Pediatric Orthopaedic Procedures Research Articles

INCREASED INCIDENCE OF ACUTE PATELLAR INSTABILITY AND PATELLAR INSTABILITY SURGERY ACROSS THE UNITED STATES IN PEDIATRIC & ADOLESCENT PATIENTS

Background: Participation in organized sports has been increasing over the last several decades for pediatric and adolescent athletes in this country. It is hypothesized that the overall incidence of acute patellar dislocation in this population would increase with more sports participation. Newer surgical techniques for patellar stabilization have also become popular and have been adapted for younger populations. The purpose of the current study was to evaluate the trend in the frequency of patellar dislocations treated at pediatric hospitals in the U.S. versus patients receiving surgical intervention for patellar dislocation. Methods: The Pediatric Health Information System (PHIS) database was queried for all patients 18 years or younger who underwent orthopaedic surgery between 2004 and 2014. A cohort of patients treated surgically for patellar dislocation was compared to a cohort of patients seen in the Emergency Department for management of a patellar dislocation. Data sets from 25 of the 48 pediatric hospitals participating in the PHIS initiative reported data consistently for the study time period and were included in the analysis. The rate of patellar dislocation surgeries per 1,000 pediatric orthopedic surgeries was analyzed for the 11-year period. Linear modeling was used to assess sex-based and overall trends. Results: During the study period, there were 447,285 orthopaedic surgeries at 25 institutions, which included 3,481 patellar dislocation procedures, suggesting a rate of 7.8 per 1,000 orthopaedic surgeries. An additional 5,244 patellar dislocations treated in the emergency room were identified. Over the study period, the number of patellar dislocation procedures increased 2.1-fold (95% CI = 1.4-3.0), while all surgeries increased 1.7-fold (95% CI = 1.3-2.0). There was only a 1.2-fold increase in patellar dislocation procedures relative to total pediatric orthopedic procedures. Emergency Department treatment of patellar dislocation increased 2.8-fold. Females yielded similar trends between operative and Emergency Department treatment of patellar instability (2.2-fold and 2.3 –fold, respectively); while males experienced a higher trend in the need for Emergency Department treatment compared to operative treatment (3.0-fold versus 2.0-fold, respectively). Conclusion / Significance: This study shows a significant rise in the rate of acute patellar instability events in pediatric and adolescent patients across the country. Interestingly, surgery for patellar instability increased by only slightly more than the rate of all pediatric orthopaedic procedures. Further research is needed to evaluate the link between increased acute patellar instability and risk for chronic patellar instability along with the potential need for surgical intervention.

How Much Will My Child's Operation Cost? Availability of Consumer Prices From US Hospitals for a Common Pediatric Orthopaedic Surgical Procedure.

Price transparency allows patients to make value-based health care decisions and is particularly important for individuals who are uninsured or enrolled in high-deductible health care plans. The availability of consumer prices for children undergoing orthopaedic surgery has not been previously investigated. We aimed to determine the availability of price estimates from hospitals in the United States for an archetypal pediatric orthopaedic surgical procedure (closed reduction and percutaneous pinning of a distal radius fracture) and identify variations in price estimates across hospitals. This prospective investigation utilized a scripted telephone call to obtain price estimates from 50 "top-ranked hospitals" for pediatric orthopaedics and 1 "non-top-ranked hospital" from each state and the District of Columbia. Price estimates were requested using a standardized script, in which an investigator posed as the mother of a child with a displaced distal radius fracture that needed closed reduction and pinning. Price estimates (complete or partial) were recorded for each hospital. The number of calls and the duration of time required to obtain the pricing information was also recorded. Variation was assessed, and hospitals were compared on the basis of ranking, teaching status, and region. Less than half (44%) of the 101 hospitals provided a complete price estimate. The mean price estimate for top-ranked hospitals ($17,813; range, $2742 to $49,063) was 50% higher than the price estimate for non-top-ranked hospitals ($11,866; range, $3623 to $22,967) (P=0.020). Differences in price estimates were attributable to differences in hospital fees (P=0.003), not surgeon fees. Top-ranked hospitals required more calls than non-top-ranked hospitals (4.4±2.9 vs. 2.8±2.3 calls, P=0.003). A longer duration of time was required to obtain price estimates from top-ranked hospitals than from non-top-ranked hospitals (8.2±9.4 vs. 4.1±5.1 d, P=0.024). Price estimates for pediatric orthopaedic procedures are difficult to obtain. Top-ranked hospitals are more expensive and less likely to provide price information than non-top-ranked hospitals, with price differences primarily caused by variation in hospital fees, not surgeon fees. Level II-economic and decision analyses.

