Todd A. Milbrandt

Down syndrome and scoliosis: a review of a 50-year experience at one institution.

Study Design. Retrospective review case series. Objective. To evaluate the incidence, patterns, and treatment of scoliosis in a Down syndrome population. Summary of Background Data. Despite a preponderance of literature concerning cervical abnormalities in Down syndrome, there is little information concerning scoliosis in this patient group. We examined the 50-year history of treating scoliosis at our institution in patients with Down syndrome. Methods. Following institutional review board approval, chart review identified patients with Down syndrome with scoliosis. We performed a radiographic review of curve pattern, and determined results of brace and operative treatment. Results. A total of 379 patients were identified as having Down syndrome. There were 33 patients diagnosed with scoliosis, for an incidence of 8.7%. Mean follow-up was 4.15 years (range 0–12). The double major curve predominated with 18 (55%). Of 33 patients, 16 (49.5%) had previously undergone thoracotomy for congenital heart defects. There were 8 (24%) patients who were braced for an average of 26.5 months (range 12–63), with an average progression in brace of 10° (range 0°–44°), 3 of whom went on to spinal fusion. There were 7 (21.2%) patients who underwent spinal fusion, including 6 posterior spinal fusions and 1 anterior spinal fusion. Four patients had complications, including 3 pseudarthroses, 4 implant failures, 3 superior junctional kyphosis, and 1 infection, for a 57% complication rate. Conclusions. Scoliosis developed in 8.7% of patients with Down syndrome. There was a high rate of cardiac surgery within this population. Bracing was ineffective for the majority of the patients treated. Although surgery has a high rate of complications, there was only one patient who underwent reoperation.

Common elbow injuries in children: evaluation, treatment, and clinical outcomes

Summary The information in this review may help orthopedic surgeonswho encounter these injuries to further improve their treatmentmethods. Further research is needed to continue to refinethese methods and reduce the incidence of adverse sequelae. Keywords pediatric, elbow, trauma Curr Opin Orthop 15:286–294.

Risk Factors for 30-Day Unplanned Readmission and Major Perioperative Complications After Spine Fusion Surgery in Adults: A Review of the National Surgical Quality Improvement Program Database.

Study Design. Retrospective review of a prospective cohort. Objective. The aim of the study was to determine the patient characteristics and surgical procedure factors related to increased rates of 30-day unplanned readmission and major perioperative complications after spinal fusion surgery, and the association between unplanned readmission and major complications. Summary of Background Data. Reducing unplanned readmissions can reduce the cost of healthcare. Payers are implementing penalties for 30-day readmissions after discharge. There is limited data regarding the current rates and risk factors for unplanned readmission and major complications related to spinal fusion surgery. Methods. Spine fusion patients were identified using the 2012 and 2013 American College of Surgeons National Surgical Quality Improvement Program Participant User File. Rates of readmissions within 30 days after spine fusion surgery were calculated using the person-years method. Cox proportional hazards models were used to assess the independent associations of spine surgical procedure types, diagnoses, patient profiles, and major perioperative complications with unplanned related readmissions. Independent risk factors for major complications were assessed by multivariable logistic regression. Results. Of the 18,602 identified patients, there was a 5.2% overall major perioperative complication rate. There was a rate of 4.4% per 30 person-days for unplanned readmissions related to index surgery. Independent risk factors for both readmissions and major perioperative complications included combined anterior and posterior surgery, diagnosis of solitary tumor, older age, and higher American Society of Anesthesiologists class. Patients with deep/organ surgical site infection carried higher risk of having unplanned readmission, followed by pulmonary embolism, acute renal failure, and stroke/cerebral vascular accident with neurological deficit. Conclusion. This study provides benchmark rates of 30-day readmission based on diagnosis and procedure codes from a high-quality database for adult spinal fusion patients and showed increased rates of 30-day unplanned readmission and major perioperative complications for patients with specific risk factors. Targeted preoperative planning on modifiable risk factors with proportional reimbursement may promote higher-quality healthcare. Level of Evidence: 3

A Cross-sectional Study of Chest Kinematics and VO2 in Children With Adolescent Idiopathic Scoliosis During Steady-state Walking.

