The Effect of Socioeconomic Deprivation on Radiographic Deformities in Children With Blount Disease

BACKGROUND

Blount disease can occur at any time during the growth process, primarily with a bimodal distribution in children younger than 4 years old and adolescents. The disease process most commonly presents in Black adolescents, with disease severity positively correlated with obesity. Given the known associations among race, obesity, and socioeconomic status, we investigated the relationship between the degree of social deprivation and severity of lower extremity deformities among a community-based cohort with Blount disease.

METHODS

A retrospective review of hospital records and radiographs of patients with previously untreated Blount disease was conducted. Patients were classified as having early-onset or late-onset Blount disease based on whether the lower limb deformity was noted before or after the age of 4 years. The area deprivation index (ADI), a nationally validated measure that assesses socioeconomic deprivation by residential neighborhood, was calculated for each patient as a surrogate for socioeconomic status. Higher state (range: 1 to 10) or national (range: 1 to 100) ADI corresponds to increased social deprivation. Full-length standing radiographs from index clinic visits were evaluated by 2 reviewers to measure frontal plane deformity. The association of ADI with various demographic and radiographic parameters was then analyzed.

RESULTS

Of the 65 patients with Blount disease, 48 (74%) children were Black and 17 (26%) were non-black children. Nineteen children (32 limbs) had early-onset and 46 children (62 limbs) had late-onset disease. Black patients had significantly higher mean state (7.6 vs. 5.4, P =0.009) and national (55.1 vs. 37.4, P =0.002) ADI values than non-black patients. Patients with severe socioeconomic deprivation had significantly greater mechanical axis deviation (66 mm vs. 51 mm, P =0.008). After controlling demographic and socioeconomic factors, the results of multivariate linear regression showed that only increased body mass index (β=0.19, 95% CI: 0.12-0.26, P <.001) and state ADI (β=0.021, 95% CI: 0.01-0.53, P =.043) were independently associated with greater varus deformity.

CONCLUSIONS

Socioeconomic deprivation was strongly associated with increased severity of varus deformity in children with late-onset Blount disease. Our analysis suggests that obesity and socioeconomic factors are the most influential with regard to disease progression.

LEVEL OF EVIDENCE

Level III.

Thinner Tibial Spine Fracture Fragments Are Associated With Risk of Fixation Failure

Purpose

To determine the rate of and risk factors for failure of tibial spine fracture (TSF) repair.

Methods

This was a retrospective review of patients aged 18 years or younger with TSF who underwent arthroscopic repair performed by a single orthopaedic surgeon at a large tertiary academic hospital between 2015 and 2022. Demographic, clinical, injury, fracture, and surgical characteristics were collected. Coronal length and sagittal length and height of the fracture fragment were measured on preoperative plain radiographs and magnetic resonance imaging of the knee.

Results

Of 25 patients who underwent arthroscopic reduction with internal fixation of TSFs, 2 (8%) experienced fixation failure. In 16 (64%), internal fixation was performed with suture anchors, whereas 8 (32%) underwent internal fixation with screws. There were 19 male patients (76%). There were no differences in demographic factors (age, race, sex, and body mass index), injury characteristics (laterality, mechanism of injury, and activity causing injury), modified Meyers-McKeever fracture classification, or method of internal fixation between the group with fixation failure and the group without failure. Coronal length (14.2 mm vs 18 mm, P = .17) and sagittal length (13.9 mm vs 18.7 mm, P = .17) of the fracture fragment also did not differ significantly between groups. Sagittal height of the fracture fragment was thinner in patients with failure of fixation (4.3 mm) than in those without failure (8 mm) (P = .02).

Conclusions

Decreased bone thickness of the displaced fragment was associated with an increased likelihood of fixation failure.

Level of Evidence

Level III, retrospective cohort study.

Fifteen Years of Spinal Fusion Outcomes in Children With Cerebral Palsy: Are We Getting Better?

STUDY DESIGN

Retrospective multicenter study.

OBJECTIVE

We reviewed 15-year trends in operative factors, radiographic and quality of life outcomes, and complication rates in children with cerebral palsy (CP)-related scoliosis who underwent spinal fusion.

SUMMARY OF BACKGROUND DATA

Over the past two decades, significant efforts have been made to decrease complications and improve outcomes of this population.

MATERIALS AND METHODS

We retrospectively reviewed a multicenter registry of pediatric CP patients who underwent spinal fusion from 2008 to 2020. We evaluated baseline and operative, hospitalization, and complication data as well as radiographic and quality of life outcomes at a minimum 2-year follow-up.

RESULTS

Mean estimated blood loss and transfusion volume declined from 2.7±2.0 L in 2008 to 0.71±0.34 L in 2020 and 1.0±0.5 L in 2008 to 0.5±0.2 L in 2020, respectively, with a concomitant increase in antifibrinolytic use from 58% to 97% (all, P <0.01). Unit rod and pelvic fusion use declined from 33% in 2008 to 0% in 2020 and 96% in 2008 to 79% in 2020, respectively (both, P <0.05). Mean postoperative intubation time declined from 2.5±2.6 to 0.42±0.63 days ( P< 0.01). No changes were observed in preoperative and postoperative coronal angle and pelvic obliquity, operative time, frequency of anterior/anterior-posterior approach, and durations of hospital and intensive care unit stays. Improvements in the Caregiver Priorities and Child Health Index of Life with Disabilities postoperatively did not change significantly over the study period. Complication rates, including reoperation, superficial and deep surgical site infection, and gastrointestinal and medical complications remained stable over the study period.

CONCLUSIONS

Over the past 15 years of CP scoliosis surgery, surgical blood loss, transfusion volumes, duration of postoperative intubation, and pelvic fusion rates have decreased. However, the degree of radiographic correction, the rates of surgical and medical complications (including infection), and health-related quality of life measures have broadly remained constant.

Incidence, risk factors, and consequences of radiographic pin migration after pinning of pediatric supracondylar humeral fractures

Current literature on pin migration is inconsistent and its significance is not understood. We aimed to investigate the incidence, magnitude, predictors, and consequences of radiographic pin migration after pediatric supracondylar humeral fractures (SCHF). We retrospectively reviewed pediatric patients treated with reduction and pinning of SCHF at our institution. Baseline and clinical data were collected. Pin migration was assessed by measuring the change in distance between pin tip and humeral cortex on sequential radiographs. Factors associated with pin migration and loss of reduction (LOR) were assessed. Six hundred forty-eight patients and 1506 pins were included; 21%, 5%, and 1% of patients had pin migration ≥5 mm, ≥10 mm, and ≥20 mm respectively. Mean migration in symptomatic patients was 20 mm compared to a migration of 5 mm in all patients with non-negligible migration ( P  < 0.001). Pin migration > 10 mm was strongly associated with LOR [odds ratio (OR) = 6.91; confidence interval (CI), 2.70-17.68]. Factors associated with increased migration included increased days to pin removal ( β  = 0.022; CI, 0.002-0.043), migration outwards versus inwards ( = 1.02; CI, 0.21-1.80), and BMI > 95th percentile (OR = 1.63; [1.06-2.50]). Factors not associated with migration included cross-pinning, number of pins, and fracture grade. In summary, we identified a 5% incidence of radiographic pin migration ≥ 10 mm and determined the factors associated with it. Pin migration became radiographically significant at >10 mm where it was strongly associated with LOR. Our findings contribute to the understanding of pin migration and suggest that interventions targeting pin migration may decrease the risk of LOR. Level of Evidence: Level III - Retrospective Cohort Study.

