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Retrospective cohort study.To validate whether fusions that end proximal to the sagittal stable vertebrae are at risk for developing distal junctional kyphosis in adolescent idiopathic scoliosis.Posterior spinal fusion is routinely used for the treatment of patients with adolescent idiopathic scoliosis. Fusions that end in either the lower thoracic or upper lumbar spine have the advantage of preserving motion segments. However, fusions ending proximal to the sagittal stable vertebrae has been shown to be at higher risk for developing distal junctional kyphosis.A multi-center database of prospectively enrolled subjects was queried for patients with adolescent idiopathic scoliosis that had Lenke type 1, 2 and 3 curves treated with posterior pedicle screw instrumentation. PA (posterior-anterior) and lateral full-length scoliosis films were obtained on each patient. PA radiographs were viewed to determine the coronal deformity and lateral radiographs to determine the sagittal deformity. Distal junctional kyphosis was defined as a greater than 10° increase in segmental kyphosis between the LIV and the LIV + 1 vertebra.346 patients were included with 85% being female and mean age of cohort 14.2 [Formula: see text] 2.08 years. At 5 years postoperatively, there was significant difference occurrence of distal junctional kyphosis dependent on whether the LIV relative to SSV with only 2.2% of fusions below the SSV developing DJK compared to 6.5% for fusions ending at the SSV and 15% for fusions with LIV above the SSV (p 0.001). There was no statistical difference in revision rates based on the relationship of LIV to SSV.There is an increased risk for development of DJK in patients with AIS treated with posterior fusion where the LIV was chosen proximal to the SSV.Level III.

Improvement of clinician understanding of acceptable deformity in pediatric distal radius fractures is needed.To assess how often children younger than 10 years undergo a potentially unnecessary closed reduction using procedural sedation in the emergency department for distal radial metaphyseal fracture and the associated cost implications for these reduction procedures.This retrospective cross-sectional study included 258 consecutive children younger than 10 years who presented to a single, level I, pediatric emergency department and who had a distal radius fracture with or without ulna involvement between January 1, 2016, and December 31, 2017. Reductions were deemed to be potentially unnecessary if the coronal and sagittal plane angulation of the radius bone measured less than 20° and shortening measured less than 1 cm on initial injury radiographs. Use of procedural sedation or transfer status to another facility was noted if present. Statistical analysis was performed from April 2019 to June 2019.Potentially unnecessary reduction was the primary outcome. Radiographic findings were measured to determine reduction necessity. Additional variables measured were age, sex, time in the emergency department, transfer status, required reduction procedure, use of sedation, and cost associated with care.Of the 258 participants studied, 156 (60%) were male, with a mean (SD) age of 6.7 (2.3) years. Among 142 patients (55%) who underwent closed reduction with procedural sedation in the emergency department, 38 (27%) procedures were determined to be potentially unnecessary. Review of Common Procedural Terminology charges revealed an approximately $7000 difference between the stated cost of a reduction procedure in the emergency department vs a cast application in an outpatient orthopedic clinic for distal radial metaphyseal fractures. The mean (SD) maximal angulation in either plane for fractures that underwent appropriate reduction was 30.6° (10.3°) compared with 13.9° (4.5°) for those unnecessarily reduced (P .001). Patients who were transfers from other facilities were more than twice as likely to undergo a potentially unnecessary reduction (odds ratio, 2.3; 95% CI, 1.1-5.0; P = .03).The findings suggest that improved awareness of these acceptable deformities in young children may be associated with limiting the number of children requiring reduction with sedation, improving emergency department efficiency, and substantially reducing health care costs.

OBJECTIVEPosterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) can be associated with significant blood loss. It has been suggested that blood loss is greater in different racial groups. The purpose of this study was to evaluate differences in blood loss between African American and Caucasian patients undergoing PSF for AIS.METHODSA retrospective review was performed of patients aged 10–18 years with AIS who were treated with PSF from 2014 to 2017 at a single children’s healthcare system. Patient demographic, radiographic, and operative data were obtained from medical records. Intraoperative blood loss was calculated using the formula described by Waters et al. Patients who declined reporting their race or had prior spinal surgery, neuromuscular or syndromic diagnoses, a history of cardiac or thoracic surgery, or a bleeding disorder were excluded. Blood loss variables were log-transformed for normality and modeled using multivariable linear regression.RESULTSA total of 433 PSFs for AIS qualified for the analysis. The average age was 14.1 years, and 73.7% of the patients were female. With respect to race, 44.6% identified themselves as African American. There was no significant difference in blood loss (p = 0.31) or blood loss per level fused (p = 0.36) in African American patients. African American patients, however, did have significantly lower preoperative hemoglobin and hematocrit levels and greater operating room time than Caucasian patients (p < 0.001). There was no difference between race and transfusion rate.CONCLUSIONSThere appears to be no relationship between race and blood loss during PSF for AIS. Standardized protocols for minimizing perioperative blood loss can be applied to both Caucasian and African American patients.

Category: Other Introduction/Purpose: Medical malpractice lawsuits can place significant economic and psychologic burden on a provider. Orthopaedic surgery is one of the most common subspecialties involved in malpractice claims. There is currently no study examining malpractice lawsuits within foot and ankle surgery. Accordingly, the purpose of this work is to examine trends in malpractice claims in foot and ankle surgery. Methods: The Westlaw legal database was queried for lawsuits pertaining to foot and ankle surgery from 2008 to 2018. Only cases involving medical malpractice were included for analysis. All available details pertaining to the cases were collected. This included plaintiff demographic and geographic data. Details regarding the cases were also collected such as anatomical location, pathology, complications, and case outcomes. Results: Forty nine malpractice lawsuits pertaining to foot and ankle were identified. Most plaintiffs in these cases were adult females, and the majority of cases occurred in the northeast (53.1%). The most common anatomical region involved in claims involved the forefoot (29%). The majority of these claims involved surgery (65%). Infection was the most common complication seen in claims (22%). The jury ruled in favor of the defendant surgeon in most cases (73%). Conclusion: This is the first study to examine trends in medical malpractice within foot and ankle surgery. Infection was the most frequent complication seen in claims and forefoot surgery was the most common anatomic location. A large portion of claims resulted after nonoperative treatment. A better understanding of the trends within malpractice claims is crucial to developing strategies for prevention.