Journal of Pediatric Orthopaedics最新文献

Background: Adolescent idiopathic scoliosis (AIS) is a common pediatric spinal deformity, with disparities in care often linked to socioeconomic status (SES). The Childhood Opportunity Index (COI) and Index of Concentration at the Extremes (ICE) are SES markers that have been used to evaluate health disparities in orthopaedic care. The utility of these SES markers in identifying differences in AIS presentation remains unclear.

Methods: Medical records between 2017 and 2020 were reviewed for patients newly diagnosed with AIS from our city-center institution with around 600,000 patient encounters annually from all communities. Patient home addresses were used to assign nationally available COI 2.0 and ICE scores. COI, which ranges from 0.0 to 100.0, was categorized into quintiles: very low (<20.0), low (20.0 to 39.9), moderate (40.0 to 59.9), high (60.0 to 79.9), and very high (>80.0). ICE was divided into ICE White versus Black income (ICEwbinc) and ICE White, Black, and Hispanic income (ICEwnhinc), with scores ranging from -1 to 1. SES markers were evaluated for associations with major curve angle magnitude at presentation and at 1-year follow-up.

Results: Of 486 eligible patients, 330 (67.9%) were female. The mean major curve angle at presentation was 26 degrees. Average COI was significantly higher in White patients (73.6) compared with Hispanic patients (30.4; P <0.001). ICEwbinc (0.4 vs. 0.0; P <0.001) and ICEwnhinc (0.33 vs. -0.1; P <0.001) were highest in White patients and lowest in Hispanic patients. Very low COI was associated with the highest average body mass index (23.4) compared with the very high COI group (20.5; P <0.001). SES markers were not associated with major curve angle at presentation and 1-year follow-up.

Conclusions: SES markers were not associated with AIS presentation or progression. These findings contribute to the growing literature showing that equitable access to AIS care is increasing across the nation. Future studies should focus on the role of early clinical detection contributing to equal access to AIS care.

Level of evidence: Level III-retrospective comparative study.

Background: Climate change presents a critical public health challenge, and the health care sector is a substantial contributor to greenhouse gas emissions. Operating rooms generate a disproportionate share of hospital waste, with orthopaedic surgery producing more waste than any other specialty. However, waste production in pediatric orthopaedic surgery remains poorly studied. This study aimed to quantify solid waste generated during common pediatric orthopaedic procedures and assess the perspectives of operating room staff regarding sustainability practices and barriers to waste reduction.

Methods: A mixed-methods study was conducted at 2 affiliated pediatric hospitals. Solid waste audits were performed on 20 pediatric orthopaedic surgeries, including anterior cruciate ligament reconstruction, pelvic osteotomy, elbow fracture fixation, and posterior spinal fusion. Waste was collected and weighed separately during the preoperative and intraoperative periods, categorized as recyclable or nonrecyclable. Descriptive statistics and t tests were used to compare waste production across procedures and time periods. In addition, a survey assessing attitudes toward sustainability and perceived barriers to waste reduction was distributed to surgeons, residents, circulators, and scrub technicians. Qualitative responses were analyzed using inductive content analysis.

Results: The average solid waste generated per procedure was 15.02 kg (SD: 9.26). Posterior spinal fusion produced the highest waste (29.49 kg), followed by pelvic osteotomy (13.40 kg), anterior cruciate ligament reconstruction (9.96 kg), and elbow fixation (7.24 kg). None of this waste was recycled at the primary study sites. Extrapolated to institutional surgical volumes, these 4 procedures contributed an estimated 5.03 metric tons of solid waste in 2024. Survey responses (n = 13; 39% response rate) identified unnecessary opening of supplies and lack of recycling infrastructure as key contributors to waste. Participants reported minimal sustainability education but expressed interest in institutional support to improve practices.

Conclusions: Pediatric orthopaedic surgery generates substantial solid waste. Despite staff awareness of the environmental impact, systemic barriers limit sustainable practices. Targeted strategies, including recycling infrastructure, preference card optimization, and staff education, are needed to reduce waste in the pediatric orthopaedic operating room.

Level of evidence: Level III-cross-sectional study.

