Publications by authors named "Lindsay M Andras"

75 Publications

What's New in Pain Management for Pediatric Orthopaedic Surgery.

J Pediatr Orthop 2021 Aug 31. Epub 2021 Aug 31.

Division of Orthopedic Surgery, Children's Hospital of Philadelphia Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA Children's Orthopaedic Center, Children's Hospital Los Angeles Keck School of Medicine of USC, Los Angelos, CA Department of Surgery and Perioperative Care, Dell Medical School, University of Texas, Austin, TX Division of Orthopedics, Rady Children's Hospital, San Diego, CA.

Background: Improving pain control and decreasing opioid prescription and usage continue to be emphasized across both pediatric and adult populations. The purpose of this review is to provide a comprehensive assessment of recent literature and highlight new advancements pertaining to pain control in pediatric orthopaedic surgery.

Methods: An electronic search of the PubMed database was performed for keywords relating to perioperative pain management of pediatric orthopaedic surgery. Search results were filtered by publication date for articles published between January 1, 2015 and December 1, 2020 and yielded 404 papers.

Results: A total of 32 papers were selected for review based upon new findings and significant contributions in the following categories: risk factors for increased opioid usage, opioid overprescribing and disposal, nonpharmacologic interventions, nonsteroidal anti-inflammatory drugs, peripheral nerve blocks, spine surgery specific considerations, surgical pathway modifications, and future directions.

Conclusions: There have been many advances in pain management for pediatric patients following orthopaedic surgery. Rapid recovery surgical care pathways are associated with shorter length of stay and improved pain control in pediatric spine surgery. Opioid overprescribing continues to be common and information regarding safe opioid disposal practices should be routinely provided for pediatric patients undergoing surgery.

Level Of Evidence: Level IV-literature review.
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http://dx.doi.org/10.1097/BPO.0000000000001956DOI Listing
August 2021

How low can you go? Implant density in posterior spinal fusion converted from growing constructs for early onset scoliosis.

Spine Deform 2021 Sep 6;9(5):1479-1488. Epub 2021 Jul 6.

Children's Orthopaedic Center, Children's Hospital Los Angeles, 4650 Sunset Blvd, MS#69, Los Angeles, CA, 90027, USA.

Study Design: Retrospective, multicenter comparative.

Objectives: Our purpose was to compare early onset scoliosis (EOS) patients treated with ultra-low, low, and high implant density constructs when undergoing conversion to definitive fusion. Larson et al. demonstrated that implant density (ID) at fusion does not correlate with outcomes in the treatment of adolescent idiopathic scoliosis, but did not address growth-friendly graduates.

Methods: EOS patients treated with growth-friendly constructs converted to fusion between 2000 and 2017 were reviewed from a multicenter database. ID was defined as number of pedicle screws, hooks, and sublaminar/bands per level fused. Patients were divided into ultra-low ID (< 1.3), low (≥ 1.3 and < 1.6), and high ID (≥ 1.6).

Exclusion Criteria:  < 2 years follow-up from fusion or inadequate radiographs.

Results: A total of 152 patients met inclusion criteria with 39 (26%) patients in the high ID group, 33 (22%) patients in the low ID group, and 80 (52%) in the ultra-low ID group. Groups were similar in operative time (p = 0.61), pre-fusion major curve (p = 0.71), mean number of levels fused (p = 0.58), clinical follow-up (p = 0.30), and radiographic follow-up (p = 0.90). Patients in the low ID group (11.6 ± 1.5 years) were slightly younger at the time of definitive fusion than patients in the ultra-low ID group (12.9 ± 2.2 years) and high ID group (12.5 ± 1.7 years) (p = 0.009). There was significantly more blood loss in the high ID group than the other two groups (high ID: 946.8 ± 606.0 mL vs. low ID: 733.9 ± 434.5 mL and ultra-low ID: 617.4 ± 517.2 mL; p = 0.01), but there was no significant difference with regard to percent of total blood volume lost (high ID: 59.3 ± 48.7% vs. low ID: 54.5 ± 37.5% vs. ultra-low ID: 51.7 ± 54.9%; p = 0.78). There was a difference in initial improvement in major curve between the groups (high ID: 21.6° vs. low ID: 18.0° vs. ultra-low ID: 12.6°; p = 0.01). However, during post-fusion follow-up, correction decreased 7.1° in the high ID group, 2.6 in the low ID group, and 2.8 in the ultra-low ID group (p = 0.19). At final follow-up, major curve correction from pre-fusion was similar between groups (high ID: 14.5° vs. low ID: 15.5° vs. ultra-low ID: 9.7°, p = 0.14). At final follow-up, there was no difference in T1-T12 length gain (p = 0.85), T1-S1 length gain (p = 0.68), coronal balance (p = 0.56), or sagittal balance (p = 0.71). The revision rate was significantly higher in the ultra-low ID group (13.8%; 11/80) versus the high ID group (2/39; 5.1%) and low ID group (0/33; 0%) (p = 0.04).

Conclusions: Although an ID < 1.3 in growth-friendly graduates produces similar outcomes with regard to curve correction and spinal length gain as low and high ID, this study suggests that an ID < 1.3 is associated with an increased revision rate.

Level Of Evidence: III.
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http://dx.doi.org/10.1007/s43390-021-00321-7DOI Listing
September 2021

Prospective Study on Tension Band Plating: Most Patients are Not Returning to Normal Activities 1 Month Following Surgery.

J Pediatr Orthop 2021 Jul;41(6):e417-e421

Children's Orthopaedic Center, Children's Hospital Los Angeles, Los Angeles, CA.

Background: Tension band plating for temporary hemiepiphysiodesis has been reported by several authors as simple and effective for treating angular deformities of the lower limb. Anecdotally, patients have reported higher pain levels than expected given the small size of incision and relatively minimal amount of dissection, and we sought to investigate this further.

Methods: Patients 16 years old or less with lower extremity angular deformities or limb length inequality were prospectively enrolled before tension band plating from 2 pediatric institutions from July 2016 to December 2018. Participants completed postoperative questionnaires regarding their pain and activity level. Pain was assessed using the FACES Pain Scale. Patients were included if they completed the 1 month survey.

Results: Of the 48 patients that met inclusion criteria (mean age at surgery: 13.1 y; range: 7 to 16 y), 39 patients completed the survey at 3 months postoperatively. There was a significant change in pain level between 1 week and 1 month postoperatively (P<0.001). Eighty-three percent (34/41) of patients were still taking pain medication at 1 week, which decreased to 38% (18/48) at 1 month. At 3 months, 21% (8/39) patients reported they were still using pain medication. At 1 month, 65% of patients (31/48) had not returned to their prior activity level. Of the 39 patients who played sports, 59% (23/39) still had not fully returned to sports at 1 month.

Conclusion: At 1 month following tension band plating, 65% of patients had not returned to their preoperative activity level, and 38% were taking pain medications. Although the tension band plate and surgical incision is small in size, patients and parents should be counseled that there are significant activity limitations and pain levels for a month or longer in many patients.