National Databases in Pediatric Orthopaedic Surgery: A Comparison of Demographics, Procedures, and Outcomes.

Large national databases have been increasingly used in recent years to determine the rate of adverse events and identify factors associated with altered surgical outcomes. This can be especially useful to evaluate rare events such as 30-day mortality. Despite differences between national pediatric databases, there have been no comparison studies in the pediatric orthopaedic population. The Healthcare Cost and Utilization Project's Kids' Inpatient Database (KID) along with the American College of Surgeons National Surgical Quality Improvement Program Pediatric (NSQIP Pediatric) databases were queried to identify common pediatric orthopaedic procedures for humeral fractures, scoliosis, slipped capital femoral epiphysis, and femoral fractures during a single year. Clinical characteristics and complications in the 2 databases were compared using Student t test, χ, or Fisher' exact test. In total, 26,978 patients in the KID and 5186 patients in the NSQIP Pediatric databases were identified. Large differences were observed between the databases in identical procedure categories with respect to age, race, sex, and length of stay. Regardless of procedure, NSQIP Pediatric had statistically higher reported rates of cumulative complications. Surgical site infections and sepsis were consistently observed to be at least twice as common in the NSQIP Pediatric database in comparison to the KID. Overall, complication rates ranged from <1% in humeral fractures to >100% in neuromuscular scoliosis. Clinically and statistically significant differences exist between the KID and NSQIP Pediatric databases. Clinicians and researchers who utilize large databases must understand the differences in data import, quality control, and population sampling in order to provide adequate representation of the population as a whole. Level III, prognostic study.

Variation in pediatric orthopedic case volume among residents: an assessment of Accreditation Council for Graduate Medical Education case logs.

The aim of this investigation was to examine graduating orthopedic resident case logs to evaluate trends in performing pediatric orthopedic procedures and compare pediatric orthopedic case volume among residents in the 90th, 50th, and 10th percentiles (by case volume) to identify caseload variation. Accreditation Council for Graduate Medical Education orthopedic resident case logs were examined for graduating years 2007-2013. Linear regression analyses were carried out to assess temporal trends in pediatric orthopedic case volume. Subgroup analyses were carried out to assess trends in cases by anatomic location. Comparisons of the number of pediatric cases performed by the 90th, 50th, and 10th percentiles of graduating residents were also performed. Pediatric orthopedic case volume increased significantly per graduating resident (295.9-373.2; P<0.001) from 2007 to 2013. Graduating residents in the 90th (494-573; P=0.001), 50th (264-334; P<0.001), and 10th (144-216; P=0.003) percentiles of case volume all sustained significant increases in the number of pediatric orthopedic cases performed. Subgroup analyses showed significant increases in pediatric orthopedic shoulder (4.8-7.3; P<0.001), humerus/elbow (25.9-32.7; P<0.001), forearm/wrist (28.6-40.4; P<0.001), hand/finger (15-16.9; P=0.005), femur/knee (44.5-51.9; P=0.002), leg/ankle (39.4-41.1; P=0.004), and spine case volume (24.9-33.6; P<0.001). On average, graduating residents in the 90th, 50th, and 10th percentiles performed 524, 302, and 169 cases, respectively. The current investigation shows significant growth in the number of pediatric orthopedic cases performed by graduating residents, particularly among upper extremity procedures. However, considerable variation in pediatric orthopedic case volume exists among residents. Although the educational effects of this case volume variation are incompletely understood, the current investigation may be beneficial in efforts to improve pediatric orthopedic educational quality.