Background: Pediatric coronal plane deformities are commonly managed by guiding growth by placing an extraperiosteal 2-hole plate across the growth plate with 1 epiphyseal and 1 metaphyseal screw. Once the correction is achieved, removing the metaphyseal screw only (sleeper plate) has been described to facilitate easier future corrections if deformity rebounds. A complication commonly described with this approach is tethering, where the patient continues to overcorrect despite the elimination of tension across the physis. This study aims to evaluate the safety and efficacy of sleeper plates and assess the rate of tethering in stainless steel (SS) versus titanium alloy (Ti) plates.

Methods: This study retrospectively reviewed patients who underwent guided growth procedures for coronal plane deformities between February 2014 and September 2023. Fifty-two sleeper plates were identified in 34 patients, out of which 30 were SS and 22 were Ti. We examined for rebounding necessitating screw reinsertion and tethering requiring plate removal. This was done by measuring mechanical lateral distal femoral angle (mLDFA), the medial proximal tibial angle (MPTA), and mechanical axis deviation (MAD) during follow-up.

Results: The median age at plate insertion was 8.6 (SS) years versus 9.7 (Ti). The median age at screw removal was 10.7 years for the SS group and 10.8 years for the Ti group after deformity correction. There was no statistically significant difference between the 2 groups with respect to age at plate insertion ( P -value=0.945) and the age at screw removal ( P -value=0.85). Overall, 40% of plates rebounded with 27% in SS and 59% in the Ti group ( P -value=0.027), which could be explained by longer follow-up in the Ti group that was statistically different ( P -value <0.001). 4/52 plates had tethering, and, of note, all the tethers were seen in the Ti group, with the median duration between screw removal and tethering first noticed being 1.1 years. All 4 patients corrected over time with the removal of the whole plate, none developed a physeal bar, and all went on to achieve normal alignment. The study had over 80% power to detect differences in tethering with a statistically significant P -value of 0.015.

Conclusion: Sleeper plate is a viable technique for correcting coronal plane deformity, though tethering leading to overcorrection is a potential complication, especially with Ti implants. Based on our results, we advise avoiding Ti implants for sleeper plates.

Level of evidence: Level III.

Background: Utility task vehicles (UTVs) differ from all-terrain vehicles (ATVs) in that they are heavier, have larger engines, and have rollover protective structures. Despite their growing popularity for recreational use, there is emerging evidence that mutilating injuries may be higher in UTVs than ATVs, but this has not been evaluated in a pediatric-only population. This study seeks to determine differences in injury characteristics between vehicle types.

Methods: A retrospective cohort study was performed at a level 1 pediatric trauma center, evaluating all patients <18 years old who presented following an ATV or UTV accident between 2018 and 2023. Demographic, injury and outcomes data was collected. Statistical analysis was performed with a combination of the Student t test for continuous data and the Fisher exact or χ 2 tests for categorical data.

Results: A total of 743 patients were identified (ATV 533, UTV 210), with a mean age of 11.8±3.7 y, with ATV patients being older (12.1±3.6 y) than UTV patients (11.2±4.0 y, P =0.003). Overall rates of admission (ATV 54% vs. UTV 60%; P =0.12), surgical treatment (ATV 42% vs. UTV 43%; P =0.87), and readmission (ATV 6% vs. UTV 5%; P =0.86) were similar between groups. UTV injuries resulted in significantly more open extremity fractures (ATV 6.6% vs. UTV 11%; P =0.045), more type IIIa/b/c open fractures (ATV=1.7%, UTV=6.2%; P =0.001), and more amputations (ATV 0.4% vs. UTV 3.3%; P =0.0009). Amputation level was transhumeral or through-elbow in 3 patients (all UTV), transtibial in 1 patient (UTV), multiple fingers in 1 patient (UTV), and single partial finger in 4 patients (2 UTV, 2 ATV).

Conclusions: UTV injuries have a higher rate of amputation, open fracture, and severe open fracture compared with ATV injuries. Significant amputations (major limb or multiple fingers) were observed only in the UTV group. Surgeons and the general public should be aware that UTVs have the potential for more severe trauma to the limb, potentially resulting in loss of limb function.

