Gaia Georgopoulos

Autologous transfusions for orthopaedic procedures at a children's hospital.

We conducted a critical review of the use of autologous transfusions in orthopaedics at a tertiary-care childrens hospital. The cases of 198 children who deposited blood before an orthopaedic operation were analyzed. There were 175 children who were enrolled in the program of preoperative deposit of autologous blood who later needed transfusion of blood; 73 per cent of them received only autologous blood. Seventy patients also had intraoperative salvage. We were unable to document a proved benefit of intraoperative salvage of blood in this group of patients. Forty patients had some difficulty donating autologous blood preoperatively, but these problems were rarely serious. Major human errors occurred in thirteen patients and resulted in some patients receiving homologous transfusions while autologous blood components were still available. Fifty-five (40 per cent) of all of the transfusions were administered in clinical circumstances that failed to meet generally accepted criteria for transfusion, and fifty-four (38 per cent) of the postoperative transfusions also failed to meet these criteria. This was true of the homologous transfusions in the study as well. Although an autologous blood transfusion is a generally safe procedure, it is not without risk, and human errors can occur. In light of the potential complications, surgeons should adhere to the standard indications for transfusion when administering autologous blood.

Intraoperative blood salvage in children and young adults undergoing spinal surgery with predeposited autologous blood: efficacy and cost effectiveness.

Summary: We conducted a retrospective review of 155 spinal operations at our institution to determine the efficacy of intraoperative salvage. Addition of intraoperative salvage had little effect on the success of a preoperative autologous donation program. Only patients with operative blood loss <2,000 ml (12% of patients) benefited from this expensive source of autologous blood. The technique tended to be most effective in children aged 16-18 years. Use of intraoperative salvage for all pediatric spinal procedures is neither necessary nor cost effective.

Treatment of adolescent hallux valgus with the first metatarsal double osteotomy: the denver experience.

The 1st metatarsal double osteotomy is described as an effective procedure for the treatment of severe adolescent hallux valgus (AHV) with low recurrence and complication rates. No study to date has evaluated the functional clinical outcome after 1st metatarsal double osteotomy. The purpose of this paper is to report the results at our institution in the treatment of severe AHV with 1st metatarsal double osteotomy. We performed a review of all patients (N = 9, 14 feet) treated at our institution with 1st metatarsal double osteotomy. We reviewed pre- and postoperative hallux valgus (HVA), 1st-2nd intermetatarsal (IMA), and distal metatarsal articular angles (DMAA) and calculated the average angular correction. Functional outcome was measured via the AOFAS Hallux Metatarsophalangeal-Interphalangeal (HMI) scale as well as the duPont Bunion Rating Score (BRS). The average patient was 15 years old at the time of surgery with an average of 27 months follow-up. The mean angular correction was 21.54°, 9.25°, and 6.21° for HVA, IMA, and DMAA, respectively. Ninety percent of the patients reported good to excellent results. We had 2 complications for an overall rate of 14%. The 1st metatarsal double osteotomy is an effective and reliable technique for treatment of severe adolescent hallux valgus. Stiffness of the 1st MTPJ is the major determinant of patient satisfaction.

Displaced supracondylar humeral fractures in children. A comparison of results and costs in patients treated by skeletal traction versus percutaneous pinning.

Clinical outcome and treatment cost were compared in 65 children treated by either percutaneous pinning or skeletal traction for displaced supracondylar humeral fractures. Clinical outcome was evaluated by loss of elbow motion and change in carrying angle. Results of treatment were basically equivalent in the two groups and were satisfactory in 90% or more. To determine treatment cost, the authors analyzed factors that vary according to the type of therapy. Cost of treatment was lowest in those who had percutaneous pinning and subsequent pin removal in the office. Compared to this group, the cost of treatment increased by 23% in those who had percutaneous pinning and removal of the pins as a surgical procedure, by 117% in those treated by traction with the olecranon pin inserted in the emergency room, and by 142% in those treated by traction with the olecranon pin inserted in the operating room.

Does Strict Adherence to the Ponseti Method Improve Isolated Clubfoot Treatment Outcomes? A Two-institution Review.

