W. Timothy Ward

Infection after the surgical treatment of adolescent idiopathic scoliosis: evaluation of the diagnosis, treatment, and impact on clinical outcomes.

Study Design. Retrospective case-control. Objective. The purpose of this study was to evaluate a single surgeons experience with infection after surgical treatment of adolescent idiopathic scoliosis, with a focus on the diagnosis, treatment, and impact on radiographic and patient-reported outcomes. Summary of Background Data. Although previous studies have evaluated this postoperative complication, no studies to date have looked at the impact of this complication on both radiographic and patient-reported outcomes. Methods. From 1986 to 2004, 236 patients were identified who underwent surgical treatment of adolescent idiopathic scoliosis and had at least 2-year follow-up. The medical records of patients who developed infection were retrospectively reviewed in detail. Preoperative and most recent postoperative radiographic parameters and Scoliosis Research Society 24 outcomes of both infected and noninfected patients were compared. Results. Of 236 patients 7 (3%) developed an infection. One was acute (17 days postoperative), and 6 were delayed (average 34.2 months postoperative). The most common presenting complaints included back pain (5 of 7) and localized swelling (4 of 7). All patients with delayed infection were treated with 1 surgery (irrigation and debridement, instrumentation removal) and 6 weeks of intravenous antibiotics. Of 6 patients 3 had pseudarthrosis. Culture results were: Staphylococcus epidermidis (n = 2), Propionibacterium acnes (n = 1), Enteroccocus faecalis (n = 1), Group A Streptococcus (n = 1), no growth (n = 1). The patient with acute infection required 6 surgical procedures and 16 weeks of antibiotics. Cultures were positive for methicillin resistant Staphylococcus aureus and Serratia marscesens. Revision fusion surgery was performed 5 months after the infection was treated. Compared with the noninfected patients, those with infection had lower percent thoracic (P = 0.01) and lumbar (P = 0.06) curve correction. There was no difference in the pain, function, self-image, satisfaction, or total Scoliosis Research Society 24 scores. Conclusion. Postoperative infection after the surgical treatment of idiopathic scoliosis can successfully be treated with irrigation and debridement, instrumentation removal, and a course of antibiotics. Although less curve correction was achieved in the infected group, there were no differences in patient-reported outcomes when compared with the noninfected group.

Adolescent idiopathic scoliosis: 5-year to 20-year evidence-based surgical results.

Surgical intervention for adolescent idiopathic scoliosis (AIS) should be proven to alter the natural history without introducing iatrogenic complications. The risks of surgery should be substantiated by a body of scientific research, which should show a clear superiority of surgery over observation, both in the short term and the long term. The purpose of this review was to conduct a systematic search of the literature to critically evaluate the scientific evidence on the long-term outcomes and complications of surgical intervention for AIS. Our search identified 39 distinct patient populations with a minimum average follow-up of 5 years. No long-term, prospective controlled studies exist to support the hypothesis that surgical intervention for AIS is superior to natural history. Although surgery reliably arrests the progression of deformity, achieves permanent correction, and improves appearance, there is no medical necessity for surgery based on the current body of literature. However, the surgeon must not underestimate the psychological indication that occurs when a patient is no longer able to cope with the deformity.

The impact of trauma in an urban pediatric orthopaedic practice.

BACKGROUND National data documenting the impact of pediatric trauma in general and of pediatric orthopaedic trauma in particular on the rates of hospital admissions and emergency-room visits have been reported. This study documents the frequency of and work involved in the care of pediatric orthopaedic trauma by a single urban pediatric orthopaedic group practice. METHODS The computerized billing records of a single practice group of 3.4 full-time-equivalent, fellowship-trained pediatric orthopaedic surgeons practicing in a freestanding pediatric hospital with a level-I trauma center were analyzed for one year (from July 2004 through June 2005). Every office visit and operative procedure was specifically sorted to determine the component of trauma care in the groups pediatric orthopaedic practice. Descriptive statistics, including the actual numbers and percentages of office fracture visits and operations for fracture care as well as the actual numbers and percentages of work relative value units generated by the physicians, are presented. RESULTS The practice generated 36,771 work relative value units, with 18,693 units (51%) from treatment provided in the operating room and 18,078 units (49%) from treatment provided in the office. A total of 1903 new fractures was seen and accounted for 5698 work relative value units (32% of all work relative value units for treatment provided in the office). The four fractures that were most frequently seen in the office were in the distal aspect of the radius (23%), forearm (14%), tibia (13%), and elbow (10%). Of the 18,693 work relative value units generated in the operating room, 5975 (32%) were from fracture care, representing the largest single category of work done in the operating room. Trauma-related operations were most commonly done for fractures of the elbow (25.3%), tibia (12%), femur (9.8%), forearm (5.5%), and the distal aspect of the radius (5%). Technically demanding fixation techniques, which are commonly used to treat fractures in adults, were frequently used, particularly for femoral and tibial fractures. CONCLUSIONS AND CLINICAL RELEVANCE This study documents the frequency and work relative value of the care of musculoskeletal injuries in an urban pediatric orthopaedic practice in the outpatient and inpatient settings. It is a snapshot in time of current trends in pediatric orthopaedic practice, but these data may have implications for future resource allocation of the pediatric orthopaedic manpower in North America.