Levels of evidence: Level III-retrospective cohort.

Background: With an annual incidence of 177 per 100,000 patients, supracondylar humerus fractures (SCHF) are the most common elbow fracture in the pediatric population. 1,2 Pain control after closed reduction and percutaneous pinning (CRPP) of SCHF may be improved with the use of a local anesthetic. We aimed to assess the effects of local bupivacaine administration on immediate post-operative pain and opioid requirements.

Methods: A retrospective chart review was performed for patients undergoing CRPP of SCHF from September 1, 2018 to September 30, 2022 at a single institution. Two groups (local vs. no local) were formed based on intraoperative administration of bupivacaine. Post-anesthesia care unit (PACU) records were reviewed for type and dose of pain medications administered and pain scores.

Results: Three hundred thirty-five patients (114 local, 221 no local) were included in review. No differences were noted in demographic or injury characteristics. The local and no-local groups had average PACU pain scores of 2.2±3.2 and 3.3±3.5, respectively. There was no significant difference between groups in percentage of patients who received Tylenol, Motrin, and Toradol. There was a significant difference in the number of patients who received morphine with 42% of patients in the local group requiring morphine compared with 64% of patients in the no-local group. The average weight-based dose of morphine in the local group was 0.002 mg/kg±0.001 and 0.003 mg/kg±0.008 in the no-local group. No differences were noted in postoperative complications or unexpected follow-up.

Conclusions: The use of local bupivacaine intraoperatively improved pain control as evidenced by fewer patients requiring morphine and lower pain scores in the local group. Local bupivacaine is a low-cost, low-risk intervention that can be used after CRPP of SCHF that may improve immediate postoperative pain and facilitate quicker transition to oral pain medications with decreased need for IV opioid medications.

Level of evidence: Level IIIB-retrospective comparative study.

One of the greatest German Renaissance artists, Albrecht Dürer, noted for his realistic works of art, painted and engraved the Christ child and Eve with characteristic postures of the upper limb resembling the sequel of Erb palsy. However, there is no Biblical evidence to suggest that the Christ child or Eve had paralysis of the upper limb. It appears conjectural as to why Dürer chose to depict the limbs of his subjects in this manner.

Background: Outcomes following shoulder instability events suggest high rates of recurrence for the pediatric population. Previous studies have not focused on those with open physes at the proximal humerus, and longer-term surgical outcomes have not been evaluated for this population. The purpose of the current study is to evaluate patient-reported outcomes and recurrence rates in skeletally immature children and adolescents undergoing arthroscopic stabilization procedures.

Methods: A retrospective review of all skeletally immature patients who underwent arthroscopic shoulder stabilization between 2009 and 2021 from 2 pediatric hospitals was performed. Demographic, injury, imaging, and intraoperative data were recorded. Patient-reported outcomes, including the Pediatric/Adolescent Shoulder Survey (PASS), return to sport, instability recurrence, and need for revision surgery, were documented. Statistical analysis was performed to assess risk factors for recurrence.

Results: One hundred one skeletally immature patients met the inclusion criteria. The mean age at the time of surgery was 14.8 ± 1.4 years, and 74% were males. The majority of patients had anterior instability (78%), 17% had posterior instability, and 5% had multidirectional instability. Contact sports were responsible for 47% of injuries. The average number of dislocations before surgery was 2.6 ± 3.4. At a mean follow-up of 5.1 ± 2.9 years, the mean PASS score was 88 ± 14. A total of 35 patients (34.7%) experienced recurrent instability, and 10 patients (10%) had a revision procedure. Patients with recurrent instability were found to be younger, had longer clinical follow-up duration, and had a lower final PASS score. Direction of instability was not associated with recurrence rate. Other factors such as sex, number of dislocations before surgical intervention, and participation in contact sports were not significantly associated with recurrent instability.

Conclusions: While the majority of skeletally immature children and adolescents undergoing arthroscopic shoulder stabilization can achieve favorable outcomes, recurrent instability remains a problem, as ∼1 in 3 patients may experience recurrent instability with younger patients being at particular risk.

Level of evidence: Level IV-retrospective case series prognostic study.