Olecranon fractures are common injuries representing roughly 5% of pediatric elbow fractures. The traditional surgical management is open reduction and internal fixation with a tension band technique where the pins are buried under the skin and tamped into the triceps. We have used a modification of this technique, where the pins have been left out of the skin to be removed in clinic. The purpose of the current study is to compare the outcomes of surgically treated olecranon fractures using a tension-band technique with buried k-wires (PINS IN) versus percutaneous k-wires (PINS OUT).

We performed a retrospective chart review on all pediatric patients (18 years of age or less) with olecranon fractures that were surgically treated at a pediatric academic center between 2015 to present. Fractures were identified using ICD-10 codes and manually identified for those with an isolated olecranon fracture. Patients were excluded if they had polytrauma, metabolic bone disease, were treated non-op or if a non-tension band technique was used (ex: plate/screws). Patients were then divided into 2 groups, olecranon fractures using a tension-band technique with buried k-wires (PINS IN) and with percutaneous k-wires (PINS OUT). In the PINS OUT group, the k-wires were removed in clinic at the surgeon's discretion once adequate fracture healing was identified. The 2 groups were then compared for demographics, time to mobilization, fracture healing, complications and return to OR.

A total of 35 patients met inclusion criteria. There were 28 patients in the PINS IN group with an average age of 12.8 years, of which 82% male and 43% fractured their right olecranon. There were 7 patients in the PINS OUT group with an average age of 12.6 years, of which 57% were male and 43% fractured their right olecranon. All patients in both groups were treated with open reduction internal fixation with a tension band-technique. In the PINS IN group, 64% were treated with 2.0 k-wires and various materials for the tension band (82% suture, 18% cerclage wire). In the PINS OUT group, 71% were treated with 2.0 k-wires and all were treated with sutures for the tension band. The PINS IN group were faster to mobilize (3.4 weeks (range 2-5 weeks) vs 5 weeks (range 4-7 weeks) p=0.01) but had a significantly higher complications rate compared to the PINS OUT group (6 vs 0, p =0.0001) and a significantly higher return to OR (71% vs 0%, p=0.0001), mainly for hardware irritation or limited range of motion. All fractures healed in both groups within 7 weeks.

Pediatric olecranon fractures treated with a suture tension-band technique and k-wires left percutaneously is a safe and alternative technique compared to the traditional buried k-wires technique. The PINS OUT technique, although needing longer immobilization, could lead to less complications and decreased return to the OR due to irritation and limited ROM.

Rapid discharge pathways (RDP) have been implemented throughout most areas of orthopaedics. The primary goal of these pathways is to standardize the post-surgical hospital course for patients in order to decrease hospital length-of-stay (LOS). Surgical treatment of adolescent idiopathic scoliosis (AIS) remains one of the most invasive pediatric orthopaedic procedure and is routinely associated with a prolonged hospital stay. The implementation of RDPs following surgery for AIS has shown to be successful; however, all of these studies have been conducted within the United States and it has been shown previously that there exists major differences in hospital LOS and in post-operative complications between Canada and the United States. Therefore, the objective of this study was to determine if the implementation of a RDP at a single children's tertiary-referral centre in Canada could decrease hospital LOS without increasing post-operative complications.

A retrospective chart review was completed for all patients who underwent posterior spinal instrumentation and fusion (PSIF) between March 1st, 2010 and February 28th, 2019, with date of implementation being March 1st, 2015. Patient pre-operative, operative, and post-operative information was collected from the charts along with the primary outcome variables: LOS, wound complication, 30-day return to the OR, 30-day emergency department admission, and 30-day hospital readmission. An interrupted time series analysis with a robust linear regression model was utilized to assess for any differences in outcomes following implementation of the RDP. Ninety days before and after the implementation of the RDP was not included in this analysis due to variances in practice that were occurring at this time.

A total of 244 participants were identified, with 113 patients in the conventional pathway and 131 patients in the RDP cohort. No significant differences in pre-operative or operative characteristics existed between the groups, except for the RDP group having approximately a 50 larger pre-operative curve and the conventional pathway having on average 200mL greater intra-operative blood loss (p<0.05). Hospital LOS was found to be significantly shorter in the RDP group, with the median LOS being 5.2 [95% IQR 4.3–6.1] days in the conventional group and 3.4 [95% IQR 3.3–3.5] days in the RDP group (p<0.05). Patients in the RDP group were also found to stand 0.9 days earlier, walk 1.1 days earlier, their Foley catheter was discontinued 0.5 days earlier and their personal controlled analgesia was discontinued 12 hours sooner (p<0.05). There were no differences in post-operative complications between the two groups (p>0.05).

This study demonstrates that implementing a RDP following PSIF for AIS can successfully decrease hospital LOS without increasing post-operative complications in a single payer universal healthcare system. The associated decrease in LOS could correlate with decreasing costs for both the healthcare system and for the patient's family.

Proximal junctional kyphosis (PJK) is defined as adjacent segment kyphosis >10° between the upper instrumented vertebrae and the vertebrae 2 levels above following scoliosis surgery. There are few studies investigating the predictors and clinical sequelae involved with this relatively common complication. Our purpose was to determine the radiographic predictors of post-op PJK and to examine the association between PJK and pain/HRQOL following surgery for AIS.

