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Purpose: The purpose of this study is to compare pediatric hip aspiration in the operating room under general anesthesia or via bedside aspiration under moderate sedation and delineate the anesthetic time required. Methods: A database query conducted at two academic institutions identified all patients under the age of 17 who underwent hip aspiration between 2000 and 2017. At one institution, aspiration was performed in the operating room under general anesthesia. Patients were kept anesthetized until cell count was complete. At the second institution, aspiration was performed in the emergency room at bedside under sedation. The medical record was reviewed for demographic data, hip aspiration results, diagnoses, treatment, and anesthesia time. Results: A total of 233 patients (233 hips) with a mean age of 7.2 years were identified. Seventy-five patients underwent aspiration in the operating room, and 158 patients underwent bedside aspiration. Patients with a negative aspiration averaged 87 min under anesthesia when performed in the operating room and 29 min under sedation when performed at bedside. Patients with a negative aspiration performed in the operating room after 5 pm averaged 99 min under anesthesia, and 73 min under anesthesia when performed between 7 am and 5 pm (p Conclusion: Pediatric hip aspiration performed in the operating room results in prolonged anesthesia times while synovial fluid is transported and processed. Anesthesia times are significantly longer after 5 pm. Bedside aspiration resulted in significantly less anesthesia exposure, with half of patients undergoing bedside aspiration avoiding general anesthesia altogether. Level of evidence: Level III.

Genu valgum is a risk factor for patellofemoral maltracking and recurrent instability and may cause mechanical overload of the lateral compartment leading to early arthritic changes in some patients. In skeletally mature adolescents, a varus-producing distal femoral osteotomy will correct the valgus malalignment when the femur contributes to the overall lower extremity deformity. The goal of a distal femoral osteotomy is to correct the lateral distal femur joint angle and restore a neutral mechanical axis through the center of the knee joint. We aim to discuss the indications and contraindications, pros and cons, preoperative planning, osteotomy options, surgical techniques, and postoperative protocol for a distal femur corrective osteotomy.

Hemoglobin (Hgb) levels are frequently checked through venipuncture [invasive hemoglobin (iHgb)] in pediatric orthopaedic patients after high blood loss procedures. This needlestick may causes further anxiety and fear in hospitalized children. Noninvasive hemoglobin (nHgb) monitoring has been effectively utilized in the adult intensive care and postoperative total joint arthroplasty setting. nHgb monitoring has not yet been validated in children for routine postoperative Hgb assessment in pediatric orthopaedics.In this prospective study, 46 pediatric orthopaedic patients were enrolled who were undergoing surgery and postoperative standard of care iHgb testing. On postoperative day 1, Hgb levels were obtained through venipuncture and nHgb monitor (Pronto-7; Masimo) within a 2-hour period. Patient preferences, iHgb and nHgb values, time to result, and provider preferences were recorded. Cost data were estimated based on the standard Medicare payment rates for lab services versus the cost of nHgb probe.nHgb results were obtained after 1 attempt in 38 patients (83%), after multiple attempts in 7 patients (15%), and could not be obtained in 1 patient. The mean time to obtain nHgb value was significantly shorter than that to obtain iHgb results (1.3±1.5 vs. 40±18.1 min; P0.0001). The mean nHgb value was significantly higher than the mean iHgb value (11.7±1.5 vs. 10.6±1.1 g/dL, P0.0001). nHgb exceeded iHgb by 2 g/dL or more in 12 (26%) patients (2.64±0.9 vs. 0.54±0.84 g/dL; P0.0001). The concordance correlation coefficient between the 2 Hgb methods was 0.59, indicating moderate agreement. Forty-three (93%) of our patients and 34 (74%) of the care providers preferred nHgb over iHgb if results were equivalent. At our institution, the cost per iHgb monitoring is approximately $28 per blood draw as compared with $5 for nHgb monitoring. Interestingly, no patients required postoperative transfusion during the study period, as asymptomatic patients with no cardiac disease are typically observed unless the Hgb is6.nHgb monitoring in postoperative pediatric patients overestimated Hgb levels compared with the standard of care methods; however, nHgb had high patient and provider satisfaction and had moderate agreement with iHgb. As no patients required transfusion, postoperative Hgb checks could likely be discontinued in some portion of our population.Level Ib-Diagnostic study.

Sacropelvic fixation is frequently used for the correction of complex pediatric spine deformities. S2-alar-iliac (S2AI) screws are a powerful method to obtain iliac fixation. Advantages include a medialized starting point that requires less soft tissue dissection, no need for connectors to the rod, and reduced screw head prominence. Though the technique for S2AI placement under free-hand and fluoroscopic techniques has been described, there is limited description of computed tomography (CT)-guided technique for the placement of S2AI screws in pediatric patients undergoing surgery for complex spinal deformity. The goal of this paper is to describe the technique for placement of S2AI screws via CT-guided navigation and compare it to traditional fluoroscopy and free-hand techniques.

Background: Patellar instability has the highest incidence in adolescents aged between 14 and 18 years. The unique relationship between the medial patellofemoral ligament (MPFL) and the distal femoral physis in skeletally immature patients warrants precisely positioned MPFL graft insertion. A paucity of data are available evaluating the results of MPFL reconstruction using allograft tendon before skeletal maturity. Purposes: (1) To assess the results of MPFL reconstruction using allograft tendon in skeletally immature patients by analyzing redislocation and reoperation rates, radiological outcomes, and patient-reported outcomes and (2) to determine whether epidemiological, intraoperative, or radiographic factors influence recurrent instability and clinical outcomes. Study Design: Case series; Level of evidence, 4. Methods: Prospectively collected data were retrospectively analyzed for 69 skeletally immature patients who experienced a first-time or recurrent lateral patellar dislocation and were treated with anatomic MPFL reconstruction. Inclusion criteria were MPFL reconstruction using allograft and the availability of preoperative magnetic resonance imaging scans in the presence of open or partially open physes. Patients with Results: A total of 79 physeal-sparing MPFL reconstructions (69 patients) met the inclusion criteria. The mean age of the patient cohort was 14.7 ± 1.8 years (range, 8.5-16.9 years). Within the mean follow-up time of 37.9 ± 12.1 months (range, 24-85 months after surgery, there were 12 patients with clinical failures resulting in reoperation. Eleven patients experienced a redislocation of the patella, and 1 patient sustained a transverse noncontact patellar fracture 6 months after index surgery that required operative fixation. No injuries to the distal femoral physes were clinically observed. At the final follow-up, patients had a mean Lysholm score (1-100) of 96.5 ± 6.7, a mean Kujala score (1-100) of 96.5 ± 7.4, and a mean Tegner Activity Scale score (1-10) of 4.9 ± 1.3. Patellar height and trochlear dysplasia did not influence redislocation or clinical scores. In total, 57 of the 63 patients (90.5%) who were engaged in sports before injury returned to the same or higher level of competition. In a subgroup analysis of patients who underwent isolated MPFL reconstruction (n = 44) without concomitant procedures, 9 patients (20.5%) experienced failure and had a redislocation. A univariate analysis of hazards for failure based on patient-specific variables was carried out. A body mass index ≥30 conveyed a hazard ratio of 2.51 (95% CI, 0.63-10.1; P = .19), and the tibial tubercle-trochlear groove distance by increments of 1 mm was associated with a hazard ratio of 2.02 (95% CI, 0.51-8.11; P = .32). Conclusion: Physeal-sparing anatomic reconstruction of the MPFL using an allograft tendon in skeletally immature patients was a safe and effective treatment for patellar instability, regardless of patellar height and trochlear dysplasia. Failure rates decreased when the MPFL reconstruction was performed concomitantly with a tibial tubercle osteotomy.

