Automating Patient-reported Data Collection: Does it Work?

OBJECTIVE

There are several electronic patient-reported outcomes (ePROs) vendors that are being used at institutions to automate data collection. However, there is little known about their success in collecting patient-reported outcomes (PROs) and it is unknown which patients are more likely to complete these surveys. In this study, we assessed rates of PRO completion, as well as determined factors that contributed to the completion of baseline and follow-up surveys.

METHODS

We queried our ePRO platform to assess rates of completion for baseline and follow-up surveys for patients from October 2019 to June 2022. All baseline surveys were administered before pediatric orthopaedic procedures, and follow-up surveys were sent at 3 months, 6 months, 1 year, and 2 years after surgery to patients with baseline data. Descriptive statistics were used to summarize the data. Univariate and multivariate analyses were performed to assess differences in patients who did and did not complete surveys.

RESULTS

This study included 1313 patients during the study period. Baseline surveys were completed by 66% of the cohort (n = 873 patients). There was a significant difference in race/ethnicity and language spoken in the patients who did and did not complete baseline surveys (P < 0.01) with lower rates of completion in African American, Hispanic, and Spanish-speaking patients. At least one follow-up was obtained for 68% of patients with baseline surveys (n = 597 patients). There were significant differences in completion rates based on race/ethnicity (P = 0.03) and language spoken (P = 0.01). There were lower rates of baseline completion for patients with government insurance in our multivariate analysis (odds ratio: 0.6, P < 0.01).

CONCLUSION

Baseline and follow-up PRO data can be obtained from the majority of patients using automated ePRO platforms. However, additional focus is needed on collecting data from traditionally underrepresented patient groups to better understand outcomes in these patient populations.

LEVEL OF EVIDENCE

Level III-retrospective cohort study.

Who gets staged surgery in severe pediatric and adolescent spine deformity?

BACKGROUND

There is significant debate regarding the indications of staged surgery for severe adolescent spinal deformity, and the factors associated with the decision to perform staged compared to same-day surgery have not been previously investigated. Thus, the purpose of this study was to determine which factors were most strongly associated with this decision.

METHODS

A prospective multicenter registry of adolescent patients with severe spinal deformity was reviewed. Two cohorts were identified: those who underwent a planned staged surgical procedure for deformity correction and those who underwent a same-day procedure. Patients who underwent an unplanned staged procedure secondary to complications during the initial procedure were excluded. Comparisons were made between these cohorts with respect to preoperative patient and radiographic variables to determine which factors were associated with the decision to perform a staged procedure. Surgical data was also compared to evaluate for differences in the intraoperative management of staged versus same-day patients.

RESULTS

Two hundred and twenty-nine patients with severe spinal deformities were identified. Forty patients (17%) underwent a planned staged procedure and 189 patients (80%) underwent a same-day procedure. On univariate analysis of preoperative variables, patients who underwent staged surgery had a significantly younger age at surgery, greater major curve magnitude, greater major curve AVT to CSVL, lesser thoracic spine height, greater radiographic trunk shift, and a greater proportion of patients undergoing revision surgery (as opposed to primary correction) compared to those who underwent a planned single-stage procedure. Multivariate logistic regression of pre-operative variables showed that age < 16 years, maximum cobb angle ≥ 120 degrees, major curve AVT to CSVL of ≥ 3.5 cm, and revision surgery were independently associated with the decision to perform a staged procedure. Intraoperatively, patients in the staged cohort more frequently underwent combined anterior and posterior procedures, grade 4 or higher Schwab osteotomies, and had a greater number of levels fused.

CONCLUSION

There is substantial variability with respect to the decision to perform surgery for severe adolescent spine deformities in a staged versus same-day fashion. This large analysis of prospectively collected data is the first to describe the factors most strongly associated with the decision to perform a staged procedure and may help guide the surgical decision-making for these patients.

Don't Throw Away the Handout: Efficacy of Patient Education in Pediatric Orthopaedic Trauma

BACKGROUND

Printed educational materials (PEMs) have been used for patient education in various settings. The purpose of this study was to determine the readability, understandability, and actionability of trauma-related educational material from the Pediatric Orthopaedic Society of North America (POSNA, Orthokids), as well as determine its efficacy in educating pediatric orthopaedic trauma patients and caregivers.

METHODS

The readability, understandability and actionability of PEMs was assessed using the Patient Education materials Assessment Tool (PEMAT). Five reviewers ranging in experience independently evaluated the educational materials. The efficacy of PEMs was assessed prospectively by randomizing patients into 2 groups. The first group (Education) received the OrthoKids educational material related to the patient's fracture. The second group (No Education) did not receive the educational material. At the first follow-up visit, parents/guardians in both groups completed surveys. Statistical analyses included descriptive and univariate statistics.

RESULTS

The understandability of PEMs was similar (68% to 74%); however, the educational materials had varying actionability scores ranging from 20% for femoral shaft fractures to 60% for elbow fractures. In total, 101 patients were randomized to assess the efficacy of educational materials (Education=51, No Education=50). There were no significant differences in sex, age, race/ethnicity, and level of education between caregivers in both groups ( P > 0.05). Only 61% (31/51) participants in the Education group reported using the educational material; however, 67% to 68% of participants in either group reported wanting PEMs. Participants in the group that did not receive PEMs were significantly more likely to use the internet to find more information (74% vs. 51%, P < 0.05).

CONCLUSIONS

This study suggests that participants that did not receive PEMs were significantly more likely to search the internet for more information. Improving the quality and actionability of educational resources on electronic platforms is needed to improve patient education. A multi-modal approach using PEMs that includes a list of high-quality online sources would likely be most effective in educating pediatric trauma patients and caregivers.

LEVEL OF EVIDENCE

I.

Hip Pain in Adolescent Patients

Hip pain is a common complaint in adolescents. There are several causes for hip pain in this population, with dysplasia and impingement being the most common; however, other conditions such as extra-articular impingement, torsional disorders, labral tears, and osteochondral lesions also require consideration. Many of these conditions are related to underlying anatomic abnormalities and increased activity in this age group. An understanding of the common pathologies of the adolescent hip is integral to the evaluation, diagnosis, and treatment of these patients.

Pediatric Heterotopic Ossification: A Comprehensive Review

PURPOSE OF REVIEW

The purpose of this review is to provide a comprehensive analysis of heterotopic ossification (HO) in pediatric patients, including an in-depth examination of the risk factors associated with this condition, current prophylactic measures, and available management strategies.

RECENT FINDINGS

HO is a medical disorder in which bone tissue inexplicably develops in soft tissues such as muscles and tendons. It involves the formation of mature, lamellar bone in extra-skeletal soft tissue, and its formation is influenced by oxygen tension, pH, the availability of micronutrients, and mechanical stimulation. HO has many cellular origins, with the most common theory being multipotent cells in local tissue. The diagnosis of HO is typically made based on exam, radiographs, and CT. Management includes both prophylactic nonsurgical options and surgical resection for severe or recalcitrant cases. The review highlights the incidence, risk factors, and management strategies associated with HO in pediatric patients. HO is a rare condition in children, with severe neurologic injury being the most common cause. Pediatric patients most commonly develop HO following severe neurologic injury, followed by trauma and surgery. Current prophylactic measures, include nonsteroidal anti-inflammatory drugs and radiation therapy though limited literature on their use in the pediatric population exists. For recalcitrant symptomatic cases, wide surgical resection can be considered but has a higher risk profile and associated morbidity. This review highlights the need for further pediatric specific research to inform guidelines and management strategies for this debilitating condition.

Scheuermann Kyphosis: Current Concepts and Management

PURPOSE OF REVIEW

Scheuermann's kyphosis (SK) is a developmental deformity of the spine that affects up to 8% of children in the US. Although, the natural progression of SK is noted to be gradual over years, severe deformity can be associated with significant morbidity. Thorough clinical examination and interpretation of relevant imaging help differentiate and confirm this diagnosis. Treatment includes both operative and nonoperative approaches. The purpose of this article is to provide an updated overview of the current theories of its pathogenesis, as well as the principles of diagnosis and treatment of SK.

RECENT FINDINGS

Although a definitive, unified theory continues to be elusive, numerous reports in the past decade provide insight into the pathophysiology of SK. These include alterations in mechanical stress and/or hormonal disturbances. Candidate genes have also been identified to be linked to the inheritance of SK. Updates to nonoperative treatment include the effectiveness of dedicated exercise programs, as well as the types and duration of orthotic treatment. Advances in surgical technique can be observed with a trend toward a posterior-only approach, with supporting evidence for careful evaluation of both the sagittal and coronal planes to determine fusion levels in order to avoid postoperative junctional pathologies. SK is an important cause of structural or rigid kyphosis. It can lead to significant morbidity in severe cases. Treatment is based on curve magnitude and symptoms. Nonoperative treatment consists of physical therapy in symptomatic patients, and bracing can be added for skeletally mature patients. Operative management can be considered in patients with large, progressive, and symptomatic deformity. Future studies can benefit from a focused investigation into patient-reported outcomes after undergoing appropriate treatment.

Rib-to-spine and rib-to-pelvis magnetically controlled growing rods: does the law of diminishing returns still apply?

PURPOSE

The Law Of Diminishing Returns (LODR) has been demonstrated for traditional growing rods, but there is conflicting data regarding the lengthening behavior of Magnetically Controlled Growing Rods (MCGR). This study examines a cohort of patients with early-onset scoliosis (EOS) with rib-to-spine or rib-to-pelvis-based MCGR implants to determine if they demonstrate the LODR, and if there are differences in lengthening behaviors between the groups.

METHODS

A prospectively collected multicenter EOS registry was queried for patients with MCGR with a minimum 2-year follow-up. Patients with rib-based proximal anchors and either spine- or pelvis-based distal anchors were included. Patients with non-MCGR, unilateral constructs, < 3 lengthenings, or missing > 25% datapoints were excluded. Patients were further divided into Primary-MCGR (pMCGR) and Secondary-MCGR (sMCGR).