Is Delayed Anterior Cruciate Ligament Reconstruction Associated With a Risk of New Meniscal Tears? Reevaluating a Longstanding Paradigm

Background

Delayed anterior cruciate ligament (ACL) reconstruction has been associated with an increased risk of meniscal tears. However, studies comparing early versus delayed ACL reconstruction have not clearly demonstrated that meniscal tears diagnosed arthroscopically are new injuries as opposed to concomitant injuries sustained during ACL rupture.

Purpose

To determine whether and how delay of ACL reconstruction is associated with risk of "new" meniscal tears (defined as those visualized arthroscopically that had not been detected on magnetic resonance imaging [MRI]) in adult and pediatric patients.

Study Design

Cohort study; Level of evidence, 3.

Methods

We retrospectively identified patients who underwent primary ACL reconstruction between 2013 and 2022 at our institution. To ensure that MRI reflected initial intra-articular pathology, we included only patients who had an MRI scan within 3 weeks after injury (173 pediatric and 369 adult patients). Multivariate Poisson regression was performed to calculate the adjusted relative risk (ARR) of new meniscal tears after delayed (≥8 weeks from injury) operative treatment.

Results

The mean (± SD) time from injury to MRI was 1.0 ± 0.8 weeks for pediatric patients and 1.1 ± 0.7 weeks for adults. Less than half of the meniscal tears observed arthroscopically had been absent on initial MRI. New medial meniscal tears occurred in 15% of pediatric patients and 16% of adults. New lateral meniscal tears occurred in 48% of pediatric patients and 34% of adults. Among pediatric patients, delayed ACL reconstruction was associated with higher risk of new medial tears (ARR, 3.9; 95% CI, 1.5-10) but not lateral tears (ARR, 0.8; 95% CI, 0.4-1.5). In contrast, adults had no significant increase in risk of meniscal tears associated with operative delay.

Conclusion

Delayed ACL reconstruction may be acceptable in adults, who may be less active and less injury-prone than children and adolescents.

Updating the Evidence: Systematic Literature Review of Risk Factors and Strategies for Prevention, Diagnosis, and Treatment of Surgical Site Infection After Pediatric Scoliosis Surgery

BACKGROUND

Surgical site infection (SSI) is a major potential complication following pediatric spinal deformity surgery that is associated with significant morbidity and increased costs. Despite this, SSI rates remain high and variable across institutions, in part due to a lack of up-to-date, comprehensive prevention, and treatment protocols. Furthermore, few attempts have been made to review the optimal diagnostic modalities and treatment strategies for SSI following scoliosis surgery. The aim of this study was to systematically review current literature on risk factors for SSI in pediatric patients undergoing scoliosis surgery, as well as strategies for prevention, diagnosis, and treatment.

METHODS

On January 19, 2022, a systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies reporting risk factors for acute, deep SSI (<90 d) or strategies for prevention, diagnosis, or treatment of SSI following pediatric scoliosis surgery were included. Each included article was assigned a level of evidence rating based on study design and quality. Extracted findings were organized into risk factors, preventive strategies, diagnostic modalities, and treatment options and each piece of evidence was graded based on quality, quantity, and consistency of underlying data.

RESULTS

A total of 77 studies met the inclusion criteria and were included in this systematic review, of which 2 were categorized as Level I, 3 as Level II, 64 as Level III, and 8 as Level IV. From these studies, a total of 29 pieces of evidence (grade C or higher) regarding SSI risk factors, prevention, diagnosis, or treatment were synthesized.

CONCLUSIONS

We present an updated review of published evidence for defining high-risk patients and preventing, diagnosing, and treating SSI after pediatric scoliosis surgery. The collated evidence presented herein may help limit variability in practice and decrease the incidence of SSI in pediatric spine surgery.

LEVEL OF EVIDENCE

Level III-systematic review.

Preoperative Anemia is an Independent Risk Factor for Increased Complications and Mortalities After Total Knee Arthroplasty Regardless of Postoperative Transfusions

BACKGROUND

Preoperative anemia is associated with adverse events following total knee arthroplasty (TKA). It remains unknown if this effect is due to comorbid conditions, adverse events associated with transfusions, or the anemia itself. We used propensity-score matching to isolate the effect of anemia on postoperative complications following TKA, regardless of blood transfusions.

METHODS

Patients undergoing primary TKA from 2010 to 2020 without receiving a perioperative blood transfusion, were identified using a large national database. A 1:1 propensity score matching was used to create cohorts of anemic and nonanemic patients matched on Charlson Comorbidity Index (CCI), American Society of Anesthesiology (ASA) classification, age, sex, and prevalence of bleeding disorders. There were 43,370 patients were included in each group (mean age 68 [range, 29 to 99; 44% male]). The 1:1 matching yielded groups with similar CCI, ASA classification, age, sex, and prevalence of bleeding disorders (all, P > .9).

RESULTS

Anemic patients had a higher incidence of major complications (4.1 versus 2.8%; P < .001), 30-day mortality rate (0.2 versus 0.1%; P < .001), and extended lengths of stay (LOS) (8.3 versus 6.6%; P < .001). Anemic patients also had increased 30-day rates of wound infection requiring hospital admission, renal failure, reintubation, myocardial infarction, and pneumonia (all, P < .001).

CONCLUSION

In matched cohorts of anemic versus nonanemic patients undergoing TKA, all who had no postoperative blood transfusion, anemic patients had higher rates of complications, extended LOS, and mortalities. Thus, anemia should be considered an independent risk factor for complications following TKA.

What Factors Are Associated With Delayed Wound Closure in Open Reduction and Internal Fixation of Adult Both-bone Forearm Fractures?

BACKGROUND

Delayed wound closure is often used after open reduction and internal fixation (ORIF) of both-bone forearm fractures to reduce the risk of skin necrosis and subsequent infection caused by excessive swelling. However, no studies we are aware of have evaluated factors associated with the use of delayed wound closure after ORIF.

QUESTIONS/PURPOSES

(1) What proportion of patients undergo delayed wound closure after ORIF of adult both-bone forearm fractures? (2) What factors are associated with delayed wound closure?