Resident Exposure to Pediatric Orthopaedic Procedures During Orthopaedic Residency

Resident Exposure to Pediatric Orthopaedic Procedures During Orthopaedic Residency

Evidence-based Pediatric Orthopaedics: How Safe is "Safe"?

The aim of minimizing the risks of complications and adverse events is at the center of surgical practice.This study aimed to assess the evidence on which pediatric orthopaedic surgical procedures are described as "safe." In particular, the objective was to ascertain the proportion of studies describing a procedure as "safe," which achieved a 95% upper limit confidence interval of risk of 5% or less for major adverse events. A primary search of Journal of Paediatric Orthopaedics 2009 to 2014 for the single term "safe" returned 71 papers appropriate for analysis. Of these, 60 positively identified at least 1 intervention as "safe." These papers were analyzed and the number of interventions and the number of complications recorded. Data sets (n=67) were created and the 95% upper confidence interval calculated for the probability of a complication. Only 16 data sets (ex 67) provided evidence that the probability of a major complication was under 5%. This work suggests there is widespread failure of understanding of how low sample sizes or can lead to an unjustifiable claim that procedures are "safe." Unclassifiable.

Prevalence of Recent Antimicrobial Exposure among Elective Surgical Patients.

The annual prevalence of antimicrobial exposure is high in the outpatient setting and should be a common exposure for surgical patients. Antimicrobials have negative side effects and may be associated with poor outcomes. Logically, one would expect surgical patients to be particularly susceptible to any negative effects of recent antimicrobial exposure. Despite these observations, however, the prevalence of recent antimicrobial exposure among surgical patients remains undefined. The purpose of this study is to define the prevalence of antimicrobial exposure in patients undergoing elective surgical procedures. Patients presenting for elective operations between August 4, 2015 and August 3, 2016 at our institution were asked prospectively about any antimicrobial exposure in the previous three months. Answers were recorded as either Yes, No, or Unsure. Patients were grouped according to age, American Society of Anesthesiologists (ASA) score, primary operative service, and post-operative destination. Descriptive statistics were employed using simple percentages and chi-square analysis when appropriate. Cochrane-Armitage test was used to evaluate temporal trends. There were 21,473 elective surgical procedures performed during the study period across 13 operative services. Answers were recorded for 91.2% cases. The overall prevalence of exposure during this period was 28.6%. Exposure varied with age, ASA score, and surgical specialty. Vascular and transplant operations had the highest prevalence of exposure while ophthalmology and pediatric orthopedic procedures had the lowest. Patients with recent antimicrobial exposure were less likely to be discharged home on the same day and more likely to be admitted to an intensive care or intermediate care unit than those who denied recent exposure. In this descriptive analysis, the prevalence of recent antimicrobial exposure is overall approximately 28.6% and is higher than anticipated. Further work is needed to determine to what extent, if any, recent antimicrobial exposure impacts post-operative outcomes.

Which Pediatric Orthopaedic Procedures Have the Greatest Risk of Adverse Outcomes?