Adolescent idiopathic scoliosis (AIS) can be treated with bracing or surgery, which may affect patient's physical activity (PA). However, there are limited objective assessments of PA in patients with AIS. This study aims to compare the outcome of spinal bracing vs. surgery in patients with AIS based on a device that measured daily PA. In total 24 patients with AIS participated, including 12 patients treated with bracing and 12 with spinal surgery. Daily PA was measured throughout 4 consecutive days using four tri-axial accelerometers and patient-reported functional status was reported using the SRS-22 questionnaire. The participants were assessed both before the treatment and after treatment at a 12-month follow-up. Patients with AIS had no significant change in their PA levels at the 12-month follow-up after surgical correction. On the contrary, patients with AIS following a year-long bracing treatment had significantly reduced time spent active (P = 0.04) with an average reduction in walking steps by 2137 steps/day (P = 0.005). There was no significant difference in function, pain, self-image and mental health domains following both treatments, as reported by the SRS-22. There was a significant improvement in satisfaction for both treatment groups (P ≤ 0.02). Significantly reduced PA and increased sedentary time are reported in patients with AIS following bracing treatment. An objective PA assessment is recommended to track the effect of scoliosis treatment on PA. Patients with AIS should be actively encouraged to achieve and maintain their recommended daily PA levels irrespective of the type of treatment. Level of evidence: Level II.

BACKGROUND Data regarding opioid prescribing patterns following pediatric orthopaedic procedures is limited. The aim of this work was to evaluate the effects of tiered guidelines for discharge opioid prescriptions following common pediatric orthopaedic procedures. METHODS Quality improvement project conducted at a single academic institution. Guidelines for discharge opioid prescriptions were implemented January 2018 and established 4 tiers of increasing invasiveness for 28 common pediatric orthopaedic procedures. Patients who underwent these procedures in 2017 comprised the preguideline cohort (N=258), while patients treated in 2019 comprised the postguideline cohort (N=212). Opioid prescriptions were reported as oral morphine equivalents (OMEs). Univariate tests were performed to assess statistically significant differences before and after implementation of the guidelines. RESULTS There was a significant decrease in OME prescribed between preguideline and postguideline cohorts (median OME 97.5 vs. 37.5). When analyzed according to procedure tiers, tiers 1, 2, and 4 showed significant decreases in OME prescribed between 2017 and 2019. The rate of no opioids prescribed at discharge increased from 13% to 23% between preguideline and postguideline cohorts. The 30-day refill rate did not significantly change. After implementation of guidelines, 91% of all prescriptions were within the guideline parameters, and there was a significant reduction in prescription variability. In tier 4 procedures, median OME prescribed decreased from 375 preguideline to 188 postguideline, but was associated with greater opioid refills within 30 days of discharge (10.2% preguideline vs. 28.8% postguideline). CONCLUSIONS Tiered guidelines for discharge opioid prescriptions following pediatric orthopaedic procedures can significantly decrease the quantity of opioids prescribed. Furthermore, we noted excellent adherence and no overall increase in the rates of narcotic refills. Such guidelines may improve pediatric orthopaedists' ability to responsibly treat postoperative pain while limiting the distribution of unneeded opioids. LEVEL OF EVIDENCE Level IV-quality improvement project.

Pediatric orthopedic surgeons must accurately assess the skeletal stage of adolescent idiopathic scoliosis (AIS) patients for selection and timing of optimal treatment. Successful treatment using vertebral growth modulation is highly dependent on skeletal growth remaining. We sought to evaluate the current-state use of the Sanders Skeletal Maturity System (SSMS) in regard to precision and accuracy. We hypothesized that pediatric orthopedic surgeons currently use SSMS with moderate precision and accuracy. Eight practicing pediatric orthopedic surgeons who perform vertebral body tethering surgery without specific training in SSMS were asked to assign the SSMS stage for 34 de-identified hand radiographs from AIS patients. Precision was evaluated as inter-rater reliability, using both Krippendorff’s α and Weighted Cohen’s kappa statistics, and as intra-rater reliability, using only Weighted Cohen’s kappa statistics. Surgeon accuracy was evaluated using Weighted Cohen’s kappa statistics with comparison of surveyed surgeons’ responses to the gold standard rating. Inter-rater reliability across the surveyed surgeons indicated moderate to substantial agreement using both statistical methods (α = 0.766, κ = 0.627) with the majority of discord occurring when assigning SSMS stages 2 through 4. The surveyed surgeons displayed substantial accuracy when compared to the gold standard (κ = 0.627) with the majority of inaccuracy involving the identification of stage 3B. When re-surveyed, the surgeons showed substantial intra-rater reliability (κ = 0.71) with increased inconsistencies when deciding between SSMS stage 3A and stage 3B. The current-state use of SSMS across pediatric orthopedic surgeons for evaluation of AIS patients displays adequate but imperfect precision and accuracy with difficulties delineating SSMS stages 2 through 4, which correlate with adolescent growth periods germane to scoliosis growth modulation surgery. Centralized assessment of hand-bone age may help ensure standardized reporting for non-fusion scoliosis research.

Background Anterior vertebral body tethering is an alternative to fusion surgery for the treatment of adolescent idiopathic scoliosis (AIS) that is purported to preserve spinal motion. There is limited information regarding the measurable motion that is maintained over the instrumented levels following thoracic anterior vertebral body tethering surgery in humans. The purpose of the present study was to assess radiographic spinal motion 1 year after anterior vertebral body tethering. Methods As part of a prospective U.S. Food and Drug Administration investigational device exemption study, 32 patients were treated with thoracic anterior vertebral body tethering. At 1 year postoperatively, patients were evaluated with standing flexion-extension and side-bending radiographs in a microdose biplanar slot scanning imaging system. The angle subtended by the screws at the upper instrumented vertebra (UIV) and lower instrumented vertebra (LIV) was measured on left and right-bending radiographs to evaluate the coronal arc of motion and was compared with preoperative values over the same levels. At 1 year postoperatively, the sagittal Cobb angle was measured over the instrumented levels on flexion and extension radiographs. Results Side-bending radiographs revealed that the mean angle subtended by the screws changed from 15° ± 8° on left-bending radiographs to 8° ± 6° on right-bending radiographs. The mean coronal arc of motion on bending was 7° ± 6°, with 20 (62.5%) of 32 patients having a coronal arc of motion of >5°. The mean preoperative coronal arc of motion over the instrumented segments was 30° ± 9°. On flexion-extension lateral radiographs made at 1 year postoperatively, the mean kyphotic angle over the instrumented segments was 33° ± 13° in flexion and 11° ± 14° in extension, for a mean postoperative arc of motion of 21° ± 12° between flexion and extension radiographs. Conclusions At 1 year following thoracic anterior vertebral body tethering for the treatment of AIS, the thoracic spine showed a measurable range of coronal and sagittal plane motion over the instrumented levels without evidence of complete autofusion. Motion in the coronal plane decreased by 77% following anterior vertebral body tethering. These findings provide proof of concept that sagittal spinal motion is preserved after thoracic anterior vertebral body tethering, although the functional importance remains to be determined. Level of evidence Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

PURPOSE Vertebral body tethering is increasingly being performed, yet postoperative pain management has not yet been optimized. We sought to determine whether the addition of a thoracic paravertebral block in addition to a standard multimodal postoperative pain management program could provide greater pain relief, reduced analgesic requirement, and reduced length of stay. METHODS Patients who underwent VBT at a single tertiary referral center were retrospectively reviewed. All patients received a single-shot intrathecal (IT) injection at the completion of the procedure in addition to a standardized multimodal pain management program. 45 patients received a thoracic paravertebral catheter with lidocaine infusion (TPVB) which was left in place for 4-6 days, whereas 24 control patients did not have a TPVB. Length of stay, maximum postoperative Numeric Pain Intensity Scale (NPIS), and total dose of opioids, ibuprofen, ketorolac and acetaminophen administered during hospitalization were evaluated. RESULTS 69 patients met inclusion criteria. The mean cumulative dose of opioids administered during hospitalization was 148 oral morphine milligram equivalent (MME) in the control group vs. 47 MME in the TPVB group (p