RESULTS

43 rib-to-spine and 31 rib-to-pelvis MCGR patients were included. There was no difference in pre-implantation, post-implantation and pre-definitive procedure T1-T12 height, T1-S1 height, and major Cobb angles between the groups (p > 0.05). Sub-analysis was performed on 41 pMCGR and 19 sMCGR rib-to-spine patients, and 31 pMCGR and 17 sMCGR rib-to-pelvis patients. There is a decrease in rod lengthenings achieved at subsequent lengthenings for each group: rib-to-spine pMCGR (rho = 0.979, p < 0.001), rib-to-spine sMCGR (rho = 0.855, p = 0.002), rib-to-pelvis pMCGR (rho = 0.568, p = 0.027), and rib-to-pelvis sMCGR (rho = 0.817, p = 0.007). Rib-to-spine pMCGR had diminished lengthening over time for idiopathic, neuromuscular, and syndromic patients (p < 0.05), with no differences between the groups (p > 0.05). Rib-to-pelvis pMCGR neuromuscular patients had decreased lengthening over time (p = 0.01), but syndromic patients had preserved lengthening over time (p = 0.65).

CONCLUSION

Rib-to-spine and rib-to-pelvis pMCGR and sMCGR demonstrate diminished ability to lengthen over subsequent lengthenings.

Variations in the Management of Closed Salter-Harris II Distal Tibia Fractures

BACKGROUND

There are no formal practice guidelines for the surgical management of closed, Salter-Harris (SH) II distal tibia fractures. The purpose of this study was to survey the indications for operative and nonoperative management of this injury across pediatric tertiary care centers.

METHODS

We surveyed pediatric orthopedic surgeons at 20 tertiary care level-1 pediatric trauma centers. Surgeons were provided with 16 clinical scenarios that varied based on patient age and sex, and highlighted the following surgical indications: translation <3 mm, translation ≥3 mm, sagittal plane angulation >5 degrees, and coronal plane angulation >5 degrees. Each case's scenario and radiographs after closed reduction were presented in a randomized manner. Consensus was defined as 80% agreement, and descriptive statistics were used to summarize the results.

RESULTS

In total, 33 of 37 surgeons completed the survey (89% response rate). All surgeons took trauma call at a level-1 pediatric trauma center and had an average of 8.8 years (SD: 6.5 y) of experience. Consensus was reached in 4 of 16 scenarios. Specifically, nonoperative management was recommended for all scenarios showing <3 mm of translation after closed reduction. The majority of surgeons recommended operative management in scenarios showing coronal plane angulation after closed reduction, but none of these scenarios reached consensus. There was a near-equal split in operative and nonoperative management in 8 of 16 scenarios. These scenarios showed ≥3 mm translation after closed reduction and sagittal plane angulation after closed reduction. Surgeons with 6 to 10 years in practice were the most likely to recommend surgery, especially in the case of >5 degrees coronal plane angulation postreduction ( P <0.05).

CONCLUSIONS

There is considerable variation regarding the indications for operative and nonoperative management of closed, SHII distal tibia fractures. Consensus was reached for nonoperative management in patients with <3 mm of translation after closed reduction; however, with greater deformity consensus regarding optimal treatment was unable to be achieved. The variation in the management of distal tibia SHII fractures is significant, suggesting that perhaps clinical equipoise exists between operative and nonoperative management.

LEVEL OF EVIDENCE

V.

Patient Expectations and Satisfaction in Pediatric Orthopedics

PURPOSE OF REVIEW

The purpose of the current review is to analyze the current literature regarding the tools available to evaluate patient expectations and satisfaction. There have been an increasing number of tools that have been developed and validated for various orthopedic procedures. Despite the growing number of tools, there are a limited number of tools available for pediatric patients.

RECENT FINDINGS

Several tools have been developed in orthopedics to evaluate patient expectations. However, there are no tools that have been validated in the pediatric population. In addition, pediatric patient expectations should be collected in conjunction with parent/caregiver expectations. Although not specifically validated for pediatric patients, there are several tools available that may pertain to pediatric patients including the HSS ACL Expectations Survey, HSS Shoulder Expectations Survey, HSS Knee Surgery Expectations Survey, HSS Foot and Ankle Surgery Expectation Survey, Sunnybrook Surgery Expectations Survey, Musculoskeletal Outcomes Data Evaluation and Management System (MODEMS) Instruments, Quick DASH, and DASH. In terms of patient satisfaction, there are even fewer tools available. Several tools have been developed to evaluate patient satisfaction and five additional tools within orthopedics. Of these tools, there are two that have been validated for pediatric patients: The Swedish Parents Satisfaction Questionnaire and the Scoliosis Research Society-22. There are a growing number of tools to evaluate patient's expectations and satisfaction in the orthopedic literature. Given most of these tools pertain to adult patients, there is a need for further development of tools specifically validated for pediatric patients and their parents/caregivers. Through the measurement of expectations and satisfaction, medical professionals can hope to improve satisfaction and outcomes.

Intraoperative Antibiotic Use in Patients With Early-onset Scoliosis: Current Practices and Trends

BACKGROUND

Best Practice Guidelines (BPGs) regarding antibiotic prophylaxis in early-onset scoliosis (EOS) patients were published in September 2019. Recommendations included using intravenous cefazolin and topical vancomycin for all index procedures, plus gram-negative coverage for neuromuscular patients. Guideline adherence is unknown. This study aimed to characterize antibiotic prophylaxis at the time of index growth-friendly procedures and assess changes in practice patterns over time.

MATERIALS AND METHODS

This retrospective review of data collected through a multicenter study group included EOS patients undergoing index growth-friendly procedures between January 2018 and March 2021, excluding revisions, lengthenings, and tetherings. Demographics, clinical measurements, intraoperative antibiotics, and 90-day complications were recorded. Descriptive and univariate statistics were utilized. Antibiotic prophylaxis from April 2018 through September 2019 and October 2019 through March 2021 were compared with evaluate change after BPG publication.

RESULTS

A total of 562 patients undergoing growth-friendly procedures were included. The most common scoliosis types included neuromuscular (167, 29.7%), syndromic (134, 23.8%), and congenital (97, 17.3%). Most index procedures involved magnetically controlled growing rods (417, 74%) followed by vertical expandable prosthetic titanium rib or traditional growing rods (105, 19%). Most patients received cefazolin alone at index procedure (310, 55.2%) or cefazolin with an aminoglycoside (113, 20.1%). Topical antibiotics were used in 327 patients (58.2%), with most receiving vancomycin powder. There was increased use of cefazolin with an aminoglycoside after BPG publication (16% vs. 25%) ( P =0.01). Surgical site infections occurred in 12 patients (2.1%) within 90 days of index procedure, 10 pre-BPGs (3%), and 2 post-BPGs (0.9%), with no significant difference in surgical site infection rate by type of antibiotic administered ( P >0.05).

CONCLUSIONS

Historical variability exists regarding antibiotic prophylaxis during index growth-friendly procedures for EOS. There continues to be variability following BPG publication; however, this study found a significant increase in antibiotic prophylaxis against gram-negative bacteria after BPG publication. Overall, greater emphasis is needed to decrease variability in practice, improve compliance with consensus guidelines, and evaluate BPG efficacy.

LEVEL OF EVIDENCE

Level III-retrospective.

Rate of Refracture After Removal of Hardware in Pediatric Femur Fractures

PURPOSE

Both flexible intramedullary nails (FINs) and plate osteosynthesis are commonly used for the treatment of femoral shaft fractures in pediatric patients. The purpose of this study is to determine the refracture rate after hardware removal in pediatric femur fractures.

METHODS

This is a retrospective cohort study that utilized the Pediatric Health Information System database to determine the number of pediatric patients ages 4 to 10 who underwent surgical fixation of a femur fracture and subsequent hardware removal between the years 2015 and 2019. All patients had a minimum of a 2-year follow-up to assess for refracture. Patients with metabolic bone disease, neuromuscular conditions, bone fragility disorders, nutritional deficiencies, and pathologic fractures were excluded.

RESULTS

Of the total, 2805 pediatric patients with 2881 femoral shaft fractures who underwent FIN (48.4%), plate fixation (36.1%), splinting/casting (14.9%), or external fixation (0.6%) were included. The mean age of patients with index fracture was 7.2 years (SD, 2.1) and 69% were males. Eight hundred eighty patients (60%) in the FIN group had their hardware removed compared with 693 patients (68%) in the plate fixation group (P = 0.07), at an average of 287 ± 191 days versus 320 ± 203 days (P = 0.03). Refracture occurred in 13 patients (1.5%) who had their hardware retained and in 21 patients (1.4%) who had their hardware removed (P = 0.732). Among 65% of patients who underwent hardware removal, refracture occurred in 7 patients with FIN (0.8%) and 14 patients with plate fixation (2.2%) (P = 0.04). Refracture occurred within 365 days from hardware removal in 1 patient with FIN (0.1%) and 7 patients with plate fixation (1%) (P = 0.01). In logistic regression, patients with FIN fixation had lower odds of refracture after hardware removal compared with plate fixation (adjusted odds ratio: 0.39; 95% CI: 0.15-0.97). Age and payor status did not reach statistical significance in multivariate analysis.

CONCLUSIONS

The rate of refracture after hardware removal for pediatric patients with a femoral shaft fracture was similar between patients with hardware retained and removal. However, patients with FIN had a lower rate of refracture AFTER hardware removal compared with plate fixation. This information can be helpful for advising families regarding the risks of refracture after hardware removal.

LEVEL OF EVIDENCE

Level IV-retrospective cohort study.

