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Schlauch AM, Manske MC, Leshikar HB, Davids JR. Posttraumatic Cubitus Varus: Respect the Columns. J Pediatr Orthop 2024:01241398-990000000-00520. [PMID: 38515131 DOI: 10.1097/bpo.0000000000002671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
Posttraumatic cubitus varus is a multiplanar deformity that results from an improperly reduced supracondylar humerus fracture. The prevention of posttraumatic cubitus varus hinges on the stable restoration of all 3 columns of the distal humerus while avoiding malrotation. The collapse of any column leads to varying degrees of deformity in the coronal, sagittal, and/or axial plane. The purpose of this article is to explain the pattern of the deformity and use this to summarize preventative tactics for avoiding its described sequelae. We also summarize, illustrate, and present case examples for the various osteotomies used to correct the deformity, and speculate future directions.
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Affiliation(s)
- Adam M Schlauch
- Department of Orthopaedic Surgery, San Francisco Orthopaedic Residency Program/St. Mary's Medical Center, San Francisco
| | - Mary Claire Manske
- Department of Orthopaedic Surgery, Shriners Hospitals for Children-Northern California
- Department of Orthopaedic Surgery, University of California Davis Health, Sacramento, CA
| | - Holly B Leshikar
- Department of Orthopaedic Surgery, Shriners Hospitals for Children-Northern California
- Department of Orthopaedic Surgery, University of California Davis Health, Sacramento, CA
| | - Jon R Davids
- Department of Orthopaedic Surgery, Shriners Hospitals for Children-Northern California
- Department of Orthopaedic Surgery, University of California Davis Health, Sacramento, CA
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White CR, Leshikar HB, White MR, White SR, Semkiw K, Farmer DL, Haus BM. Does the American College of Surgeons New Level I Children's Surgery Center Verification Affect Treatment Efficiency and Narcotic Administration in Treating Pediatric Trauma Patients with Femur Fracture? J Am Coll Surg 2023; 236:476-483. [PMID: 36729765 PMCID: PMC9924964 DOI: 10.1097/xcs.0000000000000496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 11/12/2022] [Accepted: 11/15/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND In 2015, the American College of Surgeons (ACS) created a new hospital improvement program to enhance the performance of pediatric care in US hospitals. The Children's Surgery Verification (CSV) Quality Improvement Program is predicated on the idea that pediatric surgical patients have improved outcomes when treated at children's hospitals with optimal resources. Achieving ACS level I CSV designation at pediatric trauma centers may lead to greater benefits for pediatric trauma patients; however, the specific benefits have yet to be identified. We hypothesize that achieving the additional designation of ACS level I CSV is associated with decreased narcotic use perioperatively and improved efficiency when managing pediatric patients with femur fractures. STUDY DESIGN This study is a retrospective analysis of traumatic pediatric orthopaedic femur fractures treated at a verified level I pediatric trauma center before and after CSV designation (2010 to 2014 vs 2015 to 2019). Efficiency parameters, defined as time from admission to surgery, duration of surgery, and duration of hospital stay, and narcotic administration in oral morphine equivalents (OMEs) were compared. RESULTS Of 185 traumatic femur fractures analyzed, 80 occurred before meeting ACS level I CSV criteria, and 105 occurred after. Post-CSV, there was a significant decrease in mean wait time from admission to surgery (16.64 hours pre-CSV, 12.52 hours post-CSV [p < 0.01]) and duration of hospital stay (103.49 hours pre-CSV, 71.61 hours post-CSV [p < 0.01]). Narcotic usage was significantly decreased in both the preoperative period (40.61 OMEs pre-CSV, 23.77 OMEs post-CSV [p < 0.01]) and postoperative period (126.67 OMEs pre-CSV, 45.72 OMEs post-CSV [p < 0.01]). CONCLUSIONS Achieving ACS level I CSV designation is associated with increased efficiency and decreased preoperative and postoperative narcotic use when treating pediatric trauma patients.
