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The concept of environmental sustainability, social responsibility, and good governance (ESG) is now well established in the corporate world and in for-profit organizations. However, it is not a concept that has reached medical and surgical association boardrooms in a meaningful way. It is important to define the concept of physician and corporate author expertise and objectives of ESG, provide a rationale for using ESG within orthopaedic organizations, and identify specific areas (primarily the "S" and the "G") where the American Academy of Orthopaedic Surgeons and other groups can align with this strategy.

It is important to be knowledgeable about the latest information on the diagnosis and the evidence-based management of developmental hip dysplasia and dislocation from birth through adolescence. The focus should be on the effect of the problem; normal growth and development of the hip joint; and the pathoanatomy, natural history, and long-term outcomes of developmental dysplasia of the hip, hip subluxation, and dysplasia. Many controversies exist in the management of this complex spectrum of disorders.

Surgical correction for AIS has evolved from all hooks to hybrids or all screw constructs. Limited literature exists reporting outcomes using PHDS for posterior spinal fusion (PSF). This is the largest series in evaluating results of PHDS technique. A retrospective review of consecutive AIS patients undergoing PSF by a single surgeon between 2006 and 2015 was performed. All eligible patients met a minimum 2-year follow-up. Patient demographics and radiographical parameters (radiographic shoulder height (RSH), T1 tilt, clavicle angle) at baseline, 6-week and 2-year post-operation were recorded. The primary outcome was difference in RSH from baseline measurements evaluated using repeated measures one-way analysis of variance with Bonferroni correction. A total of 219 patients (mean age at surgery: 13.68 years; 82% female) were included. The mean follow-up was 41.2 months (range 24–108 months). The RSH was significantly improved from − 14.7 ± 10.38 mm to 8.0 ± 6.9 mm (P

Background Despite widespread use of single-stage open reduction and pelvic osteotomy for treatment of developmental dysplasia of the hip (DDH) after walking age, this aggressive strategy remains controversial. We directly compared dislocated hips treated with closed reduction (CR) to those treated with open reduction and Salter innominate osteotomy (OR/IO) to estimate the relative hazard of total hip arthroplasty (THA) and the THA-free survival time. Methods In a series of patients 18 to 60 months of age, 45 patients (58 hips) underwent CR and 58 patients (78 hips) were treated with OR/IO and followed to a minimum 40 years post-reduction. Observations in the survival analysis were censored if no THA had occurred by 48 years. Multivariate Cox regression analysis was used to estimate the hazard of THA given treatment, age, and bilaterality. Complications and additional procedures were noted. Results At 48 years of follow-up, 29 (50%) of the hips survived after CR compared with 54 (69%) after OR/IO. At 45 years, the survival probability after OR/IO was 0.63 (95% confidence interval [CI] = 0.50 to 0.78) compared with 0.55 (95% CI = 0.43 to 0.72) after CR. The hazard ratio (HR) of THA was modeled as a function of treatment, age at reduction, and bilaterality. The effect of age and treatment on the outcome of hips in patients with unilateral involvement was minimal. However, age did significantly alter the relationship between treatment and outcome in bilateral cases. In the bilateral group, the predicted HR of THA was lower after CR in hips that were reduced at the age of 18 months (HR = 0.16, 95% CI = 0.04 to 0.64) but higher in those that were reduced at 36 months (HR = 4.23, 95% CI = 2.00 to 8.95). Additional procedures were indicated for 17% and 22% of hips after CR and OR/IO, respectively. Conclusions Osteoarthritis and THA was more likely after CR than OR/IO, but the data do not indicate a difference in unadjusted hip-survival time. In patients with bilateral disease, an older age at reduction was associated with an increased hazard of THA after CR than after OR/IO. Both treatments provided substantial benefit relative to the natural history of DDH, but THA is the expected outcome in middle adulthood. Level of evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

With Americans living longer, many physicians and surgeons have extended their medical and surgical practice life beyond the traditional 65-year-old retirement age. As retirement is inevitable, planning for that eventuality, which in early practice years appears unnecessary, is in fact an exercise which will pay dividends at the time of retirement. Two senior orthopaedic surgeons provide insight on the 2 main issues concerning retirement: how to prepare for retirement while in active practice, and factors to consider as to the timing of that major life event.

In a traditional view, the natural history of a condition or a disease tells us of the adult consequences of that entity, be it benign or otherwise. This knowledge then provides guidance as to who needs treatment, and allows us to assess whether our treatments alter an otherwise adverse natural history in a positive way without introducing iatrogenic complications. However, in the new paradigm for health care delivery of value-based care, we need to be able to express natural history in additional terms of burden of disease. This is something that lawmakers and people who pay for health care can understand and has a comparative value. It also serves as a benchmark to show the effectiveness of interventions aimed at reducing disease burden. In this paper, I will discuss why this POSNA symposium is important and make some recommendations on directions where we as individuals and as a professional society should be putting in our efforts and resources.

BACKGROUND: Adolescent idiopathic scoliosis (AIS) is defined as a lateral curvature of the spine of unknown etiology with a Cobb angle of greater than 10 degrees with vertebral rotation. Bracing, specifically with a rigid thoracolumbosacral orthosis (TLSO), decreases the risk of curve progression to over 50 degrees, the threshold for surgical intervention. Some authors have suggested that 30-50% in-brace correction of the Cobb angles is required to prevent significant curve progression. The purpose of the study is to evaluate the current bracing protocol at the University of Iowa as a quality control exercise for the treatment team. METHODS: AIS patients (n = 61; 8 male, 53 female) who received a Rosenberger TLSO at the University of Iowa Department of Orthopaedics and Rehabilitation from 2016-2017 were included in the study. Inclusion criteria include presence of pre-brace and in-brace x-rays within 3 months of initiating brace treatment. Patients with other diagnoses were excluded. Radiographic indicators of brace effectiveness, such as the Cobb angle, were measured. RESULTS: The in-brace x-rays of 46 (76%) patients showed less than 30% correction. Minimal changes from the pre- to in-brace x-ray were observed in other radiographic measures. CONCLUSIONS: Results indicate that if the 30-50% correction recommended by the literature is valid, then modifications to the process of measuring, fabricating or modifying our current TLSO’s for AIS are warranted. Level of evidence: III

STUDY DESIGN Comparative effectiveness study OBJECTIVE.: To evaluate factors leading to higher percentage of brace failures in a cohort of North American patients with adolescent idiopathic scoliosis relative to their peers in Italy. SUMMARY OF BACKGROUND DATA Studies of bracing in United States have shown worse outcomes than studies from European centers, possibly due to sample characteristics or treatment approaches. METHODS Sample: Braced patients, aged 10 to 15, Risser