Quality improvement in orthopaedic surgery has received increasing attention; however, there is insufficient information available about the perioperative safety of many common pediatric orthopaedic procedures. This study aimed to characterize the incidence of adverse events in a national pediatric patient sample to understand the risk profiles of common pediatric orthopaedic procedures, and to identify patients and operations that are associated with increased rates of adverse outcomes. A retrospective cohort study was conducted using the prospectively collected American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Pediatric database. Pediatric patients who underwent 29 different orthopaedic procedures were identified in the 2012 NSQIP Pediatric database. The occurrence of any adverse event, infection, return to the operating room, and readmission within 30 days, were reported for each procedure. Multivariate regression was then used to identify the association of patient and operative characteristics with the occurrence of each adverse outcome. A total of 8975 pediatric patients were identified. Supracondylar humerus fracture fixation was the most common procedure performed in this sample (2274 patients or 25.57% of all procedures), followed by posterior spinal fusion (1894 patients or 21.10% of all procedures). Adverse events occurred in 352 patients (3.92% of all patients). Four deaths were noted (0.04% of all patients), which only occurred in patients with nonidiopathic scoliosis undergoing spinal fusion. Infections occurred in 143 patients (1.59%), and 197 patients (2.19%) were readmitted within 30 days. Multiple patient characteristics and procedures were found to be associated with each adverse outcome studied. Spinal fusion, multiaxial external fixation, and fasciotomy were procedures associated with increased rates of adverse outcomes within 30 days. Patients with obesity, ASA class ≥3, and impaired cognitive status also had increased rates of adverse outcomes. The results from this study of a large, national sample of pediatric orthopaedic patients are important for benchmarking and highlight areas for quality improvement. Level III-Prognostic.

Operative Intervention of Supracondylar Humerus Fractures More Complicated in July: Analysis of the July Effect.

The "July Effect" involves the influx of new interns and residents early in the academic year (July and August), which may have greater potential for poorer patient outcomes. Current orthopaedic literature does not demonstrate the validity of this concept in arthroplasty, spine, hand, and arthroscopy. No study has investigated the possibility of this effect on common pediatric orthopaedic procedures, such as closed reduction and percutaneous pin fixation of supracondylar humerus fractures. A retrospective review of all type II or III supracondylar humerus fractures that underwent primary closed reduction and percutaneous pin fixation (CPT code 24538) at a single pediatric level 1 trauma center from July 2009 to June 2013. Patients were grouped according to time in the academic year: early (July and August) and late (May and June). Demographic data included length of follow-up, age at surgery, sex, side of injury, and Wilkin's modified Gartland classification. Outcomes included length of operation, number of pins used, length of stay, complications, and the need for repeat surgery. There were 245 patients, 101 in the early and 144 in the late group. There was no increase in surgical time [33.32±24.74 (early) vs. 28.63±10.06 (late) min, P=0.07) or complication rates [7.0% (early) vs. 2.1% (late), P=0.06) between the early and the late groups. Cases performed with junior residents demonstrated longer operative (31.72±17.07 vs. 28.96±18.71 min, P=0.02) and fluoroscopy (48.63±30.96 vs. 34.12±27.38 s, P=0.01) times. The academic orthopaedic surgeon must ensure the education of residents, while providing the highest level of safety to patients. Our study shows that education of young residents early in the academic year results in no increase in operative times, radiation exposure, or complications. Level III.

Socioeconomic Factors Are Associated With Trends in Treatment of Pediatric Femoral Shaft Fractures, and Subsequent Implant Removal in New York State.

Disparities exist in access to outpatient pediatric orthopaedic care. The purpose of this study was to assess whether disparities also exist in elective pediatric orthopaedic surgical procedures such as implant removal, and to determine which demographic and socioeconomic factors may be associated with differences in treatment. Children aged 7 to 18 inclusive who sustained femoral shaft fractures between the years 1997 and 2010 were identified in the New York State SPARCS database. Patient age, sex, race/ethnicity, insurance status, education, and poverty were identified. Factors associated with the method of fracture treatment were assessed through multivariate regression analysis. The subset of patients that received internal fixation were followed up until 2011 inclusive for implant removal. Factors associated with implant removal were assessed using a Cox proportional hazards survival analysis (time to implant removal). Of the 3220 closed femoral shaft fractures identified, 2609 (81%) were treated with internal fixation, 9 (0.3%) had open treatment without implants, 203 (6.3%) were treated with external fixation, and 399 (12.4%) with closed methods. Patients with No Fault/Accident insurance by No Fault/Accident insurance were more likely to undergo internal fixation compared with patients with private insurance (P<0.001). Of the 3220 patients, 2572 were included in the implant removal subanalysis. Implant removal was performed in 725 (28.2%) patients. In the multivariate model, patients were more likely to undergo removal if they were younger (P<0.001), white [vs. black (P<0.001), vs. Hispanic (P=0.035), vs. other (P=0.001)], and lived in neighborhoods with less poverty (P=0.016). Insurance status was not a statistically significant predictor of implant removal. There is an association between implant removal and younger age, white race, and higher socioeconomic status in children. Awareness of these disparities should prompt further evaluation of causation, whether it be from lack of evidence-based guidelines for implant removal, surgeon bias, variations in reimbursement, or disparities in access to care. Further study is recommended to better elucidate the indications for implant removal in children and the causes for the disparities identified here. Level III-retrospective cohort study.

