What’s New in Pediatric Orthopaedics

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Over the past year, a substantial number of high-quality studies were published that are relevant to the clinical practice of pediatric orthopaedics. Additionally, in an effort to improve the care of pediatric patients, the American Academy of Orthopaedic Surgeons (AAOS) updated and reissued the 2009 Clinical Practice Guideline on the treatment of pediatric diaphyseal femoral fractures1. The AAOS also recently adopted Appropriate Use Criteria for pediatric supracondylar humeral fractures with vascular injury2.SpineMultiple database studies demonstrated trends in the management of pediatric spinal deformity. Martin et al. reviewed the Nationwide Inpatient Sample (NIS) from 2001 to 2011 and found that spinal fusion rates for adolescent idiopathic scoliosis have remained stable, but anterior fusion declined by 80%3. The mean hospital charges increased by 113%, from $72,780 in 2001 to $155,278 in 2011. The mean annual increase in hospital charges to treat adolescent idiopathic scoliosis was 11.3%; in comparison, charges for nonspine conditions increased 4.5% to 6% annually. Martin et al. suggested that spinal implant costs may be a substantial driver of increased charges. Vigneswaran et al. performed a similar study with the Kids’ Inpatient Database (KID) and estimated that the incidence of surgical procedures to treat adolescent idiopathic scoliosis had increased from 0.58 admission per 10,000 individuals per year in 1997 to 0.74 admission per 10,000 individuals per year in 20124. From 1997 to 2012, the mean hospital length of stay had decreased from 6.5 to 5.6 days. Similar to these studies of adolescent idiopathic scoliosis, in their study Jain et al. reviewed the NIS and noted that the utilization of spinal fusion for Scheuermann kyphosis increased by 2.9 times from 2000 to 20085. As noted for adolescent idiopathic scoliosis, treatment has shifted toward posterior spinal fusion, but anterior-posterior fusion rates declined by 7% per year. Lower complication rates and shorter hospitalizations were noted with posterior spinal fusion compared with anterior-posterior fusion.There have been substantial efforts at quality improvement for the surgical procedure to treat spinal deformity. In an attempt to minimize neurologic complications during this procedure, a combined Scoliosis Research Society and Pediatric Orthopaedic Society of North America task force led the development of an intraoperative checklist to optimize the response to neuromonitoring changes and created a best practice guideline6. Risk factors for surgical site infection after a pediatric spine surgical procedure were also investigated. Croft et al. performed a matched case control study and found that neuromuscular scoliosis, weight for age at the ≥95th percentile, American Society of Anesthesiologists score of ≥3, and prolonged operative time were associated with a higher risk of surgical site infection7. In a retrospective series, LaGreca et al. found that the rate of delayed surgical site infection following instrumented spinal fusion was six times higher in patients with stainless steel implants compared with patients with titanium implants8. Propionibacterium acnes was the most common organism in the delayed group; this pathogen was not cultured in any of the patients with titanium implants. Further research is required to determine if titanium implants are protective against infection with this organism.Martin et al. evaluated readmissions after the surgical procedure to treat pediatric spinal deformity utilizing the National Surgical Quality Improvement Program (NSQIP) pediatric database in 20129. The rate of unplanned thirty-day readmission was 4.0% and was highest in patients with neuromuscular deformity (6.8%) and those with congenital deformity (6.3%). Surgical complexity and medical comorbidities were associated with readmission. The most common reasons for readmission were wound complications (73.3%) and gastrointestinal complications (13.3%), suggesting that quality improvement programs should target these areas to minimize the risk of readmission.

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