Video-Assisted Thoracoscopy for Vertebral Body Tethering of Juvenile and Adolescent Idiopathic Scoliosis: Tips and Tricks of Surgical Multidisciplinary Management

VATS (video assisted thoracoscopic surgery) is routinely and successfully performed in minor and major complex thoracic procedures. This technique has been recently introduced for the treatment of severe forms of idiopathic scoliosis (IS) with the aim to repair the deformity, reduce morbidity and to prevent its progression in patients with skeletal immaturity. This study aims to present VATS in anterior vertebral body tethering (AVBT) approach to support the pediatric orthopedic surgeons during vertebral body fixation. Surgical and anesthesiologic tips and tricks are reported to assure a safe procedure. The study includes preadolescents with IS and a grade of scoliosis >40° that had a high probability of deterioration due to remaining growth (December 2018 to April 2021). Skeletal immaturity of enrolled patients was assessed by Sanders classification and Risser sign. Patients had a Risser score between 0 and 1 and a Sanders score >2 and <5. AVBT technique using VATS was performed by a senior pediatric surgeon assisting the pediatric orthopedic surgeon. Twenty-three patients have been submitted to VATS AVBT in the period of study (age range 9–14 years). The patients had a classified deformity Lenke 1A or B convex right and all types of curves were treated. In all patients, the vertebrae submitted to tethering surgery ranged from D5 to D12; mean curve correction was 43%. Three postoperative complications occurred: one late postoperative bleeding requiring a chest tube positioning on 12th postoperative day; one screw dislodged and needed to be removed; one child showed worsening of the scoliosis and needed a posterior arthrodesis. Initial results of VATS AVBT in growing patients with spinal deformities are encouraging. An appropriate selection of patients and a pediatric dedicated multidisciplinary surgical approach decrease intraoperative complications, time of operation and postoperative sequelae and guarantee an optimal outcome.

The Orthopedic Effects of Electronic Cigarettes: A Systematic Review and Pediatric Case Series

Electronic cigarette (EC) use is highly prevalent, especially in the adolescent population, where 29% of Canadian adolescents have used an EC in the past thirty days per national surveys. Our pediatric orthopedic referral centre observed a cluster of delayed unions of bone fractures in adolescents using ECs and present the case series here. We then asked whether electronic cigarettes impair bone healing or influence orthopedic outcomes. A PRISMA-compliant systematic review was carried out, which revealed no human clinical studies and a general paucity of evidence around ECs and musculoskeletal health. The existing experimental evidence relevant to orthopedics is summarized. The effect of ECs on the musculoskeletal system is poorly understood and is a target for further research.

Congenital dislocation of the knee in combination with Meyer-Gorlin syndrome: A case report

BACKGROUND: Meyer-Gorlin syndrome is a rare genetic and autosomal recessive disease that is characterized by the classical triad, including, microtia, very small size or complete patellar absence, and nanism. CLINICAL CASE: Herein, presented the first clinical case description of a Russian patient with Meyer-Gorlin syndrome in combination with congenital anterior shin dislocation. The main clinical disease manifestations are characterized by a combination of microtia, patellar pathology, and dwarfism. DISCUSSION: In the practice of pediatric orthopedic surgeons, cases of congenital knee dislocations are extremely rare, especially as part of any syndromes, which cause interest in the presented clinical case publication. Our patient analysis, as well as the patients described in the literature, showed the presence of typical clinical manifestations, which allowed us to suspect the presence of Meyer-Gorlin syndrome during a clinical examination. CONCLUSIONS: This report is the first case of combined congenital knee dislocation and Meyer-Gorlin syndrome with a diagnostic triad (short stature, microtia, and patellar aplasia) in the Russian Federation. Conservative treatment with constant traction and flexion must be carefully performed to avoid complications. Without the effect of conservative therapy, surgical treatment is indicated.

Epidemiology of clubfoot in Sweden from 2016 to 2019: A national register study

Background This study aimed to estimate the birth prevalence of children born with isolated or non-isolated clubfoot in Sweden using a national clubfoot register. Secondarily we aimed to describe the clubfoot population with respect to sex, laterality, severity of deformity, comorbidity and geographic location. Methods A national register, the Swedish Pediatric Orthopedic Quality register, was used to extract data on newborn children with clubfoot. To calculate the birth prevalence of children with isolated or non-isolated clubfoot between 1st of January 2016 and 31st of December 2019, we used official reports of the total number of Swedish live births from the Swedish Board of Statistics. The Pirani score and predefined signs of atypical clubfoot were used to classify clubfoot severity at birth. Results In total 612 children with clubfoot were identified. Of these, 564 were children with isolated clubfoot, generating a birth prevalence of 1.24/1000 live births (95% confidence interval 1.15–1.35). About 8% were children with non-isolated clubfoot, increasing the birth prevalence to 1.35/1000 live births (95% confidence interval 1.25–1.46). Of the children with isolated clubfoot, 74% were boys and 47% had bilateral involvement. The children with non-isolated clubfoot had more severe foot deformities at birth and a greater proportion of clubfeet with atypical signs compared with children with isolated clubfoot. Conclusion We have established the birth prevalence of children born with isolated or non-isolated clubfoot in Sweden based on data from a national register. Moreover, we have estimated the number of children born with atypical clubfeet in instances of both isolated and non-isolated clubfoot. These numbers may serve as a baseline for expected birth prevalence when planning clubfoot treatment and when evaluating time trends of children born with clubfoot.