Background: Some surgeons are now considering fixation of traumatic chondral-only fragments in juvenile knees, but few data remain to guide treatment. Purpose: To determine if surgical fixation of chondral-only fragments in the juvenile knee results in an adequate healing response with successful imaging and clinical outcomes. Study Design: Case series; Level of evidence, 4. Methods: Data were collected on 16 skeletally immature patients treated with fixation of chondral-only fragments with a minimum 1-year follow-up. Patients were selected by the operating surgeons based on the quality and size of the chondral fragment. Demographic data, lesion characteristics, surgical procedure details, complications, and postoperative imaging were assessed. Validated outcome measures were collected pre- and postoperatively and included the following scores: International Knee Documentation Committee (IKDC), Marx Activity Scale, Knee injury and Osteoarthritis Outcome Score (KOOS), Hospital for Special Surgery Pediatric Functional Activity–Brief Scale (HSS Pedi-FABS), Patient-Reported Outcomes Measurement Information System (PROMIS)–Physical Health and PROMIS–Psychological Health, and Tegner. Results: The mean age of our patient cohort was 14.9 years. The mean size of the repaired defects measured 3.2 cm2. Injury sites included the patella (n = 1), medial femoral condyle (n = 3), trochlea (n = 4), and lateral femoral condyle (n = 8). Within the mean follow-up time of 42.3 months (range, 15-145), there was 1 clinical failure with loosening of the chondral fragment and the need for reoperation. At a mean follow-up of 3.5 years, the mean (interquartile range) patient-reported outcome scores were as follows: IKDC, 95.2 (94.3-100); Marx Activity Scale, 11.5 (11.5-16); KOOS, 95.81 (93.5-95.81); HSS Pedi-FABS, 16.94 (11.5-26); PROMIS–Physical Health, 93.75% (90%-100%); PROMIS–Psychological Health, 90% (88.75%-100%); and Tegner, 5.69 (4.75-7). All patients who were engaged in sports before injury returned to the same or higher level of competition with the exception of 1 patient. Conclusion: Primary repair of chondral-only injuries with internal fixation can be a successful treatment option in selected patients. Clinical and imaging results at final follow-up suggest that reintegration of the cartilage fragment is achievable and leads to excellent clinical function and a high return-to-sports rate.

Estimated blood loss (EBL), anesthesia time, operative time, and length of stay decreased over 67 navigated vertebral body tethering (VBT) surgeries performed in a 5-year period, indicating a steep learning curve. Retrospective review of prospectively collected data. There would be a significant improvement in the performance of VBT procedures over time at a single tertiary center in terms of perioperative and postoperative outcomes. Learning a new procedure for surgeons takes time, and previous studies have described improved efficiency as experience grows. VBT procedures are increasingly being performed in the US, but there is limited data regarding the learning curve specifically regarding the use of CT-guided navigation. We sought to assess the learning curve of VBT with respect to estimated blood loss, anesthesia time, operative time, length of stay, percent correction of the major curve at first follow-up. We further sought to characterize change in rates of 90-day complications. Pediatric scoliosis patients who underwent thoracic or lumbar CT-guided navigated VBT with a consistent surgical team at a single tertiary referral center between 2015 and 2020 were included. Student t-test was used to assess change in perioperative parameters over time, and also results between first and latest group of 20 patients were compared. 67 patients met inclusion criteria. Estimated blood loss (EBL), operative time, anesthesia time and length of stay significantly decreased over the 5-year study period. Specifically, on comparison of our first 20 patients with our last 20, the former had greater EBL (282 vs 116 ml, p = 0.0005; 8.5% vs 3.6%, p = 0.0024), operative time (4.8 h vs. 3.3 h, p

With the goal of reducing radiation dosing for patients, we sought to compare the results of slot-scanning (EOS) standing flexibility radiographs to supine bending and fulcrum radiographs for surgical planning in adolescent idiopathic scoliosis (AIS). We hypothesized that slot-scanning standing bending radiographs provide similar mean curve flexibility as supine bending and fulcrum radiographs. This is a retrospective review of 224 AIS patients with concomitant upright standing and flexibility images. Curve flexibility, defined the percent change in Cobb angle from standing upright to flexibility images, was used to compare the results of slot-scanning standing, supine and fulcrum radiographs. Statistical analysis utilized ANOVA one-way tests and two-sample t tests to detail differences as indicated. A total of 256 imaging studies were included, 75 slot-scanning standing, 112 supine, and 69 fulcrum radiographs. Fulcrum images only investigated thoracic curves and were, therefore, excluded from proximal thoracic and lumbar flexibility comparisons. Relevant mean standing curve magnitudes were similar between the groups with some variance in thoracic curves between fulcrum and supine image series (p = 0.003). There was no statistical difference in curve flexibility for proximal thoracic curves (p = 0.389) and lumbar curves (p = 0.798). However, for thoracic curves, slot-scanning standing images result in less measured curve flexibility compared to supine (p = 1.00e−7) and fulcrum images (p = 2.84e−18). Furthermore, supine bending images resulted in less measured curve flexibility in comparison to fulcrum images (p = 2.85e−7). Slot-scanning standing bending films show comparable results in curve flexibility as supine bending films for proximal thoracic and lumbar curves but may show reduced flexibility for thoracic curves when compared to supine or fulcrum bending films. Given lower radiation dosing, slot-scanning films could be substituted for traditional supine films for assessment of proximal thoracic and lumbar curve flexibility.

Anterior vertebral body tether (AVBT) is a nonfusion surgical procedure for correction of scoliosis in skeletally immature individuals. With US Food and Drug Administration approval in 2019, AVBT technology is spreading and early to midterm reports are being published. Early clinical reports are promising while precise indications, outcomes, complication profiles, and best practices are being established. Patients who are skeletally immature and wish to avoid a fusion surgery may benefit from this procedure. This article highlights the translational science foundation, early to midterm clinical reports, and future directions for this growing technique in pediatric spinal deformity surgery.

Anterior vertebral body tethering (AVBT) is an emerging approach for idiopathic scoliosis. However, overcorrection and under-correction are common causes of revision surgery, and intraoperative tensioning of the cord is one key component to achieve appropriate curve correction. We sought to determine whether preoperative flexibility radiographs or intraoperative radiographs would predict correction at first erect imaging for scoliosis patients undergoing anterior vertebral body tethering (AVBT). Single-center retrospective review. Fifty-one patients with a diagnosis of idiopathic scoliosis underwent anterior body tethering. Preoperative flexibility films and intraoperative radiographs were compared to first erect standing radiographs to determine if there was a correlation in Cobb angle. Preoperative major Cobb angle measured 52° ± 9°. Major Cobb angle on bending films was 24° ± 8°. Intraoperative imaging showed correction to a mean of 17° ± 8°. Postoperative first erect standing radiographs showed correction to a mean of 26° ± 10°. The mean difference in major Cobb angle between intraoperative radiograph and a first erect radiograph was 10° ± 4°, whereas the mean difference from preoperative bending radiograph at first erect was 2° ± 7°. Thus, correction on preoperative flexibility films correlated with the first erect radiograph. Preoperative bending radiographs provide a reasonable estimate of postoperative correction for patients undergoing AVBT with tensioning of the cord. Surgeons should expect the major Cobb angle to increase on first erect radiographs compared to intraoperative radiographs. These findings may guide patient selection and assist surgeons in achieving appropriate correction intraoperatively.