METHODS

The medical records of all patients who underwent ORIF with plate fixation for both-bone fractures by the adult orthopaedic trauma service at our institution were considered potentially eligible for analysis. Between January 2010 and April 2022, we treated 74 patients with ORIF for both-bone forearm fractures. Patients were excluded if they had fractures that were fixed more than 2 weeks from injury (six patients), if their fracture was treated with an intramedullary nail (one patient), or if the patient experienced compartment syndrome preoperatively (one patient). No patients with Gustilo-Anderson Type IIIB and C open fractures were included. Based on these criteria, 89% (66 of 74) of the patients were eligible. No further patients were excluded for loss of follow-up because the primary endpoint was the use of delayed wound closure, which was performed at the time of ORIF. However, one further patient was excluded for having bilateral forearm fractures to ensure that each patient had a single fracture for statistical analysis. Thus, 88% (65 of 74) of patients were included in the analysis. These patients were captured by an electronic medical record search of CPT code 25575. The mean ± SD age was 34 ± 15 years and mean BMI was 28 ± 7 kg/m 2 . The mean follow-up duration was 4 ± 5 months. The primary endpoint was the use of delayed wound closure, which was determined at the time of definitive fixation if tension-free closure could not be achieved. All surgeons used a volar Henry or modified Henry approach and a dorsal subcutaneous approach to the ulna for ORIF. Univariate logistic regression was used to identify which factors might be associated with delayed wound closure. A multivariable logistic regression analysis was then performed for male gender, open fractures, age, and BMI.

RESULTS

Twenty percent (13 of 65) of patients underwent delayed wound closure, 18% (12 of 65) of which occurred in patients who had high-energy injuries and 14% (nine of 65) in patients who had open fractures. Being a man (adjusted odds ratio 9.9 [95% confidence interval 1 to 87]; p = 0.04) was independently associated with delayed wound closure, after adjusting for open fractures, age, and BMI.

CONCLUSION

One of five patients had delayed wound closure after ORIF of both-bone forearm fractures. Being a man was independently associated with greater odds of delayed wound closure. Surgeons should counsel all patients with these fractures about the possibility of delayed wound closure, with particular attention to men with high-energy and open fractures. Future larger-scale studies are necessary to confirm which factors are associated with the use of delayed wound closure in ORIF of both-bone fractures and its effects on fracture healing.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Outcomes of Growth-friendly Instrumentation in Osteogenesis Imperfecta: A Preliminary Report

BACKGROUND

There is limited literature on the outcomes in patients with osteogenesis imperfecta (OI) undergoing growth-friendly instrumentation (GFI). The purpose of this study was to report the outcomes of GFI in patients with early-onset scoliosis (EOS) and OI. We hypothesized that similar trunk elongation could be obtained in OI patients, but with higher complication rates.

METHODS

A multicenter database was studied for patients with EOS and OI etiology who had GFI from 2005 to 2020, with a minimum 2-year follow-up. Demographic, radiographic, clinical, and patient-reported outcomes data were collected and compared with an idiopathic EOS cohort matched 2:1 for age, follow-up duration, and curve magnitude.

RESULTS

Fifteen OI patients underwent GFI at a mean age of 7.3±3.0 years, with an average follow-up of 7.3±3.9 years. OI patients had a mean preoperative coronal curve of 78.1±14.5 and achieved 35% correction after index surgery. There were no differences in major coronal curves and coronal percent correction between the OI and idiopathic groups at all time points. T1-S1 length (cm) was lower for the OI group at baseline (23.3±4.6 vs. 27.7±7.0; P =0.028) but both groups had similar growth (mm) per month (1.0±0.6 vs. 1.2±1.1; P =0.491). OI patients had a significantly increased risk of proximal anchor failure, which occurred in 8 OI patients (53%) versus 6 idiopathic patients (20%) ( P =0.039). OI patients who underwent preoperative halo-traction (N=4) had greater T1-S1 length gain (11.8±3.2 vs. 7.3±2.8; P =0.022) and greater percent major coronal curve correction (45±11 vs. 23±17; P =0.042) at final follow-up versus patients with no halo-traction (N=11). Staged foundation fusion was performed in 2 cases.

CONCLUSION

Compared with matched idiopathic EOS patients, OI patients undergoing GFI achieved similar radiographic outcomes but sustained greater rates of anchor failures, likely due to weakened bone. Preoperative halo-traction was a useful adjunct and may improve final correction. Staged foundation fusion is an idea to consider for difficult cases.

LEVEL OF EVIDENCE

Therapeutic-III.

Match Rates Among Underrepresented Minority and Female Applicants to Orthopaedic Surgery Residency Programs from 2011 to 2021: How Are We Doing?

Background

Orthopaedic surgery residency programs have traditionally had less representation of underrepresented minority (URM) and female trainees compared with other medical specialties. Widespread efforts have been implemented to increase the diversity of orthopaedic surgery residency programs; however, it is not known whether URM and female applicants are increasingly likely to match as a result. Thus, we aimed to study the independent association between URM and female applicants and matching into orthopaedic surgery over the past decade.

Methods

Applicant-level data from the Electronic Residency Application Service were reviewed from 2011 to 2021 with variables including demographic variables, URM status, and matriculation to an orthopaedic surgery residency program. Multivariate logistic regression was used to identify the likelihood of matriculating into orthopaedic surgery when controlling for number of applications, top 40 medical school status, AOA status, and MD/other degree.

Results

Twelve thousand one hundred eleven applicants were identified from 2011 to 2021 with a match rate of 70% overall. Two thousand fifty-six applicants (17%) were female and 1,926 (16%) classified as URM. The total number of applications increased from 1,074 in 2011 to 1,229 in 2021. The adjusted odds ratio (OR) associated with matching among all applicants decreased from 0.75 in 2011 to 0.64 in 2021, p < 0.001, and the OR of non-URM male and female applicants also decreased (female: 0.79-0.69, p < 0.001; male: 0.78-0.65, p < 0.001). The OR of URM male applicants did not change significantly (0.57-0.55, p = 0.60). The OR for URM female applicants, however, increased significantly from 0.46 to 0.61, p < 0.001. Over the entire time frame, the odds of matching were significantly lower for URM applicants compared with non-URM applicants (both male and female).

Conclusions

Overall, the adjusted odds ratio of matching into orthopaedic surgery among female URM applicants has increased over the past decade, indicating successful efforts to improve the diversity of orthopaedic surgery training programs. The odds of URM male applicants have remained relatively constant, and the odds of URM male and female applicants were significantly lower than all non-URM applicants.

Level of Evidence

III.

When to Perform Fusion Short of the Pelvis in Patients with Cerebral Palsy?: Indications and Outcomes

Patients with scoliosis secondary to cerebral palsy (CP) are often treated with posterior spinal fusion (PSF) with or without pelvic fixation. We sought to establish criteria to guide the decision of whether or not to perform fusion "short of the pelvis" in this population, and to assess differences in outcomes.