Level Of Evidence: Level II.
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http://dx.doi.org/10.1097/BPO.0000000000001781DOI Listing
July 2021

Improved Bowel Function With Oral Methylnaltrexone Following Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis.

J Pediatr Orthop 2021 May 18. Epub 2021 May 18.

Children's Orthopaedic Center Division of Pain Medicine, Children's Hospital Los Angeles, Los Angeles, CA.

Background: Methylnaltrexone, a peripheral opioid antagonist, is used to decrease opioid-induced constipation; however, there is limited evidence for its use in children. The primary objective of the study is to assess the efficacy of per os (PO) methylnaltrexone in inducing bowel movements (BMs) in patients with adolescent idiopathic scoliosis who underwent a posterior spinal fusion and instrumentation (PSFI). Secondary outcomes include hospital length of stay, postoperative pain scores, and postoperative opioid usage.

Methods: Retrospective chart review identified all adolescent idiopathic scoliosis patients above 10 years of age who underwent PSFI with a minimum of 24 hours of postoperative opioid analgesia after the initiation of the new bowel regimen protocol. The bowel regimen included daily administration of PO methylnaltrexone starting on postoperative day 1 until BM is achieved. A case-matched cohort was obtained with patients who did not receive PO methylnaltrexone and otherwise had the same bowel function regimen. Case-matched controls were also matched for age, sex, body mass index, and curve severity. t Tests and Pearson χ2 tests were used for statistical analysis.

Results: Fifty-two patients received oral methylnaltrexone (14±2.6 y) and 52 patients were included in the case-matched control group (14±2.1 y). The methylnaltrexone group had a significantly shorter hospital length of stay (3.09±0.66) compared with controls (3.69±0.80) (P<0.01). 59% (31 of 52) of the methylnaltrexone group had a BM by postoperative day postoperative day 2, compared with 30% (16 of 52) of the control group (P<0.01). In the methylnaltrexone group, 44% (23 of 52) of the patients required a Dulcolax (bisacodyl) suppository and 11% (6 of 52) required an enema, compared with 50% (26 of 52) and 33% (12 of 52) of the control group respectively (P=0.43 and 0.12). In addition, significantly less patients had abdominal distension during their postoperative stay in the methylnaltrexone group (17%, 9 of 52) compared with the control group (40%, 21 of 52) (P<0.01). There was no significant difference in self-reported average FACES pain score (P=0.39) or in opioid morphine equivalents required per hour (P=0.18).

Conclusions: Patients who received PO methylnaltrexone after PSFI had decreased length of stay and improved bowel function. Administration of methylnaltrexone did not increase maximum self-reported FACES pain values or opioid consumption compared with controls. The use of oral methylnaltrexone after PSFI reduces postoperative constipation, which has implications for reducing hospital length of stay and overall morbidity.

Level Of Evidence: Level III-retrospective comparative study.
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http://dx.doi.org/10.1097/BPO.0000000000001854DOI Listing
May 2021

Power versus manual pedicle tract preparation: a multi-center study of early adopters.

Spine Deform 2021 Sep 23;9(5):1395-1402. Epub 2021 Apr 23.

Children's Orthopaedic Center, Children's Hospital Los Angeles, Los Angeles, CA, USA.

Study Design: Retrospective cohort, multicenter. A single surgeon study demonstrated that pedicle tract preparation with power tools was associated with lower fluoroscopy times and revision rates compared to manual tools, while maintaining patient safety.

Objective: Our purpose was to determine the safety of power-assisted pedicle tract preparation by early adopters of this technology.

Methods: Retrospective review comparing patients that underwent posterior spinal fusion by seven pediatric spine surgeons at six institutions between January 1, 2008 and August 31, 2019. The manual pedicle tract preparation used a pedicle awl. Power tract preparation used a flexible 2.0-2.4 mm drill bit, followed by a larger drill bit or a reamer. All screws were inserted with power technique.

Results: In the manual tract preparation group, 9424 screws were placed in 585 cases. In the power tract preparation group, 22,209 screws were placed in 1367 cases. Seven patients (7/1952; 0.36%; 95% CI: 0.14-0.74%) had 11 mal-positioned screws (11/31,633; 0.03%; 95% CI: 0.017-0.062%). Seven screws (7/9424; 0.07%; 95% CI: 0.030-0.15%) were in the manual cohort and four (4/22,209; 0.02%; 95% CI: 0.0049-0.046%) were in the power cohort. There were significantly more revisions per screw in the manual cohort (p = 0.02). However, there were not significantly more revisions per patient in the manual cohort (manual: 0.5%, 3/585 vs. power: 0.3%, 4/1,367; p = 0.43). Of these seven, three patients (3/585; 0.5%; 95% CI: 0.1-1.5%) experienced neurologic injury or neuro-monitoring changes requiring screw removal in the manual cohort, and 1 patient (1/1,367, 0.07%; 95% CI: 0.002-0.4%) in the power cohort (p = 0.08). Three additional patients underwent revision in the power cohort: 1 for an asymptomatic lateral breech, 1 for a spinal headache/medial breech that developed after an MVA, and 1 for an iliac vein injury during pedicle tract preparation.

Conclusion: This is the first multi-center study examining power pedicle preparation. Overall, 99.9% of pedicle screws placed with power pedicle preparation did not have complications or revision. Equivalent patient safety was demonstrated compared to manual technique.

Level Of Evidence: III.
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http://dx.doi.org/10.1007/s43390-021-00347-xDOI Listing
September 2021

Surgical Site Infection Following Neuromuscular Posterior Spinal Fusion Fell 72% After Adopting the 2013 Best Practice Guidelines.

Spine (Phila Pa 1976) 2021 Sep;46(17):1147-1153

Children's Orthopaedic Center, Children's Hospital Los Angeles, Los Angeles, CA.

Study Design: Retrospective cohort study.

Objective: The purpose of this study is to investigate the incidence of surgical site infection in neuromuscular scoliosis (NMS) patients at a tertiary children's hospital before and after the implementation of strategies mentioned in the 2013 Best Practice Guideline.

Summary Of Background Data: Patients with NMS are at high risk for surgical site infection following spine surgery. In 2013, a Best Practice Guideline for surgical site infection prevention in high-risk pediatric spine surgery patients reported strategies to decrease incidence. To date, no studies have looked at the efficacy of these strategies.

Methods: A retrospective review of surgical site infection in NMS patients was performed. NMS patients undergoing primary posterior spinal fusion from January 2008 to December 2012 (Group 1) and January 2014 to December 2018 (Group 2) were included, with 2013 excluded as a transition year. The primary outcome was incidence of surgical site infection within 1 year of surgery, as defined by the Centers for Disease Control and National Healthcare Safety Network. All patients had at least 1 year of documented follow-up.