Interest in vertebral body tethering (VBT) as an alternative to posterior spinal fusion for adolescent idiopathic scoliosis (AIS) continues to grow. The purpose of this study was to prospectively assess intervertebral disk health on magnetic resonance imaging (MRI) at 1 year following VBT in AIS patients.AIS patients were enrolled in a prospective surgeon-sponsored Food and Drug Administration (FDA) Investigational Device Exemption (IDE) Study and underwent MRI at 1-year following VBT. All spanned disks and the untethered disks immediately adjacent to the upper instrumented vertebra and lowest instrumented vertebra levels were evaluated according to Pfirrmann grading criteria. Associations between patient factors and preoperative and postoperative disk health and patient-reported outcomes were evaluated.Twenty-two patients were enrolled with a postoperative MRI (25 curves, 188 disks), and 7 patients (7 curves) had both preoperative and postoperative MRIs (67 disks). The mean age was 12.7 years. Most were Risser 0 (65%) and either Sanders Skeletal Maturity Score 3 (35%) or 4 (53%). In the 7 patients with preoperative and postoperative MRI, the mean Pfirrmann grade of the disks spanned by the tether was 1.88 preoperatively and 2.31 postoperatively ( P =0.0075). No statistically significant differences in preoperative versus postoperative Pfirrmann grade were identified in the disks adjacent to the upper or lower instrumented vertebrae. No association was found between patient-reported outcomes and Pfirrmann grade.At 1 year postoperatively, increased degenerative changes in disks spanned by the tether was identifiable on MRI without evidence of adjacent segment disk disease. These changes were not associated with patient-reported outcomes.Level III.

We sought to determine whether the axial spinal cord classification by Sielatycki et al. would be associated with increased intraoperative neuromonitoring (IONM) alerts for pediatric scoliosis patients undergoing posterior spinal fusion (PSF) surgery. Children less than age 19 with scoliosis undergoing PSF were retrospectively reviewed. Axial-T2 MRI of the thoracic apex was reviewed for spinal cord/CSF architecture as described by Sielatycki et al.: Type 1—circular cord with visible CSF, Type 2—circular cord but no visible CSF at apical concavity, and Type 3—cord deformed with no intervening CSF. Intraoperative neuromonitoring reports, operative records and preoperative radiographs were reviewed. 90 patients met the inclusion criteria. Rate of neurologic events was Type 1: 2% (1/41 patients), Type 2: 14.3% (4/28), Type 3: 57.1% (12/21) (Type 1 vs 2 p = 0.06; Type 1 vs 3 p

Background Tarsal coalitions are an important reason for foot pain in children. Early estimates placed the prevalence at up to 2%, while more recent data suggest that it is as high as 11% to 13%. To our knowledge, there have been no population-based studies to determine the true incidence of symptomatic tarsal coalitions in a pediatric population. Methods A population-based database was used to identify all new diagnoses of symptomatic tarsal coalitions in children 18 years old or younger between 1966 and 2018. Patient records were reviewed for clinical data, and comparisons were made between the types and characteristics of the coalitions identified to determine differences in the affected populations. The annual age-specific, sex-specific, and type-specific incidence rates were estimated. Results During the study period, 58 patients with a total of 79 symptomatic tarsal coalitions were identified (annual incidence = 3.5 per 100,000 children). There were 43 calcaneonavicular (CN) coalitions (annual incidence = 1.9 per 100,000 children), 27 talocalcaneal (TC) coalitions (annual incidence = 1.2 per 100,000 children), as well as 9 other coalitions (7 talonavicular, 1 naviculocuboid, and 1 naviculocuneiform) (annual incidence = 0.4 per 100,000 children). The overall incidence peaked between the ages of 10 and 14 years for both boys and girls (8.1 per 100,000 and 7.4 per 100,000 children, respectively). Statistical differences were identified between the types of tarsal coalitions. TC coalitions present at an older age relative to CN and other coalitions (mean,13.9, 12.7, and 11.4 years, respectively; p = 0.02). While CN and TC coalitions were similar in composition (23% and 30%, respectively, were osseous as opposed to fibrocartilaginous), other coalitions were more likely to be osseous (78%) (p = 0.0035). Other coalitions were also less likely to require surgery than CN and TC coalitions (11%, 74%, and 56%, respectively; p = 0.0015). Conclusions This population-based study demonstrates differences in the clinical presentation of tarsal coalitions and provides an estimate of the true incidence of symptomatic tarsal coalitions in a pediatric population.

PURPOSE: The purpose of this study was to determine the outcomes of meniscus repair in the adolescent population, including: 1) failure and reoperation rates, 2) clinical and functional results, and 3) activity-related outcomes including return to sport. METHODS: Two authors independently searched MEDLINE, Cochrane Central Register of Controlled Trials & Cochrane Library, and CINHAL databases for literature related to meniscus repair in an adolescent population according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. No meta-analysis was performed in this qualitative systematic review. RESULTS: Thirteen studies, including no Level I, one Level II, one Level III, and eleven Level IV studies yielded 466 patients with 503 meniscus repairs. All defined meniscal re-tear as a primary endpoint, with a reported failure rate ranging from 0–42% at a follow-up ranging from 22–211 months. There were a total of 93 failed repairs. IKDC scores were reported in four studies with a mean improvement ranging from 24–42 (P

Retrospective cohort study. To determine whether patients who underwent surgical treatment of adolescent idiopathic scoliosis (AIS) in childhood would have an increased C-section risk in adulthood. Although the impact of scoliosis on future pregnancy and child delivery is a common question for patients and parents, there is limited data regarding pregnancy outcomes following childhood treatment of AIS. Between 1975 and 1992, 60 female patients underwent treatment for AIS with bracing, surgery, or observation and had data available regarding obstetrical history in the electronic medical record or in paper charts. In childhood, 28 had nonoperative treatment and 32 had fusion surgery. During the follow-up period, 2 nonoperative patients and 1 operative patient had fusion surgery in adulthood, but after childbearing years. Mean age at latest follow-up was 43 years (CI 38, 48). Meantime to follow-up since childhood treatment was 31 years (CI 26, 35). 29% of nonoperative patients had a C-section with at least one live birth compared to 38% of operative patients (p = 0.464). For surgical patients fused to L3 or lower, 46% required at least one C-section, compared to 32% of patients fused to L2 or higher (p = 0.40). Overall, 33% of the cohort of patients—including those with all scoliosis treatment methods—required at least one C-section, compared to the state weighted C-section rate of 20.5% (p = 0.014). The percentage of patients with operative treatment—including all levels of fusion—requiring at least one C-section was statistically different than the weighted state C-section rate (p = 0.020). In this long-term cohort of 60 US scoliosis patients, childhood operative fusion treatment was associated with a statistically significant increased incidence of C-section compared to the state incidence at both the patient level and the delivery level. III, comparative cohort study