Are Orthopaedic Residents Competent at Performing Basic Nonoperative Procedures in an Unsupervised Setting? A "Pop Quiz" of Casting, Knee Arthrocentesis, and Pressure Checks for Compartment Syndrome.

Many patient care procedures are routinely performed by orthopaedic residents while not directly supervised by attending physicians. However, resident competence to perform these procedures is often presumed and not confirmed by objective measures. The purpose of this study was to formally evaluate 3 basic pediatric orthopaedic procedures commonly performed without attending supervision. All orthopaedic residents (n=20) were asked to complete 3 procedures (placement and removal of a short arm cast, aspiration of a knee joint, and compartment pressure checks of a leg) under direct attending supervision. Attending faculty developed a checklist for each procedure, listing the appropriate steps required and criteria with which to assess the final results. Scores were calculated, including means and SDs. Change in score by postgraduate year level was determined by simple linear regression. The mean score for short arm cast application and removal was 6.2 of a total possible score of 8, with an average 1.1 increase in score per year of training (P<0.001). Uneven cast padding and lack of full thumb motion were the most common reasons for losing points. Knee joint aspiration had an average score of 6.2 of 7, with an average increase in score of 0.3 per year of training (P=0.046). Lack of equipment preparation and not donning gloves in a sterile manner were the most common reasons for losing points. Measure of leg compartment pressures had an average score of 9.7 of 12, with an average increase in score of 0.5 per increase in year of training (P=0.087). Injecting an inappropriate amount of fluid and not recording measurements were the most common reasons for losing points. The ability of a resident to appropriately perform certain procedures without direct supervision improves with advancing level of training. The most junior residents might not appropriately be placing short arm casts, aspirating knee joints, or checking compartment pressures of the leg. Level II—Diagnostic.

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

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. 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. 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. 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 IV—case series.

Evaluating the Use of Preoperative Antibiotics in Pediatric Orthopaedic Surgery

To evaluate the rate of infection after minimally invasive procedures on a consecutive series of pediatric orthopaedic patients. We hypothesized that the use of preoperative antibiotics for minimally invasive pediatric orthopaedic procedures does not significantly reduce the incidence of surgical site infection requiring surgical debridement within 30 days of the primary procedure. We retrospectively reviewed 2330 patients having undergone minimally invasive orthopaedic procedures at our institution between March 2008 and November 2010. Knee arthroscopy, closed reduction with percutaneous fixation, soft tissue releases, excision of bony or soft-tissue masses, and removal of hardware constituted the vast majority of included procedures. Two groups, based on whether prophylactic antibiotics were administered before surgery, were created and the incidence of a repeat procedure required for deep infection was recorded. Statistical analysis was performed to determine significance, if any, between the 2 groups. Chart review of the 2330 patients identified 1087 as having received preoperative antibiotics, whereas the remaining 1243 patients did not receive antibiotics before surgery. Only 1 patient out of the 1243 cases in which antibiotics were not given required additional surgery within 30 days of the primary procedure due to a complicated surgical site infection (an incidence of 0.0008%). No patients in the antibiotic group developed a postoperative infection within 30 days requiring a return to the operating room for management. Our data revealed no significant increase in the incidence of complicated infection requiring additional procedures when antibiotics were not administered before surgery. Though prophylactic antibiotics have been shown to confer numerous benefits for patients undergoing relatively major operations, their use in cases of minimally invasive and/or percutaneous orthopaedic surgery is not well defined. Our data suggest that the use of prophylactic antibiotics may not be indicated for many less invasive procedures when performed in a low-risk pediatric population. Future studies are warranted to help establish evidence-based guidelines regarding the routine use of prophylactic antibiotics in this specific population, hopefully resulting in improved cost-effectiveness and safety while slowing the emergence of new drug-resistant organisms. Level III, retrospective comparative.