Retrospective.Utilize three-dimensional (3D) measurements to assess the relationship between thoracic scoliosis severity and thoracic kyphosis in a large, multicenter cohort, and determine impact of 3D measurements on adolescent idiopathic scoliosis (AIS) curve classification. Research has demonstrated differences in two-dimensional (2D) and 3D assessment of the sagittal plane deformity in AIS. A prior smaller, single-institution study demonstrated an association between scoliosis severity and loss of 3D thoracic kyphosis.Data included retrospective compilation of prospectively enrolled bracing candidates and prospectively enrolled surgical candidates with thoracic AIS. Analysis included two groups based on thoracic curve magnitude: moderate (20-45°) and severe ( 45°). Imaging was performed using 2D radiographs. 3D thoracic kyphosis was calculated using a 2D to 3D conversion formula. Kyphosis was categorized according to the Lenke classification sagittal plane modifier.Analysis included 3032 patients. 2D kyphosis was significantly less in the moderate group (21 ± 12 vs 23 ± 14, p = 0.028). However, estimated 3D kyphosis was significantly greater in the moderate group (13 ± 10 vs 5 ± 12, p 0.001). In the moderate group, the rate of normokyphosis was 78% with 2D measures and 61% with 3D measures of T5-T12 kyphosis. In the severe group, this rate changed from 72 to 32% with use of 2D and 3D measures, respectively. In the moderate group, 16% of patients were classified as hypokyphotic using 2D measures while this rate increased 38% with 3D measures (p 0.001). In the severe group, this rate changed from 18 to 68% using 2D and 3D measures, respectively (p 0.001).Increased coronal curve severity was associated with decreased thoracic kyphosis. Hypokyphosis was more pronounced in 3D. 2D radiographs increasingly underestimate kyphosis with increasing coronal severity. Assessment of sagittal alignment from 2D radiographs can be improved with a 2D-3D conversion formula. Findings indicate potential for classification system improvement with use of 3D sagittal plane measurements.IV.

Developmental dysplasia of the hip is the all-encompassing term used to describe the wide spectrum of disorders of the development of the hip that manifest in various forms and at different ages. Developmental dysplasia of the hip often evolves over time because the structures of the hip are normal during embryogenesis but gradually become abnormal. Such variability in pathology is associated with a similarly wide range in management options and recommendations aimed at preventing hip joint arthrosis. These options may be instituted at any time between birth and adulthood as techniques aimed at preserving the native hip or replacing the arthritic hip. Many of these management options are clearly indicated and considered standard practice. However, with the evolution of the understanding of hip biomechanics, better knowledge of the long-term outcomes of hip joint-preserving surgeries, and ever-improving technology influencing hip arthroplasty come new controversies, especially whether to preserve or replace the mature hip.

Survey. Bracing is the mainstay of conservative treatment in Adolescent Idiopathic Scoliosis (AIS). The purpose of this study was to establish best practice guidelines (BPG) among a multidisciplinary group of international bracing experts including surgeons, physiatrists, physical therapists, and orthotists utilizing formal consensus building techniques. Currently, there is significant variability in the practice of brace treatment for AIS and, therefore, there is a strong need to develop BPG for bracing in AIS. We utilized the Delphi process and the nominal group technique to establish consensus among a multidisciplinary group of bracing experts. Our previous work identified areas of variability in brace treatment that we targeted for consensus. Following a review of the literature, three iterative surveys were administered. Topics included bracing goals, indications for starting and discontinuing bracing, brace types, brace prescription, radiographs, physical activities, and physiotherapeutic scoliosis-specific exercises. A face-to-face meeting was then conducted that allowed participants to vote for or against inclusion of each item. Agreement of 80% throughout the surveys and face-to-face meeting was considered consensus. Items that did not reach consensus were discussed and revised and repeat voting for consensus was performed. Of the 38 experts invited to participate, we received responses from 32, 35, and 34 for each survey, respectively. 11 surgeons, 4 physiatrists, 8 physical therapists, 3 orthotists, and 1 research scientist participated in the final face-to-face meeting. Experts reached consensus on 67 items across 10 domains of bracing which were consolidated into the final best practice recommendations. We believe that adherence to these BPG will lead to fewer sub-optimal outcomes in patients with AIS by reducing the variability in AIS bracing practices, and provide a framework future research. Level IV.

This review summarizes evidence developed at the University of Iowa concerning the management and outcomes of developmental dysplasia of the hip beginning with the observations and analyses of Dr Arthur Steindler in the early 1900s. The strong evidence-based practice tradition established by Steindler 100 years ago continues as we critically evaluate our procedures and patient outcomes, only altering approaches when warranted by strong personal and research evidence. Our practice continues to be conservative in that we strive to produce the best environment possible for the hip to develop on its own and operate only when less invasive methods have failed.

Background: Spinal muscular atrophy (SMA) is a progressive neuromuscular disease commonly including progressive scoliosis resulting in severe deformity and negatively affecting pulmonary function. Surgical correction and stabilization of this progressive deformity is generally recommended; however, the timing and method of surgical fixation remains controversial. Methods: Retrospective review of clinical, radiographic, and pulmonary function data from 16 children with SMA and surgically treated scoliosis between 1985 and 2013. Radiographic data included direct measures of major curve, coronal balance, pelvic obliquity, T1-T12 height, T1-S1 height, and T1-rod length. Estimations of rib collapse, thoracic cavity shape, and space-available-for-lung (T6:T12, width ratio; T6:T10, rib-vertebral-angle difference ratios; and lung height) were determined. Eleven patients were able to complete pulmonary function testing. Results were compared with published outcomes for growing rod constructs. Results: Posterior spinal fusion was performed at an average age of 9.8±3.6 years. The mean age at most recent follow-up was 19.4 years (range, 10 to 37 y), with a mean follow-up of 10.1 years (range, 3.1 to 26 y). Radiographic measurements improved from preoperative to latest follow-up as follows: major curve, 78±20 degrees to 27±24 degrees; coronal balance, 4.1±4.0 cm to 1.9±2.2 cm; pelvic obliquity (median), 23 to 5 degrees; T1-T12 height, 19±3 cm to 22±3 cm; T1-S1 height, 31±7 cm to 36±6 cm; T1-rod length, 0.8±1.1 cm (postop) to 2.8±1.6 cm (final); and space-available-for-lung ratio, 0.88±0.26 to 0.95±0.25. Rib collapse continued throughout the follow-up period in all but 1 patient. Pulmonary function testing demonstrated a decrease in rate of decline in forced vital capacity and forced expiratory volume when comparing preoperative with postoperative rates. Mean length of stay was 7.8±4.4 days. Complications included reintubation for low tidal volumes (n=1), pneumonia (n=1), superficial wound breakdown (n=1), and superficial infection (n=1). Conclusions: Definitive posterior spinal fusion for treatment of scoliosis associated with SMA is effective at controlling curve progression and pelvic obliquity without negatively impacting the space-available-for-lung ratio, trunk height, or pulmonary function at 10 years follow-up. Level of Evidence: Therapeutic Level IV.