BACKGROUND: Annual rankings by US News and World Report are a widely utilized metric by both healthcare leaders and patients. One longstanding measure is time to treatment of femur shaft fractures. Hospitals able to provide at least 80% of pediatric patients with an operating room start time within 18 hours of admission to the emergency department score better as part of the overall pediatric orthopedic ranking. Therefore, it is important to determine whether the 18 hour treatment time for pediatric femur shaft fractures is a clinically meaningful metric. METHODS: A retrospective review of clinical outcomes of 174 pediatric patients (age < 16) with isolated femur shaft fractures (Injury Severity Score = 9) was conducted from 1997 to 2017 at a single level I pediatric trauma center. The two comparison groups were patients receiving fracture reduction within 18 hours of ED admission (N = 87) or greater than 18 hours (N = 87). RESULTS: Patient, injury, and surgical characteristics were similar between the two groups. Both groups had a similar mean age (treatment < 18 hours = 7.5 years, treatment > 18 hours = 8.1 years). Patients who received treatment within 18 hours were more often immobilized post-operatively (70.1% versus 53.5%, p = 0.0362) and had a shorter median hospital length of stay (2 versus 3 days, p = 0.0047). There were no statistically significant differences in any outcomes including surgical site infection, time to weight-bearing (treatment < 18 hours mean = 48.1 days vs 52.5 days), time to complete radiographic fracture healing (treatment < 18 hours mean = 258.9 days vs 232.0 days), decreased range of motion, genu varus/valgus, limb length discrepancy, loss of reduction, or persistent pain. CONCLUSIONS: Treatment of pediatric femur shaft fractures within 18 hours does not impact clinical outcomes. National quality measures should therefore use evidence-based metrics to help improve the standard of care. LEVEL OF EVIDENCE: Therapeutic level III

Basic science. Investigate the ability of local applicaiton of vancomycin, either in powder form or suspended within poly(lactic-co-glycolic acid) microspheres (MS), to treat infection using a rat spinal model. Surgical site infections (SSIs) are a serious complication after spine surgery and are associated with high morbidity and mortality and often caused my coagulase negative staphylococci. A comprehensive approach to reduce SSIs has been recommended including the use of topical vancomycin. Animal and human studies have shown improved control of infection with local compared to systemic antibiotics. K-wires seeded with methicillin-resistant Staphylococcus epidermidis RP62A (MRSE) were treated with vancomycin powder, carboxymethylcellulose sodium salt (CMC) (microsphere carrier), vancomycin powder, blank MS or vancomycin-loaded MS for 24 or 48 h in vitro after which bacteria were enumerated. In addition, a spinal instrumentation model was developed in rats with a bacterial seeded K-wire implanted into the right side of L4 and L5. Rats underwent no treatment or were treated locally with either vancomycin powder, blank MS or vancomycin-loaded MS. After 8 weeks, the K-wire, bone, soft tissue and wire fastener were cultured and results analyzed. Vancomycin powder and vancomycin-loaded MS resulted in significantly fewer bacteria remaining in vitro than did CMC. Vancomycin powder- treated animals’ cultures were significantly lower than all other groups (P

Purpose Tarsal coalitions are congenital fusions of two or more tarsal bones and can lead to foot pain and stiffness. Few studies examine the long-term reoperation rates following paediatric tarsal coalition surgery. Methods A population-based database, linking medical records at all medical centres to capture the entire medical history of the full population of a Midwest county, was used to identify tarsal coalitions in children between 1966 and 2018. Records were reviewed for clinical data, surgical records and followed up to identify any subsequent surgical interventions. Results A total of 58 patients (85 coalitions) were identified; 46 calcaneonavicular (CN) coalitions, 30 talocalcaneal (TC) coalitions and nine other coalitions (seven talonavicular, one naviculocuboid, one naviculocuneiform). In all, 46 coalitions were treated surgically (43 coalition resections, three arthrodeses) and 39 were treated nonoperatively. Patients treated surgically were less likely to report ongoing symptoms at final follow-up compared with patients managed nonoperatively (33% versus 67%; p = 0.0017). With a median 14.4 years (interquartile range 9.3 to 19.7) follow-up, there was an overall re-operation rate of 8.7% (4/46). Differences in reoperation rates by initial surgery (resection versus arthrodesis; p = 0.2936), coalition type (CN versus TC versus Other; p = 0.6487) or composition (osseous versus fibrocartilaginous; p = 0.29) did not reach statistical significance. Conclusion This is the first population-based study demonstrating the durability of surgical management of tarsal coalitions in a paediatric population. At final follow-up, patients treated surgically are less likely to report persistent symptoms compared with patients managed nonoperatively. Long-term reoperation rates appear to be low (8.7%). Level of evidence III

BACKGROUND Previous studies report elevated serum titanium (Ti) levels in children with spinal implants. To provide additional data on this topic, we sought to assess serum ion levels at multiple timepoints in pediatric patients with growing spine devices, spinal fusion instrumentation, and extremity implants placed for fracture treatment. We hypothesized that serum Ti, cobalt (Co), and chromium (Cr) levels would be elevated in pediatric patients with growing spine devices compared with patients with extremity implants. METHODS Pediatric patients undergoing any primary spine implant placement, those with spine implant revision or removal surgery and patients with other appendicular implant removal had serum Ti, Co, and Cr ion levels drawn at the time of surgery. Fifty-one patients (12 growing spine devices, 13 fusions, and 26 extremity implants) had one set of labs, 31 of whom had labs drawn both preoperatively and postoperatively. Biopsies obtained from tissue specimens at the time of implant revision were analyzed histologically for the presence of metal debris and macrophage activity. RESULTS Patients with growing spine implants had elevated serum Ti (3.3 vs. 1.9 ng/mL, P=0.01) and Cr levels (1.2 vs. 0.27 ng/mL, P=0.01) in comparison to patients with fusion rods or extremity implants. With respect to patients with extremity implants, patients with growing spine devices had elevated serum Ti (3.3 vs. 0.98 ng/mL, P=0.013), Co (0.63 vs. 0.26 ng/mL, P=0.017), and Cr levels (1.18 vs. 0.26 ng/mL, P=0.005). On matched pairs analysis, patients who had labs drawn before and after spine implantation had significant increase in serum Ti levels (0.57 vs. 3.3 ng/mL, P=0.02). Histology of tissue biopsies adjacent to growing spine implants showed presence of metal debris and increased macrophage activity compared with patients with extremity implants. CONCLUSION Serum Ti, Co, and Cr levels are elevated in children with spinal implants compared with those with extremity implants, particularly in those with growing spine devices. However, the clinical significance of these findings remains to be determined. LEVEL OF EVIDENCE Level II-prospective comparative study.

Type 1 tibial spine fractures are nondisplaced or ≤2 mm-displaced fractures of the tibial eminence and anterior cruciate ligament (ACL) insertion that are traditionally managed nonoperatively with immobilization.Type 1 fractures do not carry a significant risk of associated injuries and therefore do not require advanced imaging or additional interventions aside from immobilization.Case series; Level of evidence, 4.We reviewed 52 patients who were classified by their treating institution with type 1 tibial spine fractures. Patients aged ≤18 years with pretreatment plain radiographs and ≤ 1 year of follow-up were included. Pretreatment imaging was reviewed by 4 authors to assess classification agreement among the treating institutions. Patients were categorized into 2 groups to ensure that outcomes represented classic type 1 fracture patterns. Any patient with universal agreement among the 4 authors that the fracture did not appear consistent with a type 1 classification were assigned to the type 1+ (T1+) group; all other patients were assigned to the true type 1 (TT1) group. We evaluated the rates of pretreatment imaging, concomitant injuries, and need for operative interventions as well as treatment outcomes overall and for each group independently.A total of 48 patients met inclusion criteria; 40 were in the TT1 group, while 8 were in the T1+ group, indicating less than universal agreement in the classification of these fractures. Overall, 12 (25%) underwent surgical treatment, and 12 (25%) had concomitant injuries. Also, 8 patients required additional surgical management including ACL reconstruction (n = 4), lateral meniscal repair (n = 2), lateral meniscectomy (n = 1), freeing an incarcerated medial meniscus (n = 1), and medial meniscectomy (n = 1).The classification of type 1 fractures can be challenging. Contrary to prior thought, a substantial number of patients with these fractures (20%) were found to have concomitant injuries. Overall, surgical management was performed in 25% of patients in our cohort.