Erratum: Rates of readmission and reoperation after operative management of midshaft clavicle fractures in adolescents

This is an erratum to an already published paper. We found an error in the results section and Table 1. Specifically, we have revised results with n ≤ 10 to be reflected as such, which is consistent with the reporting instructions by the Agency for Healthcare Research and Quality. Please note, these changes do not affect our results, and we had previously listed this requirement in the results section. We apologize for our unintentional mistake.

Prolonged Length of Stay and Readmissions Following In Situ Pinning of Slipped Capital Femoral Epiphysis An Analysis of Incidence and Predictive Factors

BACKGROUND

In situ pinning is one of the primary treat-ments for slipped capital femoral epiphysis (SCFE) in pedi-atric patients, many of whom have multiple comorbidities. Despite the fact that SCFE pinning is a frequently performed procedure in the United States, little is known regarding sub-optimal postoperative outcomes in this patient population. The purpose of this study was thus to identify the incidence, perioperative predictors, and specific causes of prolonged hospital length of stay (LOS) and readmissions following fixation.

METHODS

The 2016-2017 National Surgical Quality Im-provement Program database was employed to identify all patients undergoing in situ pinning of a SCFE. Significant variables, such as demographics, preoperative comor-bidities, birth history, operative characteristics (length of surgery and inpatient and outpatient procedure), and postop-erative complications were collected. The primary outcomes of interest were prolonged LOS (defined as exceeding the 90th percentile, or 2 days) and readmission within 30 days following the procedure. The specific reason for readmission was recorded for each patient. Bivariate statistics followed by binary logistic regression modeling were employed to explore the relationship between perioperative variables and prolonged LOS and readmissions.

RESULTS

A total of 1,697 patients underwent pinning, with a mean age of 12.4 years. Of these, 110 (6.5%) experienced a prolonged LOS and 16 (0.9%) were readmitted within 30 days. The most common causes of readmission related to the initial treatment were hip pain (n = 3) followed by postop-erative fracture (n = 2). Surgery on an inpatient basis (OR = 3.64; 95% CI: 1.99-6.67; p < 0.001), history of seizure disorder (OR = 6.79; 95% CI: 1.55-29.7; p = 0.01), and longer operative time (OR = 1.03; 95% CI: 1.02-1.03; p < 0.001) were significantly associated with prolonged LOS.

CONCLUSIONS

The majority of readmissions following SCFE pinning were due to postoperative pain or fracture. Patients presenting with medical comorbidities and un-dergoing pinning as an inpatient were at increased risk of experiencing a prolonged LOS.

Return to the Operating Room for Unplanned Pin Removal After Percutaneous Pinning of Supracondylar Humerus Fractures: A Retrospective Review

BACKGROUND

Pin migration is a common complication associated with closed reduced and percutaneous pinning (CRPP) of supracondylar humerus fractures (SCHF) in children. Though this complication occurs frequently, little work has been done to elicit circumstances surrounding this complication. The purpose of this study was to evaluate patients with SCHF treated with percutaneous pins who needed to return to the operating room for pin removal.

METHODS

This was a multicenter study involving children treated at 6 pediatric tertiary care centers between 2010 and 2020. Retrospective chart review was performed to identify children aged 3 to 10 years of age with a diagnosis of a SCHF. Current Procedural Terminology (CPT) codes were used to identify patients who underwent CRPP of their injuries. CPT codes for deep hardware removal requiring procedural sedation or anesthesia were used to identify patients who needed to return to the operating room for hardware removal.

RESULTS

Between 2010 and 2020, 15 out of 7862 patients who were treated for SCHF at our 6 participating study centers experienced pin migration requiring a return to the operating room for pin removal, yielding a complication rate of 0.19%. Twelve (80%) of these injuries were Wilkins modification of the Gartland classification Type III, while the remaining injuries were Type II. 2-pin fixation constructs were used in nine (60%) children; 3-pin fixation constructs were used in 6 (40%) children. Pin migration was noted 23.2±7.0 days postoperatively at clinic follow-up. Four patients were noted to have multiple pins buried at follow-up. Four patients required 1-centimeter incisions for exposure of the buried pins, while surgeons were able to remove the buried pin with just a needle driver and blunt dissection in the remainder of patients.

CONCLUSIONS

Pin migration is a common complication of closed reduction and percutaneous pinning of SCHF. There is variation in pin site management to prevent migration in the absence of underlying risk factors.

LEVEL OF EVIDENCE

Level III.

Rates and Factors Associated With Hardware Removal in Physeal Ankle Fractures: Analysis of the Pediatric Health Information System

Background

Ankle fractures are among the most common physeal fractures in children. When surgical management is warranted, subsequent hardware removal remains controversial. This study was designed to determine rates of hardware removal in patients with physeal ankle fractures and identify risk factors for removal. Procedure data was utilized to compare rates of subsequent ankle procedures in patients with hardware removed and hardware retained.

Methods

We conducted a retrospective cohort study utilizing data from the Pediatric Health Information System (PHIS) for the years 2015 through 2021. We longitudinally followed patients treated for distal tibia physeal fractures to determine the rates of hardware removal and subsequent ankle procedures. Patients with open fractures or polytrauma were excluded. We used univariate, multivariate, and descriptive statistics to characterize the rates of hardware removal, identify factors associated with removal, and assess the rates of subsequent procedures.

Results

This study included 1008 patients who underwent surgical management of a physeal ankle fracture. The mean age at index surgery was 12.6 years with an SD of 2.2 years, and 60% of patients identified as male. Two hundred forty-two patients (24%) had their hardware removed at an average time of 276 days (range, 21-1435 days) following index surgery. Patients with Salter Harris III (SH-III) or Salter Harris IV (SH-IV) fractures had hardware removed more often than patients with Salter-Harris II (SH-II) fractures (28.9% vs 11.7%, P < .01). Four-year rates of subsequent ankle procedures are similar between patients with hardware removed and hardware retained.

Conclusion

The rate of hardware removal in children with physeal ankle fractures is higher than previously reported. Patients of younger age, higher income, and with fractures involving the epiphysis (SH-III and SH-IV) are more likely to undergo hardware removal.

Level of Evidence

Level III, retrospective study.

Factors associated with subsequent surgery after septic arthritis of the knee in children

BACKGROUND

Septic arthritis of the knee in children is a challenging problem. Surgical debridement is an established treatment, but there is a paucity of literature on long-term prognosis.

AIM

To determine the rates and factors associated with return to surgery (RTS) and readmission after index surgical debridement for septic arthritis of the knee in children.

METHODS

This is a retrospective cohort study that utilizes data from the Healthcare Cost and Utilization Project (HCUP). We included patients between ages 0 to 18 years that underwent surgical debridement for septic arthritis of the knee between 2005 and 2017. Demographic data included age, gender, race, hospital type and insurance type. Clinical data including index admission length of stay (LOS) and Charlson Comorbidity Index (CCI) were available from the HCUP database. Descriptive statistics were used to summarize the data and univariate and multivariate analyses were performed.

RESULTS

Nine-hundred thirty-two cases of pediatric septic knee were included. This cohort was 62.3% male, with mean age of 9.0 (± 6.1) years. Approximately 46% of patients were white and approximately half had Medicaid insurance. Thirty-six patients (3.6%) required RTS at a minimum of 2 year after index surgery, and 172 patients (18.5%) were readmitted at any point. The mean readmission LOS was 11.6(± 11.3) d. Higher CCI was associated with RTS (P = 0.041). There were no significant associations in age, gender, race, insurance type, or type of hospital to which patients presented. Multivariate analysis showed that both increased CCI (P = 0.008) and shorter LOS (P = 0.019) were predictive of RTS.

CONCLUSION

Septic arthritis of the knee is an important condition in children. The CCI was associated with RTS at a minimum of 2 years after index procedure. No association was found with age, gender, race, insurance type, or hospital type. Shorter LOS and CCI were associated with RTS in multivariate analysis. Overall, risk of subsequent surgery and readmission after pediatric septic knee arthritis is low, and CCI and shorter LOS are predictive of RTS.

Indications and Efficacy of Halo-Gravity Traction in Pediatric Spinal Deformity: A Critical Analysis Review

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Halo-gravity traction (HGT) is a well-established technique for correcting severe spinal deformity in pediatric patients.

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HGT induces soft-tissue relaxation and gradually lengthens the spine, and it can be used preoperatively and intraoperatively.

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It is typically indicated for spinal deformity over 90° in any plane and medical optimization.

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There are several complications associated with the use of HGT, and it is critical to follow a protocol and perform serial examinations to minimize this risk.

Surgical Debridement for Acute and Chronic Osteomyelitis in Children

Background

Osteomyelitis is an infection of the bone that commonly occurs in pediatric populations. First-line treatment most often involves a course of antibiotics. In recent studies, surgical debridement, in addition to antibiotics, has been shown to provide positive clinical and functional outcomes in children. Debridement is most often indicated in patients with an abscess or in those who do not respond to empiric antibiotic therapy; however, there are limited video resources describing this technique in pediatric patients.

Description

The key steps of the procedure, which are demonstrated in the present video article, are (1) preoperative planning, (2) positioning, (3) subperiosteal exposure and debridement, (4) cortical window creation, (5) irrigation, (6) adjunctive treatment, (7) drain placement, (8) wound closure, (9) dressing and immobilization, and (10) wound check and drain removal.

Alternatives

Nonoperative treatment is usually indicated for acute osteomyelitis in which patients present with little to no necrotic tissue or abscess formation. In these cases, a course of broad-spectrum antibiotics may be sufficient for a cure.

Rationale

This procedure allows for the removal of necrotic bone and soft tissue, thus facilitating the recovery process. It also allows for the retrieval of tissue samples that may be used to guide selection of the appropriate antibiotic therapy. Surgical debridement is a safe and reliable technique that has been associated with positive long-term outcomes.