BACKGROUND Understanding national trends in the treatment of pediatric supracondylar humeral fractures will provide important insight into variations in regional treatment and identify areas for improving value and quality in care delivery in the U.S. METHODS U.S. national trends in the treatment of supracondylar humeral fractures were evaluated through query of the Humana (2007 to 2014) and ING (2007 to 2011) administrative claims databases. Geographic variation and changes in surgical and transfer rates over time were further explored through the Nationwide Emergency Department Sample (NEDS) database (2006 to 2011). Hospital characteristics impacting treatment decisions were identified. RESULTS A total of 29,642 pediatric patients with supracondylar humeral fractures were identified in the administrative claims databases and a projected 63,348 encounters for supracondylar humeral fracture were identified in the NEDS database. The majority of the patients (76.1%; 22,563 of 29,642) were treated definitively with cast immobilization. Operative treatment was performed in 23.9% of the patients (7,079 of 29,642), with no change observed in the operative rate over time (p = 0.055). Of patients undergoing operative treatment, closed reduction and percutaneous pinning (CRPP) was performed in 87.3%, with a significant increase noted in the rate of CRPP over time (p = 0.0001); open reduction was performed in 12.7%, with a significant decrease noted in the rate of open reduction over time (p < 0.0001). Regional surgical rates generally showed significant variation from 2006 to 2010, followed by a convergence in the surgical rate among all geographic regions in 2011. These trends occurred simultaneous to a significant increase in transfer rates nationwide, from 5.6% in 2006 to 9.1% in 2011 (p = 0.0011). Transfer rates were significantly higher (p < 0.0001) for nontrauma, nonteaching, and nonmetropolitan centers while surgical rates were significantly higher (p < 0.0001) for trauma, teaching, and metropolitan centers when rates were analyzed by hospital designation. CONCLUSIONS Operative treatment was performed in 24% of pediatric patients with supracondylar humeral fractures from 2007 to 2014. There was a convergence of surgical rates across geographic regions, suggesting that a "standard of care" in the treatment of supracondylar humeral fractures is being established nationally. CLINICAL RELEVANCE Cases of pediatric supracondylar humeral fracture are increasingly being transferred to and, when managed surgically, receiving care at metropolitan facilities designated as trauma centers or teaching hospitals, with a corresponding decrease observed in the rate of open reduction. The optimization of nationwide referral and treatment patterns may improve value in care delivery.

More than 100 MRIs per 1000 inhabitants are performed in the United States annually, more than almost every other country. Little is known regarding the cost of obtaining an MRI and factors associated with differences in cost. By surveying all hospital-owned and independent imaging centers in Iowa, we wished to determine (1) the cost to the consumer of obtaining a noncontrast shoulder MRI, (2) the frequency and magnitude of discounts provided, and (3) factors associated with differences in cost including location (hospital-owned or independent) and Centers for Medicare & Medicaid Services designation (rural, urban, and critical access). There were 71 hospitals and 26 independent imaging centers that offered MRI services in Iowa. Each site was contacted via telephone and posed a scripted request for the cost of the technical component of a noncontrast shoulder MRI. Radiologists’ reading fees were not considered. Statistical analysis was performed using standard methods and significance was defined as a probability less than 0.05. The mean technical component cost to consumers for an MRI was USD 1874 ± USD 694 (range, USD 500-USD 4000). Discounts were offered by 49% of imaging centers, with a mean savings of 21%. Factors associated with increased cost include hospital-owned imaging centers (USD 2062 ± USD 664 versus USD 1400 ± USD 441 at independent imaging centers; p

BACKGROUND: Vertebral fracture after posterior arthrodesis and instrumentation for idiopathic scoliosis is a rare occurrence with limited reported cases in the literature. CASE PRESENTATION: A 16-year-old female patient surgically treated for adolescent idiopathic scoliosis with T2-L1 posterior spinal fusion was in a low-energy fall resulting in fracture of L1 and new kyphosis and scoliosis of the thoracolumbar spine at the distal aspect of the fusion. The fracture was initially managed conservatively, however pain persisted and thus she was indicated for extension of the fusion and correction of the post-traumatic kyphosis. CONCLUSIONS: Fractures after posterior spinal fusion for idiopathic scoliosis are rare and evidence for the appropriate management remains limited in the literature. Level of Evidence: V

BACKGROUND: Adolescent idiopathic scoliosis (AIS) has been associated with unnecessary referrals, but the provider and patient costs associated with these referrals remain unknown. The purpose of this study was to determine the prevalence and associated costs of unnecessary referrals for AIS in a university hospital-based orthopaedic clinic. These data are required to estimate the cost-efficacy of scoliosis screening programs. METHODS: We accessed the electronic medical records of all patients referred during 2013-2014 with suspected AIS. Spine radiographs were reviewed to determine whether the referral was “unnecessary,” defined as a Cobb angle

Introduction Adolescent idiopathic Scoliosis (AIS) affects 2% to 3% of the population of which only 0.3% to 0.5% of affected patients will have a curvature of >20 degrees, the curve magnitude at which treatment is generally recommended. For AIS the current natural history data is limited and most of the information comes from a small body of literature from the University of Iowa. Methods The Iowa natural history studies began as retrospective reviews but beginning in 1976, the cohort was followed prospectively. Outcomes assessed in this group of patients included; mortality, pulmonary function, pregnancy-(effect of pregnancy on scoliosis and the effect of scoliosis on pregnancy), radiographic, curve progression, and osteoarthritis. In addition, validated questionnaires were used to evaluate back pain, pulmonary symptoms, general function, depression, and body image. Results Patients with untreated AIS can function well as adults, become employed, get married, have children, and grow to become active older adults. Unfortunately, untreated scoliosis may lead to increased back pain and pulmonary symptoms for patients with large thoracic curves. Patients with untreated AIS can also develop substantial deformity, and the cosmetic aspect of this condition cannot be disregarded. Conclusions The summary findings of this unique lifetime natural history of AIS patients provides patients and parents a solid evidence base upon which to make informed decisions.

The recently developed magnetically controlled growing rod (MCGR) system has gained popularity because it limits additional surgical lengthening procedures and promises reduction of the complication rate previously reported for the traditional growing rods. A retrospective single-center study was performed. Demographic and complications data were recorded. A statistical analysis was conducted to quantify the effect of MCGR placement and of subsequent lengthening on the Cobb angle, T1-T12 kyphosis, and the distances from T1-T12 and T1-S1. Twenty-four patients met the inclusion criteria. Six had idiopathic scoliosis and 18 patients had nonidiopathic scoliosis (neuromuscular and syndromic scoliosis). Nine patients underwent primary MCGR placement, and 15 had the traditional growing rods removed and replaced with MCGRs. The mean age at surgery and at last follow-up was 6.3 years and 8.8 years, respectively. The mean follow-up was 29.2 months. The MCGR placement significantly reduced the Cobb angle and kyphosis by an average of 21.33° and 10.79°, respectively. The T1-T12 and the T1-S1 distances increased an average of 1.19 and 1.89 cm/year, respectively, during the follow-up period. The average percentage of achieved-to-intended distraction was 65% on the concave side and 68% on the convex side at last follow-up. There were 9 postoperative complications in 8 (33%) patients, 6 of whom had nonidiopathic scoliosis. The MCGR system is reliable and effective in the treatment of patients affected by early-onset scoliosis. [ Orthopedics . 2020;43(6):e601–e608.]