Methods

Using 2 prospective databases, we analyzed 87 pediatric patients who underwent PSF short of the pelvis from 2008 to 2015 to treat CP-related scoliosis and who had ≥2 years of follow-up. Preoperative radiographic and clinical variables were analyzed for associations with unsatisfactory correction (defined as pelvic obliquity of ≥10°, distal implant dislodgement, and/or reoperation for increasing deformity at 2- or 5-year follow-up). Continuous variables were dichotomized using the Youden index, and a multivariable model of predictors of unsatisfactory correction was created using backward stepwise selection. Finally, radiographic, health-related quality-of-life, and clinical outcomes of patients with fusion short of the pelvis who had neither of the 2 factors associated with unsatisfactory outcomes were compared with those of 2 matched-control groups.

Results

Deformity correction was unsatisfactory in 29 of 87 patients with fusion short of the pelvis. The final model included preoperative pelvic obliquity of ≥17° (odds ratio [OR], 6.8; 95% confidence interval [CI], 2.3 to 19.7; p < 0.01) and dependent sitting status (OR, 3.2; 95% CI, 1.1 to 9.9; p = 0.04) as predictors of unsatisfactory correction. The predicted probability of unsatisfactory correction increased from 10% when neither of these factors was present to a predicated probability of 27% to 44% when 1 was present and to 72% when both were present. Among matched patients with these factors who had fusion to the pelvis, there was no association with unsatisfactory correction. Patients with independent sitting status and pelvic obliquity of <17° who had fusion short of the pelvis had significantly lower blood loss and hospital length of stay, and better 2-year health-related quality-of-life scores compared with matched controls with fusion to the pelvis.

Conclusions

In patients with scoliosis secondary to CP, pelvic obliquity of <17° and independent sitting status are associated with a low risk of unsatisfactory correction and better 2-year outcomes when fusion short of the pelvis is performed. These may be used as preoperative criteria to guide the decision of whether to perform fusion short of the pelvis in patients with CP.

Level of Evidence

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Temporary internal distraction for severe scoliosis: two-year minimum follow-up

PURPOSE

Temporary internal distraction (TID) is a surgical technique used to correct severe scoliosis. We sought to evaluate the long-term outcomes associated with temporary internal distraction (TID) for severe scoliosis.

METHODS

Scoliosis patients who underwent TID from 2006 to 2019 at a single institution were identified. Patients with coronal Cobb angles ≥ 90° or congenital scoliosis, and ≥ 2-year follow-up were included. Clinical and imaging data were reviewed for patient and operative characteristics and complications. Patient-reported outcomes were also analyzed.

RESULTS

51 patients (37 female) were included. Mean age at surgery was 14.3 ± 3.5 years. Mean follow-up was 5.8 ± 3.0 years. Eighteen (35%) curves were idiopathic, 24 (47%) were cerebral palsy (CP) related, and 9 (18%) were congenital. Mean Cobb angle was 103° preoperatively and 20° at final follow-up, with an intermediate angle of 55º in staged procedures. Intraoperative neuromonitoring changes occurred in 13 (25.4%) cases, but all returned to baseline with immediate lessening of distraction. Overall, three (5.8%) cases of wound dehiscence, five (9.7%) cases of deep infections, one (2%) case of screw protrusion, and one (2%) case of delayed extremity weakness occurred. Patient-reported outcomes significantly improved at final follow-up.

CONCLUSION

Our findings suggest that TID is a valuable adjunct for correcting severe scoliosis. The mean Cobb reduction achieved (81%) was higher than that reported for halo-traction and was sustained over long-term follow-up. TID also allowed a shorter a hospital stay. While intraoperative neuromonitoring changes were not uncommon, they were reversible. However, care must always be exercised as major corrections may rarely result in delayed neurologic deficits despite intact neuromonitoring.

LEVEL OF EVIDENCE

Therapeutic-Level III.

Disparities in Elective Spine Surgery for Medicaid Beneficiaries: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVES

We sought to synthesize the literature investigating the disparities that Medicaid patients sustain with regards to 2 types of elective spine surgery, lumbar fusion (LF) and anterior cervical discectomy and fusion (ACDF).

METHODS

Our review was constructed in accordance with Preferred Reporting Items and Meta-analyses (PRISMA) guidelines and protocol. We systematically searched PubMed, Embase, Scopus, CINAHL, and Web of Science databases. We included studies comparing Medicaid beneficiaries to other payer categories with regards to rates of LF and ACDF, costs/reimbursement, and health outcomes.

RESULTS

A total of 573 articles were assessed. Twenty-five articles were included in the analysis. We found that the literature is consistent with regards to Medicaid disparities. Medicaid was strongly associated with decreased access to LF and ACDF, lower reimbursement rates, and worse health outcomes (such as higher rates of readmission and emergency department utilization) compared to other insurance categories.

CONCLUSIONS

In adult patients undergoing elective spine surgery, Medicaid insurance is associated with wide disparities with regards to access to care and health outcomes. Efforts should focus on identifying causes and interventions for such disparities in this vulnerable population.

The spectrum of foot deformities in Loeys-Dietz syndrome

Loeys-Dietz syndrome (LDS) is characterized by a wide spectrum of musculoskeletal manifestations, including foot deformities. The spectrum of foot deformities in LDS has not been previously characterized. Our objective was to describe the incidence and characteristics of foot deformities in LDS. We retrospectively reviewed the demographic, clinical and imaging data for patients diagnosed with LDS who were seen at our Orthopedic surgery department from 2008 to 2021. We performed descriptive analyses and compared distributions of deformities by LDS genetic mutations. Of the 120 patients studied, most presented for evaluation of foot deformities ( N  = 56, 47%) and scoliosis ( N  = 45; 38%). Ninety-seven patients (81%) had at least one foot deformity, and 87% of these patients had bilateral foot deformities. The most common deformities were pes planovalgus (53%) and talipes equinovarus (34%). Of patients with foot deformities, 58% presented for evaluation of the feet. Of patients with pes planovalgus, only 17% presented for evaluation of the feet. Among patients with pes planovalgus, 2% underwent surgery and 16% used orthotics compared with 76% and 42%, respectively, for patients with talipes equinovarus. We found no association between deformities and genetic mutations. Bilateral foot deformities are highly prevalent in patients with LDS and are the most common reason for presentation to orthopedic surgeons. Although pes planovalgus is the most common deformity, it rarely prompted surgical treatment. Orthopedic surgeons treating LDS patients should be aware of the unique characteristics of foot deformities in LDS.

Synovectomy in juvenile idiopathic arthritis: A systematic review and meta-analysis

BACKGROUND

Juvenile idiopathic arthritis (JIA) is an inflammatory arthropathy with onset in children younger than 16 years. Treatment is primarily medical; however, surgical interventions, such as arthroscopic or open synovectomy, can be beneficial. Many studies have investigated synovectomy in JIA, but the results of these studies have not been synthesized to our knowledge. Therefore, we performed a systematic review of the literature reporting synovectomy as a treatment for JIA to provide clinical recommendations regarding its risks and benefits.