Expected Outcomes

We expect that some patients will require repeat surgical debridement procedures to decrease pathogen burden and prevent future complications. However, we expect that the majority of patients who undergo surgical debridement for uncomplicated osteomyelitis will recover full functionality of the affected limb with no associated long-term sequelae10.

Important Tips

Understand preoperative imaging to identify areas of infection, localize critical structures and the physis, and plan surgical approaches.Use extensile approaches and preserve vascularity during the approach.Perform subperiosteal dissection and create a cortical window to debride areas of infection, but avoid excessive periosteal stripping.Close the dead space and wound in a layered manner.

Acronyms and Abbreviations

MRI = magnetic resonance imagingK-wire = Kirschner wireMRSA = methicillin-resistant Staphylococcus aureusPDS = polydiaxonone.

Management of Displaced Midshaft Clavicle Fractures in Pediatrics and Adolescents: Operative vs Nonoperative Treatment

The purpose of the current review is to describe the management of displaced midshaft clavicle fractures in pediatric and adolescent patients. Midshaft clavicle fractures are relatively common in pediatric and adolescent patients. They most commonly occur from direct trauma and are often related to sports participation in adolescents. Recent literature in the management of adult midshaft clavicle fractures has supported operative management due to improved functional outcomes, decreased time to union, leading to early return to activity. A similar trend of increasing frequency in operative management has been seen in pediatric and adolescent patients with no consensus in the literature on optimal management. Nonoperative treatment consists of with a brief period of sling immobilization followed by range of motion. Operative management may be considered for open fractures, fractures with significant neurovascular compromise and soft tissue complications. Studies have shown comparable mid- to long-term functional and patient-reported outcomes after operative and nonoperative management of midshaft clavicle fractures in pediatric patients.

Rates of Operative Management of Midshaft Clavicle Fracture in Adolescents Have Increased in Florida between 2005 and 2014

Background: It is not known if the adult literature on midshaft clavicle fracture treatment with open reduction internal fixation (ORIF) has influenced injury management in adolescents. Purpose: We sought to longitudinally evaluate the rates of operative management of adolescent midshaft clavicle fractures in the state of Florida. Methods: We conducted a retrospective review of data from the following Healthcare Cost and Utilization Project databases: the State Inpatient Database, the State Ambulatory Surgery and Services Database, and the State Emergency Department Database. Patients in Florida ages 10 to 18 years with midshaft clavicle fractures between 2005 and 2014 were identified along with data on age, sex, race/ethnicity, insurance type, treatment, and income percentile. We reviewed the data to identify trends in the rates of operative management of midshaft clavicle fractures. We then compared the rates of operative management between the first 3 years and the most recent 3 years (2005-2007 vs 2012-2014). Various demographic and socioeconomic factors were compared between patients treated with and without surgery. Descriptive statistics as well as univariate and multivariate analyses were performed. Results: There were 4297 midshaft clavicle fractures in adolescents identified between 2005 and 2014, and 338 (7.8%) of these fractures underwent operative management. There was a significant increase in the rate of operative management; it increased from 4.3% (n = 59) of the 1373 clavicle fractures that occurred between 2005 and 2007 to 11.2% (n = 130) of the 1164 clavicle fractures that occurred between 2012 and 2014. Patients with commercial insurance and patients who were older were more likely to undergo ORIF. Patients with Medicaid were more likely to undergo ORIF between 2012 and 2014 compared with patients with Medicaid between 2005 and 2007. Conclusions: Operative management rates of adolescent midshaft clavicle fractures have significantly increased in Florida over a decade; additional research is needed to understand these findings.

Surgical Correction of Neuromuscular Scoliosis Secondary to Congenital Zika Syndrome: A Case Report

CASE

Congenital Zika syndrome (CZS) has been noted after the South American pandemic of Zika virus which peaked in 2015 to 2016, and the associated sequelae are still being described. Scoliosis has been noted in patients with CZS; however, there is a paucity of literature on the prevalence or management of scoliosis secondary to this condition. We report the case of a 5-year-old girl with severe neuromuscular scoliosis due to CZS that was managed with halo-gravity traction, followed by a growth-friendly construct.

CONCLUSION

This case report highlights the need for more research focusing on the survivors of the Zika pandemic.

Trends in Management of Pediatric Distal Radius Buckle Fractures

BACKGROUND

Distal radius buckle fractures (DRBFx) represent nearly half of the pediatric wrist injuries. DRBFx are stable injury patterns that can typically be successfully managed with brief immobilization. The purpose of this study was to evaluate opinions and preferences of pediatric orthopaedic specialists regarding the management of DRBFx.

METHODS

The POSNA Trauma Quality, Safety, and Value Initiative (QSVI) Committee developed a 20-question survey regarding the treatment of DRBFx in children. The survey was sent twice to all active and candidate POSNA members in June 2020 (n=1487). Questions focused on various aspects of treatment, including type and length of immobilization, follow-up, and radiographs and on potential concerns regarding patient/family satisfaction and pain control, medicolegal concerns, misdiagnosis, and mismanagement.

RESULTS

A total of 317 participants completed the survey (response rate=21.3%). In all, 69% of all respondents prefer to use a removable wrist splint, with 76% of those in practice <20 years preferring removable wrist splints compared with 51% of those in practice >20 years (χ 2 =21.7; P <0.01). Overall, 85% of participants utilize shared decision-making in discussing management options with patients and their families. The majority of participants felt that the risk of complications associated with DRBFx was very low, but concern for misdiagnosis and mismanagement have required some respondents to perform closed or open reductions.

CONCLUSIONS

In 2020, the majority of respondents treat DRBFx with removable splints (69%) for 3 or fewer weeks (55%), minimal follow-up (85%), and no reimaging (64%). This marks a dramatic shift from the 2012 POSNA survey when only 29% of respondents used removable splinting for DRBFx.

LEVEL OF EVIDENCE

Level II.

Issues With Big Data: Variability in Reported Demographics and Complications Associated With Posterior Spinal Fusion in Pediatric Patients

BACKGROUND

Clinical and administrative registries provide large volumes of data that can be used for clinical research. However, there are several limitations relating to the quality, consistency, and generalizability of big data. In this study, we aim to compare reported demographics and certain outcomes in patients undergoing posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS), neuromuscular scoliosis (NS), and Scheuermann kyphosis (SK) between 3 commonly utilized databases in pediatric orthopaedic research.

METHODS

We used International Classification of Diseases, Ninth Revision (ICD-9), International Classification of Diseases, 10th Revision (ICD-10), and Current Procedural Terminology (CPT) codes to identify patients in the National Surgical Quality Improvement Program (NSQIP), Healthcare Cost and Utilization Project (HCUP), and Pediatric Health Information System (PHIS) between the ages of 10 to 18 that underwent PSF for AIS, SK, and NS from 2012 to 2015. We compared various demographic factors, such as sex, race/ethnicity, age, and rates of postsurgical infection and 30-day readmissions. Data was analyzed with descriptive and univariate statistics.

RESULTS

We identified 9891 patients that underwent PSF in NSQIP, 10,771 patients in PHIS, and 4335 patients in HCUP over the study period. There were significant differences in patient demographics, readmission rates, and infection rates between all patients that underwent PSF across the databases (P<0.01), as well as specifically in patients with AIS (P<0.01). HCUP had the highest proportion of Hispanic patients that underwent PSF (13.5%), as well as patients who had AIS (13.3%) or NS (17.9%). The PHIS database had the highest proportion of patients undergoing PSF for SK. Among patients with NS, there were significant differences in race across the databases (P<0.01), but no significant differences in sex, ethnicity, or readmission (P>0.05). In addition, there were significant differences in race (P=0.04) and readmission (P=0.01) across databases for patients with SK, but no differences in sex or ethnicity (P>0.05). NSQIP reported the highest rate of 30-day readmissions for patients undergoing PSF (17.9%) compared with other databases (HCUP 4.1%, PHIS 12.1%).

CONCLUSIONS

There are significant differences in patient demographics, sample sizes, and rates of complications for pediatric patients undergoing PSF across 3 commonly utilized US administrative databases. Given the variability in reported outcomes and demographics, generalizability is difficult to extrapolate from these large data sources. In addition, certain databases should be selected to appropriately power studies focusing on particular patient populations or outcomes.

Effect of non-steroidal anti-inflammatory drugs on fracture healing in children: A systematic review

BACKGROUND

Non-steroidal anti-inflammatory drugs (NSAIDs) are among the most commonly prescribed medications in the United States. Although they are safe and effective means of analgesia for children with broken bones, there is considerable variation in their clinical use due to persistent concerns about their potentially adverse effect on fracture healing.

AIM

To assess whether NSAID exposure is a risk factor for fracture nonunion in children.

METHODS

We systematically reviewed the literature reporting the effect of NSAIDs on bone healing. We included all clinical studies that reported on adverse bone healing complications in children with respect to NSAID exposure. The outcomes of interest were delayed union or nonunion. Study quality was assessed using the Newcastle-Ottawa scale for non-randomized studies. A final table was constructed summarizing the available evidence.

RESULTS

A total of 120 articles were identified and screened, of which 6 articles were included for final review. Nonunion in children is extremely rare; among the studies included, there were 2011 nonunions among 238822 fractures (0.84%). None of the included studies documented an increased risk of nonunion or delayed bone healing in those children who are treated with NSAIDs in the immediate post-injury or peri-operative time period. Additionally, children are likely to take these medications for only a few days after injury or surgery, further decreasing their risk of adverse side-effects.

CONCLUSION

This systematic review suggests that NSAIDS can be safely prescribed to pediatric orthopaedic patients absent other contraindications without concern for increased risk of fracture non-union or delayed bone healing. Additional prospective studies are needed focusing on higher risk fractures and elective orthopaedic procedures such as osteotomies and spinal fusion.