This study describes a new procedure for a safer and easier access for the intrathecal injection of the recently approved nusinersen therapy in spinal muscular atrophy. This therapy changed the natural history of the disease, but, to date, scoliosis surgery was an excluding criteria for nusinersen therapy. The bone mass, due to the posterior spinal fusion of the scoliosis surgery, prevents the needle for the nusinersen administration from intervertebral access. This is a single-center, single-surgeon case series descriptive study. A laminotomy at the L3-L4 level was performed to provide safer access for the intrathecal injection. The procedure was carried out during the scoliosis surgery in patients who underwent posterior spinal fusion (PSF) after the nusinersen therapy was introduced, whereas for those who underwent PSF earlier, a second procedure was necessary to perform a laminotomy. A fat grafting was used to prevent bone overgrowth in the laminotomy. Markers were applied as radiographic references for the intrathecal injection. Five patients were enrolled, four females and one male. The mean age of the patients was 11 years. Three patients underwent PSF before the introduction of the nusinersen therapy. Two patients underwent PSF after the nusinersen therapy was available. All of them underwent a laminotomy with a fat grafting at the L3-L4 laminotomy level and received nusinersen therapy without complications. The procedure described is simple and effective in providing safe intrathecal access to make these patients eligible for such important therapy.

Background Knee pain has a variety of etiologies in the pediatric population, including septic arthritis, osteomyelitis, fracture, ligamentous injury, and neoplasms. Extrinsic sources of knee pain may also be intra-abdominal, although abdominal pathology is much more likely to manifest as hip or proximal thigh musculature pain. Case Report A 5-year-old healthy male presented with atraumatic right knee pain, discomfort with weightbearing, fever, and elevated inflammatory laboratory markers. Physical examination and magnetic resonance imaging findings of the knee were benign, leading to low clinical suspicion for knee septic arthritis. Blood cultures were positive for a gastrointestinal organism, Granulicatella adiacens, suggesting abdominal pathology leading to referred pain. Ultrasound evaluation and computed tomography (CT) of the abdomen revealed a large abscess secondary to perforated appendicitis, which was treated with CT-guided drainage and i.v. antibiotics. The patient's musculoskeletal pain subsided with treatment of the appendicitis. Why Should an Emergency Physician Be Aware of This? Acute appendicitis may present as knee pain, with other signs and symptoms mimicking septic arthritis, such as fever, inability to bear weight, and elevated inflammatory markers. Considering an array of differential diagnoses in pediatric patients with apparent knee septic arthritis is crucial to prevent delay in diagnosis of alternative infectious sources.

In the context of the White Book of Physical and Rehabilitation Medicine (PRM), this paper deals with Research, the future of PRM. PRM students and specialists are mainly involved in biomedical research, investigating the biological processes, the causes of diseases, their medical diagnosis, the evaluation of their consequences on functioning, disability and health and the effects of health interventions at an individual and a societal level. Most of the current PRM research, often interdisciplinary, originates from applied research which, using existing knowledge, is directed towards specific goals. Translational medical research, research and development, implementation research and clinical impact research are in this field. PRM physicians, mainly master or PhD students, are nowadays increasing their participation in basic research and in pre- clinical trials. PRM physicians are involved in primary research, which is an original first hand research, but also in secondary research, which is the analysis and interpretation of primary research publications in a field, with a specific methodology. Secondary research remains an important activity of the UEMS PRM section and it will be the field of the new created Cochrane Rehabilitation. Secondary research with interest for persons with disabilities, will be developed world wide on the basis of evidence based medicine, with the participation of PRM physicians and of all other health and social professionals involved in rehabilitation. The development of research activities with interest for PRM in Europe is a challenge for the future, which has to be faced now. The European PRM schools, the European master and PhD program with their supporting research and clinical facilities, the European PRM organizations with their websites, the PRM scientific journals and European congresses are a strong basis to develop research activities, together with the development of Cochrane Rehabilitation field and of our cooperation with European high level research facilities, European and international scientific societies in different fields. PRM will be a leader in this field of research.

STUDY DESIGN Retrospective review of a prospective cohort. OBJECTIVE To determine the incidence, risk factors, and causes for 30-day unplanned readmission after pediatric spinal deformity surgery. SUMMARY OF BACKGROUND DATA The government has targeted 30-day readmissions as a quality of care measure. However, few studies have analyzed readmission in pediatric cohorts. METHODS A multicenter registry designed to collect pediatric surgical outcomes was queried for patients undergoing spinal deformity surgery in 2012. Patients were divided into groups of those with and without an unplanned readmission within 30 days postoperatively. Univariate and multivariate logistic regression analyses were used to compare the cohorts, and to identify variables associated with readmission. RESULTS In total, 75 of 1890 pediatric patients undergoing spinal fusion for deformity had an unplanned 30-day readmission (3.96%). Readmissions were highest in the neuromuscular group (6.83%) and lowest in the idiopathic (2.66%) and infantile (1.31%) cohorts, (P < 0.01). The top reasons for readmission included wound complications (73.3%) and gastrointestinal disturbances (13.3%). In the univariate analysis, increasing surgical complexity, particularly fusions to the pelvis and isolated anterior spinal fusions, as well as increasing medical comorbidity burden were each associated with readmission (P < 0.05 for each). In the subsequent multivariate analysis, isolated anterior spinal fusions (odds ratio, 7.65; 95% confidence interval, 1.32-44.3) structural pulmonary abnormalities (odds ratio, 2.53; 95% confidence interval, 1.22-5.23) and an American Society of Anesthesiologists class of 3 or 4 (odds ratio, 2.18; 95% confidence interval, 1.07-4.47) were independently associated with readmission. CONCLUSION The overall rate of 30-day unplanned readmissions after pediatric deformity surgery was low, but not insignificant. Surgeons should consider discharge optimization in the at-risk patient cohorts defined here, and should focus on wound complications and gastrointestinal disturbances to minimize readmissions. Quality reporting metrics should incorporate these risk factors to avoid unduly penalizing surgeons who take on complex cases. LEVEL OF EVIDENCE 3.

STUDY DESIGN: Retrospective review of prospectively collected data. OBJECTIVE: To determine whether anchor density is associated with curve correction and patient-reported outcomes. SUMMARY OF BACKGROUND DATA: There is limited information as to whether anchor density affects the results of adolescent idiopathic scoliosis surgery. METHODS: A total of 952 patients with adolescent idiopathic scoliosis met inclusion criteria (Lenke 1, 2, and 5 curves) with predominantly screw constructs (no. of screws/no. of total anchors >75%). Anchor density was defined as the number of screws, hooks, and wires per level fused, with less than 1.54 considered low density. Analysis of covariance was undertaken to determine association of anchor density with percent curve correction, Scoliosis Research Society (SRS), and Spinal Appearance Questionnaire (SAQ) scores, controlling for flexibility, fusion length, demographics, and surgeon. RESULTS: High- compared with low-anchor density was associated with increased percent curve correction in Lenke 1 curves at 1 year (69% vs. 66% correction, P = 0.0022), controlling for percent preoperative curve flexibility, length of fusion, and sex (model, P < 0.0001). Similar associations held at 2-year follow-up and for Lenke 2 curves. Decreased thoracic kyphosis was found with increased anchor density for Lenke 1 and 2 curve patterns. There were no associations found between anchor density and Lenke 5 curves. For Lenke 1 curve patterns at 2 years postoperatively, in the high- versus low-anchor density cohorts, there were statistically higher SRS Activity (4.3 vs. 4.2, P = 0.019), Appearance (4.3 vs. 4.1, P = 0.0005), Satisfaction (4.5 vs. 4.3, P = 0.028), and Total scores (4.3 vs. 4.2; P = 0.024). Similarly, the SAQ Appearance score at 1 year similarly was improved in the high-anchor density group (high: 14.1 vs. low: 15.0, P = 0.03) for Lenke 1 curve patterns only. CONCLUSION: For Lenke 1 and 2 curve patterns, improved percent correction of major coronal curve was noted in the high-screw density cohort. Although statistical significance was reached, it is unclear whether screw density resulted in clinically significant differences in patient-reported outcomes.