When operative treatment is indicated, tibial spine fractures can be successfully managed with open or arthroscopic reduction and internal fixation (ARIF). The purpose of the study is to evaluate short-term treatment outcomes of tibial spine fractures in patients treated with both open and arthroscopic fracture reduction.We performed an Institutional Review Board (IRB)-approved retrospective cohort study of pediatric tibial spine fractures presenting between January 1, 2000 and January 31, 2019 at 10 institutions. Patients were categorized into 2 cohorts based on treatment: ARIF and open reduction and internal fixation (ORIF). Short-term surgical outcomes, the incidence of concomitant injuries, and surgeon demographics were compared between groups.There were 477 patients with tibial spine fractures who met inclusion criteria, 420 of whom (88.1%) were treated with ARIF, while 57 (11.9%) were treated with ORIF. Average follow-up was 1.12 years. Patients treated with ARIF were more likely to have an identified concomitant injury (41.4%) compared with those treated with ORIF (24.6%, P=0.021). Most concomitant injuries (74.5%) were treated with intervention. The most common treatment complications included arthrofibrosis (6.9% in ARIF patients, 7.0% in ORIF patients, P=1.00) and subsequent anterior cruciate ligament injury (2.1% in ARIF patients and 3.5% in ORIF, P=0.86). The rate of short-term complications, return to the operating room, and failure to return to full range of motion were similar between treatment groups. Twenty surgeons with sports subspecialty training completed 85.0% of ARIF cases; the remaining 15.0% were performed by 12 surgeons without additional sports training. The majority (56.1%) of ORIF cases were completed by 14 surgeons without sports subspecialty training.This study demonstrated no difference in outcomes or nonunion following ARIF or ORIF, with a significantly higher rate of concomitant injuries identified in patients treated with ARIF. The majority of identified concomitant injuries were treated with surgical intervention. Extensive surgical evaluation or pretreatment magnetic resonance imaging should be considered in the workup of tibial spine fractures to increase concomitant injury identification.Level III.

Vertebral body tethering (VBT) has been described for patients with idiopathic scoliosis. Results of the technique for non-idiopathic scoliosis have not yet been reported.An international multicenter registry was retrospectively queried for non-idiopathic scoliosis patients who underwent VBT with minimum 2-year follow-up. Success at 2 years was defined as Cobb angle 35 degrees and no fusion surgery.Of the 251 patients treated with VBT, 20 had non-idiopathic scoliosis and minimum 2-year follow-up. Mean age at surgery was 12.4 years (range 10 to 17 years). Mean major Cobb angle at enrollment was 56 degrees. Of those, 18 patients had a major thoracic curve and two had a major lumbar curve. Of the 20 patients, nine met criteria for success (45%). Eight of the 20 patients had poor outcomes (four fusions, four with curve 50 degrees). Success was associated with smaller preoperative Cobb angle (50 vs. 62 degrees, p = 0.01) and smaller Cobb angle on initial postop imaging (28 degrees vs. 46 degrees, p = 0.0007). All patients with Cobb angle 35 degrees on 1st postop imaging had a successful result, with the exception of one patient who overcorrected and required fusion. Syndromic vs. neuromuscular patients had a higher likelihood of success (5 of 7, 71%, 2 of 10, 20%, p = 0.03).Selected non-idiopathic scoliosis can be successfully treated with VBT, but failure rates are high and were associated with large curves, inadequate intraoperative correction and neuromuscular diagnosis. Achieving a Cobb angle less than 35 degrees on 1st standing radiograph was associated with a successful outcome which was achieved in 45% of patients.Level IV (retrospective review study).

Background:An increased posterior tibial slope (PTS) results in greater force on the anterior cruciate ligament (ACL) and is a risk factor for ACL injuries. Biomechanical studies have suggested that a reduction in the PTS angle may lower the risk of ACL injuries. However, the majority of these investigations have been in the adult population.Purpose:To assess the mean medial and lateral PTS on pediatric cadaveric specimens without known knee injuries.Study Design:Cross-sectional study; Level of evidence, 3.Methods:A total of 39 pediatric knee specimens with computed tomography scans were analyzed. Specimens analyzed were between the ages of 2 and 12 years. The PTS of each specimen was measured on sagittal computed tomography slices at 2 locations for the medial and lateral angles. The measurements were plotted graphically by age to account for the variability in development within age groups. The anterior medial and lateral tibial plateau widths were measured. The distance between the top of the tibial plateau and the physis was measured. The independent-samples t test and analysis of variance were used to analyze the measurements.Results:The mean PTS angle for the medial and lateral tibial plateaus was 5.53° ± 4.17° and 5.95° ± 3.96°, respectively. The difference between the PTS angles of the medial and lateral tibial plateaus was not statistically significant ( P > .05). When plotted graphically by age, no trend between age and PTS was identified.Conclusion:This data set offers values for the PTS in skeletally immature specimens without a history of ACL injury and suggests that age may not be an accurate predictive factor for PTS.

Direct comparisons between vertebral body tethering (VBT) and posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) are limited. We aimed to evaluate 2-year results of VBT and PSF to report comparative outcomes.26 prospectively enrolled VBT patients were matched 1:1 by age, gender, Risser sign and major curve magnitude with PSF patients. At a minimum 2-year follow-up, surgical results and radiographic outcomes were reviewed.Operative time, anesthesia time, blood loss, and length of stay were significantly lower in the VBT group ( 0.001, p = 0.003, p 0.001, p 0.001, respectively). The major curve at 2 years was corrected by 46% in the VBT group vs. 66% in the PSF (p = 0.0004). Success following VBT, defined as no fusion surgery and Cobb angle 35° at the 2-year follow-up, was seen in 20 VBT patients (77%) (p = 0.0003) and correlated with mean Cobb angle of 35° on 3-month imaging. 12 VBT patients (46%) showed curve improvement over time, and those patients had significantly lower mean Cobb angle on the 3-month radiograph than non-modulators (23° vs 31°, p = 0.014). At 2 years, cord breakage occurred in five patients (19%). By 2 years, three VBT patients developed complications (2 pleural effusion and 1 overcorrection needing return to OR). In contrast to PSF, growth continued at T1-T12 (mean 13 mm) and over the instrumented levels (mean 10 mm) following VBT, compared to no growth over instrumented segments in the fusion cohort (p = 0.011, p = 0.0001).In Sanders stages 3 and 4 patients treated in the USA, Cobb angle 35° on 3-month imaging was associated with success at the 2-year follow-up. Curve correction was superior in the PSF group with 96% achieving curve correction to 35° vs. 77% of the VBT patients. Cord breakage was noted in 19% of VBT patients at the 2-year follow-up. Three patients developed complications in both the VBT and PSF cohorts.Level II (prospective study with matched retrospective comparison group).

Long-term outcomes of surgical treatment for pediatric developmental dysplasia of the hip (DDH) are not well defined. The purpose of this study was to report long-term radiographic and clinical outcomes, survivorship free of total hip arthroplasty (THA), and predictors of subsequent THA following childhood treatment of DDH. This study was a single-institution retrospective review of hips treated for DDH with closed or open reduction at a minimum 10-year follow-up. 107 patients (119 hips) were included with a mean patient age of 3.3 years at childhood treatment. At mean 30.5 years follow-up, 24 hips had undergone THA (20%). Mean patient age at time of THA was 33.5 years. None of the hips treated with closed reduction alone required THA, whereas 8 hips treated with open reduction (25%) underwent THA. Hips with patient age > 4 years at the time of treatment had lower survivorship at 35 years follow-up (50% vs. 85%; p < 0.001). Additionally, femoral osteotomy (OR 2.0, p < 0.001), and previous treatment elsewhere (27% vs. 16%; p < 0.01) were associated with subsequent THA. Early referral and appropriate intervention may prove important, as age and prior treatment were predictive of subsequent THA.