METHODS

On March 8, 2022, we searched the Cochrane Library, Embase, PubMed, Scopus, and Web of Science for studies evaluating clinical outcomes of open or arthroscopic synovectomy to treat JIA in patients younger than 18 years. We included only studies published in English and excluded studies of synovectomy to treat other arthropathies, septic arthritis, hemophilia, or foreign body arthropathy. The level of evidence for included studies was determined by using the Oxford Centre for Evidence-Based Medicine criteria. We qualitatively analyzed clinical outcomes data, including patient-reported pain relief, rates of symptom recurrence, and postoperative complications.

RESULTS

Of 428 articles assessed, 14 were included in our analysis. One was a randomized trial, 1 was a case-control study, and all others were case-series. Studies consistently reported that synovectomy was associated with improved function and decreased pain postoperatively. However, comparisons with modern medical therapy were lacking. Rates of arthritis recurrence varied, with increasing symptom recurrence with longer follow-up and re-synovectomy rates up to 15%. Oligoarticular disease and early disease course were associated with better response to synovectomy, whereas systemic and polyarticular disease were associated with poor response. Stiffness requiring manipulation under anesthesia was the most common complication (4% of all included patients).

CONCLUSION

Although synovectomy is associated with positive functional outcomes and pain reduction postoperatively, there was inadequate comparison thus inadequate evidence to recommend it over modern medical therapy. The current literature suggests that synovectomy should be offered only to patients for whom medical management has failed, while noting the risks of decreased range of motion and symptom recurrence over time.

AAMC Guidance on Interviewing for the 2022-2023 Residency Application Cycle: Orthopaedic Program Director Perspectives

In May 2022, the Association of American Medical Colleges (AAMC) published guidelines regarding interviews for the 2022-2023 residency application cycle. These guidelines recommended virtual interviews and discouraged "hybrid" interviewing. We conducted a survey of orthopaedic program directors (PDs) to understand their perspectives on these new guidelines and their plans for the upcoming cycle.

METHODS

A 19-question multicenter, cross-sectional research survey was emailed to 98 PDs (38.8% response rate) through Qualtrics XM. Contact information was obtained from a public national database.

RESULTS

Most orthopaedic residency programs (60.5%) were planning on conducting in-person interviews before any AAMC and hospital guidelines, and most (65.8%) will likely be conducting virtual interviews post-guidelines. PDs voiced mixed opinions about virtual interviews (39.4% in favor vs. 47.4% against). PDs were also split on whether forgoing the AAMC guidance would be irresponsible for residency programs (47.4% believe it would be irresponsible vs. 44.8% believe it would not); however, a plurality are in favor of the AAMC's guidance (42.1%). Furthermore, PDs agreed that virtual interviews have disadvantages including favoring top-tier applicants, students from home institutions, and in-person rotators, making ranking applicants and learning about a program's culture more difficult. Most PDs (84.2%) felt that hybrid interviews would disadvantage applicants who would choose the virtual option.

CONCLUSION

AAMC guidance seems to be influencing how most orthopaedic surgery programs will conduct residency interviews for the 2022-2023 cycle. Most PDs agreed with the AAMC guidelines but voiced concerns regarding several disadvantages for all 3 proposed interview options (virtual, in-person, and hybrid). Our results indicate that the recent AAMC guidelines may have contributed to a shift in opinions among PDs but are not sufficient to create a consensus on the best practices for residency interviews. Our findings should encourage solutions focused on the deeper systemic issues within the orthopaedic application process in the post-coronavirus 2019 pandemic era.

Anemia and Its Severity Is Associated With Worse Postoperative Outcomes Following Open Reduction Internal Fixation of Ankle Fractures

BACKGROUND

Ankle fractures are often treated in a nonemergent fashion and therefore offer the chance for treatment of preoperative anemia. Although preoperative anemia has been associated with postoperative morbidity following certain types of orthopaedic procedures, its effect on postoperative outcomes following open reduction internal fixation (ORIF) of ankle fractures has not been evaluated. The purpose of this study was to determine the influence of preoperative anemia on 30-day postoperative outcomes following ankle fracture ORIF.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ASC-NSQIP) registry was queried from 2005 to 2019 for patients undergoing ankle fracture ORIF. Patients were stratified into nonanemic, mildly anemic, and moderately to severely anemic. Univariate analyses were used to assess differences in patient characteristics between cohorts. Multivariate logistic regressions adjusting for these differences were performed to assess the effect of preoperative anemia on 30-day postoperative outcomes.

RESULTS

We obtained data for 21 211 patients, of whom 14 931 (70.39%) were not anemic, 3982 (18.77%) were mildly anemic, and 2298 (10.83%) were moderately to severely anemic. After adjustment, mild preoperative anemia was associated with higher odds of any adverse event (P < .001), deep surgical site infections (SSIs; P = .013), sepsis (P = .001), 30-day readmission (P < .001), and extended length of stay (LOS) (P < .001). Similarly, moderate to severe anemia in these patients was also associated with increased odds of any adverse event (P < .001), deep SSIs (P = .003), sepsis (P = .001), readmission (P < .001), and extended LOS (P < .001). Both mild (P = .004) and moderate to severe (P < .001) anemia groups had higher odds of requiring a blood transfusion.

CONCLUSION

Preoperative anemia is associated with an increased risk of adverse postoperative outcomes in patients undergoing ORIF for ankle fractures. Future studies should evaluate whether optimization of hematocrit in these patients results in improved outcomes.

LEVEL OF EVIDENCE

Level III, comparative study.

Prescription Patterns, Associated Factors, and Outcomes of Opioids for Operative Foot and Ankle Fractures: A Systematic Review

BACKGROUND

Pain management after foot and ankle surgery must surmount unique challenges that are not present in orthopaedic surgery performed on other parts of the body. However, disparate and inconsistent evidence makes it difficult to draw meaningful conclusions from individual studies.

QUESTIONS/PURPOSES

In this systematic review, we asked: what are (1) the patterns of opioid use or prescription (quantity, duration, incidence of persistent use), (2) factors associated with increased or decreased risk of persistent opioid use, and (3) the clinical outcomes (principally pain relief and adverse events) associated with opioid use in patients undergoing foot or ankle fracture surgery?

METHODS

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for our review. We searched PubMed, Embase, Scopus, Cochrane, and Web of Science on October 15, 2021. We included studies published from 2010 to 2021 that assessed patterns of opioid use, factors associated with increased or decreased opioid use, and other outcomes associated with opioid use after foot or ankle fracture surgery (principally pain relief and adverse events). We excluded studies on pediatric populations and studies focused on acute postoperative pain where short-term opioid use (< 1 week) was a secondary outcome only. A total of 1713 articles were assessed and 18 were included. The quality of the 16 included retrospective observational studies and two randomized trials was evaluated using the Methodological Index for Non-Randomized Studies criteria and the Jadad scale, respectively; study quality was determined to be low to moderate for observational studies and good for randomized trials. Mean patient age ranged from 42 to 53 years. Fractures studied included unimalleolar, bimalleolar, trimalleolar, and pilon fractures.