Study Design Prognostic study and validation using prospective clinical trial data. Objective To derive and validate a model predicting curve progression to ≥45° before skeletal maturity in untreated patients with adolescent idiopathic scoliosis (AIS). Summary of Background Data Studies have linked the natural history of AIS with characteristics such as sex, skeletal maturity, curve magnitude, and pattern. The Simplified Skeletal Maturity Scoring System may be of particular prognostic utility for the study of curve progression. The reliability of the system has been addressed; however, its value as a prognostic marker for the outcomes of AIS has not. The BrAIST trial followed a sample of untreated AIS patients from enrollment to skeletal maturity, providing a rare source of prospective data for prognostic modeling. Methods The development sample included 115 untreated BrAIST participants. Logistic regression was used to predict curve progression to ≥45° (or surgery) before skeletal maturity. Predictors included the Cobb angle, age, sex, curve type, triradiate cartilage, and skeletal maturity stage (SMS). Internal and external validity was evaluated using jackknifed samples of the BrAIST data set and an independent cohort (n = 152). Indices of discrimination and calibration were estimated. A risk classification was created and the accuracy evaluated via the positive (PPV) and negative predictive values (NPV). Results The final model included the SMS, Cobb angle, and curve type. The model demonstrated strong discrimination (c-statistics 0.89–0.91) and calibration in all data sets. The classification system resulted in PPVs of 0.71–0.72 and NPVs of 0.85–0.93. Conclusions This study provides the first rigorously validated model predicting a short-term outcome of untreated AIS. The resultant estimates can serve two important functions: 1) setting benchmarks for comparative effectiveness studies and 2) most importantly, providing clinicians and families with individual risk estimates to guide treatment decisions. Level of Evidence Level 1, prognostic.

Study design A systematic review. Objective The aim of this study was to provide an evidence-based recommendation for when and how to employ imaging studies when diagnosing back pain thought to be caused by spondylolysis in pediatric patients. Summary of background data Spondylolysis is a common structural cause of back pain in pediatric patients. The radiologic methods and algorithms used to diagnose spondylolysis are inconsistent among practitioners. Methods A literature review was performed in PubMed and Cochrane databases using the search terms "spondylolysis," "pediatric," "adolescent," "juvenile," "young," "lumbar," "MRI," "bone scan," "CT," and "SPECT." After inclusion criteria were applied, 13 articles pertaining to diagnostic imaging of pediatric spondylolysis were analyzed. Results Ten papers included sensitivity calculations for comparing imaging performance. The average sensitivity of magnetic resonance imaging (MRI) with computed tomography (CT) as the standard of reference was 81.4%. When compared with single-photon emission CT (SPECT), the average sensitivity of CT was 85% and the sensitivity of MRI was 80%. Thirteen studies made a recommendation as to how best to perform diagnostic imaging of patients with clinically suspected spondylolysis. When compared with two-view plain films, bone scans had seven to nine times the effective radiation dose, while four-view plain films and CT were approximately double. Of the diagnostic methods examined, MRI was the most expensive followed by CT, bone scan, four-view plain films, and two-view plain films. Conclusion Due to their efficacy, low cost, and low radiation exposure, we find two-view plain films to be the best initial study. With unusual presentations or refractory courses, practitioners should pursue advanced imaging. MRI should be used in early diagnosis and CT in more persistent courses. However, the lack of rigorous studies makes it difficult to formulate concrete recommendations. Level of evidence 3.

In 2002, the U.S. Bone and Joint Decade coalition presented compelling evidence to President George W. Bush that musculoskeletal disorders are the leading cause of physical disability. President Bush declared 2002-2011 the National Bone and Joint Decade to help bring attention to the societal impact of this increasing burden of musculoskeletal conditions1,2. The aims of the campaign were to raise awareness of the increasing societal impact of musculoskeletal injuries and disorders, to empower patients to participate in decisions about their care, to increase funding for prevention activities and …

Healthcare costs in the United States continue to rise, and substantial variations in the type, quality, and location of that care persist. It is critically important for all healthcare stakeholders to address and define value in orthopaedic care delivery. Evidence-based orthopaedic care delivery, reliable quality and performance measurement, and the delivery of the best care at the lowest cost are the key strategies to improve the value of musculoskeletal care. A failure to implement these strategies could negatively affect the reimbursement of all healthcare providers--at both the private and government payer levels.

Background: Clinical evidence regarding the ability of braces to decrease the risk of curve progression to surgical threshold in patients with adolescent idiopathic scoliosis (AIS) continues to strengthen. Unfortunately, there is still a great deal of uncertainty regarding the impact of brace wear on psychosocial well-being or the impact of psychological well-being on brace wear adherence. The purpose of this study is to evaluate psychosocial well-being, in particular body image and quality of life (QOL), and brace wear adherence in female AIS patients undergoing brace treatment. Methods: The Bracing in Adolescent Idiopathic Scoliosis Trial (BrAIST) was a multicenter, controlled trial using randomized and preference assignments into an observation or brace treatment group. BrAIST patients were skeletally immature adolescents diagnosed with AIS having moderate curve sizes (20 to 40 degrees). Patients in the bracing group were instructed to wear a thoracolumbosacral orthosis, at least 18 h/d. Scores on the Spinal Appearance Questionnaire and the PedsQL4.0 Generic Scales from 167 female BrAIST patients who were randomized to brace treatment (n=58) and patients who chose brace treatment (n=109) were analyzed. Results: At baseline and at 12 months, no differences were found between the least-adherent brace wear group (

STUDY DESIGN A retrospective review of 24 cases of adolescent idiopathic scoliosis (AIS). Intraoperative push-prone test to determine the lowest instrumented vertebrae (LIV). OBJECTIVE To determine the LIV using intraoperative push-prone test. BACKGROUND Determination of the LIV in surgical treatment of the AIS remains controversial. Different classifications schemes have been proposed to help surgeons in making this decision. Most schemes depend on flexibility views. However, variability in technique of obtaining flexibility views and interpretation of these views in relation to the classification schemes make decision making in choosing the LIV difficult. METHODS An intraoperative push-prone image was used to determine LIV. RESULTS We were able to stop 1 or 2 levels above the stable vertebra in most cases. All patients had a well-balanced thorax over the pelvis. CONCLUSIONS Intraoperative push-prone test is a useful adjunct to predict the LIV in AIS.

