Clinical Care Guideline for Improving Pediatric Acute Musculoskeletal Infection Outcomes.

BACKGROUND: Acute pediatric musculoskeletal infections are common, leading to significant use of resources and antimicrobial exposure. In order to decrease variability and improve the quality of care, Children's Hospital Colorado implemented a clinical care guideline (CCG) for these infections. The purpose of this study is to evaluate clinical and resource outcomes PRE and POST this CCG. METHODS: Retrospective chart review evaluated patients admitted to a large pediatric quaternary referral center (CHCO) diagnosed with acute osteomyelitis, septic arthritis, pyomyositis, and/or musculoskeletal abscess prior to and after guideline implementation. Primary outcomes included length of stay and overall antibiotic use, with additional secondary clinical, process, and therapeutic outcomes examined. RESULTS: 82 patients were identified in both the pre-CCG and post-CCG cohorts. There was a reduction in the median of all primary outcomes, including length of stay (0.6 median days decrease, P = .04), length of IV antibiotic therapy (4.9 median days decrease, P < .0001), and days of IV antibiotic therapy (6.4 median days decrease, P = .0004). Our median length of stay post-CCG was 4.9 days, the shortest reported length of stay for pediatric acute musculoskeletal infections to date. Additionally, there was a 24.5 hour reduction in median length of fever (P = .02), faster CRP normalization (P < .0001), 50% decrease in the number of related readmissions (P = .02), 34% decrease in central venous catheters placed (P < .0001), decreased time to first culture (P = .02), and 79% pathogen identification post-CCG (P = .056). CONCLUSIONS: Implementation of a CCG for acute musculoskeletal infections improves patient, process and resource outcomes.

A technique for pediatric chest wall reconstruction using custom-designed titanium implants: description of technique and report of two cases.

PURPOSE: We present a surgical technique for chest wall reconstruction using custom-designed titanium implants developed for two female patients to provide both chest wall symmetry and adequate stability for staged breast reconstruction. METHODS: A retrospective review was performed for two adolescent female patients with large chest wall defects who underwent the described technique. The etiology of the chest wall deficiency was secondary to Poland's syndrome in one patient, and secondary to surgical resection of osteosarcoma in the other patient. For each patient, a fine-cut computed tomography scan was obtained to assist with implant design. After fabrication of the prosthesis, reconstruction was performed though a curvilinear thoracotomy approach with attachment of the implant to the adjacent ribs and sternum. Wound closure was obtained with use of synthetic graft material, local soft tissue procedures, and flap procedures as necessary. RESULTS: The two patients were followed post-operatively for 35 and 38 months, respectively. No intra-operative or post-operative complications were identified. Mild scoliosis that had developed in the patient following chest wall resection for osteosarcoma did not demonstrate any further progression following reconstruction. CONCLUSIONS: We conclude that this technique was successful at providing a stable chest wall reconstruction with satisfactory cosmetic results in our patients.

Factors predictive of concomitant injuries among children and adolescents undergoing anterior cruciate ligament surgery.