RESULTS

Proportions of postoperative persistent opioid use (defined as use beyond 3 or 6 months postoperatively) ranged from 2.6% (546 of 20,992) to 18.5% (32 of 173) and reached 39% (28 of 72) when including patients with prior opioid use. Among the numerous associations reported by observational studies, two or more preoperative opioid prescriptions had the strongest overall association with increased opioid use, but this was assessed by only one study (OR 11.92 [95% confidence interval (CI) 9.16 to 13.30]; p < 0.001). Meanwhile, spinal and regional anesthesia (-13.5 to -41.1 oral morphine equivalents (OME) difference; all p < 0.01) and postoperative ketorolac use (40 OME difference; p = 0.037) were associated with decreased opioid consumption in two observational studies and a randomized trial, respectively. Three observational studies found that opioid use preoperatively was associated with a higher proportion of emergency department visits and readmission (OR 1.41 to 17.4; all p < 0.001), and opioid use at 2 weeks postoperatively was associated with slightly higher pain scores compared with nonopioid regimens (β = 0.042; p < 0.001 and Likert scale 2.5 versus 1.6; p < 0.05) in one study.

CONCLUSION

Even after noting possible inflation of the harms of opioids in this review, our findings nonetheless highlight the need for opioid prescription guidelines specific for foot and ankle surgery. In this context, surgeons should utilize short (< 1 week) opioid prescriptions, regional anesthesia, and multimodal pain management techniques, especially in patients at increased risk of prolonged opioid use.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Opioid Use for Operative Foot and Ankle Fractures: A Systematic Review

Category:

Ankle; Trauma

Introduction/Purpose:

Patients treated operatively for foot and ankle fractures may be at higher risk of undertreated pain as well as overuse of opioid medications. We sought to synthesize the recent literature investigating use of opioids for analgesia following foot and ankle fracture surgery. To accomplish this, we aimed to determine the patterns of opioid use and prescription (e.g., quantity, duration, incidence of persistent use), risk or protective factors for persistent opioid use, and clinical outcomes (e.g., relief of pain, adverse events) associated with opioid use in this population.

Methods:

We followed PRISMA guidelines for our review. We systematically searched PubMed, Embase, Scopus, Cochrane, and Web of Science. We included studies published from 2010 to present that assessed patterns of opioid use, risk factors for increased opioid use, and outcomes associated with opioid use following foot/ankle fracture surgery. Two reviewers performed title/abstract screening and full-text review. The quality of included studies was evaluated using MINORS criteria.

Results:

In our review, 1713 articles were assessed and 18 were included (Figure 1). MINORS scores ranged from 13 to 18, indicating moderate study quality. Overall, there was wide variability in opioid use between and within studies. Rates of postoperative persistent opioid use ranged from 7-39%. Risk factors for increased opioid use included preoperative opioid exposure, mental health disorders, tobacco consumption, and certain injury patterns. Protective factors were spinal anesthesia, peripheral nerve block, and postoperative ketorolac. Opioid use was not associated with decreased pain or improved satisfaction. Opioid use was associated with increased rates of pain-related emergency department visits and readmission. Preoperative opioid use was associated with the greatest odds of increased postoperative use.

Conclusion:

There is a high incidence of persistent opioid use after foot and ankle fracture surgery. Opioid use was associated with negative health outcomes without decreasing pain levels or increasing patient satisfaction after foot/ankle fracture surgery. The wide variability of reported opioid use emphasizes the need for standardized guidelines for postoperative opioid use in this patient population, and our findings suggest that lower opioid prescription may be advisable.

Epidemiology of Isolated Ankle Dislocations in the United States

Category:

Trauma; Ankle

Introduction/Purpose:

Isolated ankle dislocations (IADs) are rare type of dislocation associated with significant morbidity. Prompt reduction is indicated to prevent negative sequelae. Considering the potential negative outcomes associated with this injury, we sought to identify populations at increased risk.

Methods:

The National Electronic Injury Surveillance System (NEISS) database was queried to identify patients who presented to Emergency Departments (EDs) in the U.S. for IADs between 2001-2019. NEISS codes indicating ankle dislocation as the primary diagnosis were utilized. Population estimates were derived from the U.S. Census Bureau for calculation of incidence in person- years. Chi-square analysis and Wald chi-square tests were performed to assess differences between subgroups.

Results:

An estimated 52,520 IADs (2,862 per year) were identified among a population at risk of 5,853,993,882 person-years. The estimated incidence of IADs in the general population presenting to EDs was 0.90 per 100,000 person-years. Patients with IADs were most commonly male (61.6%), white (71.9%), and between 15-35 years old (60.1%). Patients aged 15-20 years comprised the highest proportion of IADs (19.6%). Surprisingly, sport-related activities accounted for a minority of injuries (38.2%), with most of these occurring during basketball (47.8%), football (12.9%), and soccer (9.8%). Most IADs were due to non- athletic activity, with falls from stairs (30.8%) and ladders (13.4%), and skateboarding (5.0%) being the most common mechanisms. When comparing injured male and female patients, female patients were older (45.2 vs 32.0 years; P<0.001), more likely to be injured during non-athletic activities (83.9% vs 48.1%; P<0.001), and more likely to be hospitalized after ED visit (27.3% vs 17.6%; P<0.001).

Conclusion:

IADs are extremely rare. They occur most frequently during non-athletic activities in young-to-middle-aged Caucasian men. Although more common in males, females with IADs tend to be older, more likely to be injured during non- athletic activities compared to sports, and more likely to be hospitalized. This suggests that, when IADs do occur in women, they may be at higher risk for negative outcomes.

Height Gain After Spinal Fusion for Idiopathic Scoliosis: Which Model Fits Best?

BACKGROUND

Patients will often inquire about the magnitude of height gain after scoliosis surgery. Several published models have attempted to predict height gain using preoperative variables. Many of these models reported good internal validity but have not been validated against an external cohort. We attempted to test the validity of 5 published models against an external cohort from our institution. Models included were Hwang, Van Popta, Spencer, Watanabe, and Sarlak models.

METHODS

We retrospectively queried our institution's records from 2006 to 2019 for patients with adolescent idiopathic scoliosis treated with posterior spinal fusion. We recorded preoperative and postoperative variables including clinical height measurements. We also performed radiographic measurements on preoperative and postoperative radiographic studies. We then tested the ability of the models to predict height gain by evaluating Pearson correlation coefficient, root mean square error, Akaike Information Criterion for each model.

RESULTS

A total of 387 patients were included. Mean clinical height gain was 3.1 (±1.7) cm.All models demonstrated a moderate positive Pearson correlation coefficient, except the Hwang model, which demonstrated a weak correlation. The Spencer model was the only model with acceptable root mean square error (≤0.5) and was also the best fitting with the lowest Akaike Information Criterion (-308). The mean differences in height gain predictions between all models except the Hwang model was ≤1 cm.

