Improving Lower Extremity Casting Quality by Providing an Experienced Assistant in Pediatric Tibia Fractures Managed by Trainees

Background: The value of employing an orthopedic technician or advanced practice provider (OT/APP) to assist trainees during on-call hours has not been assessed. As the third most common pediatric long bone fracture, most tibial fractures can be managed with closed reduction and casting. Purpose: We sought to determine whether clinical outcomes could be positively affected for traumatic childhood tibia fractures by using an experienced OT/APP to aid orthopedic surgery residents with closed reduction and casting. Methods: We performed a retrospective chart review of tibial shaft fractures that occurred between 2010 and January 2017. Fractures undergoing manipulation and closed reduction by orthopedic surgery residents (post-graduate year 2 to 4) in the emergency department were included and differentiated into 2 cohorts: (1) residents who performed the procedure alone and (2) residents who were assisted by an OT/APP. Comparisons in cast quality and treatment success were made using univariate statistics followed by a multivariate Classification and Regression Tree (CART) analysis. Results: Of the 73 patients who met our criteria, 38 received treatment by a resident alone and 35 by a resident assisted by an OT/APP. Evidence to support our hypothesis was found with the resident-alone group "over" padding the casts posteriorly. Univariate analysis demonstrated that the rate of subsequent surgical intervention was more than double in the resident-alone group (31% vs 14%), yet OT/APP castings underwent more wedging at follow-up (17% vs 0%). CART analysis revealed initial fracture severity and lack of OT/APP assistance as predictors of surgical intervention with terminal nodes, in increasing order of risk of requiring surgical intervention: lower translation on sagittal and anteroposterior (AP), lower sagittal translation with greater AP translation, greater sagittal translation with OT/APP assistance, and greater sagittal translation without assistance. The initiation of a cast application-training program in 2015 decreased the need for surgical treatment in the resident-only group (pre-program 38.5% vs post-program 17%), although this was not statistically significant. Conclusion: When residents were assisted by OT/APP with initial tibia closed reduction and casting, subsequent loss of reduction was more likely to be managed with cast wedging; when this assistance was not available, there was a higher rate of fractures needing surgical intervention due, in part, to poor casting technique. The reduction in the rate of surgical intervention after an internal training program was implemented suggests that trainees may improve their casting ability without added help of an experienced assistant. Future study should be performed on distal radius fractures to determine if the presented findings are valid across casting types

Recurrence of Patellar Instability in Adolescents Undergoing Surgery for Osteochondral Defects Without Concomitant Ligament Reconstruction.

BackgroundFirst-time patellar dislocation with an associated chondral or osteochondral loose body is typically treated operatively to address the loose fragment. The incidence of recurrent instability in this patient population if the medial patellofemoral ligament (MPFL) is not reconstructed is unknown.PurposeTo determine the recurrent instability rate in patients undergoing surgery for patellar instability with chondral or osteochondral loose bodies, as well as to identify and stratify risk factors for recurrent instability.Study designCase series; Level of evidence, 4.MethodsThis was a retrospective analysis of adolescent patients treated operatively for acute patellar dislocation with associated chondral or osteochondral loose bodies between 2010 and 2016 at a single pediatric level I trauma center with minimum 2-year follow-up. Potential demographic, injury-related, radiographic, and surgical risk factors were recorded. The primary outcome variable was recurrent subluxation and/or dislocation. Secondary outcome variables included need for additional procedures, Kujala score, Single Assessment Numerical Evaluation (SANE) score, and patient satisfaction.ResultsForty-one patients were included. In total, 61% experienced recurrent instability at a mean follow-up of 4.1 years and 39% required subsequent MPFL reconstruction. Tibial tubercle-trochlear groove (TT-TG) distance greater than 15 mm was a risk factor for recurrent instability ( P = .03). Patients with TT-TG distance greater than 15 mm and greater than 20 mm had recurrent instability rates of 75% and 86%, respectively. MPFL repair did not reduce the rate of recurrent instability ( P = .87). Recurrent instability was associated with significantly worse mean Kujala (93.9 vs 83.0; P = .01), SANE (88.9 vs 73.1; P = .01), and patient satisfaction scores (9.4 vs 7.3; P = .002).ConclusionIf the MPFL is not reconstructed during index loose body treatment, children have a 61% recurrent instability rate. Patients with TT-TG distance greater than 15 mm, and particularly greater than 20 mm, are at highest risk for recurrent instability

A Detailed Comparative Analysis of Anterior Versus Posterior Approach to Lenke 5C Curves

STUDY DESIGN: Prospective cohort study. OBJECTIVE: To prospectively compare radiographic, perioperative, and functional outcomes between anterior spinal instrumentation and fusion (ASIF) and posterior spinal instrumentation and fusion (PSIF) in Lenke 5C curves. SUMMARY OF BACKGROUND DATA: Historically, ASIF has been the treatment of choice for treatment of thoracolumbar adolescent idiopathic scoliosis. More recently, PSIF has gained popularity for its ease, versatility, and amount of correction achieved. Current literature lacks a prospective comparative analysis between these two approaches to better aid treating surgeons in decision making when treating Lenke 5C curves. METHODS: A prospective, longitudinal multicenter adolescent idiopathic scoliosis database was used to identify 161 consecutive patients with Lenke 5C curves treated by ASIF with a dual rod system, or PSIF with a pedicle screw-rod construct. Pre- and 2-year postoperative radiographic data, Scoliosis Research Society outcome scores, and perioperative comparisons were made between the two approaches. RESULTS: A total of 69 patients were treated with ASIF and 92 patients with PSIF. Curve extent, magnitude, stable, and end vertebrae distribution before surgery were similar between the two groups. At 2-year follow-up, there were no significant differences in percentage correction of the main curve (ASIF: 59.1%, PSIF: 59.6%), C7 decompensation (ASIF: -0.6 ± 1.2, PSIF: -0.3 ± 1.4 cm), length of hospital stay (ASIF: 5.6 days, PSIF: 5.7 days), postoperative day conversion to oral pain medication (ASIF: 3.2 days, PSIF: 3.2 days), and SRS outcome scores (P = 0.560) between the two groups. The number of levels fused was significantly lower in ASIF group (ASIF: 4.7, PSIF: 6.3; P < 0.001), but PSIF resulted in significantly less disc angulation below lowest instrumented vertebrae (ASIF: 3.4°, PSIF: 1.7°; P = 0.011), greater lumbar lordosis (P < 0.001), and greater % correction of lumbar prominence (P = 0.017). CONCLUSION: The amount of correction achieved was similar between ASIF and PSIF. ASIF resulted in shorter fusions (average 1.6 levels) compared with PSIF. This was at the expense of increased disc angulation below the lowest instrumented vertebrae, less lumbar lordosis, and a lower % correction of the lumbar prominence than PSIF