BackgroundDespite being recognized as the gold standard in isolated clubfoot treatment, the Ponseti casting method has yielded variable results. Few studies have directly compared common predictors of treatment failure between institutions with high versus low failure rates.Questions/purposesWe asked: (1) is the provider’s rigid adherence to the Ponseti method associated with a lower likelihood of unplanned clubfoot surgery, and (2) at the institution that did not adhere rigidly to Ponseti’s principles, are any demographic or treatment-related factors associated with increased likelihood of unplanned clubfoot surgery?MethodsAfter institutional review board approval, a consecutive series of patients with a diagnosis of isolated clubfoot who underwent treatment between January 2003 and December 2007 were identified. At Institution 1, 91 of 133 patients met the eligibility criteria and were followed for a minimum of 2 years compared with 58 of 58 patients at Institution 2. At Institution 1, 16 providers managed care using a conservative casting approach based on the Ponseti method. However, treatment was adapted by the provider(s). At Institution 2, one orthopaedic surgeon managed care with strict adherence to the Ponseti method. Surgical indications at both institutions included the presence of a persistent equinovarus foot position while standing. A chart review was used to collect data related to proportion of patients undergoing unplanned additional treatment for deformity recurrences after Ponseti casting, demographics, and treatment patterns.ResultsThe proportion of subjects who underwent unplanned major surgical intervention was greater (odds ratio [OR], 51.1; 95% CI, 6.8–384.0; p < 0.001) at Institution 1 (60 of 131, 47%) compared with Institution 2 (two of 91, 2%). There was no difference (p = 0.200) in the proportion of patients who underwent additional casting, repeat tendo Achilles lengthening, and/or anterior tibialis tendon transfer only (minor recurrence) at Institution 1 (nine of 131, 7%) compared with Institution 2 (11 of 91, 13%). At Institution 1, an increase in the number of revision casts (multiple vs no casts, hazard ratio [HR] = 3.9; 95% CI, 2.0–7.6; p < 0.001) and an increase in the number of cast-related complications (multiple vs no complications, HR = 2.8; 95% CI, 1.2–6.7; p = 0.019) were associated with increased risk of major surgery in the multivariate analysis.ConclusionsRigid commitment to the Ponseti method in the conservative treatment of patients with isolated clubfoot was associated with a lower risk of subsequent unplanned surgical intervention. In addition, clubfoot treatment programs that use a care model that prioritizes continuity in care and dedication to the Ponseti method may decrease the proportion of patients who undergo unplanned surgical intervention.Level of EvidenceLevel III, therapeutic study.

Delayed Anterior Cruciate Ligament Reconstruction in Young Patients With Previous Anterior Tibial Spine Fractures

Background: Avulsion fractures of the anterior tibial spine in young athletes are injuries similar to anterior cruciate ligament (ACL) injuries in adults. Sparse data exist on the association between anterior tibial spine fractures (ATSFs) and later ligamentous laxity or injuries leading to ACL reconstruction. Purpose: To better delineate the incidence of delayed instability or ACL ruptures requiring delayed ACL reconstruction in young patients with prior fractures of the tibial eminence. Study Design: Case series; Level of evidence, 4. Methods: We identified 101 patients between January 1993 and January 2012 who sustained an ATSF and who met inclusion criteria for this study. All patients had been followed for at least 2 years after the initial injury and were included for analysis after completion of a questionnaire via direct contact, mail, and/or telephone. If patients underwent further surgical intervention and/or underwent later ACL reconstruction, clinical records and operative reports pertaining to these secondary interventions were obtained and reviewed. Differences between categorical variables were assessed using the Fisher exact test. The association between time to revision ACL surgery and fracture type was assessed by Kaplan-Meier plots. The association between need for revision ACL surgery and age, sex, and mechanism of surgery was assessed using logistic regression. Results: Nineteen percent of all patients evaluated underwent delayed ACL reconstruction after a previous tibial spine fracture on the ipsilateral side. While there were a higher proportion of ACL reconstructions in type II fractures, there was not a statistically significant difference in the number of patients within each fracture group who went on to undergo later surgery (P = .29). Further, there was not a significant association between fracture type, sex, or mechanism of injury as it related to the progression to later ACL reconstruction. However, there was a significant association between age at the time of injury and progression to later ACL reconstruction (P = .02). For every year increase in age at the time of injury, the odds of going on to undergo delayed ACL reconstruction were greater by a factor of 1.3 (95% CI, 1.1-1.6). Conclusion: Although an ATSF is a relatively rare injury, our cohort of patients suggests that a subset of young patients with all types of tibial spine fractures will require later ACL reconstruction. There is a need to counsel patients that a delayed ACL rupture is a potential risk after an ATSF, especially as children approach skeletal maturity. Further patient follow-up and prospective studies are required.

