Search

Background: Posterior Spinal Fusion (PSF) for idiopathic scoliosis results in severe postoperative pain. At our institution, a protocol for postoperative analgesia is followed, but anesthetic maintenance is decided by the anesthesiologist. Previous studies have shown that postoperative use of dexmedetomidine may improve analgesia for these patients, but the effect of intraoperative dexmedetomidine on postoperative pain scores remains unknown. Purpose: We sought to retrospectively compare pain scores from the Postoperative Anesthesia Care Unit (PACU) and from PACU discharge until midnight between PSF patients who did and did not receive intraoperative dexmedetomidine. Methods: After obtaining IRB approval, we retrospectively identified 79 patients aged 10-17 years who had undergone PSF for idiopathic scoliosis from June 2015-August 2018 and who received intrathecal morphine. Patients were then divided into two groups based on whether or not they received intraoperative dexmedetomidine. A multivariable linear regression model was constructed with the dependent variable of highest PACU pain score and exposure of interest intraoperative dexmedetomidine use. Secondary analyses were conducted similarly within those who received dexmedetomidine to examine the effects of dose on PACU pain scores, using a p-value < 0.05. Results: After adjusting for age, weight, sex, levels fused, intrathecal morphine, diazepam, and ketamine doses, there was no statistically significant difference in average PACU pain scores between those who did and did not receive intraoperative dexmedetomidine (β = -0.85, 95% CI: -2.48, 0.68; p = 0.31). Conclusion: Intraoperative use of dexmedetomidine during posterior spinal fusion for adolescent idiopathic scoliosis appears to have no effect on postoperative pain scores.

Purpose: There has been a recent shift towards operative management of mid-shaft clavicle fractures in adults and adolescents. This has been largely based on studies in the adult population that showed reduced rates of nonunion, symptomatic malunion and better short-term functional outcomes. For injuries with a comminuted “Z-type” fracture pattern, characterized by vertical positioning of a segmental fragment, it is commonly accepted to treat surgically due to concerns about healing and bony prominence. The purpose of this study was to assess the clinical, radiographic, and patient-reported outcome measures (PROs) in adolescents with comminuted Z-type mid-shaft clavicle fractures by comparing an operative and nonoperative cohort. Methods: Patients aged 10 to 18 years treated for a diaphyseal clavicle fracture between August 2013 and February 2016 at one of eight geographically diverse pediatric centers were screened and enrolled at the time of injury. Inclusion criteria were a comminuted Z-type fragment ≥1cm in size, with >35 degrees of angulation relative to the long axis of the clavicle, and >100% fracture displacement at time of presentation. Clinical course, complications, validated PROs, quality of life metrics, and satisfaction scores were analyzed and compared between the operative (Op) and nonoperative (NonOp) cohorts. Results: Eighty-two patients (37 NonOp, 45 Op) were included, 60 (73%) of whom provided 2-year PROs with similar response rates between treatment cohorts. There were no significant differences in demographics or fracture characteristics in the two cohorts other than fracture shortening being greater in the operative cohort (mean 29mm) compared to the nonoperative cohort (mean 23mm, p=0.01). This confounder was controlled for in both regression analysis and propensity score matching. There was no statistically significant difference in the rates of nonunion (none), delayed union (Op 2%, NonOp 0%, p=1.0), symptomatic malunion (Op 0%, NonOp 3%, p=0.4), refracture (Op 4%, NonOp 3%, p=1.0), unexpected surgery (Op 11% vs. NonOp 5%, p=0.45), or clinically significant complications (Op 16%, NonOp 5%, p=0.17) between cohorts. There were no differences in PROs (Table 1), even when controlling for fracture shortening. Conclusions: Z-type mid-shaft clavicle fractures are one of the most severe fracture patterns seen in adolescent shoulders. Yet, in this comparative investigation of 2-year PROs and complications, surgery appears to offer no benefit over nonoperative management. Significance: The comparable natural histories between this study’s operative and nonoperative cohorts are critical for surgeons and their adolescent patients to understand when deciding appropriate management, particularly when reviewing what are often very concerning appearing initial radiographs.