A successful disease screening strategy requires a high incidence of the condition, efficacy of early treatment, and efficient detection. There is limited population-based data describing trends in incidence of adolescent idiopathic scoliosis (AIS) in the United States and potential role of school screening programs on the incidence of AIS. Thus, we sought to evaluate the incidence of AIS over a 20-year period between 1994 and 2013 using a population-based cohort.The study population comprised 1782 adolescents (aged 10 to 18 y) with AIS first diagnosed between January 1, 1994 and December 31, 2013. The complete medical records and radiographs were reviewed to confirm diagnosis and coronal Cobb angles at first diagnosis. Age-specific and sex-specific incidence rates were calculated and adjusted to the 2010 United States population. Poisson regression analyses were performed to examine incidence trends by age, sex, and calendar period.The overall age-adjusted and sex-adjusted annual incidence of AIS was 522.5 [95% confidence interval (CI): 498.2, 546.8] per 100,000 person-years. Incidence was about 2-fold higher in females than in males (732.3 vs. 338.8/100,000, P0.05). The incidence of newly diagnosed AIS cases with radiographs showing a Cobb angle10 degrees was 181.7 (95% CI: 167.5, 196.0) per 100,000 person-years. The overall incidence of AIS decreased significantly after discontinuation of school screening in 2004 (P0.001). The incidence of bracing and surgery at initial diagnosis was 16.6 (95% CI: 12.3, 20.9) and 2.0 (95% CI: 0.5, 3.4) per 100,000 person-years, respectively.Overall population-based incidence of AIS decreased after school screening was discontinued. However, incidence of patients with a Cobb angle10 degrees, initiation of bracing and surgery did not change significantly over time. This provides further data to help determine the role of scoliosis screening.Level III.

Purpose The aim of this study is to review the management of all paediatric humerus diaphyseal fractures treated at a single institution over a 20-year period. Methods Retrospective review from between 1996 and 2016 identified 96 humerus shaft fractures in paediatric patients (0 to 17 years). After excluding those deceased from inciting trauma, pathological and perinatal fractures, 80 patients remained for analysis. Data collected included age, fracture type, displacement, nerve palsy, treatment, complications and time to union. Radiographs were reviewed at the time of injury and at latest follow-up. Results Of 80 paediatric humeral diaphyseal fractures, 65 (81%) were treated with immobilization. In all, 15 (19%) fractures were treated with surgical stabilization. Most common indications were fracture displacement, open fractures and to improve mobilization in patients with multiple injuries. Fractures were stabilized with a plate (eight), flexible nails (five), external fixation (one) and percutaneous pinning (one). The operative group, compared with the nonoperative group, was older, had more high-energy mechanisms, more open fractures and increased fracture displacement. All patients in the nonoperative and operative groups went on to union with minimal complications. A nerve palsy was present in five patients (6%)with three of the five involving the radial nerve (4%). All nerve palsies were observed and had full neurological recovery. Conclusion Over a 20-year period nonoperative management of paediatric humerus shaft fractures was successful in the majority of patients. Operative stabilization, when rarely indicated, had a low complication rate and improved radiographic alignment. All nerve injuries fully recovered without surgical intervention. Level of evidence IV

Background Obesity as a cause of lower extremity deformity in children has been well established. This deformity is most often seen as tibia vara, however, at our institution we have observed more obese children and adolescents over age 7 years with excessive or progressive idiopathic genu valgum. Our hypothesis is that children with idiopathic genu valgum have high rates of obesity which impact the severity of their disease. Methods Retrospective review of existing data was performed on 66 consecutive children/112 limbs over age 7 years with idiopathic genu valgum, seen from 2010 to 2013. Children with known metabolic or skeletal disease were excluded. Genu valgum was defined as mechanical axis in zone II or III and mechanical tibiofemoral angle ≥4 degrees on standing anteroposterior radiograph of the lower extremities. Body mass index (BMI) was calculated and classified by Center for Disease Control percentiles. Skeletal maturation was rated by closure of pelvic and peri-genu physes. Severity of genu valgum was also assessed by femoral and tibial mechanical axes and the mechanical axis deviation. Results Mean patient age was 12.2±2.2 years. 47% of patients had BMI≥30 and 71% were categorized as obese (>95th percentile). No sex differences were identified. Skeletal maturation explained 25% of the variance in the mechanical axis deviation and 22% of the mechanical tibiofemoral angle. BMI predicted 9.8% of the tibial valgus. Because of its skewed distribution, BMI percentile was a less useful parameter for assessment. Conclusions The 71% obesity rate found in our children with idiopathic genu valgum is significantly higher than the normal population. Higher BMI is associated with more tibial valgum but skeletal maturation was the main predictor of overall valgus severity. This suggests that obesity may play a role in the etiology of idiopathic genu valgum which progresses with skeletal maturation, thereby increasing the risk of osteoarthritis in adulthood. Level of evidence Level III.

Purpose Placement of pedicle screws can be performed using freehand/fluoroscopic technique or intraoperative computed tomography (CT)–guided navigation. We sought to compare screw malposition and return to operating room (OR) for pedicle screw malposition for screws placed with and without CT-guided navigation. Methods This study was a single-center retrospective comparative study. All patients younger than 18 years with minimum two-year follow-up who underwent pedicle screw instrumentation between 2009 and 2015 were included. Institutional review board approval was obtained and patient charts were reviewed for patient demographics and surgical outcomes. If available, incidental CTs following the index surgery were reviewed to assess screw position. Results A total of 217 patients underwent spinal instrumentation. Overall, 112 patients had pedicle screws placed using fluoroscopic guidance, whereas 105 patients had screws placed using low-dose intraoperative CT-guided navigation (O-arm; Medtronics). Of the total cohort, 107 (49.3%) patients had adolescent idiopathic scoliosis, and the remainder had neuromuscular, tumor, congenital, or other diagnoses. Patients in each group had a similar number of levels fused (fluoroscopic = 10.9 vs. CT navigation = 9.8, p = .06). There was no difference in total estimated blood loss (1,127 vs. 1,179 mL, p = .63) or in blood loss per level fused (133.7 vs. 146.6 mL, p = .47). Patients with screws placed using fluoroscopic guidance had a shorter total operative time (441 vs. 468 minutes, p = .04); however, there was no difference when controlling for number of levels fused (58.3 vs. 61.5 minutes/level, p = .63). Postoperative CTs were available in 51 patients representing 526 imaged screws, which showed a significantly higher rate of severely malpositioned (>4 mm) screws in the fluoroscopic group than the CT navigation group (3.3% vs. 1.0%, p = .027). There was a 3.6% rate of return to OR for pedicle screw malposition in the freehand/fluoroscopic group compared with 0% in the CT-guided navigation group (p = .048). Including patients with less than two-year follow-up (169 fluoroscopy, 220 CT guidance) also found higher rates of screw malposition (13.5% vs. 7.1%, p = .004), severe screw malposition (3.0% vs. 0.50%, p = .04), and return to OR due to screw malposition (2.4% vs. 0%, p = .02) in patients with screws placed using fluoroscopic guidance. Conclusion Patients with pedicle screws placed with CT-guided navigation had a lower rate of severely malpositioned screws and unplanned returns to the OR. There was no significant difference in blood loss or operative time when controlling for number of levels fused. Significance In the era of health care “never-events,” return to OR for screw malposition could certainly be deemed unacceptable. Use of intraoperative CT-guided navigation thus far eliminated return to OR for screw malposition in a complex cohort of pediatric spinal deformity patients, without measurable increase in operative time or blood loss.