Pediatric orthopaedic practice management: The role of midlevel providers

The efficient functioning of a pediatric orthopaedic office practice is subject to many variables. Determining the number and nature of care providers is a challenging problem and unique to each practice. The threshold to hire new or additional personnel will depend on the core practitioners’ perception of practice satisfaction and patient mix. The number of operative pediatric orthopaedic surgeons necessary in a practice, as well as how many nonoperative care providers, is related to many different practice characteristics. Hiring additional surgeons to provide nonoperative patient care may be neither feasible nor possible. Personal decisions regarding the surgeons’ lifestyle and compensation requirements will impact decisions regarding the chosen provider mix. A well-run office should be efficient and comfortable for both patients and staff, have sufficient ancillary support, and be financially sound. The composition of this office will vary, depending on practice location and size. There are several different types of employees who combine as a team to run an office practice. In many circumstances, a practice may experience a marginally increased demand on its outpatient services, but this demand may not be enough to justify the increased capacity and financial overhead associated with hiring an additional pediatric orthopaedic surgeon. In other circumstances, the practice may experience a large increase in office work, but surgical volume may not keep pace, creating a practice opportunity that is not appealing to a pediatric orthopaedic surgeon desiring a heavy surgical load. Physiatrists and pediatricians with specialized musculoskeletal training may fill this void, but there are downsides to the incorporation of these individuals into pediatric orthopaedic practices. This article covers some of these concerns. The use of midlevel providers (MLPs), specifically nurse practitioners (NP) and physician assistants (PAs), functioning as physician extenders has become increasingly popular in all medical and surgical fields. The large volume of office pediatric orthopaedic work, frequently uncomplicated musculoskeletal complaints, lends itself well to the use of MLPs. This article reviews the use of MLPs in today’s pediatric orthopaedic practice setting.

A comparison of the lenke and king classification systems in the surgical treatment of idiopathic thoracic scoliosis.

Study Design. Retrospective case control study. Objective. To evaluate the use of the Lenke and King classification systems in the surgical treatment of main thoracic adolescent idiopathic scoliosis (AIS), with a specific focus on radiographic and patient reported outcomes. Summary of Background Data. There is considerable debate as to whether King or Lenke classification best fulfills the criteria for a useful classification to determine distal fusion level, i.e., is mentally descriptive of the curve being treated, uses reproducible information to provide guidance in determining distal fusion level, is prognostic of patient reported and radiographic outcomes, and has good user reproducibility. Methods. Patients operated for AIS between 1986 and 2002 with posterior spinal fusion and dual rod posterior instrumentation were retrospectively classified according to the Lenke and King classification systems. Only patients with Lenke type I curves and minimum 2-year follow-up were included. Preoperative and most recent postoperative radiographs were reviewed. The Lenke and King recommended distal fusion levels were calculated for each patient according to criteria obtained from the literature, and were compared to our actual fusion level. Patients were divided into groups based on our actual distal fusion level (i.e., longer, shorter, or in agreement with Lenke and King). The radiographic parameters and SRS 24 outcomes of patients within each group were compared. Results. Seventy-five patients with Lenke type 1 AIS were included in the study. The distribution of King curve types were: 31 King II curves, 34 King III curves, 9 King IV curves, and 1 double major curve. Our actual distal fusion level was in agreement with the calculated Lenke recommendation in 49% and the King recommendation in 51% of the cases. Difficulties in using the Lenke classification system were identified in up to 59% of the study patients. There were no statistically significant objectives or patient reported (SRS) differences between the groups fused in agreement, longer, or shorter than the calculated Lenke or King recommendations. Conclusion. At intermediate follow-up, there does not seem to be significant radiographic or patient reported differences whether fusion levels are in agreement, longer, or shorter than those recommended by the Lenke or King classification systems.

The current medical practice of the pediatric orthopaedic surgeon in North America.