Results: One hundred ninety eight patients were included, 62 in Group 1 and 136 in Group 2. Age, BMI, sex, fusion to pelvis, preoperative Cobb angle, incontinence, drain use, blood loss, surgical time, and other perioperative values were similar (P > 0.05). Deep surgical site infection occurred in 10 (16.1%) patients in Group 1 and six (4.4%) patients in Group 2 (P = 0.005). Thirteen (59.1%) identified organisms were gram-negative, with 11 (84.6%) isolated from Group 1 (P = 0.047). Polymicrobial infections accounted for six (37.5%) infections overall.

Conclusion: The incidence of surgical site infection in NMS patients decreased significantly (16.1% vs. 4.4%) after the implementation of the strategies mentioned in the 2013 Best Practice Guideline. Further studies are required to continue to decrease the incidence in this high-risk population.Level of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000004050DOI Listing
September 2021

C1-C2 Distraction Ligamentous Injury Treated with Halo-Vest Application: A Case Report.

JBJS Case Connect 2021 03 17;11(1). Epub 2021 Mar 17.

Children's Orthopaedic Center, Children's Hospital Los Angeles, Los Angeles, California.

Case: There is a paucity of literature regarding pediatric upper cervical spine traumatic instability, atlanto-occipital dislocations, and fractures, with no clear treatment algorithm. We present a 12-year-old girl with significant posterior C1-C2 distraction and resultant ligamentous injury after a motor vehicle collision who was treated with a halo vest for 3 months. At 8-month follow-up, follow-up magnetic resonance imaging demonstrated complete ligamentous healing without instability on dynamic radiographs, and at 18-month follow-up, the patient made a full recovery.

Conclusion: In some pediatric patients with isolated posterior ligamentous injury, as long as anatomic alignment can be achieved with halo-vest application, a fusion may be avoided.
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http://dx.doi.org/10.2106/JBJS.CC.20.00456DOI Listing
March 2021

Pain for Greater Than 4 Days Is Highly Predictive of Concomitant Osteomyelitis in Children With Septic Arthritis.

J Pediatr Orthop 2021 Apr;41(4):255-259

Children's Orthopedic Center, Children's Hospital Los Angeles.

Background: There is no evidence-based consensus on the risk factors for concomitant osteomyelitis and septic arthritis. The purpose of this study was to investigate clinical parameters predictive of concomitant osteomyelitis in children with septic arthritis.

Methods: A retrospective review was conducted on patients with septic arthritis with magnetic resonance imaging (MRI) between January 2004 and October 2016 at a tertiary care pediatric hospital. Medical charts were reviewed for information including symptoms, diagnosis of osteomyelitis, serum laboratory studies, joint fluid analyses, imaging results, and treatment. Positive diagnosis of osteomyelitis was defined as a hyperintense signal of osseous structures on T2-weighted MRI consistent with infection per attending pediatric radiologist final read.

Results: A total of 71 patients with 73 septic joints were included. The mean age was 6±4 (0.1 to 17) years and the mean follow-up was 14.9±24.1 (1.0 to 133.1) months. Septic arthritis with concomitant osteomyelitis occurred in 43 of 71 (61%) patients, whereas 28 of 71 (39%) patients had septic arthritis alone. Inflammatory markers such as white blood cell count, erythrocyte sedimentation rate, and C-reactive protein on admission were not associated with concomitant osteomyelitis. Multivariate logistic regression revealed that positive joint fluid bacterial culture (P=0.021) and pain for >4 days before admission (P=0.004) are independent risk factors for concomitant osteomyelitis in children with septic arthritis. Among the 24 septic arthritis patients with pain for >4 days before presentation, 96% (23/24) had concomitant osteomyelitis, whereas 43% (20/47) of patients with pain for ≤4 days had concomitant osteomyelitis.

Conclusion: Pain for >4 days before presentation is an independent predictor of osteomyelitis in children with septic arthritis. In pediatric septic arthritis, MRI should be considered, particularly in patients presenting with pain for >4 days as 96% of these patients had concomitant osteomyelitis.

Level Of Evidence: Level III-retrospective comparative study.
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http://dx.doi.org/10.1097/BPO.0000000000001771DOI Listing
April 2021

What's New in Pediatric Orthopaedics.

J Bone Joint Surg Am 2021 02;103(4):287-294

Children's Hospital of Los Angeles, Los Angeles, California.

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http://dx.doi.org/10.2106/JBJS.20.01953DOI Listing
February 2021

Using a dedicated spine radiology technologist is associated with reduced fluoroscopy time, radiation dose, and surgical time in pediatric spinal deformity surgery.

Spine Deform 2021 Jan 11;9(1):85-89. Epub 2020 Aug 11.

Keck School of Medicine at University of Southern California, Los Angeles, CA, USA.

Study Design: Retrospective comparative study OBJECTIVES: The goal of this study was to investigate fluoroscopy time and radiation exposure during pediatric spine surgery using a dedicated radiology technologist with extensive experience in spine operating rooms. Repetitive use of intraoperative fluoroscopy during posterior spinal fusion (PSF) exposes the patient, surgeon, and staff to radiation.

Methods: Retrospective review was conducted on patients with posterior spinal fusion (PSF) of ≥ 7 levels for adolescent idiopathic scoliosis (AIS) at a pediatric hospital from 2015 to 2019. Cases covered by the dedicated radiology technologist (dedicated group) were compared to all other cases (non-dedicated group). Surgical and radiologic variables were compared between groups.

Results: 230 patients were included. 112/230 (49%) were in the dedicated group and 118/230 (51%) were in the non-dedicated group. Total fluoroscopy time was significantly reduced in cases with the dedicated technologist (46 s) compared to those without (69 s) (p = 0.001). Radiation dose area product (DAP) and air kerma (AK) were reduced by 43% (p < 0.001) and 42% (p < 0.001) in the dedicated group, respectively. The dedicated group also had reduced total surgical time (4.1 vs. 3.5 h; p < 0.001) and estimated blood loss (447 vs. 378 cc (; p = 0.02). Multivariate regression revealed that using a dedicated radiology technologist was independently associated with decreased fluoroscopy time (p = 0.001), DAP (p < 0.001), AK (p < 0.001), surgical time (p < 0.001), and EBL (p = 0.02).

Conclusions: In AIS patients undergoing PSF, using a dedicated radiology technologist was independently associated with significant reductions in fluoroscopy time, radiation exposure, surgical time, and EBL. This adds to the growing body of research demonstrating that the experience level of the team-not just that of the surgeon-is necessary for optimal outcomes.

Level Of Evidence: III.
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http://dx.doi.org/10.1007/s43390-020-00183-5DOI Listing
January 2021

Standing in Schroth trained position significantly changes Cobb angle and leg length discrepancy: a pilot study.

Spine Deform 2020 Dec 26;8(6):1185-1192. Epub 2020 Jun 26.

Children's Orthopedic Center, Children's Hospital Los Angeles, 4650 Sunset Blvd, MS#69, Los Angeles, CA, 90027, USA.

Study Design: Retrospective.