CONCLUSIONS

Four of the 5 models demonstrated moderate correlation and had good external validity compared with their development cohorts. Although the Spencer model was the best fitting, the clinical significance of the difference in height predictions compared with other models was low. The Watanabe model was the second best fitting and had the simplest formula, making it the most convenient to use in a clinical setting. We offer a simplified equation to use in a preoperative clinical setting based on this data-ΔHeight (mm)=0.77*(preoperative coronal angle-postoperative coronal angle).

LEVEL OF EVIDENCE

Not Applicable.

Early Postoperative Complications in Total Hip and Knee Arthroplasty Before and During the COVID-19 Pandemic: A Retrospective Analysis of 38,234 Patients

Background

The outcomes of total joint arthroplasty during the coronavirus disease 2019 (COVID-19) pandemic are unknown. We sought to compare early postoperative complications in total hip arthroplasty (THA) and total knee arthroplasty (TKA) prior to and during the COVID-19 pandemic.

Methods

Patients in the American College of Surgeons National Surgical Quality Improvement Program database who had THA or TKA in the latter halves (July to December) of 2019 and 2020 were identified. Patients were divided into pre-COVID-19 (2019) and during-COVID-19 (2020) cohorts. Propensity score matching and logistic regression were used to detect correlations between operative period and outcomes. Statistical significance was set at α = 0.05.

Results

A total of 38,234 THA and 61,956 TKA patients were included. There was a significantly higher rate of outpatient procedures in 2020 than that in 2019 for both THA (41.68% vs 6.59%, P < .001) and TKA (41.68% vs 7.56%, P < .001). On matched analysis, surgery in 2020 had lower odds of hospital stay for >1 day (THA: odds ratio [OR] 0.889; P < .001) (TKA: OR 0.644; P < .001) and nonhome discharge (THA: 0.655; P < .001) (TKA: 0.497; P < .001). There was also increased odds of superficial surgical site infection in THA (OR 1.272; P = .040) and myocardial infarction in TKA patients (OR 1.488; P = .042) in 2020 compared to those in 2019. There was no difference in the 15 other outcomes assessed.

Conclusions

Total joint arthroplasty surgery remains safe despite the COVID-19 pandemic. A statistically significant increase was detected in superficial surgical site infection and myocardial infarction risk during 2020 compared to 2019; however, the clinical significance of this is questionable. A shift away from inpatient stay was also present, possibly reflecting efforts to minimize nosocomial exposure to COVID-19.

Temporary Internal Distraction for Severe Scoliosis

Temporary internal distraction (TID) is a surgical technique that can be utilized to correct severe scoliotic deformities. It allows the correction of severe curves (i.e., exceeding 90° to 100°) while minimizing the risk of neurologic injury associated with large corrections^1,2.

Description

TID can be performed as a single or staged procedure. During the first part, cephalad anchors are placed on the spine or ribs, and caudad anchors are placed on the spine or pelvis. Temporary distraction rods are inserted, osteotomies and/or releases are performed, and iterative distractions are utilized for the duration of the procedure. If adequate correction is achieved, the final fusion may be completed at this time. If not, a staged approach may be performed: the wound is closed and the patient is returned to the operating room 1 to 3 weeks later, at which time the temporary rods are removed, further distraction is performed, and the final fusion instrumentation is placed. Around 80% to 90% cumulative correction of the major coronal angle should be achievable.

Alternatives

The mainstay of treatment for large scoliotic curves is typically surgical correction and fusion. The main alternative to TID is traditional halo-gravity traction followed by fusion^3-5. In rare cases, nonoperative treatment may be appropriate if comorbidities and/or prognoses that preclude surgery exist.

Rationale

Halo traction is an effective adjunct for the treatment of large scoliotic curves; nonetheless, it has several disadvantages. First, halo traction requires a prolonged hospital stay with restriction of mobility and interference with daily activities. Second, this procedure may be less effective in cases of lumbar deformity, in which halo traction achieves limited tensile forces. Third, this procedure is associated with several risks, such as cranial nerve injuries and pin track complications^3-6. Finally, halo traction is contraindicated for certain conditions, such as cervical instability.TID, on the other hand, involves the application of iterative corrective forces directly to the area of deformity, allowing a stronger correction¹. TID takes advantage of the viscoelastic nature of the spine to achieve a higher percent correction compared with halo traction, with a low risk of neurologic injury^1,2. TID also avoids the prolonged hospital stay, mobility restriction, and complications associated with halo traction. When performed as a staged procedure, TID allows accurate assessment of neurologic function with the patient awake and moving.TID is most effective for severe scoliotic multisegment deformities rather than short rigid curves, which are better treated by osteotomies.

Expected Outcomes

This procedure provides satisfactory outcomes and a low risk of complications. In our retrospective case series, TID resulted in a mean major coronal angle correction of 53% after the first distraction and 80% to 90% after definitive fusion¹. The overall percent correction was higher than that reported for halo traction¹.The major risks of TID include infection and spinal injury. The risk of infection is decreased by antibiotic prophylaxis, perioperative nutritional optimization, and careful soft-tissue handling and wound closure. The risk of spinal cord injury is decreased by intraoperative neuromonitoring. Neuromonitoring changes occur in around 40% of cases, but these are almost always reversible and seldom lead to neurologic deficits if detected and appropriately treated, as described below².Although risks exist, no complications have occurred among the 32 cases we presented in our series^1,2.

Important Tips

Temporary anchors should be expected to loosen during distraction. Therefore, temporary anchors must be placed strategically so as to not jeopardize the purchase of the final implants.Gradual corrections must be performed over time, utilizing the viscoelastic nature of the spine to minimize risk of neurologic injury.Accurate neuromonitoring is essential for this procedure.If neuromonitoring changes occur, distraction must be stopped and the correction attained must be decreased.

Acronyms and Abbreviations

TID = temporary internal distractionLIV = lowest instrumented vertebraAP = anteroposteriorTP = transverse processSAI = sacral-alar-iliacMAP = mean arterial pressureTPN = total parenteral nutritionVCR = vertebral column resectionJIS = juvenile idiopathic scoliosisAIS = adolescent idiopathic scoliosis.

Talipes Equinovarus in Loeys-Dietz Syndrome

BACKGROUND

Loeys-Dietz syndrome (LDS) commonly presents with foot deformities, such as talipes equinovarus (TEV), also known as "clubfoot." Although much is known about the treatment of idiopathic TEV, very little is known about the treatment of TEV in LDS. Here, we summarize the clinical characteristics of patients with LDS and TEV and compare clinical and patient-reported outcomes of operative versus nonoperative treatment.