Background: Randomized controlled trials are powerful tools to evaluate the outcomes of clinical treatments. However, these trials tend to be expensive and time-consuming, and their conclusions can be threatened by several limitations. This study estimated the strength of three common limitations (underenrollment, selective enrollment, and nonadherence to protocol) in a proposed study of adolescent idiopathic scoliosis. Methods: Patients with scoliosis and their parents were asked to complete a web-based survey about their preferences concerning a hypothetical randomized trial. Adolescents without scoliosis and their parents also participated. Surveys included questions about treatment preference, likelihood of participation, required risk reduction, and propensity to drop out or choose a different treatment while enrolled in the study. Results: Ninety adolescents and eighty-three parents participated. Observation was preferred to bracing by the majority of subjects. Overall, 33% of the parents and adolescents would both agree to participate in the hypothetical trial. Of the subjects who would not agree to participate, the majority would rather share the decision-making responsibility with the physician than have the treatment chosen in a random fashion. Many of the subjects would consider changing treatments during the course of the trial if they were not satisfied with the outcomes; the majority of parents who preferred bracing would consider crossing over to the bracing arm if their children were randomized to observation. Conclusions: Recruitment into a randomized trial of bracing compared with observation for the treatment of adolescent idiopathic scoliosis may well be problematic, considering the relatively small percentage of families who said they would consider randomization. Additionally, the threat of nonadherence to protocol may be strong and must be addressed in the protocol of the trial. Most families wanted to make the treatment decision with the physician in lieu of randomization; therefore, the role of the physician in patient recruitment and retention should not be underestimated.

We asked whether radiographic angles and signs of hip osteoarthrosis differ between radiographs of the pelvis taken in standing and supine positions. We retrospectively reviewed the radiographs of 61 patients (72 hips) with developmental dislocation of the hip. The minimum followup after closed reduction was 15 years (mean, 44 years; range, 15–64 years). We used pelvic radiographs in supine and standing positions taken at the same time and determined the following parameters: minimal joint space width, acetabular roof obliquity (AC angle), depth of the acetabulum (ACM angle), and center-edge angle. Osteoarthrosis was assessed according to Kellgren and Lawrence. Two independent observers measured all radiographs manually with a goniometer. AC angle, center-edge angle, and minimum joint space width differed between the radiographs taken in supine and standing positions at followup, whereas osteoarthrosis grading and the ACM angle did not. The AC angle depended on patient position and predicted development of osteoarthrosis. The minimum joint space width was influenced by the radiographic position with greater values in the supine position. ACM angle and the osteoarthrosis grade according to Kellgren and Lawrence were unaffected by the patient’s position. Level of Evidence: Level II, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Pediatric spinal deformity is a common manifestation of multiple disorders. The clinical picture varies depending on the age at presentation, the severity of the curve at the time of diagnosis, and the underlying cause. Knowledge of the natural history of these varied conditions, the dynamics of growth in the developing spine, and normal axial skeletal biomechanics are fundamental in planning an appropriate treatment. Furthermore, in many instances the spinal anomaly is just part of the problem in a globally affected patient. Treatment alternatives must be judged based on their capacity to positively alter the natural course of the disease and provide a long-standing solution into a patient's adulthood.

To determine if community equipoise exists concerning the effectiveness of bracing in adolescent idiopathic scoliosis.Bracing is the standard of care for adolescent idiopathic scoliosis despite the lack of strong reasearch evidence concerning its effectiveness. Thus, some researchers support the idea of a randomized trial, whereas others think that randomization in the face of a standard of care would be unethical.A random of Scoliosis Research Society and Pediatric Orthopaedic Society of North America members were asked to consider 12 clinical profiles and to give their opinion concerning the radiographic outcomes after observation and bracing.An expert panel was created from the respondents. They expressed a wide array of opinions concerning the percentage of patients within each scenario who would benefit from bracing. Agreement was noted concerning the risk due to bracing for post-menarchal patients only.: This study found a high degree of variability in opinion among clinicians concerning the effectiveness of bracing, suggesting that a randomized trial of bracing would be ethical.

Political, social, and economic forces occupy an increasingly larger role in health care. It is essential that orthopaedic surgeons become familiar with the ever-changing landscape within which they practice. Greater comprehension of the current issues in health policy will enable practitioners to appreciate these issues and understand the importance of the involvement of the AAOS in the political process. Five topics in particular will continue to have a great impact on the practice of orthopaedic surgery: the flawed Medicare payment formula, implementation of a pay-for-performance program, the creation of gainsharing agreements between hospitals and physicians, the medical liability crisis, and the importance of advocacy with the political action committee of the AAOS.

We present a summary of our research into the natural history and treatment of adolescent idiopathic scoliosis (AIS). This work has answered critical clinical questions and in aggregate has substantially contributed to the evidence base for the prognosis and treatment of AIS. Evidence-based practice has been defined by Straus and Sackett1 as the best research evidence when combined with clinical experience (based on knowledge and experience developed over time from practice, including inductive reasoning) and patient circumstances. The first step in pediatric evidence-based practice is to understand the natural history of the disease or condition in order to learn the adult consequences of the condition. We need to understand what we are trying to prevent with treatment. The second step is to determine the outcomes of treatments to establish that treatment has favorably altered the natural history without introducing iatrogenic complications. The focus of our research over the last thirty-eight years has been to establish the evidence base for a variety of pediatric orthopaedic conditions. We present an overview of our research contributing to the current evidence for the prognosis and treatment of AIS. Arthur Steindler, MD, cared for a large number of patients with AIS between 1932 and 1948 and kept meticulous records of their initial presentation and subsequent visits. Our research was possible because of these records and the loyalty of these patients to Dr. Steindler and the University of Iowa. AIS is characterized by a lateral curvature of the spine of 10° or greater with rotation of the vertebrae. The diagnosis is made when other causes of scoliosis have been ruled out. Two to three percent of children younger than sixteen years of age will have a curvature of 10° or greater, and 0.3% to 0.5% will have a curvature of 20°, the size at which …

Study Design. The Bracing in Adolescent Idiopathic Scoliosis Trial (BrAIST) included skeletally immature high-risk patients with adolescent idiopathic scoliosis (AIS) with moderate curve sizes (20°– 40°). BrAIST was a multicenter, controlled trial using both randomized and preference treatment arms into either an observation group or a brace treatment group. Objective. The aim of this study was to analyze and compare body image and quality-of-life (QOL) in female AIS patients who were observed or treated with a brace. Summary of Background Data. Brace treatment is an effective means for controlling progressive scoliosis and preventing the need for surgery, but there is no consensus regarding the effect of brace treatment on body image or on QOL in adolescents with AIS. Methods. Data from female BrAIST patients in the randomized (n = 132) or preference (n = 187) arms and were observed (n = 120) or brace treated (n = 199) were analyzed. Patients completed the Spinal Appearance Questionnaire (SAQ) and the Pediatric Quality of Life Inventory (PedsQOL) 4.0 Generic Scales at baseline and 6 month follow-up visits up to 2 years. Items on the SAQ measured three body image constructs (self, ideal, and overall). The PedsQOL measured health, activities, feelings, social factors, and school. Results. . In general, there were no significant differences within or between study arms or treatments regarding body image or QOL through 2 years of follow-up. Poorer body image was significantly correlated with poorer QOL during the first 2 years of follow-up regardless of study arm or treatment. Patients who crossed-over to a different treatment and patients with largest Cobb angles ≥ 40 degrees had significantly poorer body image, in particular self-body image, compared with those that did not. Conclusion. This study does not support findings from previous research indicating that wearing a brace has a negative impact on or is negatively impacted by body image or QOL. Level of Evidence: 2