Objective: The aim of this study is to evaluate if standing in a Schroth trained position influences the radiographic assessment of Cobb angle and other radiographic parameters compared to a normal standing position. Schroth method has been associated with improved Cobb angle. This study aims to evaluate if standing in the Schroth trained position influences radiographic assessment of Cobb angle compared to a normal standing position.

Methods: This is a retrospective review of patients with adolescent idiopathic scoliosis (AIS) who were participating in Schroth therapy at the time of radiographs. Ten pairs of radiographs were included in this study. Each pair consisted of two micro-dose biplanar PA thoracolumbar spine radiographs obtained on the same day, one with the patient standing in the Schroth trained position and one in their normal standing position. Each pair of radiographs was independently evaluated by three attending pediatric spine surgeons for Cobb angle, coronal balance, shoulder balance, and leg length discrepancy, for a total of 30 paired readings (3 readings for each of the 10 pairs of radiographs).

Results: Major Cobb angle was a mean of 6° less (p = 0.02) and the compensatory curve was 5° less (p = 0.03) in the Schroth trained position compared to their normal standing position. Neither coronal balance (p = 0.40) nor shoulder balance (p = 0.16) was significantly different. Mean leg length discrepancy was 6.8 mm greater in the Schroth trained versus normal position (p < 0.001).

Conclusion: Standing in a Schroth trained position for a PA spine radiograph was associated with a mean change in major Cobb angle of 6° compared to a normal standing position. If bracing was recommended for curves > 25° and surgery for curves > 45°, different treatment recommendations would have been made in 33% (10/30) of attendings' readings for the Schroth versus normally paired radiographs taken on the same day on the same patient. Studies evaluating the effect of Schroth therapy on Cobb angle must report if patients are standing in a normal or Schroth trained position during radiographs for conclusions to be valid, or differences may be due to a temporary, voluntary change in posture.

Level Of Evidence: III.
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http://dx.doi.org/10.1007/s43390-020-00157-7DOI Listing
December 2020

Pre-operative methicillin resistant Staphylococcus aureus results do not predict surgical site infections in children undergoing varus derotational osteotomy.

Medicine (Baltimore) 2020 Jun;99(26):e20517

Keck School of Medicine, University of Southern California.

Literature regarding the value of pre-operative nasal methicillin resistant Staphylococcus aureus (MRSA) swabs to predict surgical site infections (SSIs) in children undergoing lower extremity surgery is limited. The purpose of our study was to determine if pre-operative nasal MRSA swab results were predictive of SSI development in children undergoing a femoral varus derotational osteotomy (VDRO).Patients who underwent VDRO between 2004-2016 were reviewed to determine pre-operative MRSA colonization rates and SSI devolvement rates. Patients with less than 1 year of follow-up, previous history of infections, or absent pre-operative MRSA swab were excluded. SSI rates of patients with negative MRSA and positive MRSA swab result were compared using the Fisher exact test. Aside from contact isolation precautions, no other changes in treatment were made during inpatient hospital course based on positive pre-operative nasal MRSA swab results.247 patients met the inclusion criteria (mean age: 9.3 ± 3.6 years, 62% male). There were 242 (98%) patients with a negative MRSA swab and 5 (2%) patients with a positive MRSA swab. Out of the 242 patients with a negative MRSA swab, 4 developed an SSI. Of the patients with positive MRSA swab results, 0% (0/5) developed an SSI compared to 1.7% (4/242) of negative MRSA swab results who developed an SSI. Results indicated no significant difference in SSI development rates between the groups (P = 1.00).In this series of children undergoing VDRO surgery, the results of a pre-operative MRSA nasal swab had no relationship to SSI incidence and no impact on clinical patient care. Pre-operative MRSA nasal swabs appear to be of limited benefit for routine pre-operative screening in this patient population.Level III, retrospective comparative.
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http://dx.doi.org/10.1097/MD.0000000000020517DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7329002PMC
June 2020

Operative fixation of medial epicondyle fractures: complication rates based on mode of fixation.

Medicine (Baltimore) 2020 05;99(21):e20015

Elite Sports Medicine, Connecticut Children's Medical Center, CT.

The purpose of this study is to define the rate of implant failure and risk factors for failure in patients treated operatively for displaced medial epicondyle fractures.Patients <18 years of age with medial epicondyle humerus fractures that were treated with screw or k-wire fixation between 2005 and 2015 were eligible. Inclusion criteria included follow-up until radiographic union and no known medical conditions that could impair healing.Thirty four patients with 35 fractures were identified with an average age of 12 years old. 11.4% (n = 4/35) of fractures were treated using K-wires, 25.7% (n = 9/35) were treated using a screw and washer construction, and 62.9% (n = 22/35) were treated using screw alone. There were 16 reported complications (46%) including implant prominence requiring reoperation (6), implant failure (1), and fracture displacement (1). Other complications included non-union/delayed union (4), new ulnar nerve palsy (2), and decreased range of motion (2). Rates of complications were not different between the types of fixation (P = 1.0). Those who developed complications were younger than those who did not (P = 0.05). 91.4% of patients returned to full activity including weight bearing and throwing sports.Although 25% of patients experienced implant complications and the overall complication rate approached 50%, nearly all reported return to full activity.
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http://dx.doi.org/10.1097/MD.0000000000020015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7249945PMC
May 2020

40% reoperation rate in adolescents with spondylolisthesis.

Spine Deform 2020 10 6;8(5):1059-1067. Epub 2020 May 6.

Children's Orthopaedic Center, Children's Hospital Los Angeles, 4650 Sunset Blvd, Mailstop #69, Los Angeles, CA, 90027, USA.

Study Design: Multicenter retrospective.

Objective: To determine the long-term complication rate associated with surgical treatment of spondylolisthesis in adolescents. There is limited information on the complication rate associated with posterior spinal fusion (PSF) of spondylolisthesis in the pediatric and adolescent population.

Methods: Patients who underwent PSF for spondylolisthesis between 2004 and 2015 at four spine centers, < 21 years of age, were included. Exclusion criteria were < 2 years of follow-up or anterior approach. Charts and radiographs were reviewed.

Results: 50 patients had PSF for spondylolisthesis, 26 had PSF alone, while 24 had PSF with trans-foraminal lumbar interbody fusion (TLIF). Mean age was 13.9 years (range 9.6-18.4). Mean follow-up was 5.5 years (range 2-15). Mean preoperative slip was 61.2%. 20/50 patients (40%) experienced 23 complications requiring reoperation at a mean of 2.1 years (range 0-9.3) for the following: implant failure (12), persistent radiculopathy (3), infection (3), persistent back pain (2), extension of fusion (2), and hematoma (1). In addition, there were 22 cases of radiculopathy (44%) that were transient. Rate of implant failure was related to preoperative slip angle (p = 0.02). Reoperation rate and rates of implant failure were not associated with preoperative % slip (reoperation: p = 0.42, implant failure: p = 0.15), postoperative % slip (reoperation: p = 0.42, implant failure: p = 0.99), postoperative kyphosis of the lumbosacral angle (reoperation: p = 0.81, implant failure: p = 0.48), change in % slip (reoperation: p = 0.30, implant failure: p = 0.12), change in slip angle (reoperation: p = 0.42, implant failure: p = 0.40), graft used (reoperation: p = 0.22, implant failure: p = 0.81), or addition of a TLIF (reoperation: p = 0.55, implant failure: p = 0.76).

