic surgeon (MD) group or a PT group for weekly serial casting. Main outcome measures included the number of casts required to achieve correction, clinical recurrence of the deformity, and the need for additional surgical intervention. RESULTS: One hundred twenty-six infants were included in the study. Patient demographics and characteristics (sex, race, family history of clubfoot, laterality, and severity of deformity) were similar between treatment groups, with the only significant difference being the mean age of entry into the study (5.2 weeks in the MD group and 9.2 weeks in the PT group, P=0.01). Mean length of follow-up was 2.6 years. The number of casts required trended to a lower number in the MD group. There was no significant difference in the rates of clinical recurrence or additional surgical intervention between groups. CONCLUSIONS: Ponseti casting for treatment of clubfoot performed by orthopaedic surgeons and PTs results in equivalent outcomes without any difference in complications. Although the number of casts required trended to a lower number in the MD group, this likely did not result in any clinical significance, as the difference in cast number equaled <1 week's difference in the overall duration of serial casting. LEVEL OF EVIDENCE: Level I-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.