Adolescent idiopathic scoliosis (AIS) is the most common form of structural spinal deformities that have a radiological lateral Cobb angle - a measure of spinal curvature - of ≥10(°). AIS affects between 1% and 4% of adolescents in the early stages of puberty and is more common in young women than in young men. The condition occurs in otherwise healthy individuals and currently has no recognizable cause. In the past few decades, considerable progress has been made towards understanding the clinical patterns and the three-dimensional pathoanatomy of AIS. Advances in biomechanics and technology and their clinical application, supported by limited evidence-based research, have led to improvements in the safety and outcomes of surgical and non-surgical treatments. However, the definite aetiology and aetiopathogenetic mechanisms that underlie AIS are still unclear. Thus, at present, both the prevention of AIS and the treatment of its direct underlying cause are not possible.

STUDY DESIGN Retrospective review of prospectively collected data. OBJECTIVE To determine a cutoff below which worsening renal function is associated with increased risk of morbidity and to determine the types and magnitude of morbidity associated with renal impairment. SUMMARY OF BACKGROUND DATA Renal impairment is associated with an increased risk of morbidity after lumbar spine surgery. However, the degree to which increasing levels of renal dysfunction are associated with morbidity has not been well defined. METHODS A large, multicenter, clinical registry was queried for all adult patients undergoing lumbar spine surgery in 2012, and 13,576 cases were identified. An estimated glomerular filtration rate (eGFR) was calculated for each patient. Propensity scores were used to match patients on the basis of preoperative comorbidities and the procedure-type performed. The incidence of 30-day morbidity was then compared between patients with no or mild renal impairment (eGFR ≥60 mL/min/1.73 m) and those with moderate or severe disease (eGFR

STUDY DESIGN: Matched case-control study. OBJECTIVE: To identify modifiable risk factors for surgical site infections (SSIs) after pediatric spinal fusion. SUMMARY OF BACKGROUND DATA: The number of SSIs after pediatric spinal fusions increased. METHODS: Between July 2001 and July 2010, 22 of 598 pediatric patients who underwent spinal fusion at a university hospital acquired SSIs. Each patient with an SSI was matched with 2 controls by procedure date. Bivariable and multivariable analyses were used to identify risk factors for SSIs and outcomes of SSIs. RESULTS: Gram-negative organisms caused more than 50% of the SSIs. By multivariable analysis, neuromuscular scoliosis (odds ratio [OR] = 20.8; 95% confidence interval [CI], 3.1-889.5; P < 0.0001) and weight-for-age at the 95th percentile or higher (OR = 8.6; 95% CI, 1.2-124.9; P = 0.02) were preoperative factors associated with SSIs. Blood loss (OR = 1.0; 95% CI, 1.0-1.0; P = 0.039) and allografts and allografts in combination with other grafts were operative risk factors for SSIs. The final overall risk model for SSIs was weight-for-age at the 95th percentile or higher (OR = 4.0; 95% CI, 1.4-∞; P = 0.037), American Society of Anesthesiologists score 3 or more (OR = 3.8; 95% CI, 1.6-∞; P = 0.01), and prolonged operation duration (OR = 1.0/min increase; 95% CI, 1.0-1.0; P = 0.004). SSIs were associated with 2.8 days of additional postoperative length of stay (P = 0.02). Neuromuscular scoliosis was the only factor significantly associated with hospital readmission (OR = 23.6; 95% CI, 3.8-147.3; P = 0.0007). CONCLUSION: Our results suggest that pediatric patients undergoing spinal fusion might benefit from antimicrobial prophylaxis that covers gram-negative organisms. Surgical duration, graft implantation, and blood loss are potentially modifiable operative risk factors. Neuromuscular scoliosis, high weight-for-age, and American Society of Anesthesiologists scores 3 or more may help surgical teams identify patients at high risk for SSI.

STUDY DESIGN Retrospective chart review. OBJECTIVES To evaluate the efficacy of the Rosenberger thoracic lumbar sacral orthosis in preventing curve progression in adolescent idiopathic scoliosis. SUMMARY OF BACKGROUND DATA Radiographic outcomes of patients using the Rosenberger thoracic lumbar sacral orthosis have never been reported in the literature, but reports of other thoracic lumbar sacral orthoses conflict concerning the ability braces to improve on the natural history of adolescent idiopathic scoliosis. METHODS Seventy-one patients with progressive adolescent idiopathic scoliosis treated with the Rosenberger were evaluated at an average of 2.3 years following brace discontinuation. Initial curves averaged 29 degrees. Braces were prescribed for 16 to 20 hours per day and worn for an average of 3.2 years. Patients were between 9 and 16 years of age, and all were skeletally immature at the time of bracing. RESULTS Twenty-one patients (30%) underwent instrumentation and arthrodesis despite bracing. Forty (56%) had more than 5 degrees of progression. Overall, 43 (61%) had surgery and/or progressed by the time of follow-up. The average curve correction was 33% in patients who did not have surgery and 21% in those patients who did (P < 0.04). Other significant factors associated with brace failure included absence of menarche before treatment, younger age at presentation and initial bracing, increased apical rotation of the primary curve at presentation, and a thoracic curve pattern. CONCLUSIONS The Rosenberger brace demonstrated an overall failure rate similar to untreated rates from published natural history studies, although subgroups of patients had lower failure rates. These findings suggest the need for further refinement of the indications for the Rosenberger brace.

STUDY DESIGN A genetic study of patients with familial adolescent idiopathic scoliosis. OBJECTIVES The purpose of this study was to evaluate the evidence for linkage on chromosome 4q and determine whether mutations in the gene coding for melatonin receptor are present. SUMMARY OF BACKGROUND DATA Adolescent idiopathic scoliosis is the most common spine deformity arising during childhood, but its cause remains unknown. The fact that adolescent idiopathic scoliosis is often seen in several members of the same family strongly suggests a genetic factor. Recent work by Wise et al provides evidence for linkage of adolescent idiopathic scoliosis at several different chromosome sites, including 4q. In addition, there is some evidence that adolescent idiopathic scoliosis may be related to a disturbance in melatonin metabolism, and the human melatonin-1A receptor is known to be located on chromosome 4q. METHODS Probands having clinically relevant idiopathic scoliosis (Cobb angle >30 degrees) and their relatives were identified. Radiographic confirmation was required for a positive diagnosis. Linkage analysis was performed with 15 microsatellite markers of chromosome 4q spaced at approximately 10-cM resolution and 5 microsatellite markers surrounding the site for human melatonin receptor. The gene for human melatonin receptor was screened for mutations in the coding region using genomic DNA samples by single-strand conformational polymorphism analysis. Amplimers showing a band shift were reamplified and sequenced bidirectionally. RESULTS There was no evidence for linkage at chromosome 4q in this study population. Twenty-nine individuals demonstrated aberrant single-strand conformation polymorphism band patterns, and sequence evaluation demonstrated six genetic polymorphisms for the gene for human melatonin receptor. These genetic variations were found in both affected and nonaffected individuals, and there was no correlation between gene variants and the phenotype for adolescent idiopathic scoliosis. CONCLUSIONS The results of this study demonstrated no evidence of linkage to chromosome 4q and no mutations in the coding region of the gene for human melatonin receptor. The identification of variants in the human melatonin receptor could provide a useful tool for testing the gene in the predisposition to various other melatonin-related disorders and for clarifying the role of melatonin in adolescent idiopathic scoliosis.