Conclusion: PSF of spondylolisthesis in the adolescent population was associated with a 40% reoperation rate and high rate of post-operative radiculopathy. Addition of a TLIF did not impact reoperation rate or rate of radiculopathy.
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http://dx.doi.org/10.1007/s43390-020-00121-5DOI Listing
October 2020

High Parental Anxiety Increases Narcotic Use in Adolescent Patients Following Spinal Fusion.

J Pediatr Orthop 2020 Oct;40(9):e794-e797

Children's Orthopedic Center, Children's Hospital Los Angeles, Los Angeles, CA.

Background: Parental mental status and behavior may influence postoperative recovery and the use of pain medication. The purpose of this study is to identify if parents with high anxiety are associated with prolonged narcotic use in adolescent patients following posterior spinal fusion surgery. Prolonged narcotic use in this study was defined as opioid use at their first postoperative visit.

Methods: AIS patients age 11 to 20 years undergoing posterior spinal fusion and a parent were prospectively enrolled. At the preoperative appointment, patients completed the Spence Children's Anxiety Scale and parents completed the State-Trait Anxiety Inventory. High parental anxiety was defined as 1 SD above the normative mean. At the first postoperative visit, patients were asked about medication use.

Results: A total of 58 patients (49 females and 9 males) were enrolled. Overall, 29% (17/58) of parents had a high general anxiety trait on the State-Trait Anxiety Inventory and 71% (41/58) had normal general anxiety. Of the patients whose parents had high general anxiety, 47% (8/17) were still taking narcotics at their first postoperative visit compared with 20% (8/41) of patients with normal anxiety parents (P=0.03).

Conclusions: Patients with high general anxiety parents were more than twice as likely to still be on narcotics at their first postoperative visit. This information can be used to counsel families on the impact of anxiety on narcotic usage.

Level Of Evidence: Level II-prognostic studies-investigating the effect of a patient characteristic on the outcome of the disease.
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http://dx.doi.org/10.1097/BPO.0000000000001549DOI Listing
October 2020

Intraoperative Ultrasound Provides Dynamic, Real-Time Evaluation of the Spinal Cord and Can Be Useful in Cases of Intraoperative Neuromonitoring Signal Changes: A Report of 3 Cases.

JBJS Case Connect 2020 Jan-Mar;10(1):e0501

Children's Orthopaedic Center, Children's Hospital Los Angeles, Los Angeles, California.

Cases: We describe 3 pediatric spinal deformity cases that experienced neuromonitoring changes or neurologic changes in which intraoperative ultrasound allowed for evaluation of the site of cord compression to direct management. This resulted in complete neurologic recovery in all 3 patients.

Conclusions: Intraoperative ultrasound is a useful adjunct in pediatric orthopaedic spine surgery with neuromonitoring signal loss.
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http://dx.doi.org/10.2106/JBJS.CC.18.00501DOI Listing
January 2021

Five or more proximal anchors and including upper end vertebra protects against reoperation in distraction-based growing rods.

Spine Deform 2020 08 3;8(4):781-786. Epub 2020 Mar 3.

Children's Orthopaedic Center, Children's Hospital Los Angeles, Los Angeles, CA, USA.

Study Design: Retrospective multi-center enrollment.

Objective: To examine the impact of patient and surgical factors on proximal complication and revision rates of early onset scoliosis patients using a multicenter database. Proximal anchor pullout and junctional kyphosis are common causes necessitating revision surgery during growth friendly treatment of early onset scoliosis (EOS). Many options exist for proximal fixation and may impact the rate of these complications.

Methods: Retrospective review of multicenter database of patients with growth friendly constructs for EOS. Inclusion criteria were patients with index instrumentation < 10 years of age and minimum of 2 year follow-up.

Results: 353 patients met the inclusion criteria and had the following constructs: growing rods with spine anchors = 303; growing rods with rib anchors = 15 and VEPTR = 35. Mean age at index instrumentation was 6.0 years. Mean preoperative Cobb angle was 76° and mean kyphosis was 54°. Mean follow-up was 6.0 years. 21.8% of patients (77/353) experienced anchor pullout. Lower anchor pullout rates were associated with a higher numbers of proximal anchors (p = 0.003, r = - 0.157), and 5 or more anchors were associated with lower rates of anchor pullout (p = 0.014). Anchor type (rib hooks vs spine anchors vs rib cradle) did not impact rate of anchor pullout (p = 0.853). Kyphosis data was available for 198 patients. 23.2% (46/198) of these patients required proximal extension of their construct after index surgery. Initial instrumentation below the upper end vertebrae (UEV) of kyphosis was associated with higher rates of subsequent proximal revision; 28.9% (20/69) compared to 20.1% (26/129) for those instrumented at or above the UEV (p = 0.035). Preoperative kyphosis and change in thoracic kyphosis were not associated with anchor pullout (p = 0.436, p = 0.115) or proximal revision rates (p = 0.486, p = 0.401).

Conclusion: Five or more anchors are associated with lower rates of anchor pullout. Proximal anchor placement at or above the UEV resulted in a significant decrease in rates of proximal extension of the construct.
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http://dx.doi.org/10.1007/s43390-020-00064-xDOI Listing
August 2020

Dedicated spine nurses and scrub technicians improve intraoperative efficiency of surgery for adolescent idiopathic scoliosis.

Spine Deform 2020 04 24;8(2):171-176. Epub 2020 Feb 24.

Children's Orthopedic Center, Children's Hospital Los Angeles, 4650 Sunset Blvd., MS#69, Los Angeles, CA, 90027, USA.

Study Design: Retrospective comparative study.

Objective: To determine how the use of dedicated spine surgical nurses and scrub technicians impacted surgical outcomes of posterior spinal fusions for adolescent idiopathic scoliosis (AIS). Dedicated team approaches to surgery have been shown to improve surgical outcomes. However, their study on orthopaedics and spine surgery is limited.

Methods: A retrospective review of all patients who underwent a primary posterior spinal fusion of seven or more levels for AIS at a tertiary care pediatric hospital with a minimum of 2 years of follow-up from 2006 to 2013 was conducted. Our institution had dedicated spine surgeons and anesthesiologists throughout the study period, but use of dedicated spine nurses and scrub technicians was variable. The relationship between the proportion of nurses and scrub technicians that were dedicated spine and surgical outcome variables was examined. A multiple regression was performed to control for the surgeon performing the case and the start time.