Pediatric Orthopedic Trauma Care During the COVID-19 Pandemic: A Survey of the Pediatric Orthopedic Society of North America

Background: The COVID-19 pandemic has dramatically altered the practice of pediatric orthopedic trauma surgery in both outpatient and inpatient settings. While significant declines in patient volume have been noted, the impact on surgeon decision-making is unclear. Purpose: We sought to investigate changes in pediatric orthopedic trauma care delivery as a result of COVID-19 and determine their implications for future orthopedic practice. Methods: An electronic survey was distributed to all members (N = 1515) of the Pediatric Orthopedic Society of North America (POSNA) in March to April 2021; only members who provided care for pediatric orthopedic trauma patients were asked to complete it. The survey included questions on hospital trauma call, inpatient care, outpatient clinic practice, and 3 unique fracture case scenarios. Results: A total of 147 pediatric orthopedic surgeons completed the survey, for a 9.7% response rate, with 134 (91%) taking trauma call at a hospital as part of their practice. Respondents reported significant differences across institutions regarding COVID-19 testing, hospital rounding, and employee COVID-19 screening. Changes in outpatient fracture management were observed, including a decreased number of follow-up visits for nondisplaced clavicle fractures, distal radius buckle fractures, and toddler's fractures. Of respondents who changed their fracture follow-up schedules due to COVID-19, over 75% indicated that they would continue these outpatient treatment schedules after the pandemic. Conclusions: This survey found changes in pediatric orthopedic trauma care as a result of the COVID-19 pandemic. The use of telemedicine and abbreviated follow-up practices for common fracture types are likely to persist following the resolution of the COVID-19 pandemic.

Developmental Dysplasia of the Hip: Controversies in Management

PURPOSE OF REVIEW

Many aspects of developmental hip dysplasia (DDH) care and evaluation are still active areas of debate. Recent studies have provided more insight into these topics such as strategies for reducing osteonecrosis, assessing hip reduction after closed and open reduction, and the management of residual acetabular dysplasia.

RECENT FINDINGS

The presence of the ossific nucleus at the time of reduction does not alter the risk of osteonecrosis. The risk of osteonecrosis may be higher when hips are immobilized in excessive abduction. Limited sequence MRI may be the best choice for assessing hip reduction after closed and open reduction; however, new technologies are emerging such as 3D fluoroscopy and perfusion MRI. The treatment of residual acetabular dysplasia with bracing has been shown to be effective and the decision to perform a pelvic osteotomy is based on patient-specific factors. The spectrum of DDH treatment has evolved over the past several decades. Recent studies have provided insights into strategies for osteonecrosis prevention, hip evaluation during after reduction, and the management of residual acetabular dysplasia. However, there is ample room for additional and more rigorous studies guiding advanced imaging for assessing hip reduction such as 3D fluoroscopy and perfusion MRI, as well as the management of residual acetabular dysplasia.

Variability in evaluation and treatment of tibial tubercle fractures among pediatric orthopedic surgeons

The purpose of this study was to determine the variability in clinical management of tibial tubercle fractures among a group of pediatric orthopedic surgeons. Nine fellowship-trained academic pediatric orthopedic surgeons reviewed 51 anteroposterior and lateral knee radiographs with associated case age. Respondents were asked to describe each fracture using the Ogden classification (type 1-5 with A/B modifiers), desired radiographic workup, operative vs. nonoperative treatment strategy and plans for post-treatment follow-up. Fair agreement was reached when classifying the fracture type using the Ogden classification (k = 0.39; P < 0.001). Overall, surgeons had a moderate agreement on whether to treat the fractures operatively vs. nonoperatively (k = 0.51; P < 0.001). Nonoperative management was selected for 80.4% (45/56) of type 1A fractures. Respondents selected operative treatment for 75% (30/40) of type 1B, 58.3% (14/24) of type 2A, 97.4% (74/76) of type 2B, 90.7% (39/43) of type 3A, 96.3% (79/82) of type 3B, 71.9% (87/121) of type 4 and 94.1% (16/17) of type 5 fractures. Regarding operative treatment, fair/slight agreement was reached when selecting the specifics of operative treatment including surgical fixation technique (k = 0.25; P < 0.001), screw type (k = 0.26; P < 0.001), screw size (k = 0.08; P < 0.001), use of washers (k = 0.21; P < 0.001) and performing a prophylactic anterior compartment fasciotomy (k = 0.20; P < 0.001). Furthermore, surgeons had fair/moderate agreement regarding the specifics of nonoperative treatment including degree of knee extension during immobilization (k = 0.46; P < 0.001), length of immobilization (k = 0.34; P < 0.001), post-treatment weight bearing status (k = 0.30; P < 0.001) and post-treatment rehabilitation (k = 0.34; P < 0.001). Significant variability exists between surgeons when evaluating and treating pediatric tibial tubercle fractures.

Diagnosis and Management of Spondylolysis and Spondylolisthesis in Children

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Spondylolysis is defined as a defect of the pars interarticularis, and spondylolisthesis is defined as a slippage of a vertebra relative to the immediately caudal vertebra.

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Most cases of spondylolysis and low-grade spondylolisthesis can be treated nonoperatively. Depending on a patient's age, nonoperative treatment may include a thoracolumbosacral orthosis (TLSO), physical therapy, and activity modification. Bracing and physical therapy have been found to be more effective than activity modification alone.

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Patients with dysplastic spondylolisthesis are at higher risk for progression and should be monitored with serial radiographs every 6 to 9 months.

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Operative management is recommended for symptomatic patients with failure of at least 6 months of nonoperative management or patients with high-grade spondylolisthesis.

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Surgical techniques include pars defect repair, reduction, and fusion, which may include posterior-only, anterior-only, or circumferential fusion.

Does the Deformity Index Reliably Predict the Shape of the Femoral Head at Healing of Legg-Calvé-Perthes Disease?

BACKGROUND

Treatment of Legg-Calvé-Perthes disease (LCPD) aims to preserve the spherical shape of the femoral head. The deformity index (DI) <0.3, measured 2 years from disease onset, is a surrogate measure that predicts that the femoral head will be Stulberg class I or II at skeletal maturity. There is no study that compares the predictive value of DI against a quantitative measure of the shape of the femoral head when the disease heals. We undertook this study to assess the reproducibility of a new method of measurement of DI and see if DI could predict the shape of the femoral head when the disease healed.

METHODS

DI was measured 2 years after disease onset and the Sphericity Deviation Score (SDS) was measured at healing of LCPD on radiographs of 43 children. Reproducibility of measurement was tested. Each healed femoral head was classified as spherical or aspherical based on subjective visual assessment. The DI values were compared with SDS values.

RESULTS

The reproducibility of measurement of SDS was excellent and superior to that of DI. The mean duration of disease was 3.97±0.96 years. Only 17 of 32 hips with DI values <0.3 at 2 years had spherical femoral heads at healing (SDS <10). Three hips with SDS values <10 had DI values >0.3. The positive and negative predictive values of a DI <0.3 in predicting if the femoral head will be spherical (SDS <10) when the disease healed were 53% and 73%, respectively.

CONCLUSION

Though DI can be reproducibly measured the predictive value of a DI <0.3, to accurately identify hips that are likely to heal with spherical femoral heads, is not sufficiently high to justify its use as an outcome measure.

Rates of readmission and reoperation following pelvic osteotomy in adolescent patients: a database study evaluating the pediatric health information system

Rates and reasons for readmission and reoperation following adolescent pelvic osteotomy are not well-defined. This study aimed to (1) determine 30-day and 90-day readmission rates and the 2-year reoperation rate after pelvic osteotomy in adolescents and (2) identify reasons for readmission and reoperation. The Pediatric Health Information System database was queried between 10 January 2015 and 1 January 2020 for patients meeting selected International Classification of Diseases (ICD-10) procedure and diagnosis codes relating to pelvic osteotomies. Readmission rates were calculated within 30 and 90 days from index osteotomy. The ipsilateral reoperation rate was calculated within 2 years from index osteotomy. Reasons for these outcomes were identified. Univariate and multivariate analyses were utilized to identify readmission risks. Of 1475 patients, 5.4% and 9.2% were readmitted within 30 and 90 days, respectively. Reasons for readmission were consistent across both time points and included infection, hip-related orthopedic conditions and neurologic conditions. Younger age (OR 0.83, 95% CI: 0.76, 0.89; P < 0.0001) and male sex (OR 1.77, 95% CI: 1.23–2.54; P = 0.002) were predictive of readmission within 90 days. The 2-year reoperation rate was 32.1%, of which 79.8% underwent reoperation for hardware removal, 17.7% for revision and 1.3% for hip replacement. 30-day readmission, 90-day readmission and 2-year reoperation rates after adolescent pelvic osteotomy were 5.4%, 9.2% and 32.1%, respectively. Younger age and male sex were predictive of 90-day readmission. Most ipsilateral reoperations were for hardware removal. Understanding readmission and reoperation risks following pelvic osteotomy can benefit patient counseling and improve expectations of post-surgical outcomes.

Level of Evidence:

IV, case series.

Perioperative Pain Management Practices Vary Across Time and Setting for Pediatric ACL Reconstruction: Trends From a National Database in the United States

Background:

Surgical and anesthetic techniques have enabled a shift to the ambulatory setting for the majority of patients with anterior cruciate ligament (ACL) tears. While this change likely reflects improvements in acute pain management, little is known about national trends in pediatric perioperative pain management after ACL reconstruction (ACLR).

Purpose:

To describe recent trends in the United States in perioperative pain management for pediatric ACLR.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

Pediatric patients (age, ≤18 years) who underwent ACLR with peripheral nerve blocks between January 2008 and December 2017 were identified in the Pediatric Health Information System database. We modeled the use of oral and intravenous analgesic medications over time using Bayesian logistic mixed models. Models were adjusted for patient age, sex, race, primary payer, and treatment setting (ambulatory, observation, or inpatient).