Objectives: Operative management of clavicle fractures is increasingly advocated for athletes and young adults. Surgical indications and optimal treatment for comminuted or severely shortened clavicle fractures in adolescent athletes remain unclear. The purpose of this study was to evaluate the outcomes of non-operatively and operatively treated comminuted and/or severely shortened (>25mm) clavicle fractures in older adolescent athletes. Methods: Athletes aged 14 to 18 years with mid-shaft clavicle fractures who had non-operative (NONOP) or operative (OP) treatment at one of eight participating centers between 2013 and 2017 were screened for the presence of comminution and/or fracture shortening >25mm. Demographics, injury mechanism, fracture characteristics and treatment (NONOP vs. OP) were prospectively recorded and patients followed for a minimum of two years. Complications, rates and timing of return to sport (RTS), and patient reported outcomes (PROs: ASES, QuickDASH, MARX shoulder activity, EQ-5D, EQ-VAS, and patient satisfaction) were analyzed. Results: The two groups included 137 patients (70 NONOP, 67 OP), with a similar distribution among various sports—most commonly football—and rates of competitive athletic participation (NONOP: 81%, OP: 85%) (Figure 1). Of the 137 patients, 100 [NONOP n=52, 15.3 years, 44 males (84.6%); OP n= 48, 15.5 years, 40 males (83.3%)] provided PROs at > 2 years. Comminution (C) and shortening (S) were not different between groups [NONOP C=24 (46.2%), S=28mm (24.5, 33.2); OP C=35 (72.9%), S=28mm (25.0, 36.5)], but the OP group demonstrated 3 mm greater vertical displacement [NONOP 13.0 (9.6, 18.0) mm, OP 16.0 (11.8, 21.0) mm; pConclusions: In this prospective multi-center cohort of comminuted and/or severely shortened (>25mm) clavicle fractures in adolescent athletes, there was no difference in complications, RTS, or PROs between non-operatively and operatively treated patients at 2 years. Despite several studies suggesting the contrary in adult populations, comparably excellent outcomes of severe clavicle fractures in adolescent athletes can be achieved with non-operative treatment.

Objectives: The phenomenon of bony remodeling of healed displaced clavicle midshaft fractures in adolescents remains poorly understood. The purpose of the current study was to evaluate and quantify clavicle remodeling in a large population of adolescents with completely displaced fractures treated non-operatively to understand the factors that may influence this process. Methods: Patients were identified from the database(s) of a multi-center study group investigating the functional outcomes of adolescent clavicle fractures. Patients between the ages of 10 and 19 years with completely displaced mid-diaphyseal clavicle fractures that were treated non-operatively who had further imaging of the affected clavicle at a minimum of 9 months from initial injury were included. Radiographic measurements were performed on the injury and final follow-up films. Fracture remodeling was subjectively classified as ‘complete/near-complete’, ‘moderate’, or ‘minimal’ (Figure 1) and subsequently analyzed quantitively and qualitatively to determine factors associated with deformity correction. Results: Ninety-eight patients (mean age of 14.4±2.2 years) were analyzed at a mean radiographic follow-up of 3.4± 2.3 years. Fracture shortening, superior displacement, and angulation significantly improved during the follow-up period by 59%, 61%, and 30% respectively (pConclusions: Significant clavicle remodeling occurs in adolescent patients with displaced fractures, including older adolescents and particularly when followed for longer time intervals. This finding may help explain why symptomatic malunions are so infrequently observed in adolescent patients, even in severely displaced fractures.

Objective Adequate resources are required to rapidly diagnose and treat pediatric musculoskeletal infection (MSKI). The workload MSKI consults contribute to pediatric orthopaedic services is unknown as prior epidemiologic studies are variable and negative work-ups are not included in national discharge databases. The hypothesis was tested that MSKI consults constitute a substantial volume of total consultations for pediatric orthopaedic services across the United States. Study design Eighteen institutions from the Children's ORthopaedic Trauma and Infection Consortium for Evidence-based Study (CORTICES) group retrospectively reviewed a minimum of 1 year of hospital data, reporting the total number of surgeons, total consultations, and MSKI-related consultations. Consultations were classified by the location of consultation (emergency department or inpatient). Culture positivity rate and pathogens were also reported. Results 87,449 total orthopaedic consultations and 7,814 MSKI-related consultations performed by 229 pediatric orthopaedic surgeons were reviewed. There was an average of 13 orthopaedic surgeons per site each performing an average of 154 consultations per year. On average, 9% of consultations were MSKI related and 37% of these consults yielded positive cultures. Finally, a weak inverse monotonic relationship was noted between percent culture positivity and percent of total orthopedic consults for MSKI. Conclusion At large, academic pediatric tertiary care centers, pediatric orthopaedic services consult on an average of ~3,000 'rule-out' MSKI cases annually. These patients account for nearly 1 in 10 orthopaedic consultations, of which 1 in 3 are culture positive. Considering that 2 in 3 consultations were culture negative, estimating resources required for pediatric orthopaedic consult services to work up and treat children based on culture positive administrative discharge data underestimates clinical need. Finally, ascertainment bias must be considered when comparing differences in culture rates from different institution's pediatric orthopaedics services, given the variability in when orthopaedic physicians become involved in a MSKI workup.