Study Design. A cross-sectional study. Objective. The aim of this study was to identify the differences in oxygen consumption in children with adolescent idiopathic scoliosis (AIS) and age-matched control subjects using traditional methods and chest kinematics. Summary of Background Data. AIS is a disorder affecting 2 to 3% of children between the ages of 10 and 16 and accounts for up to 85% of all scoliosis cases. The spinal deformities and subsequent rib conformational changes associated with AIS can have a significant deleterious effect on the oxygen consumption for children with mild to severe scoliosis. Previous studies found that the oxygen consumption in children with AIS was significantly more than that of peers and during walking require more energy than typically developing children. Methods. Thirty children (four male, 26 female), 11.7 to 18.7 years of age, were enrolled: 15 adolescent children diagnosed with mild to moderate AIS (mean cobb angle 36.2 degrees) and 15 matched adolescents. Oxygen consumption during steady-state treadmill walking was measured using a traditional methods and simultaneous kinematic analysis of the chest wall. Results. There were no significant differences in the volume of oxygen consumed in any of the phases of treadmill walking (resting, exercise, and recovery) or in breath per minute ventilation and tidal volume between control subjects and children with scoliosis (P > 0.05). Significant differences were found between assessment methods, with the kinematic analysis overestimating the average tidal volume while walking (P < 0.05). Conclusion. Children with mild to moderate AIS and typically developing children do not demonstrate oxygen consumption differences when walking at a steady state on a treadmill. However, kinematic analysis of the chest wall tends to overestimate the tidal volume when walking. An offset equation is required for some variables when using kinematic data to assess oxygen consumption in children who would otherwise not comply with traditional oxygen consumption testing. Level of Evidence: 3

Pediatric orthopaedic trauma and associated injuries of snowmobile, ATV, and dirtbike accidents: a 19-year experience at a Level 1 pediatric trauma center

Objectives: The purpose of this study was to evaluate the type and severity of orthopaedic and associated injuries for snowmobile, All-terrain vehicles (ATV) and motorized dirtbike accidents in a pediatric patient population. Methods: A total of 758 patients who presented following either snowmobile (n=87), ATV-related (n=308) or dirtbike (n=363)-related trauma at our institution between 1996 and 2015 were retrospectively reviewed. Results: A total of 441 axial and appendicular fractures occurred requiring 533 procedures. Snowmobile and dirtbike accidents were associated with a higher rate of fractures (63%, 64%) than the ATV group (50%) (P=0.0008). Snowmobile injuries had the highest rate of spinal (23%) and lower extremity fractures (53%) (P=0.0004). Snowmobile and dirtbike cohorts had higher rate of femur fractures (22%, 17%, P=0.001) whereas the ATV cohort had higher rates of upper extremity (18%), hand (11%), scapula (4.6%), and open fractures (28.6%) (P<0.01). Head trauma was the most commonly associated injury in 275 patients with the highest rate in the ATV group (44%) who also had the highest rate of no helmet use (76%). Snowmobile and ATV patients had higher Injury Severity Score (11.3, 9.6) than dirtbike patients (7.8) (P=0.001). ATV patients were found to be younger (11.8 y) compared with snowmobile (13.2 y) and dirtbike (13.5 y) (P<0.01). Conclusions: Pediatric snowmobile, ATV and dirtbike accidents result in severe orthopaedic and associated injuries with each vehicle demonstrating significantly different injury patterns. Injury prevention should focus on improved safety mechanisms, protective gear, safe areas for off-road vehicle use and strict laws with minimum age requirements Level of Evidence: Level IV.

Efficacy of 2 Regional Pain Control Techniques in Pediatric Foot Surgery.

Background: Peripheral nerve blocks (PNBs) have the potential to reduce postoperative pain. The use of ultrasound (US) to guide PNBs may be more beneficial than nerve stimulation (NS); however, very few studies have studied this technique in children. The objective of this study was to compare postoperative pain control in pediatric patients who had general anesthesia (GA) alone compared with those who had PNB performed by NS, or PNB with both NS and US guidance. Our hypothesis was that compared with NS, the US-guided PNB would result in reduced postoperative pain and opioid use, and that both PNB conditions would have improved outcomes compared with GA. Methods: A retrospective chart review of foot and ankle surgery included 103 patients who were stratified into 3 groups: GA, PNB with NS, and PNB with NS and US. Pain levels were measured with visual pain scales at 2, 4, 6, 8, 12, and 24 hours postoperatively. Days of hospitalization, morphine and oxycodone use by weight, and time to first PRN opioid use were also recorded. A repeated measure analysis of variance was used to compare the groups, and the proportion of patients who reported a visual analog scale score of 0 was calculated for each time point. Results: There were no significant differences in pain levels between groups for the first 12 hours, but the US group had higher pain levels at 24 hours. Both US and NS groups had a longer time to PRN opioid use and used significantly less morphine compared with GA. The US group had a significantly greater proportion of pain-free patients than the other 2 groups for the first 6 hours. Conclusions: The use of US guidance is beneficial in postoperative pain control. Both US-guided and NS-guided PNB are preferable to GA alone for lower extremity orthopaedic surgery in the pediatric population. Level of Evidence: III, retrospective comparative study.