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Affiliation(s)
- Carter R White
- From the University of California, Davis, School of Medicine, Sacramento, CA (CR White, Leshikar, MR White, Farmer, Haus)
| | - Holly B Leshikar
- From the University of California, Davis, School of Medicine, Sacramento, CA (CR White, Leshikar, MR White, Farmer, Haus)
- the University of California, Davis, Children’s Hospital Department of Orthopaedic Surgery, Sacramento, CA (Leshikar, Haus)
| | - Micaela R White
- From the University of California, Davis, School of Medicine, Sacramento, CA (CR White, Leshikar, MR White, Farmer, Haus)
| | | | - Karen Semkiw
- the University of California, Davis, Children’s Hospital Department of General Surgery, Sacramento, CA (Semkiw, Farmer)
| | - Diana L Farmer
- From the University of California, Davis, School of Medicine, Sacramento, CA (CR White, Leshikar, MR White, Farmer, Haus)
- the University of California, Davis, Children’s Hospital Department of General Surgery, Sacramento, CA (Semkiw, Farmer)
| | - Brian M Haus
- From the University of California, Davis, School of Medicine, Sacramento, CA (CR White, Leshikar, MR White, Farmer, Haus)
- the University of California, Davis, Children’s Hospital Department of Orthopaedic Surgery, Sacramento, CA (Leshikar, Haus)
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Marcin JP, Tancredi DJ, Galante JM, Rinderknecht TN, Haus BM, Leshikar HB, Zwienenberg M, Rosenthal JL, Grether-Jones KL, Hamline MY, Hoch JS, Kuppermann N. Measuring the impact of a "Virtual Pediatric Trauma Center" (VPTC) model of care using telemedicine for acutely injured children versus the standard of care: study protocol for a prospective stepped-wedge trial. Trials 2022; 23:1051. [PMID: 36575536 PMCID: PMC9793356 DOI: 10.1186/s13063-022-06996-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Accepted: 12/08/2022] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND The current standard of care in the treatment of children with physical trauma presenting to non-designated pediatric trauma centers is consultation with a pediatric trauma center by telephone. This includes contacting a pediatric trauma specialist and transferring any child with a potentially serious injury to a regionalized level I pediatric trauma center. This approach to care frequently results in medically unnecessary transfers and may place undue burdens on families. A newer model of care, the "Virtual Pediatric Trauma Center" (VPTC), uses telemedicine to make the expertise of a level I pediatric trauma center virtually available to any hospital. While the use of the VPTC model of care is increasing, there have been no studies comparing the VPTC to standard care of injured children at non-designated trauma centers with respect to patient- and family-centered outcomes. The goal of this study is to compare the current standard of care to the VPTC with respect to family-centered outcomes developed by parents and community advisory boards. METHODS We will use a stepped-wedge trial design to enroll children with physical trauma presenting to ten hospitals, including level II, level III, and non-designated trauma centers. The primary outcome measures are parent/family experience of care and distress 3 days following injury. Secondary aims include 30-day healthcare utilization, parent/family out-of-pocket costs at 3 days and 30 days after injury, transfer rates, and parent/family distress 30 days following injury. We expect at least 380 parents/families of children will be eligible for the study following an emergency department physician's request for a level I pediatric trauma center consultation. We will evaluate parent/family experience of care and distress using previously validated instruments, healthcare utilization by family recollection and medical record abstraction, and out-of-pocket costs using standard economic analyses. DISCUSSION We expect that the findings from this study will inform other level I pediatric trauma centers and non-pediatric trauma centers on how to improve their systems of care for injured children. The results will help to optimize communication, confidence, and shared decision-making between parents/families and clinical staff from both the transferring and receiving hospitals. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04469036. Registered July 13, 2020 before start of inclusion.