Experience with a propofol-ketamine mixture for sedation during pediatric orthopedic surgery

Various combinations of propofol and ketofol have been described for the provision of procedural sedation in both adults and children. Utilization of 'ketofol' for deep sedation during prolonged pediatric orthopedic procedures has not previously been described. During an orthopedic aid trip, a 1:1 mixture of propofol and ketamine (200 mg of each drawn up to 22 ml) was utilized to provide deep sedation or general anesthesia as an adjunct to regional analgesia for lower limb surgery. Details for 18 patients having a total of 19 procedures were recorded with a record of intraoperative and postoperative parameters including initial bolus doses and infusion rates of ketofol required to produce deep sedation. Mean operating time was 153.7 min (range 64-241 min). The mean initial bolus dose of ketofol was 0.19 ml·kg(-1) (range 0.1-0.5 ml·kg(-1) ) or 1.7 mg·kg(-1) each of propofol and ketamine (range 0.9-4.5 mg·kg(-1) ). The mean upper limit of the infusion rate required to maintain deep sedation was 0.19 ml·kg(-1) ·h(-1) (range 0.07-0.26 ml·kg(-1) ·h(-1) ) or 1.7 mg·kg(-1) ·h(-1) (range 0.6-2.4 mg·kg(-1) ·h(-1) ) and the mean lower limit of the infusion rate was 0.08 ml·kg(-1) ·h(-1) (range 0.02-0.13 ml·kg(-1) ·h(-1) ) or 0.7 mg·kg(-1) ·h(-1) (range 0.2-1.2 mg·kg(-1) ·h(-1) ). The mean initial bolus dose of ketofol was 0.19 ml·kg(-1) (range 0.1-0.5 ml·kg(-1) ). There were no episodes of hypo- or hypertension or of desaturation. Mean time to eye opening after infusion cessation was 5.1 min (median 2 min; range 0-17 min). Ketofol successfully produced deep sedation for prolonged pediatric orthopedic procedures in conjunction with regional analgesia. Further research to confirm its safety and applicability to a wider range of settings is required.

Urban Pediatric Orthopaedic Surgical Practice Audit: Implications for the Future of This Subspecialty

The growth and development of the physis distinguishes the child from the adult. There are historical lines of referral that direct a substantial amount of elective procedures for adolescent idiopathic scoliosis and for hip and foot pathology in children and adolescents to pediatric orthopaedic surgeons. Over twenty million children are injured each year, with an incidence of one of every four children1,2. Trauma is the leading cause of death and disability in children3-6. Coincident with an ever-expanding amount of pediatric trauma, many general hospitals have terminated their pediatric trauma services7-9. These factors have resulted in increasing numbers of children presenting to pediatric orthopaedic surgical outpatient clinics and to pediatric hospitals, particularly those with active pediatric trauma programs. Trauma call responsibility has become an important quality-of-life issue for many pediatric orthopaedic surgeons8,10-15. In an attempt to better understand the status quo of pediatric orthopaedic surgical practice, we analyzed the pediatric orthopaedic surgical practice at our institution over the last decade with specific attention directed to the area of trauma surgery. Our goal was to specifically define the current surgical composition of an urban pediatric orthopaedic surgical practice and contrast it to the work done almost a decade earlier. This information should be of value to all practicing pediatric orthopaedic surgeons, residents considering a career in pediatric orthopaedics, hospital administrators, and orthopaedic training program directors designing an optimal residency training exposure. We utilized the operating-room computerized database of surgical cases at our institution to identify all pediatric orthopaedic surgical procedures done in the operating room for fiscal years 1998 and 1999 and compared them with data for fiscal years 2006 and 2007. If necessary, the operative reports were reviewed for further clarification of the …