Incidence of Deep Vein Thrombosis and Pulmonary Embolism in the Elective Pediatric Orthopaedic Patient.

Background: Although venous thromboembolism (VTE) has been well studied in the pediatric trauma population, rates of VTE associated with elective pediatric orthopaedic procedures have not been addressed in current literature. The purpose of this retrospective study was to identify the incidence of VTE in the elective pediatric orthopaedic surgical population and delineate subsets of this population at greatest risk. This study may provide valuable data to begin the process of resolving the controversy surrounding deep vein thrombosis prophylaxis in the pediatric orthopaedic population. Methods: The Pediatric Health Information System was queried for patients admitted on an ambulatory or inpatient basis, aged below 18 years, from January 2006 to March 2011 during which an elective orthopaedic surgery was the principal procedure performed. Patients with diagnoses or procedures related to infection, trauma, malignancy, or coagulopathies were excluded. Patients admitted through the emergency department or whose orthopaedic procedure was not performed on the admission date were excluded. Age, sex, ethnicity, race, admission year, and all procedures/diagnoses were recorded. The presence of VTE at the index admission or any subsequent readmission within 90 days was recorded. All criteria were coded using ICD-9-CM codes. Generalized logistic regression analyses were used to identify factors related to VTE. Results: A total of 143,808 admissions (117,676 patients) matched the inclusion criteria. Thirty-three had a VTE during the index admission with an additional 41 at subsequent readmissions, for a total incidence of 0.0515% by admission and 0.0629% by patient. In the multivariable model, variables significantly (P<0.05) related to VTE included increasing age, admission type, diagnosis of metabolic conditions, obesity, and/or syndromes, and complications of implanted devices and/or surgical procedures. No procedure variables were significantly related to VTE in the multivariable model. Conclusions: The incidence of VTE in this cohort of pediatric patients undergoing elective orthopaedic surgery was 0.0515%. In children, underlying diagnosis seems to be a stronger predictor of VTE than procedures performed. Diagnosis with a metabolic condition, syndrome, and/or obesity, complications of implanted devices and/or surgical procedures, older age, and admission as an inpatient were significantly related to the development of a VTE. Level of Evidence: Level II—retrospective prognostic study.

Opinion survey regarding pediatric orthopaedic trauma call and emergency trauma management.

Background: To determine the attitudes and practices of pediatric orthopaedic surgeons regarding on-call coverage and emergency fracture management. Methods: A 32-question online survey was sent to all 597 active members of the Pediatric Orthopaedic Society of North America. There were 296 completed surveys, for a response rate of 49.6%. Results: Of the respondents, 85.1% were male. The respondents ranged in age from 30 to older than 70 years, with 54% between 36and 50 years of age, corresponding to an average of 15 years in practice. Seventy-seven percent of the respondents felt that taking trauma call is an integral aspect of being a pediatric orthopaedist. Of the respondents, 64.9% take call 1 to 9 times per month, 15.8% take 10 to 19 calls, 2.7% take 20 or more, and 16.6% take no call. The number of orthopaedists taking call per practice was fairly evenly distributed between 3 and 10. Call was shared equally in 32% of practices, and mandatory in 72%. Twenty-eight percent of the respondents were additionally compensated for taking calls, in amounts ranging from

The efficacy of intra-articular injections for pain control following the closed reduction and percutaneous pinning of pediatric supracondylar humeral fractures: a randomized controlled trial.

100 to

Rotation and Displacement Predict Adverse Events in Pediatric Supracondylar Fractures.

2000 per night, with 1000 dollars the most common rate. One third of operative cases are done that night; one third, the next day; and one third, later in the week. Twenty-four percent of the respondents have dedicated operative block time on the day after the call. Forty-seven percent have a dedicated fracture clinic, of which 51% receive institutional support. Conclusions: Providing emergency trauma care for children is an integral aspect of pediatric orthopaedics. This survey provides information on the attitudes and strategies of practicing pediatric orthopaedic surgeons in the face of decreasing manpower and increasing demand for such services.