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Affiliation(s)
- James P. Marcin
- grid.27860.3b0000 0004 1936 9684Department of Pediatrics, University of California, Davis, Sacramento, CA USA
| | - Daniel J. Tancredi
- grid.27860.3b0000 0004 1936 9684Department of Pediatrics, University of California, Davis, Sacramento, CA USA
| | - Joseph M. Galante
- grid.27860.3b0000 0004 1936 9684Department of Surgery, University of California, Davis, Sacramento, CA USA
| | - Tanya N. Rinderknecht
- grid.27860.3b0000 0004 1936 9684Department of Surgery, University of California, Davis, Sacramento, CA USA
| | - Brian M. Haus
- grid.27860.3b0000 0004 1936 9684Department of Orthopedic Surgery, University of California, Davis, Sacramento, CA USA
| | - Holly B. Leshikar
- grid.27860.3b0000 0004 1936 9684Department of Orthopedic Surgery, University of California, Davis, Sacramento, CA USA
| | - Marike Zwienenberg
- grid.27860.3b0000 0004 1936 9684Department of Neurological Surgery, University of California, Davis, Sacramento, CA USA
| | - Jennifer L. Rosenthal
- grid.27860.3b0000 0004 1936 9684Department of Pediatrics, University of California, Davis, Sacramento, CA USA
| | - Kendra L. Grether-Jones
- grid.27860.3b0000 0004 1936 9684Department of Emergency Medicine, University of California, Davis, Sacramento, CA USA
| | - Michelle Y. Hamline
- grid.27860.3b0000 0004 1936 9684Department of Pediatrics, University of California, Davis, Sacramento, CA USA
| | - Jeffrey S. Hoch
- grid.27860.3b0000 0004 1936 9684Department of Public Health Sciences, University of California, Davis, Sacramento, CA USA
| | - Nathan Kuppermann
- grid.27860.3b0000 0004 1936 9684Department of Pediatrics, University of California, Davis, Sacramento, CA USA ,grid.27860.3b0000 0004 1936 9684Department of Emergency Medicine, University of California, Davis, Sacramento, CA USA
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Shieh AK, Saiz Jr AM, Hideshima KS, Haus BM, Leshikar HB. Defining length stability in paediatric femoral shaft fractures treated with titanium elastic nails. J Child Orthop 2021; 15:525-531. [PMID: 34987661 PMCID: PMC8670542 DOI: 10.1302/1863-2548.15.210081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 09/30/2021] [Indexed: 02/03/2023] Open
Abstract
INTRODUCTION Optimal paediatric femoral shaft fracture patterns or lengths amenable to titanium elastic nail stabilization have not been well defined. The purpose of this study is to identify radiographic parameters predictive of treatment failure with flexible intramedullary nails based upon fracture morphology. METHODS A retrospective review was performed of all femoral shaft fractures treated with flexible intramedullary nails over a five-year period. All patients with at least six weeks of postoperative radiographic imaging were included. Fracture characteristics included location, pattern, length, obliquity, angulation, translation and shortening. Postoperative radiographs were reviewed to determine shortening and angulation. RESULTS There were 58 patients with 60 femoral shaft fractures stabilized with titanium nails, with 46 healing within acceptable parameters and 14 considered malunions. Six of the 14 malunions developed complications requiring early unplanned intervention. No patients in the treatment success group had a complication. Between the treatment success and failure groups, fracture pattern, location, length, obliquity, angulation, translation or shortening were not statistically different. Mean nail canal fill was significantly lower in the failure group (0.72 versus 0.81; p = 0.0146), with a receiver operating characteristic curve identifying canal fill 76% as the optimal threshold. CONCLUSION This is the first study to measure the length and obliquity of paediatric femoral shaft fractures and to determine their relationship to radiographic alignment after healing. None of the preoperative fracture characteristics were predictive of malalignment or shortening. We recommend the use of larger nail sizes in the treatment of paediatric femoral shaft fractures, especially if there is concern for residual instability. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Alvin K. Shieh
- Department of Orthopaedic Surgery, University of California Davis Medical Center, Sacramento, California, United States
| | - Augustine M. Saiz Jr
- Department of Orthopaedic Surgery, University of California Davis Medical Center, Sacramento, California, United States
| | - Kelsey S. Hideshima
- School of Medicine, University of California Davis Medical Center, Sacramento, California, United States
| | - Brian M. Haus
- Department of Orthopaedic Surgery, University of California Davis Medical Center, Sacramento, California, United States
| | - Holly B. Leshikar
- Department of Orthopaedic Surgery, University of California Davis Medical Center, Sacramento, California, United States,Correspondence should be sent to Holly B. Leshikar, University of California Davis Medical Center, Department of Orthopaedic Surgery, 4860 Y Street, Suite 3800, Sacramento, CA 95817, United States. E-mail:
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