Patient-Controlled Epidural Analgesia Versus Continuous Epidural Infusion with Ropivacaine for Postoperative Analgesia in Children

Epidural ropivacaine infusion has been used in children; however, patient-controlled epidural analgesia (PCEA) has not been evaluated in the pediatric population. In this study, we compared the clinical efficiency of PCEA and of continuous epidural infusion analgesia (CEA) in children. Forty-eight children undergoing orthopedic surgery were randomized to receive PCEA or CEA with ropivacaine 0.2%. All patients underwent a standard general anesthetic. Children also received ketoprofen and propacetamol. Pain scores and side effects were recorded for 48 h. If the visual analog score scale score was >4 of 10, analgesia was considered inadequate, and rescue treatment was administered. Both groups obtained effective pain relief. Children in the PCEA group received significantly less local anesthetic than those in the CEA group (0.20 +/- 0.08 mg x kg(-1) x h(-1) versus 0.40 +/- 0.08 mg x kg(-1) x h(-1); P < 0.001). Motor effects, supplemental analgesic requirements, and side effects did not differ. We concluded that PCEA with ropivacaine 0.2% can provide adequate postoperative analgesia for pediatric orthopedic procedures with smaller dose requirements than CEA. We studied patient-controlled epidural analgesia (PCEA) and continuous epidural infusion analgesia (CEA) with 0.2% ropivacaine during the postoperative period in children. We found that either PCEA or CEA with plain ropivacaine 0.2% provided adequate pain relief in children during the first 48-h postoperative course. However, adequate analgesia was obtained with 50% less volume infused with PCEA compared with CEA.

Endoscopic pelvic osteotomy for the treatment of hip dysplasia.

Adolescent and adult hip dysplasia can be surgically treated by rotating the acetabulum into a better weight-supporting position; however, open pelvic osteotomies are among the most invasive of all pediatric orthopaedic procedures. Endoscopic pelvic osteotomy offers the theoretical advantages of magnified visualization of the bone cuts, minimized surgical dissection, and rapid postoperative recovery. The technique of endoscopically assisted triple innominate osteotomy requires the combination of endoscopic skills and facility with more standard surgical approaches.

Developing and Implementing Pediatric Analgesia and Sedation Guidelines at San Francisco General Hospital

A Pediatric Analgesia and Sedation Subcommittee, under the auspices of the San Francisco General Hospital Department of Pediatrics, Quality Assurance Committee, was created and charged with the development of pediatric guidelines. Membership included all health care providers who treated children in all care areas of the hospital: pediatricians, emergency physicians, family practitioners, neurologists, surgeons, intensivists, anesthesiologists, registered nurses, and pharmacists. Guiding principles were that the pediatric pain and sedation guidelines would be effective, easy to employ, based on well-accepted medications, and be child friendly. The focus was to develop analgesia and sedation guidelines for patients undergoing a wide range of medical and surgical procedures. The subcommittee then constructed a series of tables with the appropriate management strategies (including specific medications, doses and delivery routes) for pediatric orthopedic, surgical, and diagnostic procedures, and for sickle ce...

Healing of a Large Nonossifying Fibroma After Grafting With Bone Matrix and Marrow

Healing of a large tibial nonossifying fibroma in a 12-year-old girl occurred following excision, curettage, and filling of the bony defect with human demineralized bone matrix powder mixed with a small quantity of the patient's bone marrow. The use of this graft composite was successful in the treatment of the lesion and reduced the potential risk and morbidity associated with pediatric orthopedic surgical procedures with autogeneic iliac crest and other bone grafts.