Surgeon practices regarding infection prevention for growth friendly spinal procedures

Purpose The rate of infection in patients having growth sparing surgery for early onset scoliosis has been reported up to 25 % during the course of treatment. A recent study demonstrated significant variability in the approach to infection prevention in adolescent and neuromuscular scoliosis. The purpose of this study is to conduct a similar survey in order to understand approaches used by experienced pediatric spinal surgeons with regard to infection prevention in growth friendly spinal procedures. Materials and methods After preliminary internal testing of a survey by the authors, a final 21-question survey was created and approved by the authors and electronically distributed to all members of the Chest Wall Spinal Deformity Study Group and the Growing Spine Study Group (n = 57). A total of 40 responses were obtained (70 %). Results: Significant variability in practice was demonstrated across the majority of the questions answered. Several of the questions demonstrated relative equipoise between practices, including preoperative MRSA screening, preoperative chlorhexidine baths, postoperative antibiotic duration after insertion, use of topical antibiotics, use of drains, use of IV gram negative coverage or vancomycin, and skin preparation. Conclusion: Other studies have demonstrated that variability in practice may have a negative impact on clinical outcomes, so one could postulate that steps that can reduce variability in the current population may help improve outcomes in this population. Areas of clinical equipoise can be used to help design and direct multicenter studies with an ultimate goal of reducing infections in this population. Level of evidence Level V. Electronic supplementary material The online version of this article (doi:10.1007/s11832-014-0584-1) contains supplementary material, which is available to authorized users

Extent of Spine Deformity Predicts Lung Growth and Function in Rabbit Model of Early Onset Scoliosis

<div><p>Early onset deformity of the spine and chest wall (initiated <8 years of age) is associated with increased morbidity at adulthood relative to adolescent onset deformity of comparable severity. Presumably, inhibition of thoracic growth during late stage alveolarization leads to an irreversible loss of pulmonary growth and thoracic function; however the natural history of this disease from onset to adulthood has not been well characterized. In this study we establish a rabbit model of early onset scoliosis to establish the extent that thoracic deformity affects structural and functional respiratory development. Using a surgical right unilateral rib-tethering procedure, rib fusion with early onset scoliosis was induced in 10 young New Zealand white rabbits (3 weeks old). Progression of spine deformity, functional residual capacity, total lung capacity, and lung mass was tracked through longitudinal breath-hold computed tomography imaging up to skeletal maturity (28 weeks old). Additionally at maturity forced vital capacity and regional specific volume were calculated as functional measurements and histo-morphometry performed with the radial alveolar count as a measure of acinar complexity. Data from tethered rib rabbits were compared to age matched healthy control rabbits (N = 8). Results show unilateral rib-tethering created a progressive spinal deformity ranging from 30° to 120° curvature, the severity of which was strongly associated with pulmonary growth and functional outcomes. At maturity rabbits with deformity greater than the median (55°) had decreased body weight (89%), right (59%) and left (86%) lung mass, right (74%) and left (69%) radial alveolar count, right lung volume at total lung capacity (60%), and forced vital capacity (75%). Early treatment of spinal deformity in children may prevent pulmonary complications in adulthood and these results provide a basis for the prediction of pulmonary development from thoracic structure. This model may also have future use as a platform to evaluate treatment effectiveness.</p></div

Pediatric forearm fractures with in situ intramedullary implants

Purpose The purpose of this investigation is to present our institutional experience with fractures of the pediatric forearm with in situ intramedullary nails. Methods: Six patients treated at our institution for forearm fracture with in situ intramedullary implants between 2004 and 2013 were reviewed. Patient demographics, injury and radiographic characteristics, method of treatment, time to union, and complications were collected from the medical record. Results: 485 patients with forearm fractures were treated with intramedullary implants and six patients presented with a fracture with in situ implants (1.2 %). Fractures in all six patients resulted from a second traumatic event after radiographic healing but before implant removal at a mean of 13.0 months from the initial procedure. One patient had an adequately aligned fracture and was treated with casting without reduction. The remaining five patients (83 %) returned to the operating room for treatment. Two patients underwent rod removal and placement of new intramedullary implants, and two patients were treated with rod removal and plating without attempt at closed reduction. One patient underwent closed reduction in the operating room with successful re-bending of the radial implant and replacement of the ulna implant. All patients went on to uncomplicated radiographic union at a mean 3.6 months. Conclusions: The incidence of fracture of pediatric forearm with in situ intramedullary implants is low. This rare complication can be treated by several different methods, including revision TENS placement, revision to plate fixation, or in situ bending of rods, with the expectation for successful uncomplicated union

Deformity.

<p>(A) Maximal overall spine deformity, θ_M, in each group at all time points and (B) TRA in each group for all time points are shown. Bonferroni statistical significance is indicated: *p<0.05; **p<0.01; ***p<0.001.</p

Radial alveolar count.

<p>Alveolar histology of a representative (A) Normal and (B) Severe rabbit showing the radial alveolar count. A line is drawn from the center of the respiratory bronchiole perpendicular to the nearest interlobular septa, each saccule bisected by this line is counted.</p

Comparisons of CT and histology derived measures of lung development in the left and right lungs.

<p>Values are shown for each experimental group as a percentage of Normal, with standard deviation in parentheses. Statistically significant correlations are indicated:</p><p>*p<0.05</p><p>**p<0.01</p><p>***p<0.001.</p><p>Comparisons of CT and histology derived measures of lung development in the left and right lungs.</p

Tethering surgery.

<p>Tethering ribs 3–9 comprising the right hemithorax: (A) longitudinal incision exposing ribs; (B) ribs constricted with blue vessel loop; (C) polyester suture tied off to maintain constriction of right hemithorax, vessel loop removed.</p

Local specific volume.

<p>Comparison of image registration results between Normal (top row), Moderate (center) and Severe (bottom) rabbits. Column (A): coronal slice with the registration displacement map, magnitude and direction of displacements are indicated by yellow vectors. Column (B): axial slice with derived sVol map, hot colors indicate greater expansion and green neutral. Column (C): Comparison of regional sVol, posterior to anterior, between Normal, Severe, and Moderate rabbits at each phase of inspiration. Error bars show SD.</p

Progression of Deformity.

<p>Linear regression comparing spine deformity at 6 weeks to 28 weeks post-natal age is shown.</p

Respiratory elastance.

<p>Dynamic elastance versus spine deformity, θ_M. Normal rabbits are indicated by circles, Moderate deformity by triangles, and Severe deformity by diamonds.</p