Results:

The study criteria produced a sample of 18,605 patients. Older children were more likely to receive intravenous acetaminophen, intravenous ketorolac, and oral and intravenous opioids. Younger children were more likely to receive ibuprofen. In our adjusted logistic model, treatment setting was found to be an independent predictor of the utilization of all medications. We found an increase in the overall utilization of oral acetaminophen (adjusted odds ratio [adj OR], 1.14 [95% CI, 1.04-1.23]), intravenous acetaminophen (adj OR, 1.42 [95% CI, 1.22-1.65]), and oral opioids (adj OR, 1.16 [95% CI, 1.06-1.28]) over the study period at a typical hospital. We found significant heterogeneity in medication use across hospitals, with the most heterogeneity in intravenous acetaminophen. Other studied descriptive variables did not appear to predict practices.

Conclusion:

After adjusting for patient characteristics and treatment settings, pain management strategies varied among hospitals and over time. Patient age and treatment setting predicted practices. Regional anesthesia, opioid medications, and intravenous ketorolac remained the mainstays of treatment, while intravenous acetaminophen emerged in use over the course of the study period. The variability in the pain management of pediatric patients undergoing ACLR suggests that further study is necessary to establish the most effective means of perioperative pain management in these patients.

Rate of utilization of physical therapy after common pediatric elbow fractures

Supracondylar, medial epicondyle and lateral condyle fractures are the three most common elbow fractures in pediatric patients. There is a paucity of literature discussing the utilization of physical therapy following these injuries. The purpose of the current study was to determine the rate of utilization of physical therapy after these injuries as well as determine factors that may affect the need for physical therapy after common elbow fractures in pediatric patients. We retrospectively chart reviewed all pediatric elbow fractures that were managed at a major pediatric health system from 2013 to 2020. This study included patients under the age of 18 years and utilized International Classification of Diseases (ICD)-9, ICD-10 and Current Procedural Terminology codes to identify patients. Descriptive statistics, chi-square test and multivariate analyses were performed to compare differences between groups. This study included 2037 patients. Overall, 90 patients (4.4%) received a physical therapy referral at an average time of 90.1 (± 54.6) days between discharge and referral. The rate of physical therapy was 2.7% after nonoperative and 6.3% after operative treatment (P < 0.01). Overall, patients that sustained medial epicondyle fractures were prescribed physical therapy at a higher rate (19.8%) than supracondylar (1.4%) or lateral condyle fractures (5.0%) (P < 0.01). For each fracture type, physical therapy utilization was higher among those treated operatively versus those treated nonoperatively (P < 0.01). Physical therapy is more commonly prescribed for patients with medial epicondyle fractures and patients that received operative management. Additional research is needed to determine clinical indications and efficacy of physical therapy after common elbow fractures in pediatric patients.

Orthopaedic outcomes of prenatal versus postnatal repair of myelomeningocele

Myelomeningocele, characterized by extrusion of the spinal cord through a spinal canal defect, is the most common form of spina bifida, often resulting in lifelong disability and significant orthopaedic issues. A randomized controlled trial (RCT) has shown the efficacy of prenatal repair in decreasing the need for shunting and improving motor outcomes. However, no studies have evaluated the effects of prenatal repair on orthopaedic outcomes. The purpose of this study was to determine the rates of orthopaedic conditions in patients with prenatal and postnatal repair of myelomeningocele and compare the rates of treatment required. This study analyzes the relevant outcomes from a prospective RCT (Management of Myelomeningocele Study). Eligible women were randomized to prenatal or postnatal repair, and patients were evaluated prospectively. Outcomes of interest included rates of scoliosis, kyphosis, hip abnormality, clubfoot, tibial torsion, and leg length discrepancy (LLD) at 12 and 30 months. The need for orthopaedic intervention at the same time points was also evaluated. Statistical analyses included descriptive statistics and univariate analyses. Data for the full cohort of 183 patients were analyzed (91 prenatal, 92 postnatal). There were no differences in rates of scoliosis, kyphosis, hip abnormality, clubfoot or tibial torsion between patients treated with prenatal or postnatal repair. The rate of LLD was lower in the prenatal repair group at 12 and 30 months (7 vs. 16% at 30 months, P = 0.047). The rates of patients requiring casting or bracing were significantly lower in patients treated with prenatal repair at 12 and 30 months (78 vs. 90% at 30 months, P = 0.036). Patients treated with prenatal myelomeningocele repair may develop milder forms of orthopaedic conditions and may not require extensive orthopaedic management.

Does an elbow arthrogram change management after closed reduction of mildly displaced lateral condyle fractures in children?

The purpose of this study was to investigate whether an elbow arthrogram after closed reduction and percutaneous fixation of lateral condyle fractures results in a change in surgical management. This is a retrospective review of lateral condyle fractures managed with closed reduction and percutaneous fixation followed by an elbow arthrogram at our institution between 2008 and 2019. Chart and radiographic review was performed and operative notes were reviewed to determine rates of subsequent intervention after arthrogram. Descriptive statistics were used to summarize the data. This study included 47 patients. The majority of patients were male (34 patients, 72%), and the mean age at time of injury was 5.5 ± 2.6 years. The mean radiographic displacement was 2.6 mm (range 0.8-6.9 mm). All fractures were managed by fellowship-trained pediatric orthopaedic surgeons with an average of 10.5 years of experience (range 0-32 years). Fractures were stabilized with percutaneous pins in 44 patients (94%) and percutaneous screws in three patients (6%). No patients had subsequent changes in management after an elbow arthrogram. There were no complications related to performance of the arthrogram. Closed reduction and percutaneous fixation is often indicated for mildly displaced lateral condyle fractures. Articular reduction after percutaneous fixation is commonly assessed using an elbow arthrogram; however, it did not change surgical management in any case reviewed over the 10-year study period. While there seems to be little risk of performing an arthrogram, the clinical utility should be further evaluated.

Rates of readmission and reoperation after operative management of midshaft clavicle fractures in adolescents

BACKGROUND

The national rates of readmission and reoperation after open reduction internal fixation (ORIF) of midshaft clavicle fractures in adolescents is unknown.

AIM

To determine rates of and risk factors for readmission and reoperation after ORIF of midshaft clavicle fractures in adolescents.

METHODS

This retrospective study utilized data from the Healthcare Cost and Utilization Project State Inpatient Database for California and Florida and included 11728 patients 10–18 years of age that underwent ORIF of midshaft clavicle fracture between 2005 and 2012. Readmissions within ninety days, reoperations within two years, and differences in patient demographic factors were determined through descriptive, univariate, and multivariate analyses.

RESULTS

In total, 3.29% (n = 11) of patients were readmitted within 90 d to a hospital at an average of 18.91 ± 18 d after discharge, while 15.87% (n = 53) of patients underwent a reoperation within two years at an average of 209.53 ± 151 d since the index surgery. The most common reason for readmission was a postoperative infection (n < 10). Reasons for reoperation included implant removal (n = 49) at an average time of 202.39 ± 138 d after surgery, and revision ORIF (n < 10) with an average time of 297 ± 289 d after index surgery. The odds of reoperation were higher for females (P < 0.01) and outpatients (P < 0.01), while the odds of reoperation were lower for patients who underwent surgery in California (P = 0.02).

CONCLUSION

There is a low rate of readmission and a high rate of reoperation after ORIF for midshaft clavicle fractures in adolescents. There are significant differences for reoperation based on patient sex, location, and hospital type.

Pediatric firearm-associated fractures: Analysis of management and outcomes

BACKGROUND

Firearm-associated injuries (FAIs) are among the leading causes of morbidity and mortality in children living in the United States. Most victims of such injuries survive, but may experience compromised function related to musculoskeletal injuries. Although complex firearm-associated fractures (FAFs) often require specialized orthopaedic, vascular, and plastic surgical intervention, there is minimal research describing their management and outcomes. The purpose of this study is to describe the epidemiology and presentation of pediatric FAFs, as well as evaluate the management and outcomes of these injuries.

AIM

To describe the epidemiology and presentation of pediatric FAFs, as well as evaluate the management and outcomes of these injuries.

METHODS

A retrospective chart review was performed at a major, pediatric level 1 trauma center. The study included patients aged 18 or younger who presented with FAIs between 2008-2018. Additional data was collected on patients with FAFs including demographic and clinical data such as age, sex, race, payor type, fracture location, injury severity score (ISS), and radiographic and clinical outcomes. The management of FAFs was analyzed as well as need for readmission and reoperation. Descriptive statistics were used to summarize the results and univariate analyses were performed to assess differences between groups.

RESULTS

Between 2008 and 2018, there were a total of 61 patients who presented with FAIs. In this cohort, 21 patients (34%) sustained FAFs (25 fractures) with a mean age of 11 (Range: 10 mo to 18 years old) at the time of presentation. Approximately 52% (n = 11) of patients with FAFs were male, 76% (n = 8 and n = 8, respectively) identified as black or other, and 71% (n = 15) had government insurance. FAFs were most commonly noted in the upper extremity (n = 7) and lower extremity (n = 6). In patients with FAFs, the mean ISS at presentation was 11.38 (Range: 2-38), and 24% of patients (n = 5) were classified as having a major trauma. There were no significant differences in age, sex, race, and payor type in FAF patients that presented with and without major trauma (P > 0.05). When comparing FAF and non-FAF patients, there was a statistically significant difference in ISS (11.38 vs 14.45, P = 0.02). In total, 33% (n = 7) of patients with FAFs required orthopaedic surgical management, which was most commonly comprised of debridement (n = 6/7, 86%), and 14% (n = 1/7) of these patients required coordinated care with plastic and/or vascular surgery. There were no significant differences in age and payor type in patients with FAFs treated with and without orthopaedic surgery. Of the patients with FAFs, 52% (n = 11) had a minimum 90-d follow-up, and 48% (n = 10) had a minimum 2-year follow-up. Two patients were readmitted within 90-d, while one patient required a reoperation within 2-years.