BACKGROUND: The timing of treatment for pediatric anterior cruciate ligament (ACL) injuries remains controversial. The risks of delaying reconstruction and the differences between age groups are poorly defined. PURPOSE: To investigate factors that contribute to the prevalence and severity of concomitant chondral and meniscal injuries among patients aged 14 to 19 years versus those aged ≤14 years at the time of ACL reconstruction. The hypothesis was that concomitant injuries would be more prevalent in older versus younger subjects. Also, a delay in surgery would be predictive of the presence and severity of concomitant knee injuries requiring additional operative procedures. STUDY METHODS: Cohort study; Level of evidence, 3. METHODS: All subjects who underwent primary ACL reconstruction at a single tertiary pediatric hospital between 2005 and 2012 were retrospectively reviewed. The location, severity, and treatment of all concomitant knee injuries were recorded. Chi-square tests were used to compare the prevalence of chondral and meniscal injuries in the older (age, 14-19 years; n = 165) versus younger (age, ≤14 years; n = 66) cohorts. A multivariable logistic regression analysis was used to identify factors related to the presence of a concomitant injury that required additional treatment. Kaplan-Meier analyses were used to explore the relation between time to surgery and meniscal injury severity. RESULTS: There was a significant relationship between time to surgery and the development of an irreparable meniscal injury (P < .05 for all) in both the younger and older groups. Time to surgery correlated with severity of chondral injury in the younger cohort (P = .0343) but not in the older cohort (P = .8877). In the younger cohort, only a delay in surgery >3 months (odds ratio [OR] = 4.8; 95% CI, 1.7-14.4; P = .0027) was significantly predictive of the presence of an injury that required additional operative procedures. In the older patients, a return to activity before surgery (OR = 3.8; 95% CI, 1.52-11.9; P = .0034) and obesity (OR = 2.5; 95% CI, 1.1-7.4; P = .0381) were significantly predictive of an injury that required additional operative procedures. CONCLUSION: Compared with younger subjects, the prevalence of concomitant knee injuries as well as the need for additional operative procedures was greater among older subjects. A delay to surgery correlated with increased severity of injury among both older and younger populations. A delay in surgery >3 months was the strongest predictor of the development of a concomitant injury in the younger cohort. A return to activity and obesity were significantly related to the presence of a concomitant knee injury in the older cohort.

A deadly digital dressing: a case of surgical decompression for finger ischemia due to circumferential finger dressing.

BACKGROUND: Tubular gauze dressings are commonly used, but have potential to cause iatrogenic finger ischemia. OBJECTIVES: To inform health care providers of an avoidable complication and to discuss appropriate methods of prevention and treatment. CASE REPORT: We discuss a teenage female's finger that narrowly avoided amputation after a tubular gauze dressing caused iatrogenic ischemia. Surgical decompression using a novel technique successfully salvaged the finger. Operative intervention for this complication has previously been unreported. CONCLUSION: It is important that circumferential digital dressings are applied correctly. Vascular insufficiency from an occlusive dressing is an iatrogenic and avoidable complication. Successful operative decompression may be indicated to minimize tissue loss and improve circulation.

The effect of sliding knots on the suture-tendon interface strength: a biomechanical analysis comparing sliding and static arthroscopic knots.

BACKGROUND: The tissue-suture interface remains the most common site of failure in rotator cuff repairs. It is currently unknown if arthroscopic sliding knots injure the tissue and weaken the suture-tendon interface. PURPOSE: To evaluate the effect sliding knots have on the strength of the suture-tendon interface. STUDY DESIGN: Controlled laboratory study. METHODS: A total of 32 sheep infraspinatus tendons were randomized among 4 groups of stitches (n = 8): simple-static, simple-sliding, mattress-static, and mattress-sliding. All high-strength, No. 2 suture stitch-knot combinations were created in an arthroscopic simulated environment, and sliding knots were tied with shortening of the suture and sliding of the knot down to the tissue interface to simulate surgical technique. Each graft was cyclically loaded on a mechanical testing system from 5 to 20 N for 20 cycles and then loaded to failure. A least squares analysis of variance model was used to test significance of sliding stitches upon cyclic elongation, peak-to-peak displacement, and ultimate load. Estimated means and standard deviations are reported from the regression model. RESULTS: A mattress-static stitch (116 N) was significantly stronger than a mattress-sliding stitch (70 N; P < .001). The ultimate loads for the simple-static (46 N) and sliding (50 N) stitches were not statistically different. For cyclic elongation, the only difference was the mattress-sliding stitch (0.95 mm) having a greater elongation than the simple-static (0.61 mm; P = .01) and simple-sliding (0.68 mm; P = .04) stitches. Both mattress stitches had significantly less peak-to-peak displacement (0.39 and 0.41 mm) than the simple stitches (0.47 and 0.46 mm; P < .001). CONCLUSION: Sliding suture through tissue weakens the suture-tendon interface in mattress stitch constructs but not in simple stitch constructs. Mattress stitches have superior holding strength compared with simple stitches. CLINICAL RELEVANCE: Clinical relevance is uncertain. In situations with poor tissue quality or concern regarding tension across the repair, consideration should be given to using static knots as opposed to sliding knots when placing mattress stitches.