Results: A total of 146 patients met criteria. When teams were composed of < 60% dedicated spine nurses and scrub technicians, there was 34 min more total OR time (p = .008), 27 min more surgical time (p = .037), 7 min more nonsurgical OR time (p = .030), 30% more estimated blood loss (EBL) (p = .013), 27% more EBL per level instrumented (p = .020), 113% more allogeneic transfusion (p = .006), and 104% more allogeneic transfusion per level instrumented (p = .009). There was no significant difference in length of stay, unplanned staged procedures, surgical site infection, reoperation, or major medical complications.

Conclusions: Performing posterior spinal fusions for AIS patients with dedicated spine nurses and scrub technicians is associated with a significant decrease in total OR time, blood loss, and transfusion rates.

Level Of Evidence: III.
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http://dx.doi.org/10.1007/s43390-020-00037-0DOI Listing
April 2020

Growth guidance constructs with apical fusion and sliding pedicle screws (SHILLA) results in approximately 1/3rd of normal T1-S1 growth.

Spine Deform 2020 06 24;8(3):531-535. Epub 2020 Feb 24.

Keck School of Medicine, University of Southern California, Los Angeles, USA.

Study Design: Retrospective, multicenter.

Objective: To investigate clinical outcomes in particular T1-S1 growth in patients with SHILLA instrumentation independent of inventor's reports. Guided growth with apical fusion and sliding pedicle screws (GGC/SHILLA) is an alternative to distraction-based growing rods for the treatment of EOS. A recent report of patients treated with GGC primarily at the center where the procedure was invented reported surprisingly good spinal growth similar to normal growth.

Methods: Retrospective review of EOS patients treated with GGC between 2007 and 2013 was performed from a multicenter database prior to final fusion. Inclusion criteria were < 10 years at index surgery and minimum 2-year follow-up. Patients with GGC performed at the inventor's institution or prior spinal instrumentation were excluded. Predicted normal T1-S1 change during the growth period was calculated for each patient based on Dimeglio's growth rates.

Results: 20 patients (mean age at surgery: 5.7 years) with the following diagnoses met inclusion criteria: syndromic (N = 9), neuromuscular (N = 5), idiopathic (N = 3) and congenital (N = 3). Preoperative mean Cobb was 77° (range 33°-111°). Mean increase in T1-S1 length from preoperative to postoperative was 51.5 mm, and change from postoperative to final follow-up was 21.8 mm (4.2 mm/year) which was 36% of predicted growth. 15/20 (75%) patients underwent 21 revision surgeries most commonly for implant complications (N = 26) and 8/20 (40%) underwent definitive fusion at a mean of 5.1 ± 1.2 years after guided growth surgery.

Conclusion: This study constitutes the largest case series of patients with EOS treated with GGC outside of the inventor's institution. The change in T1-S1 observed through the follow-up period in EOS patients treated with GGC was approximately 1/3rd of predicted normal growth, and less than 1/3rd of growth reported in previous reports. Similar curve correction and complication rates but less T1-S1 growth during the growth period were found compared to prior GGC (SHILLA) series.
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http://dx.doi.org/10.1007/s43390-020-00076-7DOI Listing
June 2020

Two cases of paralysis secondary to aneurysmal bone cysts with complete neurologic recovery.

Spine Deform 2020 04 11;8(2):339-344. Epub 2020 Feb 11.

Children's Orthopaedic Center, Children's Hospital Los Angeles, 4650 Sunset Blvd, MS#69, Los Angeles, CA, 90027, USA.

Design: Case report (retrospective).

Objective: These two cases of paralysis secondary to aneurysmal bone cysts (ABCs) demonstrated complete neurologic recovery following decompression and posterior spinal fusion. Although neurologic injury from ABCs has been described, information about the prognosis in the pediatric population is limited.

Methods: We review two cases of paralysis caused by ABCs in the thoracic spine in pediatric patients.

Results: Two patients (aged 12 and 13 years) presented to our emergency department with inability to ambulate and 0/5 strength in their lower extremities due to spinal cord compression from ABCs in their thoracic spine. Both patients had been unable to ambulate (case 1: nonambulatory for 2 weeks before presentation; case 2: nonambulatory for 1 week before presentation). The second patient also had loss of bowel and bladder control. They were managed with decompression and posterior spinal fusion. Both patients made complete neurologic recoveries.

Conclusions: It is unclear whether age, chronicity of compression, or other factors contributed; nevertheless, the recovery in these two similar patients far exceeded initial expectations, especially in the case that presented as an American Spinal Injury Association Impairment Scale class A.

Level Of Evidence: Level V.
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http://dx.doi.org/10.1007/s43390-019-00023-1DOI Listing
April 2020

Isolated femoral shaft fractures in children rarely require a blood transfusion.

Injury 2020 Mar 8;51(3):642-646. Epub 2020 Jan 8.

Children's Orthopaedic Center, Children's Hospital Los Angeles 4650 Sunset Blvd, MS#69, Los Angeles, CA 90027 United States. Electronic address:

Background: No recent study has examined how a trend toward surgical fixation for pediatric femoral shaft fractures has impacted blood loss and transfusion requirements. The purpose of this study was to determine the factors influencing transfusions in the treatment of pediatric femoral shaft fractures.

Methods: A retrospective review of patients with femoral shaft fractures treated surgically from 2004 - 2017 at a tertiary pediatric hospital was conducted. Electronic medical records were reviewed for fixation method, additional injuries, blood loss (estimated blood loss (EBL), hemoglobin, hematocrit) and transfusion. The relationship between fixation method with blood loss and transfusion was examined. Two groups were compared, those with and without additional injuries. Additional injuries were defined as additional fractures and/or abdominal, chest, or head injuries.

Results: 172 patients met inclusion criteria. There were 129 patients with isolated femoral shaft fractures and 43 patients with femoral shaft fractures and concomitant additional injuries. The transfusion rate in patients with isolated femoral shaft fractures was 0.8% (1/129) which was significantly lower than in patients with additional injuries; 39.5% (17/43) (p < 0.05). In patients with additional injuries, there was a significant relationship between number of additional surgeries and odds of transfusion (OR=2.1, CI: 1.2-3.6, p < 0.05). In patients with isolated femoral shaft fractures, EBL was higher in patients treated with rigid intramedullary nails (148.5 ± 119.0 mL) than flexible intramedullary nails (34.1 ± 56.3 mL) (p < 0.05). However, there was no significant difference in transfusion or changes in hemoglobin/hematocrit between fixation methods in patients with isolated femoral shaft fractures.

Conclusion: Pediatric patients with surgically treated isolated femoral shaft fractures rarely require transfusion (<1%), while patients with femoral shaft fractures and additional injuries had a high transfusion rate (39.5%). Surgical fixation method had a significant impact on EBL, with rigid intramedullary nail fixation having a significantly higher EBL than flexible intramedullary nails, however it did not lead to higher rates of transfusions. Blood transfusions are rarely needed in isolated femoral shaft fractures, despite the trend towards increase in surgical fixation and newer fixation techniques.
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http://dx.doi.org/10.1016/j.injury.2020.01.005DOI Listing
March 2020

Slipped Capital Femoral Epiphysis in Children without Obesity.