CONCLUSION

Over 25% of FAIs in pediatric patients result in FAFs. FAFs often present to pediatric trauma centers and the majority of these injuries occur in non-Caucasian males with government insurance. Most FAFs do not need orthopaedic surgical management; 14% of these injuries require subspecialty care by orthopaedic surgery, vascular surgery, or plastic surgery. Patients with FAFs also have lower ISS compared to patients who sustained FAIs without fracture. Thus, these patients should be treated at pediatric trauma centers with specialty care and additional research is needed to focus prevention efforts, understand reasons for poor follow-up, and evaluate outcomes after injury.

Proximal Humerus Fractures in the Pediatric Population

PURPOSE OF REVIEW

The purpose of this review is to review recent literature focusing on proximal humerus anatomy, epidemiology of these fractures, diagnosis and treatment options, and clinical outcomes.

RECENT FINDINGS

Non- or minimally displaced proximal humerus fractures treated nonoperatively do not lead to short- or long-term complication and do not cross over to operative treatment. There is a higher rate of operative management with older age, increased injury severity score, treatment at an adult hospital, and private insurance. Operative management is preferred with closed or open reduction and percutaneous pinning, but elastic nailing and plate fixation are other options with good postoperative outcomes. Pediatric proximal humerus fractures occur after fall onto the affected shoulder or arm. Diagnosis is usually made with radiographs. Understanding the proximal humerus anatomy is critical to the proper management of these injuries to aid reduction and predict remodeling potential. There is considerable debate around the management of proximal humerus fractures in the pediatric population. Treatment is based on patient age, fracture displacement, and remodeling capacity. Nonoperative management is successful in younger patients or less displaced fractures, and operative management is usually considered in older patients with more displaced fractures.

Diagnosis and Management of Unstable Slipped Capital Femoral Epiphysis: A Critical Analysis Review

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An unstable slipped capital femoral epiphysis (SCFE) is characterized by the inability to walk and is associated with a high risk of osteonecrosis.

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An unstable SCFE is less common than a stable SCFE; however, the demographics are similar in both groups of patients with SCFE.

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The diagnosis of an unstable SCFE is characterized by a history of antecedent pain and the inability to walk on examination, and it is confirmed by radiographic assessment.

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Management of an unstable SCFE includes closed reduction, open reduction, and capital realignment, which have all been noted to have lower rates of osteonecrosis than reported in historic reports.

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All management approaches have certain advantages and disadvantages, and comparative studies are needed to guide clinical decision-making.

Venous Thromboembolism After Pelvic Osteotomy in Adolescent Patients: A Database Study Characterizing Rates and Current Practices

BACKGROUND

Current risks and practices in medical prophylaxis of venous thromboembolism (VTE) after major elective lower extremity surgeries such as pelvic osteotomies have not been well-defined in the pediatric population. The purpose of this study was to (1) evaluate population rates of VTE in adolescents undergoing pelvic osteotomies, and (2) characterize current practices on types of VTE prophylaxis being utilized after pelvic osteotomies.

METHODS

The study evaluated the Pediatric Health Information System database between October 1, 2015 and January 1, 2020 for patients between 10 and 18 years of age meeting selected ICD-10 procedure and diagnosis codes relating to pelvic osteotomies. The rate of VTE was calculated within 90 days of index procedure. Types of pharmacologic prophylaxis were characterized. Continuous variables were compared with 2-sample t tests; proportions and categorical variables were compared with Fisher exact or χ2 tests, all with 2-tailed significance <0.05.

RESULTS

Of 1480 included patients, 9 were diagnosed with VTE within 90 days of surgery (VTE rate: 0.61%). Four of 9 (44.4%) had received pharmacologic prophylaxis postoperatively. There were no differences in baseline demographics or length of stay between patients that did or did not develop VTE (P>0.05). Overall, 52.0% received at least one form of pharmacologic prophylaxis postoperatively. The most common pharmacologic prophylaxis used was aspirin (47.6%), of which 64.4% received 81 mg dosing. There was no difference in VTE rates in those with or without prophylaxis (0.52% vs. 0.70%, P=0.75). However, those prescribed prophylaxis were significantly older (15.2±2.3 vs. 13.6±2.4 y, P<0.0001) and had a higher proportion of females (71.8% vs. 54.6%, P<0.01).

CONCLUSIONS

The overall rate of VTE in pediatric patients after pelvic osteotomies is non-negligible. There is heterogeneity in the type of anticoagulant utilized; however, VTE prophylaxis is most commonly prescribed in older adolescents and female patients. Guidelines for medical prevention of deep venous thrombosis and pulmonary embolism in the pediatric population are warranted after hip preservation surgery.

LEVEL OF EVIDENCE

Level IV, case series.

Septic Arthritis of the Knee in Children: A Critical Analysis Review

» Septic arthritis of the knee is the most common type of septic arthritis in children, and it may result in irreversible joint damage. » Staphylococcus aureus is the most common pathogen associated with septic arthritis, but other causative pathogens are possible in children with certain risk factors. » The diagnosis of septic arthritis of the knee is based on history and physical examination, blood tests, and arthrocentesis. » Empiric treatment with anti-staphylococcal penicillin or a first-generation cephalosporin is usually recommended but may be tailored according to local resistance patterns and clinical culture data. » Open or arthroscopic surgical debridement including extensive lavage is effective in eradicating infection, and most patients do not require additional surgical intervention.

Intermediate-Term Outcomes Following Operative and Nonoperative Management of Midshaft Clavicle Fractures in Children and Adolescents: Internal Fixation May Improve Outcomes

Although multiple prospective comparative studies exist for adults with midshaft clavicle fractures, few comparative studies exist in older children and adolescents. This study compares intermediate-term functional, pain, radiographic, and complication outcomes in children and adolescents with midshaft clavicle fractures treated operatively or nonoperatively.

The Pulseless Supracondylar Elbow Fracture: A Rational Approach

BACKGROUND

Supracondylar humerus fractures are the most common type of pediatric elbow fracture, accounting for 60-70% of all elbow fractures in children. Initial trauma and subsequent fracture displacement may damage surrounding neurovascular structures, leading to reports of associated neurovascular injury at rates as high as 49%, with vascular compromise reported in 3-19% of cases. This may be attributable to complete transection, kinking of the artery with reduced flow, thrombosis, intimal tear, arterial contusion or spasm, entrapment of the vessel within the fracture site or traumatic aneurysm of the brachial artery with subsequent thrombus formation.

PURPOSE

While there is general agreement that a child presenting with a pulseless white (dysvascular) hand associated with a displaced supracondylar humerus fracture requires emergent operative management, whether or not surgical exploration of the brachial artery is warranted in a patient with a pulseless pink hand is debatable. Given the lack of consensus, an individualized approach based on clinical findings at initial presentation, including quality of distal perfusion including doppler signal, associated median nerve injury, availability of a surgeon with microvascular skill-set, and access to vigilant post-operative monitoring, combined with an open discussion of the pros and cons of various treatment options with the family is prudent.

METHODS

Herein we outline our management principles, developed with careful consideration of the available literature and informed by practical experience.

RESULTS

We recommend emergent management of pulseless supracondylar fractures, especially those that present with a pulseless white hand or with a dense median nerve palsy, with operative fracture reduction and fixation. In all children presenting with a pulseless supracondylar humerus fracture, the vascular status should be reassessed after adequate fracture reduction and fixation, and in patients with continued signs of abnormal distal perfusion, such as weak or absent Doppler signals or sluggish capillary refill, surgical exploration of the brachial artery with reestablishment of adequate distal flow should be conducted immediately.

CONCLUSION

Much of the existing evidence surrounding the supracondylar humerus fracture associated with a pink, pulseless hand is of low quality. This shortcoming should serve as an impetus for establishment of an international registry of all dysvascular pediatric supracondylar fractures, with adequate documentation of the vascular exam before and after reduction, intra-operative and post-operative management and long term follow-up, to provide optimal management guidelines based on robust evidence.

Open Reduction and Suture Fixation of Acute Sternoclavicular Fracture-Dislocations in Children

Background

Acute sternoclavicular fracture-dislocation is associated with high-energy trauma and is being increasingly recognized in children¹. These injuries are associated with compression of mediastinal structures and can be life-threatening¹. The management of acute sternoclavicular fracture-dislocation includes closed reduction or open surgical stabilization; however, limited success is reported with closed reduction^2,3. To our knowledge, there are no detailed descriptions of open reduction and suture fixation of acute sternoclavicular fracture-dislocation in children.

Description

Following diagnosis of acute sternoclavicular fracture-dislocation, the timing of surgical treatment is determined according to several patient and surgical factors. Among patients with hemodynamic instability, respiratory compromise, or evidence of asymmetric perfusion, surgical treatment is needed on an emergency basis. In the absence of these factors, surgical treatment can be performed on an urgent basis. It is important to communicate with vascular or thoracic surgeons prior to proceeding to the operating room because of the rare case in which advanced surgical access or vascular repair is required. In the operating room, general anesthesia and large-bore intravenous access are required. Patients are positioned supine on a radiolucent table, and a small bump is placed between the scapulae to elevate the medial aspect of the clavicle. The contralateral sternoclavicular joint and medial aspect of the clavicle should be prepared into the sterile field, as well as both sides of the groin in case vascular access is needed. A 6 to 8-cm incision is centered on the medial aspect of the clavicle, extending to the manubrium. Standard dissection to the clavicle is performed, and care is taken to maintain the integrity of the sternoclavicular ligament complex. Circumferential dissection of the medial clavicular metaphysis is usually required in order to mobilize the dislocated fragment. Reduction of the physeal fracture usually requires axial traction and extension of the ipsilateral shoulder with the aid of a reduction clamp on the medial clavicular metaphysis. In some cases, a Freer elevator can be placed between the metaphysis and epiphysis to shoehorn the clavicle from posterior to anterior. Once reduced, the fracture-dislocation is usually stable; however, the reduction is augmented with suture fixation. The sternoclavicular joint capsule should be repaired if disrupted, and the incision should be closed in layers. Postoperatively, the arm is placed in a sling, and range of motion is commenced at 4 weeks.

