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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.MethodsChildren and adolescents who were 10 to 18 years of age with midshaft clavicle fractures treated from 2006 to 2017 were identified through electronic picture archiving and communication system (PACS) radiographic and chart review. Closed injuries with a minimum of 1 year from the time of the injury were included. Patients completed patient-reported outcome measures and a focused questionnaire. The primary outcome was the abbreviated Disabilities of the Arm, Shoulder and Hand Questionnaire (QuickDASH) score; the secondary outcomes included the University of California Los Angeles (UCLA) Activity Scale, Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference (PI) and PROMIS Physical Function (PF) Upper Extremity (UE), Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS), Numeric Rating Scale (NRS) for Pain, and rates of implant removal, nonunion, and refracture. Univariate comparisons between the operatively treated group and the nonoperatively treated group were performed.ResultsIn this study, 302 patients were identified; of these, 79 patients (43 operatively treated and 36 nonoperatively treated) or their parent or legal guardian consented and the patients completed the study protocol. The mean age (and standard deviation) at the time of the injury was 16.0 ± 1.7 years for the operatively treated group and 13.5 ± 1.8 years for the nonoperatively treated group (p < 0.001). The median follow-up was 3.8 years. The patient-reported outcome scores were similar (p > 0.05 for all comparisons) between the operatively treated group and the nonoperatively treated group, even for patients at or near skeletal maturity and those with shortening of ≥15 mm or ≥100% translation. There were no nonunions. The refracture rate was 5% (2 of 43) for the operatively treated group and 3% (1 of 36) for the nonoperatively treated group (p = 1.00). There were 19% (8 of 43) who underwent implant removal. Responders were similar to nonresponders, other than female patients (p < 0.001) and surgically treated patients (p = 0.049) being more likely to respond.ConclusionsIn the subset of this cohort who responded and completed the study, both operatively and nonoperatively treated patients had excellent functional and pain outcomes, similar refracture rates, and no nonunions. Even in widely displaced and translated fractures, and in those at or near skeletal maturity, outcomes were similar. Operative management should potentially be reserved for special circumstances. A prospective comparative study of older adolescents (female patients who are 14 to 18 years of age and male patients who are 16 to 20 years of age) with displaced midshaft clavicle fractures is warranted.Level of evidenceTherapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Backgroundε-Aminocaproic acid (EACA) is an antifibrinolytic agent that has been shown to decrease blood loss and transfusion requirements in several populations undergoing various surgical procedures. However, the efficacy of EACA has not been assessed in pediatric patients with cerebral palsy undergoing bilateral varus rotational femoral osteotomies. The purpose of this study was to assess the efficacy of intravenous EACA in reducing calculated intraoperative blood loss and transfusions in this population.MethodsPatients aged 18 years or younger were eligible. Patients were randomized to receive EACA or placebo (saline), and randomization was stratified based on sex and whether or not additional soft tissue or osseous procedures were performed. On the basis of retrospective data, the calculated sample size was 12 patients per arm to detect a difference of 250-mL blood loss. The primary outcome was calculated intraoperative blood loss. Secondary outcomes included transfusion requirements, 24-hour drain output, length of stay, and incidence of complications.ResultsThe mean age of patients in this study was 8 years (SD: 2.4 y). There were no differences in age, sex, height, weight, type of anesthesia, operative time, and associated procedures between the EACA and placebo groups (P>0.05). Preoperative hematocrit was lower in the EACA group (37.1 vs. 40.0, P=0.04). Calculated intraoperative blood loss was 536 mL in the EACA group and 628 mL in the placebo group (P=0.45). Transfusions were required in 62% of patients in the EACA group and 67% of patients in the placebo group (P=0.68). Total 24-hour drain output was 72.5 mL in the EACA group and 103.3 mL in the placebo group (P=0.37). Length of stay was similar between both groups, and there were no drug or placebo-related complications in either group.ConclusionsThere was no difference in blood loss or transfusion requirements associated with EACA compared with placebo; however, this study is underpowered to detect smaller differences in blood loss. Additional studies with larger sample sizes are needed to confirm these findings and further elucidate the indications for antifibrinolytic agents in pediatric patients.Level of evidenceLevel I.

BackgroundThere 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.MethodsChildren 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.ResultsIn 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

BackgroundThere 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.MethodsChildren 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.ResultsIn 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

Backgroundε-Aminocaproic acid (EACA) is an antifibrinolytic agent that has been shown to decrease blood loss and transfusion requirements in several populations undergoing various surgical procedures. However, the efficacy of EACA has not been assessed in pediatric patients with cerebral palsy undergoing bilateral varus rotational femoral osteotomies. The purpose of this study was to assess the efficacy of intravenous EACA in reducing calculated intraoperative blood loss and transfusions in this population.MethodsPatients aged 18 years or younger were eligible. Patients were randomized to receive EACA or placebo (saline), and randomization was stratified based on sex and whether or not additional soft tissue or osseous procedures were performed. On the basis of retrospective data, the calculated sample size was 12 patients per arm to detect a difference of 250-mL blood loss. The primary outcome was calculated intraoperative blood loss. Secondary outcomes included transfusion requirements, 24-hour drain output, length of stay, and incidence of complications.ResultsThe mean age of patients in this study was 8 years (SD: 2.4 y). There were no differences in age, sex, height, weight, type of anesthesia, operative time, and associated procedures between the EACA and placebo groups (P>0.05). Preoperative hematocrit was lower in the EACA group (37.1 vs. 40.0, P=0.04). Calculated intraoperative blood loss was 536 mL in the EACA group and 628 mL in the placebo group (P=0.45). Transfusions were required in 62% of patients in the EACA group and 67% of patients in the placebo group (P=0.68). Total 24-hour drain output was 72.5 mL in the EACA group and 103.3 mL in the placebo group (P=0.37). Length of stay was similar between both groups, and there were no drug or placebo-related complications in either group.ConclusionsThere was no difference in blood loss or transfusion requirements associated with EACA compared with placebo; however, this study is underpowered to detect smaller differences in blood loss. Additional studies with larger sample sizes are needed to confirm these findings and further elucidate the indications for antifibrinolytic agents in pediatric patients.Level of evidenceLevel I.

This paper proposes a spatiotemporal clustering algorithm and its implementation in the R package spotoroo. This work is motivated by the catastrophic bushfires in Australia throughout the summer of 2019-2020 and made possible by the availability of satellite hotspot data. The algorithm is inspired by two existing spatiotemporal clustering algorithms but makes enhancements to cluster points spatially in conjunction with their movement across consecutive time periods. It also allows for the adjustment of key parameters, if required, for different locations and satellite data sources. Bushfire data from Victoria, Australia, is used to illustrate the algorithm and its use within the package. [ABSTRACT FROM AUTHOR]