J Pediatr 2020 03 16;218:192-197.e1. Epub 2020 Jan 16.

Children's Orthopaedic Center, Children's Hospital Los Angeles, Los Angeles, CA. Electronic address:

Objective: To evaluate rates and characteristics of slipped capital femoral epiphysis (SCFE) in children who are not obese to prevent missed diagnoses and subsequent complications.

Study Design: A multicenter, retrospective review identified all patients with SCFE from January 1, 2003 to December 31, 2012. Patients were excluded if they received previous surgery at an outside institution, had no recorded height and weight, or had medical co-morbidity associated with increased risk of SCFE. Body mass index (BMI) percentile for age was calculated and categorized for each patient (patients without obesity vs with obesity).

Results: In total, 275 patients met inclusion criteria. Average BMI was 91.2 percentile (range: 8.4-99.7). Thirteen percent (34 patients) were considered "normal weight" (BMI 5%-85%), 17% (48 patients) were considered "overweight" (BMI 85%- 95%), and 70% (193 patients) were considered "obese" (BMI >95%). Average BMI percentile was higher in male than female patients (93.2 ± 12.7 vs 88.5 ± 21.4, P = .034). Patients without obesity were older compared with patients with obesity (12.2 ± 1.7 vs 11.7 ± 1.6 years, P = .015). Fewer patients without obesity were seen at the hospital in the southwest. The southwest had fewer patients without obesity than the northeast (18.3% vs 36.1%, P = .002). Patients without obesity were more likely to present with a severe slip as graded by Wilson percent displacement (27.2% vs 11.4%, P = .007) and an unstable slip (32.9% vs 14.7%, P = .001).

Conclusion: Rates of nonobese SCFE in this study are higher than reported in the previous literature. Normal weight patients with SCFE are more likely to be older, female, and present with a severe and unstable SCFE.
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http://dx.doi.org/10.1016/j.jpeds.2019.11.037DOI Listing
March 2020

Prospective Evaluation of a Treatment Protocol Based on Fracture Displacement for Pediatric Lateral Condyle Humerus Fractures: A Preliminary Study.

J Pediatr Orthop 2020 Aug;40(7):e541-e546

Children's Orthopaedic Center, Children's Hospital Los Angeles, Los Angeles, CA.

Background: To prospectively evaluate a displacement-based classification system and an outcome-derived algorithm in the treatment of children with lateral condyle fractures.

Methods: All children with a lateral condyle fracture were prospectively enrolled at our institution between 2013 and 2016. Fractures were classified and treated on the basis of the following classification system: type 1: <2 mm; treated with long arm casting, type II: 2 to 4 mm; treated with closed reduction and percutaneous pinning (CRPP), and type III: >4 mm; open reduction and percutaneous pinning (ORPP). Functional outcomes were assessed at 6 to 12 weeks and at 1-year follow-ups using the Pediatric Outcomes Data Collection Instrument (PODCI).

Results: A total of 55 patients (mean age, 6 y; range 2 to 12 y) were prospectively enrolled. There were 17 (31%) type I fractures treated with a long arm cast, 8 (15%) type II treated with CRPP, and 30 (54%) type III treated with ORPP. Postoperative complications included delayed union (N=5) and pin site infection (N=3). Delayed unions on the basis of fracture type was type I (1/17, 6%), type II (1/8, 13%), and type III (3/30, 10%) (P=0.85). The rate of delayed unions in type II and III fractures fixed with k-wires was 11% (4/38). Four patients required a second operation with screw fixation. No significant differences were found across PODCI domains at 1-year follow-up when comparing our study population with normative data.

Conclusions: This is the first prospective study of a treatment protocol for pediatric lateral condyle fractures and validates the use of displacement as a guide for best evidence-based treatment. Children with a lateral condyle fracture can achieve excellent functional outcomes in all classification types with comparable complication rates when radiographic fracture displacement is used to guide surgical and clinical decision making.

Level Of Evidence: Level II.
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http://dx.doi.org/10.1097/BPO.0000000000001491DOI Listing
August 2020

Bilateral Congenital Posterior Hemivertebrae and Lumbar Spinal Stenosis Treated With Posterior Spinal Fusion and Instrumentation.

J Am Acad Orthop Surg Glob Res Rev 2019 Oct 2;3(10). Epub 2019 Oct 2.

Keck School of Medicine, University of Southern California, Los Angeles, CA (Dr. Nazareth, Dr. Andras, Dr. Krieger, and Dr. Skaggs); the Children's Orthopaedic Center, Children's Hospital Los Angeles, Los Angeles, CA (Dr. Nazareth, Dr. Andras, and Dr. Skaggs); and the Department of Neurosurgery, Children's Hospital Los Angeles, Los Angeles, CA (Dr. Krieger).

Posterior hemivertebrae are wedge shaped deformities that can result in progressive kyphosis. Surgical intervention at an early age may be required, however choice of surgical technique is controversial. The aim of this report was to describe a case of progressive congenital lumbar kyphosis and bilateral posterior hemivertebra with retropulsion of tissue into the spinal canal treated successfully by posterior spinal fusion and instrumentation without anterior hemivertebra resection or decompression. We report on a patient with bilateral lumbar posterior hemivertebra at L1-L2 treated with posterior spinal fusion and instrumentation at less than 1 year of age. At 10 mo of age, the patient underwent posterior spinal fusion and instrumentation with resection of L1 and L2 posterior elements. No resection of the anterior aspect of the bilateral hemivertebrae was performed. Correction of the kyphotic deformity was maintained at last radiographic follow-up at five years post-operatively and there is no evidence of spinal stenosis. Early intervention with resection of posterior elements and fusion with instrumentation for bilateral congenital lumbar hemivertebrae provided adequate deformity correction and maintenance of the spinal canal width without anterior resection. Despite his young age, instrumentation was both feasible and beneficial in maintaining alignment.
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http://dx.doi.org/10.5435/JAAOSGlobal-D-19-00054DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6855501PMC
October 2019

Pelvic Obliquity Correction in Distraction-Based Growth Friendly Implants.

Spine Deform 2019 11;7(6):985-991

Children's Spine Study Group, P.O. Box 397, Valley Forge, PA 19481, USA.

Design: Multicenter retrospective review.

Objective: To evaluate radiographic outcomes and complication rates of patients treated with distraction based implants and pelvic fixation with either screws (sacral-alar-iliac [SAI] screws or iliac screws) or hooks (S hook iliac fixation).

Summary Of Background Data: Multiple options exist for pelvic fixation in distraction-based growing rod systems; however, limited comparative data are available.

Methods: Early-onset scoliosis (EOS) patients of all diagnoses with distraction-based implants that had pelvic fixation from 2000 to 2013 were reviewed from two EOS multicenter databases. Patients were divided into two groups by type of pelvic fixation: (1) screw group (SAI screws or iliac screws) or (2) S hooks. Exclusion criteria were as follows: index instrumentation ≥10 years old and follow up <2 years. A total of 153 patients met the inclusion criteria. Mean age at index surgery was 6.1 years (range 1.0-9.9 years) and mean follow-up was 4.9 years.