Pain and overcorrection in clubfeet treated by Ponseti method

Long-term outcomes of Ponseti casting have consistently shown improvement over soft-tissue release. The incidence of foot pain and overcorrection in clubfeet treated by Ponseti method has not been reported. We studied the rate of overcorrection and its association with pain in clubfeet treated with Ponseti casting. A retrospective review of clubfoot patients treated with Ponseti method with at least 8 years of follow-up was carried out. Patient charts were reviewed for demographic data, recurrence, type and number of procedures, and patient-reported complaints of foot pain. Pedobarographs were used to document overcorrection. Eighty-one patients comprising 115 clubfeet were included in the study. There were 14 (12.2%) feet with valgus overcorrection and 101 feet that had achieved a normal, plantigrade position. Overall, 50% of patients with overcorrected clubfeet and 32% with corrected, plantigrade clubfeet experienced pain. Overcorrection was found to be predictive of pain complaints (P<0.001). Hence, valgus overcorrection occurs after Ponseti casting, with an incidence of 12%.

High-energy Pediatric Scapula Fractures and Their Associated Injuries

Objectives: The purpose of this study was to evaluate pediatric scapula fractures occurring in high-energy motorized vehicle accidents and their associated injury patterns in a pediatric patient population. Methods: One thousand nine hundred sixty-eight pediatric patients who presented after either on-road or off-road motorized vehicle accidents between 1996 and 2015 were retrospectively reviewed. Thirty-eight patients were found to have scapula fractures and the remaining 1930 were identified as controls. Results: A total of 39 scapula fractures occurred in 38 patients. The most common pattern was the AO/OTA 14-A3 (n=32), followed by 14-A2 (n=5), 14-B1 (n=1), and 14-C2 (n=1). Scapula fracture patients experienced higher rate of spine fractures (42% vs. 18%, P=0.001), skull fractures (26% vs. 12%, P=0.02), rib fractures (40% vs. 7.6%, P<0.0001), clavicle fractures (34% vs. 6%, P<0.0001), and upper extremity fractures (58% vs. 21%, P<0.0001) compared with controls. Scapula fracture patients had higher Injury Severity Scores (22.1 vs. 10.8, P<0.0001), thoracic injury (79% vs. 31%, P<0.0001), intracranial hemorrhage (32% vs. 15%, P=0.012), pneumothorax (55% vs. 8%, P<0.0001), and lung contusion (63% vs. 12%, P<0.0001). No difference in mortality was observed for scapula and control patients (5% vs. 2%, P=0.302). Conclusions: Pediatric scapula fractures were not associated with higher mortality rates in this series but were associated with significant morbidity as demonstrated by high rates of associated intracranial hemorrhage, skull fractures, thoracic injury, upper extremity fractures, and spine fractures compared with control patients. Surgeons who care for pediatric trauma patients should view scapula fractures as an indicator for more significant injuries. Level of Evidence: Level III.

The Effectiveness of the Ponseti Method for Treating Clubfoot Associated With Amniotic Band Syndrome.

Background: Amniotic band syndrome (ABS) is a congenital disorder with an associated incidence of clubfoot deformity in over 50% of patients. Although early reports in the literature demonstrated a poor response to casting treatments, recent application of the Ponseti technique in ABS patients have been more promising. Methods: A retrospective review of all patients with clubfoot and a concurrent diagnosis of ABS were reviewed at a single institution. Patients not managed initially with the Ponseti method were excluded. Data collected included patient age at presentation, sex, unilateral or bilateral, amniotic band location and associated findings, and response to treatment—number of casts and requirement of Achilles tenotomy, tibialis anterior tendon transfer, or other surgical procedures. Duration of treatment at latest follow-up visit was noted and outcome was based on clinical foot appearance and plan for any further procedures. Results: Twelve patients (7 female and 5 male) with a total of 21 feet (9 bilateral and 3 unilateral) were identified. The average age at presentation was 3 weeks (range, 1 to 9 wk). The average number of casts was 6 (range, 3 to 11). Seventeen of 21 feet (81.0%) underwent percutaneous Achilles tenotomy. The initial correction rate for all patients with the Ponseti technique was 20/21 feet (95.2%) and recurrence was noted in 7/21 feet (33.3%). One patient underwent primary posteromedial release and 2 patients had associated neurological deficits. The average follow-up was 3.9 years (range, 9 mo to 10 y) and all but one patient had supple, plantigrade feet. Conclusion: The Ponseti technique is an effective first-line treatment in patients who have clubfeet associated with ABS, including those with a neurological deficit. Level of Evidence: Level IV.