Musculoskeletal disorders in children are common and comprise 20% to 30% of the complaints observed by primary care physicians. Most primary care physicians prefer to refer patients with pediatric musculoskeletal conditions to the pediatric orthopaedic surgeon; most of whom are treated nonoperatively. Pediatric orthopaedic surgeons are well trained to provide efficient, cost-effective, and definitive quality care. This article supports the supposition that pediatric orthopaedic surgeons are the primary care physicians for children with musculoskeletal disorders. This article focuses on the primary clinical responsibilities of the pediatric orthopaedic surgeon, describes the value of this practice, and contrasts their responsibilities from that of other orthopaedic subspecialties.

Hematoma Block Versus Sedation for the Reduction of Distal Radius Fractures in Children

PURPOSE To determine which mode of anesthesia, hematoma block (HB) or procedural sedation (PS), was preferable for distal radius fracture (DRF) reduction in children. METHODS Fifty-two children (mean age, 12 y; range, 5-16 y) presenting with DRFs requiring reduction were prospectively enrolled and offered either PS or HB for anesthesia. Following reduction, families completed a satisfaction survey regarding mode of anesthesia and overall care (rated 0-10, with 10 being the best score) and an assessment of discomfort (rated 0-10, with 0 being no pain). Length of stay in the emergency department (ED) and complications related to procedure and method of anesthesia were recorded. Radiographic alignment was evaluated before and after reduction. RESULTS Twenty-six patients underwent reduction with either PS or HB. Midazolam was used in addition to HB in 8 patients. One patient was converted from HB to PS due to inadequate block. There was no significant difference in prereduction and postreduction angulation between the groups, and reductions maintained satisfactory alignment. Overall satisfaction and satisfaction with anesthesia were excellent for both groups, with respective means of 9.5 and 9.5 for PS and 9.3 and 9.6 for HB. Patient discomfort was minimal in both groups, with a mean of 1.6 for PS and 2.2 for HB. Length of stay was significantly shorter for HB patients, with patients spending a mean of 2.2 hours less in the ED. Three patients required further intervention following initial reduction. One patient in each group required revision reduction, and 1 PS patient underwent closed reduction and pinning. CONCLUSIONS Use of HB for the reduction of pediatric DRFs provided radiographic alignment, patient satisfaction, and pain control comparable with that of PS, while significantly decreasing ED time and resources.

Demographic and financial implications of pediatric emergency department fracture manipulation.

Background: The demographic features, work relative value units (WRVUs), and financial implications of pediatric emergency department (ED) manipulative fracture treatment are presented. The aims of this study are to quantify these parameters and gauge their impact on lifestyle and reimbursement. Methods: All ED fracture reductions performed by orthopaedic residents in a childrens hospital for fiscal year 2004 were grouped by month, day, time, anatomical location, and payer mix. Work relative value units and reimbursement were assigned for each fracture, contrasting the use of global current procedural terminology manipulation facture codes to the actual use of global current procedural terminology nonmanipulation codes first generated when the child presented to the senior staff office. Results: Three hundred seventy-five fractures were manipulated in the ED. Eighty-one manipulations were done on Saturday and 61 on Sunday compared with an average of 47 for the other 5 days. Nineteen percent of manipulations were performed between 7 am and 6 pm, 37% between 6 and 11 pm, and 44% between 11 pm and 7 am. Sixty-nine percent of the children had private insurance, 29% had Medicaid, and 2% had no medical coverage. Potentially 2358 WRVUs could have been recorded had senior staff been present for the reduction in the ED compared with the actual total of 1168 WRVUs recorded in the office a few days later. Using a proxy model of 100% Western Pennsylvania Medicare coverage for these fractures,

Converting Scoliosis Research Society-24 to Scoliosis Research Society-22r in a Surgical-Range, Medical/Interventional Adolescent Idiopathic Scoliosis Patient Cohort

179,754 of reimbursement was available with manipulation included compared with

Bernese Periacetabular Osteotomy in the Surgical Management of Adolescent Acetabular Dysplasia

106,010 without manipulation. For our actual payer mix, manipulation would have contributed a 37% increase to fracture care margin for these 375 fractures but would have only provided a 2.5% increase to overall pediatric orthopaedic revenue production for fiscal year 2004. Conclusions: The component of reimbursement resulting from manipulation contributed significantly to fracture care margin for those fractures requiring manipulation but did not have a significant impact on overall pediatric orthopaedic revenue production. The added senior staff work effort required to gain the manipulation reimbursement component of fracture care in the ED is substantial considering the small contribution to overall revenue. Clinical Relevance: Alternative mechanisms of compensation should be devised if the goal is to offer financial incentive to senior staff for their availability for all fracture manipulations in the ED.