BACKGROUND Dysplasia of the cruciate ligaments has been found in many patients with congenital fibular deficiency. A recent classification system has shown that radiographic tibial spine changes can predict the hypoplasia and aplasia of the cruciate ligaments. We used this radiographic classification to determine the frequency of these abnormalities and how they correlate with the severity of fibular deficiency and lateral femoral condylar hypoplasia. METHODS Using a hospital database search for fibular deficiency, 99 patients ≥6 years with unilateral fibular deficiency were identified. Existing radiographs of both knees were available for 75 patients and reviewed for the tibial spine changes and Achterman and Kalamchi classification of the fibular deficiency. Measurements of femoral condyle heights in 74 of 75 patients were recorded before any surgery to the distal femoral physis to assess lateral femoral condylar hypoplasia. RESULTS Twenty-two patients had hypoplasia of the lateral tibial spine+normal medial spine, 29 had absence of the lateral tibial spine+hypoplastic medial spine, and 11 had absence of both tibial spines. Five tibial spines were normal and 8 were unclassifiable. The severity of the tibial spine dysplasia, particularly absence of the lateral tibial spine, correlated with the severity of the fibular deficiency. (P

Anterior vertebral body tether (AVBT) is a nonfusion surgical procedure for correction of scoliosis in skeletally immature individuals. With US Food and Drug Administration approval in 2019, AVBT technology is spreading and early to midterm reports are being published. Early clinical reports are promising while precise indications, outcomes, complication profiles, and best practices are being established. Patients who are skeletally immature and wish to avoid a fusion surgery may benefit from this procedure. This article highlights the translational science foundation, early to midterm clinical reports, and future directions for this growing technique in pediatric spinal deformity surgery.

Vertebral body tethering is increasingly being performed, yet postoperative pain management has not yet been optimized. We sought to determine whether the addition of a thoracic paravertebral block in addition to a standard multimodal postoperative pain management program could provide greater pain relief, reduced analgesic requirement, and reduced length of stay.Patients who underwent VBT at a single tertiary referral center were retrospectively reviewed. All patients received a single-shot intrathecal (IT) injection at the completion of the procedure in addition to a standardized multimodal pain management program. 45 patients received a thoracic paravertebral catheter with lidocaine infusion (TPVB) which was left in place for 4-6 days, whereas 24 control patients did not have a TPVB. Length of stay, maximum postoperative Numeric Pain Intensity Scale (NPIS), and total dose of opioids, ibuprofen, ketorolac and acetaminophen administered during hospitalization were evaluated.69 patients met inclusion criteria. The mean cumulative dose of opioids administered during hospitalization was 148 oral morphine milligram equivalent (MME) in the control group vs. 47 MME in the TPVB group (p 0.0001). Severe postoperative NPIS of ≥ 7 was reported in 9 out of the 24 control patients (38%) and in 13 out of the 45 patients (29%) who received a TPVB in addition to the standardized care (p = 0.46). There was no significant difference in the mean cumulative dose of NSAIDs (ibuprofen, ketorolac) consumed by the control group compared to the TPVB group (2632 mg vs. 1630 mg, p = 0.77). Mean length of stay in the control group was 3.8 vs. 3.0 days in the TPVB group (p 0.001). There were no major complications associated with use of the TPVB.In this series compared to controls, patients treated with a TPVB had reduced postoperative requirement of opioids and decreased length of hospital stay.

Pediatric orthopedic surgeons must accurately assess the skeletal stage of adolescent idiopathic scoliosis (AIS) patients for selection and timing of optimal treatment. Successful treatment using vertebral growth modulation is highly dependent on skeletal growth remaining. We sought to evaluate the current-state use of the Sanders Skeletal Maturity System (SSMS) in regard to precision and accuracy. We hypothesized that pediatric orthopedic surgeons currently use SSMS with moderate precision and accuracy.Eight practicing pediatric orthopedic surgeons who perform vertebral body tethering surgery without specific training in SSMS were asked to assign the SSMS stage for 34 de-identified hand radiographs from AIS patients. Precision was evaluated as inter-rater reliability, using both Krippendorff's α and Weighted Cohen's kappa statistics, and as intra-rater reliability, using only Weighted Cohen's kappa statistics. Surgeon accuracy was evaluated using Weighted Cohen's kappa statistics with comparison of surveyed surgeons' responses to the gold standard rating.Inter-rater reliability across the surveyed surgeons indicated moderate to substantial agreement using both statistical methods (α = 0.766, κ = 0.627) with the majority of discord occurring when assigning SSMS stages 2 through 4. The surveyed surgeons displayed substantial accuracy when compared to the gold standard (κ = 0.627) with the majority of inaccuracy involving the identification of stage 3B. When re-surveyed, the surgeons showed substantial intra-rater reliability (κ = 0.71) with increased inconsistencies when deciding between SSMS stage 3A and stage 3B.The current-state use of SSMS across pediatric orthopedic surgeons for evaluation of AIS patients displays adequate but imperfect precision and accuracy with difficulties delineating SSMS stages 2 through 4, which correlate with adolescent growth periods germane to scoliosis growth modulation surgery. Centralized assessment of hand-bone age may help ensure standardized reporting for non-fusion scoliosis research.

Background: When operative treatment is indicated, tibial spine fractures can be successfully managed with open or arthroscopic reduction and internal fixation. Hypothesis/Purpose: We hypothesized both approaches can lead to satisfactory outcomes for fracture healing, but that open treatment without preoperative advanced imaging can potentially lead to missed concomitant injuries. Methods: We performed an Institutional Review Board (IRB)-approved retrospective cohort study of pediatric tibial spine fractures presenting between January 1, 2000 and January 31, 2019 at 10 institutions. Patients were categorized into two cohorts based on treatment: arthroscopic reduction and internal fixation (ARIF) and open reduction and internal fixation (ORIF). Surgical outcomes, the incidence of concomitant injuries, and surgeon demographics were compared between groups. Results: There were 477 patients with tibial spine fractures who met inclusion criteria, 420 of whom (88.1%) were treated with ARIF, while 57 (11.9%) were treated with ORIF. Patients treated with ARIF were more likely to have an identified concomitant injury (41.4%) compared to those treated with ORIF (24.6%, p=0.021). Patients treated with ARIF were also more likely to have pre-treatment MRI (41.7% vs. 22.8%, p =0.010). Most concomitant injuries (74.5%) required surgical intervention. The most common treatment complications included arthrofibrosis (6.9% in ARIF patients, 7.0% in ORIF patients, p=1.00) and subsequent ACL injury (2.1% in ARIF patients and 3.5% in ORIF, p=0.86). The rate of complications, return to the operating room, and failure to return to full range of motion were similar between groups. Twenty surgeons with sports subspecialty training completed 85.0% of ARIF cases; the remaining 15.0% were performed by 12 surgeons without additional sports training. The majority (56.1%) of ORIF cases were completed by 14 surgeons without sports subspecialty training. Conclusion: This is the largest study comparing ARIF to ORIF in pediatric tibial spine fractures. This study demonstrated no difference in outcomes or nonunion following ARIF or ORIF for pediatric tibial spine fractures. There were significantly higher rates of concomitant injuries in patients treated with ARIF, however, these patients also had a higher rate of pre-treatment MRI. The majority of these concomitant injuries (74.5%) required surgical intervention. Pre-treatment MRI should be considered in the workup of tibial spine fractures to increase identification of concomitant injury. Concomitant injuries may be missed in tibial spine fractures treated with an open approach, especially in cases where preoperative advanced imaging is not obtained. Surgeon preference and training may impact treatment approach and identification and treatment of concomitant injury.