Results: Pelvic fixation in the 153 patients was as follows: screw group = 42 and S hook group = 111. When comparing patients with >20° of initial pelvic obliquity, the screw group had significantly more correction; mean 26° ± 13° for the screw group versus mean 17° ± 7° in the S hook group (p = .039). There was no significant difference in change in T1-S1 length (40 vs. 39 mm, p = .89) or correction of Cobb angle (30° vs. 24°, p = .24). The total complication rate for the screw group was 14% (6/42) versus 25% (28/111) in the S hook group, though this did not achieve significance (p = .25). The most common complications were device migration (13), implant failure (8), and implant prominence (4) for S hooks and implant failure (3), implant prominence (2), and device migration (1) for the screw group.

Conclusion: In distraction-based growth-friendly constructs, pelvic fixation with screws achieved better correction of pelvic obliquity than S hooks. Complications were almost twice as common with S hooks than screws, though this did not reach statistical significance.
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http://dx.doi.org/10.1016/j.jspd.2019.03.003DOI Listing
November 2019

Side Plank Pose Exercises for Adolescent Idiopathic Scoliosis Patients.

Glob Adv Health Med 2019 4;8:2164956119887720. Epub 2019 Nov 4.

Children's Orthopaedic Center, Children's Hospital Los Angeles, Los Angeles, California.

Background: Fishman et al. reported that side plank poses asymmetrically strengthened the convex side of the curve and decreased primary Cobb angle by 49% among compliant patients with adolescent idiopathic scoliosis (AIS).

Methods: AIS patients with curves of 10° to 45° were randomized into the front plank (control) or side plank group. The side plank was performed with their curve convex down. A weekly survey monitored compliance, defined by completing poses 4 or more times a week.

Results: A total of 64 patients were enrolled; 34% (22 of 64) of patients (mean age = 13 years) were compliant. In the control group, there were 11 compliant patients with 6 undergoing brace treatment. At enrollment, they had a mean Cobb angle of 30° (range: 14°-40°) and mean scoliometer reading of 13°. At 6 months, they had a mean Cobb angle of 30° (range: 14°-42°) and mean scoliometer of 12°. In the side plank group, there were 11 compliant patients with 5 undergoing brace treatment. At enrollment, they had a mean Cobb angle of 32° (range: 21°-44°) and mean scoliometer reading of 12°. At 6 months, they had a mean Cobb angle of 31° (range: 17°-48°) and a mean scoliometer reading of 13°. There were no significant changes in either the control or side plank group in regards to primary Cobb angle (control:  = .53, side plank:  = .67) or scoliometer (control:  = .22, side plank:  = .45).

Conclusion: There were no significant changes in primary Cobb angle or scoliometer after 6 months of side plank exercises. In contrast to a prior study, there was no improvement in curve magnitude in AIS patients performing side plank exercises.
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http://dx.doi.org/10.1177/2164956119887720DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6831967PMC
November 2019

Comparison of Ponte Osteotomies and 3-Column Osteotomies in the Treatment of Congenital Spinal Deformity.

J Pediatr Orthop 2019 Nov/Dec;39(10):495-499

Children's Orthopedic Center, Children's Hospital Los Angeles, Los Angeles, CA.

Background: Congenital spinal deformity (CSD) has traditionally been treated with 3-column osteotomies [hemivertebrectomy (HV) or vertebral column resection (VCR)] to address rigid deformities. Alternatively, multiple Ponte osteotomies (PO) may provide correction while minimizing risk. The purpose of this study was to compare safety and outcomes of patients undergoing surgical treatment for CSD with these 3 procedures.

Methods: Retrospective review of CSD patients treated with posterior spinal fusion between 1996 to 2013. Patients treated with multiple Ponte osteotomies (PO group) were compared with those managed with 3-column osteotomies (HV/VCR group). Patients with previous instrumentation, isolated cervical deformity, growing spine instrumentation, or <2 year follow-up were excluded. Deformity angular ratio (DAR) was calculated as curve magnitude divided by number of levels of the deformity.

Results: There were 49 patients [17 PO, 32 HV/VCR (26 HV, 6 VCR)]. For the PO group, mean age was 14 years, and they had an average of 4 ponte osteotomies and 11 levels fused. Mean total DAR was 25 and mean number of congenital anomalies was 1.8 in the PO group. The HV/VCR group had a mean age of 7 years and 5 levels fused. Mean total DAR was 28 and mean number of congenital anomalies was 2.1 in the HV/VCR group. Patients had a mean of 54.1% correction of coronal deformity in the PO group and 54.4% in the HV/VCR group (P=0.78). Signal changes were observed less frequently with PO (1/17) and HV (1/26) than with VCR (4/6), P=0.001. Revision rates were 17.6% (3/17) in the PO group and 37.5% (12/32) in the HV/VCR group (P=0.35).

Conclusions: Patients with CSD and a mean total DAR of 25 treated with multiple PO and long fusions had correction comparable with the HV/VCR group. Patients treated with VCR had the highest incidence of signal changes and postoperative neurologic deficits.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1097/BPO.0000000000001057DOI Listing
January 2020

Hoverboard injuries in children and adolescents: results of a multicenter study.

J Pediatr Orthop B 2019 Nov;28(6):555-558

St. Christopher Children's Hospital, Philadelphia, Pennsylvania, USA.

With the increasing popularity of hoverboards in recent years, multiple centers have noted associated orthopaedic injuries of riders. We report the results of a multi-center study regarding hoverboard injuries in children and adolescents. who presented with extremity fractures while riding hoverboards to 12 paediatric orthopaedic centers during a 2-month period were included in the study. Circumstances of the injury, location, severity, associated injuries, and the required treatment were recorded and analysed using descriptive analysis to report the most common injuries. Between-group differences in injury location were examined using chi-squared statistics among (1) children versus adolescents and (2) males versus females. Seventy-eight patients (M/F ratio: 1.8) with average age of 11 ± 2.4 years were included in the study. Of the 78 documented injuries, upper extremity fractures were the most common (84.6%) and the most frequent fracture location overall was at the distal radius and ulna (52.6%), while ankle fractures comprised most of the lower extremity fractures (66.6%). Majority of the distal radius fractures (58.3%) and ankle fractures (62.5%) were treated with immobilization only. Seventeen displaced distal radius fractures and three displaced ankle fractures were treated with closed reduction in the majority of cases (94.1% versus 66.7%, respectively). The distal radius and ulna are the most common fracture location. Use of appropriate protective gear such as wrist guards, as well as adult supervision, may help mitigate the injuries associated with the use of this device; however, further studies are necessary to demonstrate the real effectiveness of these preventions.
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http://dx.doi.org/10.1097/BPB.0000000000000653DOI Listing
November 2019
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