Eleven consecutive patients with 12 congenital pseudarthroses of the tibia had intramedullary fixation and autogenous bone grafting as an initial treatment. None of these patients had previous surgeries or other concomitant procedures. The average age of the patients at the time of surgery was 2.5 years (range, 0.5-8.8 years). Four patients achieved initial union after the first index operation; two patients achieved union with no additional procedures, and three patients required an exchange intramedullary fixation for persistent nonunion after refractures that eventually healed. Seven patients did not achieve union after the first index operation; four patients achieved healing after multiple procedures including repeat intramedullary fixation, free vascularized fibular grafting, or both; two patients eventually had below-knee amputations after multiple procedures failed; and one patient did not achieve union of the pseudarthrosis. The important factors leading to failure of union were the distal location of the tibial pseudarthrosis and the presence of concomitant pseudarthrosis of the fibula.

Research is a foundational component of an orthopaedic residency. It fosters intellectual curiosity and pursuit of excellence, while teaching discipline and the scientific method. These are the key principles for careers in both community-based practice and academia. Currently, no consensus exists on how to best engage residents and support their research endeavors. In 2014, the American Academy of Orthopaedic Surgeons Board of Specialty Societies Research and Quality Committee convened a Clinician-Scientist Collaboration Workgroup. The workgroup's task was to identify barriers to clinical and basic science research, and to propose feasible recommendations to overcome these barriers. Herein, we have compiled the opinions of various stakeholder constituencies on how to foster scholarly pursuits during an orthopaedic residency. These opinions reflect the workgroup's conclusions that research is directly and indirectly influenced by funding, departmental support, and mentorship, and that early exposure and dedicated time to pursue scholarly activities may have a positive impact on lifelong research interests.

CASE We present a case of a pathologic vertebral fracture and encroachment into the spinal canal from a vertebral hemangioma in a 13-year-old boy. The original approach of embolization followed by an anterior-posterior resection and stabilization through a costotransversectomy had to be converted intraoperatively to a combined anterior and posterior approach secondary to excessive bleeding. CONCLUSION Because of the hypervascularity and the extensive nature of aggressive vertebral hemangiomas, surgeons attempting procedures similar to the case described herein must be prepared to adapt to the circumstances when preoperative embolization is not totally effective. Surgical technique, proper anesthesia, and patient clotting capacity are important factors to consider.

STUDY DESIGN Retrospective cohort study. OBJECTIVE To determine the trends and causes for increases in hospital charges in adolescent idiopathic scoliosis (AIS) fusions. SUMMARY OF BACKGROUND DATA Trends in utilization rates, surgical procedure types, and hospital charges for AIS fusions have not been well investigated. METHODS We used International Classification of Diseases, Ninth Revision, billing codes to identify 29,594 AIS fusion cases from the National Inpatient Service (NIS) database between 2001 and 2011. Data were trended over time, and contrasted against other common procedures. To identify specific drivers of charges, we queried our own hospital's billing system, and averaged charges from 40 cases (10 cases for each of 4 yr studied). Dollar amounts were adjusted for inflation to 2011 dollars. RESULTS Utilization rates for AIS fusions have remained constant, whereas utilization of adult spinal fusions increased by 64% (P = 0.0004). Utilization of anterior thoracic fusions decreased by 80% (P < 0.0001). Mean hospital charges for AIS spinal fusions increased from $72,780 in 2001 to $155,278 in 2011 (113% increase), averaging 11.3% annually (P < 0.0001), with charges for adult spinal procedures increasing at a similar rate (13.4% annually, P < 0.0001). Charges for the other nonspine conditions increased to a lesser degree (range of 4.5%-6% annually, P < 0.001 for each). At our institution, spinal implant charges increased 27.6% annually, whereas surgeon charges decreased 0.5% annually, and all other charges increased only 5.2% annually. Over time, our surgeon used greater numbers of pedicle screws, and greater numbers of implants per surgery and per level fused (P < 0.05 for each). Implant charges were 28% of the total hospital bill in 2003, rising to 53% in 2012. CONCLUSION Although utilization rates for AIS fusions have remained constant over time, hospital charges have increased substantively, and there has been a shift toward performing posterior only surgical procedures. This corresponds to the widespread adoption of pedicle screw-based constructs. Spinal implants may be the primary driver of increased charges. Strategies directed toward implant cost savings may thus have the largest impact. LEVEL OF EVIDENCE 4.

Study Design. Retrospective review of prospectively collected data. Objective. To determine the incidence and risk factors for 30-day wound complication after spinal arthrodesis in pediatric patients. Summary of Background Data. Although multiple prior studies have reported on wound complications in pediatric spine, the majority have been single-center retrospective series. Methods. The National Surgical Quality Improvement Program (NSQIP) employs on-site personnel to prospectively collect 30-day morbidity data from 50 pediatric centers. Year 2012 was the first year of enrollment, and 1915 cases with thoracic or lumbar spinal fusion were included. Patients were divided into cohorts of those with and without a wound complication, with univariate and multivariate analyses used to identify risk factors. A P value of less than 0.05 was considered significant. Results. Wound complications occurred in 67 patients (3.5%). The incidence was significantly higher in patients with congenital (4.35%) or neuromuscular (4.67%) diagnoses, as opposed to idiopathic (2.7%) or infantile (1.61%). Procedures with fusions extending to the pelvis (9.91%) or an osteotomy (4.99%) were associated with higher risk. Longer hospital lengths of stay, increased operative time, increased patient body mass index, and patients with cardiac, gastrointestinal, neurological, or pulmonary comorbidities were also associated with a higher risk. In the multivariate analysis, a body mass index of more than 30 kg/m2, patients with cardiac risk factors, and fusions extending to the pelvis were independent risk factors. Conclusions. Data from this large prospective multicenter study confirm that the incidence of early wound complications in pediatric spine surgery is low. Patients with a fusion extending to the pelvis, obese patients, and patients with significant cardiac conditions were independently associated with higher risk for this complication. These data should be useful for patients' counseling and for preoperative risk stratification. Interventions for minimizing wound complication risk may be most applicable to the high-risk groups identified here. Conclusions. Level of Evidence: 2