METHODS

We identified 47 patients with TEV from a cohort of 252 patients with LDS who presented to our academic tertiary care hospital from 2010 to 2016. A questionnaire, electronic health records, clinical photos and radiographs, and telephone calls were used to collect baseline, treatment, and outcome data. The validated disease-specific instrument was used to determine patient-reported foot/ankle functional limitations after treatment. Patients were categorized into nonoperative and operative groups, with the operative group subcategorized according to whether the posteromedial release was performed.

RESULTS

Within our TEV cohort, bilateral TEV was present in 40 patients (85%). Thirty-seven patients underwent surgery (14 involving posteromedial release), and 10 were treated nonoperatively. The operative group had a higher incidence of posttreatment foot/ankle functional limitation (71%) than the nonoperative group (25%) ( P =0.04). The pain was the most common functional limitation (54%). The posteromedial release was associated with a higher incidence of developing hindfoot valgus compared with surgery not involving posteromedial release (43% vs. 8.7%, P =0.04) and compared with nonoperative treatment (43% vs. 0.0%, P =0.02).

CONCLUSIONS

We found that patients with LDS have a high incidence of bilateral TEV. Operative treatment was associated with posttreatment foot/ankle functional limitations, and posteromedial release was associated with hindfoot valgus overcorrection deformity. These findings could have implications for the planning of surgery for TEV in LDS patients.

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

Critically Appraising the Quality of Reporting of American College of Surgeons TQIP Studies in the Era of Large Data Research

BACKGROUND

The American College of Surgeons-Trauma Quality Improvement Program (ACS-TQIP) database is one of the most widely used databases for trauma research. We aimed to critically appraise the quality of the methodological reporting of ACS-TQIP studies.

STUDY DESIGN

The ACS-TQIP bibliography was queried for all studies published between January 2018 and January 2021. The quality of data reporting was assessed using the Strengthening the Reporting of Observational studies in Epidemiology-Reporting of Studies Conducted Using Observational Routinely Collected Health Data (STROBE-RECORD) statement and the JAMA Surgery checklist. Three items from each tool were not applicable and thus excluded. The quality of reporting was compared between high- and low-impact factor (IF) journals (cutoff for high IF is >90th percentile of all surgical journals).

RESULTS

A total of 118 eligible studies were included; 12 (10%) were published in high-IF journals. The median (interquartile range) number of criteria fulfilled was 5 (4-6) for the STROBE-RECORD statement (of 10 items) and 5 (5-6) for the JAMA Surgery checklist (of 7 items). Specifically, 73% of studies did not describe the patient population selection process, 61% did not address data cleaning or the implications of missing values, and 76% did not properly state inclusion/exclusion criteria and/or outcome variables. Studies published in high-IF journals had remarkably higher quality of reporting than those in low-IF journals.

CONCLUSION

The methodological reporting quality of ACS-TQIP studies remains suboptimal. Future efforts should focus on improving adherence to standard reporting guidelines to mitigate potential bias and improve the reproducibility of published studies.

Racial differences in late-onset Blount disease

PURPOSE

Blount disease is most common among obese Black children. The reason for Blount's racial predisposition is unclear. Given that obesity is a risk factor for Blount disease and the known associations between race, obesity, and socioeconomic status in the United States, we hypothesized that socioeconomic status and severity of obesity differ between Black and non-Black children with late-onset Blount disease. We additionally examined differences in treatment types between Black and non-Black children.

METHODS

One hundred twenty-five patients from two institutions were included. Age at presentation, age of onset, body mass index, race, sex, and treatment type were recorded. These variables were compared between Black and non-Black children. Insurance type and estimated household income were used as markers of socioeconomic status.

RESULTS

Of the 125 patients with late-onset Blount disease, body mass index percentiles were higher for Black patients (96th ± 12th percentile) than non-Black patients (89th ± 22nd percentile) (p = 0.04). Black patients also had lower estimated incomes (US$48,000 ± US$23,000 vs US$62,000 ± US$30,000) (p = 0.01) and much higher rates of Medicaid enrollment (69% vs 24%) (p < 0.01) than did non-Black patients. Regarding treatment types, osteotomy was more common among Black patients (60%) than non-Black patients (38%) (p = 0.033).

CONCLUSION

The race-related associations we found between obesity and socioeconomic status suggest that non-genetic factors may contribute to observed racial differences in the prevalence of Blount disease.

LEVEL OF EVIDENCE

level III.

Appraising the Quality of Reporting of American College of Surgeons NSQIP Emergency General Surgery Studies

BACKGROUND

The quality of emergency general surgery (EGS) studies that use the American College of Surgeons-National Quality Improvement Program (ACS-NSQIP) database is variable. We aimed to critically appraise the methodologic reporting of EGS ACS-NSQIP studies.

STUDY DESIGN

We searched the PubMed ACS-NSQIP bibliography for EGS studies published from 2004 to 2019. The quality of reporting of each study was assessed according to the number of criteria fulfilled with respect to the 13-item RECORD statement and the 10-item JAMA Surgery checklist. Three criteria in each checklist were not applicable and were therefore excluded. An analysis was conducted comparing studies published in high and low impact factor (IF) journals.

RESULTS

We identified a total of 99 eligible studies. Twenty-six percent of studies were published in high IF journals, and 73% of the journals had a policy requiring adherence to reporting statements. The median number of criteria fulfilled for the RECORD statement (out of 10 items) and the JAMA Surgery checklist (out of 7 items) were both equal to 4 (interquartile range [IQR] 3, 5). Sixty-three percent of studies did not explain the methodology for data cleaning, 81% of studies did not describe the population selection process, and 55% did not discuss the implications of missing variables. There were no differences in overall scores between studies published in high and low IF journals.

CONCLUSIONS

The methodologic reporting of EGS studies using ACS-NSQIP remains suboptimal. Future efforts should focus on improving adherence to the policies to mitigate potential sources of bias and improve the credibility of large database studies.

Targeted educational program improves infant positioning practice in the NICU

Quality problem or issue

Infant positioning may interfere with neuromotor development. Bedside education and Infant Positioning Assessment Tool (IPAT) improve nurses' and doctors' proficiency in applying proper infant positioning.

Initial assessment

Nursing compliance with proper positioning is suboptimal due to many factors. One factor was the inadequate knowledge and practice of infant positioning, since the baseline mean IPAT score was 3.4.

Choice of solution

Three experienced neonatal intensive care unit (NICU) nurses were chosen as position champions to help other NICU nurses apply proper positioning and monitor IPAT scores. Education and hands-on demonstration sessions were developed based on the observed baseline practice.

Implementation

Periodic education with hands-on demonstration was given to NICU nurses and residents. Infants' positions were objectively scored using IPAT. Two Plan, Do, Study and Act cycles were completed and adjustments were made based on each cycle's achieved results.

Evaluation

Mean IPAT scores increased from 3.4 at baseline and 6.3 in the second cycle to 7.3 in the third cycle of intervention.

Lessons learned

A systematic approach targeting infants' positioning succeeded in improving nurses' and residents' clinical performance. Not reaching significant change until after 18 months highlights the difficulty and complexity in changing behaviors.