Pediatric Orthopedic Trauma Care During the COVID-19 Pandemic: A Survey of the Pediatric Orthopedic Society of North America

Background: The COVID-19 pandemic has dramatically altered the practice of pediatric orthopedic trauma surgery in both outpatient and inpatient settings. While significant declines in patient volume have been noted, the impact on surgeon decision-making is unclear. Purpose: We sought to investigate changes in pediatric orthopedic trauma care delivery as a result of COVID-19 and determine their implications for future orthopedic practice. Methods: An electronic survey was distributed to all members (N = 1515) of the Pediatric Orthopedic Society of North America (POSNA) in March to April 2021; only members who provided care for pediatric orthopedic trauma patients were asked to complete it. The survey included questions on hospital trauma call, inpatient care, outpatient clinic practice, and 3 unique fracture case scenarios. Results: A total of 147 pediatric orthopedic surgeons completed the survey, for a 9.7% response rate, with 134 (91%) taking trauma call at a hospital as part of their practice. Respondents reported significant differences across institutions regarding COVID-19 testing, hospital rounding, and employee COVID-19 screening. Changes in outpatient fracture management were observed, including a decreased number of follow-up visits for nondisplaced clavicle fractures, distal radius buckle fractures, and toddler’s fractures. Of respondents who changed their fracture follow-up schedules due to COVID-19, over 75% indicated that they would continue these outpatient treatment schedules after the pandemic. Conclusions: This survey found changes in pediatric orthopedic trauma care as a result of the COVID-19 pandemic. The use of telemedicine and abbreviated follow-up practices for common fracture types are likely to persist following the resolution of the COVID-19 pandemic.

Opioid Reduction Through Postoperative Pain Management in Pediatric Orthopedic Surgery

OBJECTIVES Our goal with this initiative was to reduce discharge opioid prescriptions while maintaining optimal pain management through the use of standardized pain prescribing guidelines for pediatric patients after orthopedic surgical procedures. METHODS Through analysis of established yet inconsistent prescribing practices, we created a 4-tiered guideline for pediatric orthopedic postoperative pain management prescription ordering. Following the Model for Improvement methodology including iterative plan-do-study-act cycles, the team created an electronic medical record order set to be used at discharge from the hospital. The provider compliance with this order set was monitored and analyzed over time by using provider-level and aggregate control charts. A secondary measure of opioid prescriptions (morphine milligram Eq [MME] dosage per patient) was tracked over time. The balancing measure was the analysis of unanticipated opioid prescription refills. RESULTS Greater than 90% compliance with the guidelines was achieved and sustained for 20 months. This resulted in a 54% reduction in opioids prescribed during the improvement period (baseline = 71 MME per patient; postintervention = 33 MME per patient) and has been sustained for 12 months. The percentage of unanticipated opioid prescription refills did not significantly change from the period before the institution of the guidelines and after institution of the guidelines (2017 = 3%; 2019 = 3%). CONCLUSIONS The creation of these guidelines has led to a significant reduction in the number of opioids prescribed while maintaining effective postoperative pain management.

Bismuth Pelvic X-Ray Shielding Reduces Radiation Dose Exposure in Pediatric Radiography

Background. Radiation using conventional X-ray is associated with exposure of radiosensitive organs and typically requires the use of protection. This study is aimed at evaluating the use of bismuth shielding for radiation protection in pediatric pelvic radiography. The effects of the anteroposterior and lateral bismuth shielding were verified by direct measurements at the anatomical position of the gonads. Methods. Radiation doses were measured using optically stimulated luminescence dosimeters (OSLD) and CIRS ATOM Dosimetry Verification Phantoms. Gonad radiographs were acquired using different shields of varying material (lead, bismuth) and thickness and were compared with radiographs obtained without shielding to examine the effects on image quality and optimal reduction of radiation dose. All images were evaluated separately by three pediatric orthopedic practitioners. Results. Results showed that conventional lead gonadal shielding reduces radiation doses by 67.45%, whereas dose reduction using one layer of bismuth shielding is 76.38%. The use of two layers of bismuth shielding reduces the dose by 84.01%. Using three and four layers of bismuth shielding reduces dose by 97.33% and 99.34%, respectively. Progressively lower radiation doses can be achieved by increasing the number of bismuth layers. Images obtained using both one and two layers of bismuth shielding provided adequate diagnostic information, but those obtained using three or four layers of bismuth shielding were inadequate for diagnosis. Conclusions. Bismuth shielding reduces radiation dose exposure providing appropriate protection for children undergoing pelvic radiography. The bismuth shielding material is lighter than lead, making pediatric patients more comfortable and less apt to move, thereby avoiding repeat radiography.

Lynn Taylor Staheli (1933 - 2021) - in memory of the outstanding pediatric orthopedic surgeon of our time

Lynn Taylor Staheli is Professor Emeritus at the University of Washington, a distinguished pediatric orthopedic surgeon, author of numerous studies and books, and a major contributor to the development of pediatric orthopedics. Professor Staheli was a founding editor of the Journal of Pediatric Orthopaedics and founder of Global HELP. In recent years he has been active in the promotion of modern approaches in pediatric orthopedics. Lynn Taylor Staheli passed away on August 9, 2021. He was 87 years old.