Alternatives

Alternative management of acute sternoclavicular fracture-dislocation includes closed reduction, plate fixation⁴, and ligament reconstruction⁵.

Rationale

In our experience, closed reduction is often unsuccessful, which is consistent with the experiences reported by other authors^2,3. In addition, suture fixation is sufficient and plate fixation is not required because this injury is relatively stable following reduction. Lastly, ligament reconstruction with use of autograft or allograft may be indicated but is more relevant in chronic cases with injury or attenuation of the sternoclavicular ligament complex. Open reduction allows for direct visualization of the fracture reduction, and suture fixation allows for increased stability without the need for hardware or secondary surgical procedures.

Expected Outcomes

We expect patients to achieve full range of motion and strength without any joint instability as reported by Waters et al.³.

Important Tips

There is an inherent risk of vascular injury with open reduction and suture fixation. This risk is mitigated with perioperative planning and consultation with vascular or thoracic surgeons. General surgeons should always be available when these procedures are performed in case of vascular issues or emergencies.It is sometimes difficult to reduce the dislocation, but additional maneuvers allow for controlled reduction of the displaced clavicle, such as using a Freer elevator and serrated clamp.Assessing fracture reduction can be difficult intraoperatively. Including the contralateral sternoclavicular joint in the sterile surgical field can be helpful in assessing fracture reduction and osseous contour.

Open and Closed Reduction for Developmental Dysplasia of the Hip in New York State: Incidence of Hip Reduction and Rates of Subsequent Surgery

Background:

There are limited data on the incidence and outcomes of open and closed hip reduction in patients with developmental dysplasia of the hip (DDH). The aims of this study were to determine the incidence of open and closed reduction of the hip using population-level data and to assess the rates of subsequent surgery.

Methods:

Children aged 3 years and younger with DDH who underwent open or closed reduction of the hip between 1997 and 2013 were identified in the New York Statewide Planning and Research Cooperative System (SPARCS) database. Patient age, sex, race, and insurance status as well as concurrent procedures were extracted. Admissions through 2014 were searched for subsequent surgeries, providing a minimum 1-year post-reduction surveillance for all patients. Age-specific incidence rates were calculated using New York State annual population data. The rates of concurrent and subsequent surgeries were calculated. A sensitivity analysis was performed to provide a range for the rates of subsequent surgery. Univariate analyses consisted of chi-square or Fisher exact tests for categorical variables.

Results:

In total, 897 patients (637 who underwent closed reduction and 260 who underwent open reduction) were identified. The age-specific incidence per 100,000 population was 12.5 for closed reduction and 2.6 for open reduction for <1-year-olds, 2.2 for both closed and open reductions for 1-year-olds, 0.4 for closed reduction and 1.0 for open reduction for 2-year-olds, and <0.3 for closed reduction and 0.5 for open reduction for 3-year-olds. Overall, closed reductions were performed more frequently over the study period (p < 0.01). The estimated rate of subsequent ipsilateral surgery was 12.4% (range, 9.4% to 33.1%) after index closed reduction and was 14.2% (range, 8.5% to 40.1%) after index open reduction.

Conclusions:

We found that the incidence of closed or open hip reduction for DDH was small and that there was an increase in the number of closed reductions performed over time. The rates of subsequent surgery remained relatively high for patients after index closed or open hip reduction.

Level of Evidence:

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

Outcomes of periacetabular osteotomy for borderline hip dysplasia in adolescent patients

Treatment of borderline acetabular dysplasia (lateral center edge angle ≥18°) remains controversial, and there is a paucity of literature focusing on outcomes in adolescent patients. The purpose of this study was to evaluate the outcomes of a periacetabular osteotomy (PAO) as surgical management of borderline acetabular dysplasia in adolescent patients. We performed a retrospective review of prospectively collected data and included patients ≤ 21 years of age that underwent PAO for borderline acetabular dysplasia. All patients had a minimum of 1-year follow-up. Outcomes were assessed using modified Harris Hip Scores (mHHS), Hip Outcome Scores (HOS) and international Hip Outcome Tool (iHOT-33). Descriptive and univariate statistical analyses were performed. This study included 33 adolescent patients (35 hips) with symptomatic, borderline acetabular dysplasia. The majority of patients was female (32 patients, 97%); half of all patients reported a history of hip pain for over 1 year; and seven patients had previous hip arthroscopy. In addition to PAO, seven hips (20%) underwent a concurrent hip arthroscopy at the time of surgery. There were significant improvements in mean mHHS, HOS-activities of daily living (ADL), HOS-Sport and iHOT-33 scores after surgery (P < 0.01). Minimal clinically important difference in outcome scores was achieved for over 90% of patients at a minimum of 1-year follow-up. Borderline acetabular dysplasia is a major cause of hip pain in adolescent patients. Patients with symptomatic borderline acetabular dysplasia report a significant benefit after a PAO to correct structural hip instability.

Predicting subsequent contralateral slipped capital femoral epiphysis: an evidence-based approach

PURPOSE

The purpose of this study was to identify risk factors for developing a subsequent contralateral slipped capital femoral epiphysis (SCFE) and provide a prediction score to quantify risk of subsequent slip at the time of initial presentation.

METHODS

This retrospective study included patients that presented with a unilateral SCFE between 2006 and 2017. Chart and radiographic review were performed to collect demographic, clinical and radiographic risk factors. Descriptive statistics, univariate analyses and multivariate regression analysis were used to compare risk factors between patients that did or did not develop a subsequent contralateral SCFE.

RESULTS

This study included 183 patients and 33 patients (18%) developed a subsequent contralateral SCFE. Younger age at time of initial presentation, lower modified Oxford Score and smaller difference in epiphyseal-diaphyseal angle between both sides during index presentation were significant predictors of subsequent contralateral SCFE. Specifically, age ≤ 11 years, modified Oxford Score ≤ 20 and difference in epiphyseal-diaphyseal angle of ≤ 21° between both hips were predictive of a contralateral slip (Area Under the Curve = 0.78; p < 0.05). The presence of each risk factor increased the risk of subsequent contralateral SCFE and having all three risk factors increased the risk to 73%.

CONCLUSION

There is a significant risk of subsequent contralateral SCFE in patients with unilateral SCFE, and predictive risk factors include younger age, lower modified Oxford Score and smaller difference in epiphyseal-diaphyseal angle between the affected and unaffected hips.

LEVEL OF EVIDENCE

Level III.

Septic Arthritis of the Hip in Children: A Critical Analysis Review

Septic arthritis of the hip is a common and potentially devastating condition in children. Septic arthritis is most commonly caused by Staphylococcus aureus, but other pathogens should be considered on the basis of patient age and presence of risk factors. Diagnosis of septic arthritis is based on history and physical examination, laboratory tests, radiographs, ultrasound, and arthrocentesis. Treatment comprises empiric antibiotics and joint debridement, and antibiotics are subsequently tailored on the basis of culture data, local resistance patterns, and clinical response. Late sequelae of septic arthritis include osteonecrosis, chondrolysis, growth disturbance, subluxation or dislocation, and progressive ankylosis. Surgical treatments to address these issues have been described.

Percutaneous Pinning of Pediatric Proximal Humeral Fractures

Background

Proximal humeral fractures are relatively common in pediatric patients. These injuries are usually treated nonoperatively in younger children or children with minimally displaced fractures. However, closed reduction or open reduction followed by percutaneous pinning is recommended for older children with displaced fractures. Percutaneous pinning has several advantages, but there are limited reports of a safe and reliable surgical technique in the literature.

Description

Patients are positioned in a modified beach-chair position to allow orthogonal imaging. The injured extremity is draped free from the remainder of the body. Closed reduction, which comprises a combination of traction, abduction, and rotation, is attempted. Internal or external rotation may be required, depending on the fracture line and deforming forces. If an anatomic closed reduction cannot be obtained, a block to reduction should be suspected and open reduction should be performed via a deltopectoral approach. Once the fracture is reduced, two 2.5-mm threaded Kirschner wires from the small external fixator set are used to percutaneously fix the fracture. Any small external fixator set can be used, and if not available, individual threaded wires of similar size can be used. Alternatively, Kirschner wires can be advanced to the fracture site prior to reduction and then advanced into the humeral epiphysis once the fracture is reduced. Care is taken to avoid the axillary nerve, which is reliably within 6 cm of the anterolateral aspect of the acromion, and wires are placed distal to this site. Once pin position has been confirmed radiographically, the construct is secured with pin-to-pin clamps to improve rigidity and further decrease the risk of pin migration. A soft dressing and shoulder immobilizer are placed postoperatively. Patients are followed with biweekly radiographs, and pins are removed in the outpatient office or under conscious sedation at 4 weeks. Leaving pins for a longer period may increase the risk of skin irritation and potentially infection.

Alternatives

Alternatives to closed reduction or open reduction and percutaneous pinning include nonoperative management and elastic intramedullary nailing. Nonoperative treatment is a reliable option for most patients. However, it is not suitable for older children with severely displaced fractures because of diminished remodeling potential. Elastic intramedullary nailing is a good option for distal fractures. However, it is not suitable for proximal fractures, and it has been associated with longer operative times and more blood loss than percutaneous pinning. It also requires a second procedure.

Rationale

This procedure allows for anatomic fixation of proximal humeral fractures and provides a rigid construct to maintain reduction. It is not technically challenging, requires limited postoperative immobilization, and decreases the risk of a second general anesthetic.