SummaryBackground Posterior spinal fusion to correct idiopathic scoliosis is associated with severe postoperative pain. Intrathecal morphine is commonly used for analgesia after adolescent posterior spinal fusion; however, anticipating and managing the increase in pain scores after resolution of analgesic effect of intrathecal morphine analgesia is challenging. In 2014, we developed a clinical protocol detailing both the administration of intrathecal morphine intraoperatively and the transition to routine, scheduled oral analgesics at 18 h postoperatively. The goal of our study was to examine the efficacy of our intrathecal morphine protocol vs epidural hydromorphone for postoperative analgesia after posterior spinal fusion. Methods Following IRB approval, we retrospectively identified developmentally intact children of ages 10–20 years in our electronic database with a diagnosis of idiopathic scoliosis who had undergone elective posterior spinal fusion surgery from June 2014 to April 2015. For the intrathecal morphine group, intrathecal morphine was administered in a dose of 12 μg·kg−1 (max 1000 μg) prior to incision. Postoperatively, all children in the intrathecal morphine group had an order to receive oral oxycodone (0.1 mg·kg−1, max 5 mg) starting at 18 h postintrathecal morphine injection. For the epidural hydromorphone group, catheters were placed by the surgeon and bolused with 5 μg·kg−1 hydromorphone (max 200 μg) and 1 μg·kg−1 fentanyl (max 50 μg), followed by a continuous infusion of 40–60 μg·h−1, and patient-controlled bolus doses of 5 μg with a lockout interval of 30 min. All patients in both groups had postoperative orders for acetaminophen, diazepam, and ketorolac. Results During the study time period, 20 patients received intrathecal morphine and were successfully matched with 20 patients who received epidural hydromorphone. All patients in the intrathecal morphine group were transitioned to oral analgesics on the first postoperative day, without need for intravenous opioids after discharge from the postanesthesia care unit. Compared to the epidural hydromorphone group, the intrathecal morphine group reported lower pain scores in the postanesthesia care unit (difference in means −4.26 [95% CI −6.56, −1.96], P = 0.001) and first 8 h after surgery (difference in means −1.88 [95% CI −3.84, 0.082, P = 0.060) and higher pain scores on the 2nd postoperative day (difference in means 1.60 [95% CI 0.10, 3.10], P = 0.037). The documented time to ambulation and time of Foley catheter removal were statistically earlier in the intrathecal morphine group, and the hospital length of stay was significantly shorter (3.0 ± 0.5 days vs 3.5 ± 0.7 days; P = 0.03). Adverse events did not significantly differ between the groups. Conclusion The efficacy of intraoperative intrathecal morphine for postoperative analgesia in the posterior spinal fusion patient population has been shown previously; however, the pain and analgesic trajectory, including transition to other analgesics, has not previously been studied. Our findings suggest that for many patients, use of intrathecal morphine in addition to routine administration of nonopioid medications facilitates direct transition to oral analgesics in the early postoperative period and earlier routine ambulation and discharge of posterior spinal fusion patients.

This study investigates patient-reported opioid consumption after pediatric operations.

Objectives: To investigate the two-year functional outcomes and complications following operative versus non-operative treatment of completely displaced midshaft clavicle fractures in adolescents. Methods: All patients 10-18 years-old treated for a midshaft clavicle fracture between August, 2013 and August, 2018 at one of 8 geographically diverse, high-volume, tertiary-care pediatric centers were enrolled, with independent treatment decisions determined by individual providers. The sub-population of patients with completely displaced fractures was prospectively followed for over 2 years. Clinical course, complications, validated patient-reported outcome measures (PROs), quality of life metrics, and satisfaction scores were analyzed. To address the ceiling effect of the PRO/satisfaction data following clavicle injuries, a priori thresholds for ‘suboptimal’ scores were established (ASES scores 10, EQ-5D Results: Of the 909 patients enrolled in the prospective study, 417 patients (45.9%) demonstrated completely displaced fractures and maintained enrollment over the study period, 277 (66%) of whom had reached two year follow up, and 151 of whom provided adequate PRO data, representing a 55% response rate. Of these patients, 55 (36%) underwent operative treatment, while 96 (64%) were treated non-operatively. Those treated surgically showed no difference in gender distribution (76% males,p=0.43), athletic participation (p=0.76), or fracture pattern (p=0.18), but were older (mean age 15.3 vs. 13.5 years, pConclusion: At eight large pediatric centers with many surgeons making independent treatment decisions, non-operative treatment of adolescent clavicle fractures demonstrated lower complication rates and similar satisfaction and functional outcomes.These data establish a comprehensive functional assessment of adolescents treated for clavicle fractures, which represents the epidemiological sub-population most affected by this condition. Unlike several adult studies demonstrating superiority in operative treatment, this adolescent study demonstrates equivalent function and fewer complications associated with non-operative treatment. [Table: see text]

Case: We conducted a retrospective review of three cases of femoral neck fractures treated operatively in patients with osteogenesis imperfecta (OI). All of our patients had acetabular protrusio as well as coxa vara deformity. All patients successfully underwent cannulated screw fixation without avascular necrosis (AVN). One patient required a sub-adductor hip arthrogram during a revision procedure to assist with visualization of the proximal femur which resulted in improved screw purchase.Conclusions: We report on three cases of femoral neck fractures in OI patients and a previously undescribed technique; using a hip arthrogram to assist in fluoroscopic evaluation of the proximal femur in these osteopenic patients.