The Post-Operative Recovery after Scoliosis Correction: Home Experience (PORSCHE) study was a prospective multicenter cohort of AIS patients undergoing spinal fusion surgery. Pre-op and minimum 2 year f/u scoliosis and sagittal spinopelvic parameters (thoracic kyphosis–TK, lordosis–LL, pelvic tilt-PT, sacral slope-SS, pelvic incidence-PI) were measured and compared to numeric rating scale for pain (NRS) score, SRS-30 HRQOL and to the presence or absence of PJK (proximal junctional angle >100). Continuous and categorical variables were assessed using logistic regression and binomial variables were compared to binomial outcomes using chi-square.

163 (137 females) patients from 8 Canadian centers met inclusion criteria. At final f/u, PJK was present in 27 patients (17%). Pre-op means for PJK vs No PJK: Age 14.1 vs 14.7yr; females 85 vs 86%; scoliosis 57±22 vs 62±15deg; TK 28±18 vs 19±16deg ∗, LL 62±11 vs 60±12deg, PT 8±12 vs 10±10deg, SS 39±8 vs 41±9deg, PI 47±14 vs 52±13deg, SVA −9±30 vs −7±31mm. Final f/u for PJK vs No PJK: Scoliosis 20±11 vs 18±8deg, final TK 26±12 vs 19±10deg∗, LL 60±11 vs 57±12deg, PT 9±12 vs 12±13deg, SS 39±9 vs 41±9deg, PI 48±17 vs 52±14deg, SVA −23±26 vs −9±32mm∗. Significant findings: Pre-op kyphosis >40deg has an odds ratio (OR) of 4.41 (1.50–12.92) for developing PJK∗. The presence of PJK was not associated with any significant differences in NRS or SRS-30. ∗denotes p<0.05.

This prospective multicenter cohort of AIS patients demonstrated a 17% risk of developing PJK. Pre-op thoracic kyphosis >40deg was associated with the development of PJK; however, the presence of PJK was not associated with increased pain or decreased HRQOL.

Superior mesenteric artery (SMA) syndrome is a rare medical complication of scoliosis surgery. In order to delineate the clinical features, progression and treatment of duodenal obstruction due to SMA syndrome after spinal fusions and to determine the relationship between spinal deformity correction and SMA syndrome, a retrospective study of all patients developing SMA syndrome following spinal fusion was conducted at a tertiary care center.

Charts were reviewed for symptoms of SMA syndrome, type and magnitude of spinal deformity, age at surgery, radiographic correction, complications, and other medical problems. The information gathered was divided according to non-orthopaedic and orthopaedic parameters.

All patients (five female and three male) in this study had spinal fusions performed. Overall, the patients were skeletally mature with a Risser stage average of 3.6. The average correction in the coronal plane was 28.4% in the thoracic spine and 44.6% in the lumbar spine. Sagittal correction averaged 25.9 % and 27% in the thoracic and lumbar spines respectively.. BMI index average was 17.6 (i.e. under-weight individuals). Signs and symptoms of SMA syndrome such as nausea, vomiting, epigastric pain, bloating, and weight loss developed at an average of 11.6 days. Seven patients were managed conservatively, and only one patient required surgery. All patients recovered fully.

This study identified purely asthenic body habitus (low BMI) and significant coronal correction in the lumbar region as risk factors for the development of SMA syndrome after spinal fusion Prolonged nausea and vomiting after spinal fusion requires GI imaging to rule out SMA syndrome, particularly within the first seven-ten days of surgery. Clinicians should also be aware of the possible delayed onset of symptoms in some patients. Nutritional support should be started immediately to prevent further adverse outcomes.

Subtrochanteric femoral fractures are uncommon in children, consequently there are no good treatment guidelines in the literature. This series reviewed all subtrochanteric femur fractures in skeletally immature adolescents older than ten years treated at a pediatric trauma center. There were fifteen adolescents with open growth plates. Treatment was non-operative in four and operative in eleven. Each of the adolescents treated non-operatively developed an unsatisfactory result, while eight of the eleven who were treated operatively experienced a satisfactory result. These results suggest improved outcome with operative treatment in this patient population.

It was the purpose of this study to describe treatment options and make recommendations for management of subtrochanteric femur fractures among skeletally immature adolescents older than ten years of age.

This series consisted of a retrospective review of all cases of subtrochanteric fractures in adolescents with open growth plates. The outcome was classified on the basis of radiographic criteria.

There were fifteen adolescents with an average age of thirteen years and one month. The average length of follow-up was two years and nine months. Treatment was non-operative in four and operative in eleven, utilizing a variety of fixation devices. There was fracture union in each case, although there was one delayed union. Complications included limb length discrepancy in three, each of which were treated non-operatively, one transient peroneal nerve palsy and asymptomatic heterotopic ossification. One adolescent, treated with a rigid intramedullary rod, developed avascular necrosis of the femoral head. The result was unsatisfactory in each of the non-operative cases, while eight of the eleven treated operatively developed satisfactory results.

Children less than ten years of age may be treated non-operatively. However, in skeletally immature adolescents, operative treatment resulted in improved outcomes. Rigid intramedullary fixation is contraindicated in skeletally immature adolescents due to the risk of avascular necrosis of the femoral head.

This series is the first to emphasize treatment and make management recommendations regarding subtrochanteric fractures in this age group.

Internal fixation is more effective than non-operative treatment for subtrochanteric femur fractures in skeletally immature adolescents, however the ideal method of fixation requires further study.

In order to determine the effectiveness of part-time bracing in juvenile idiopathic scoliosis (JIS) a retrospective review of thirty-four patients treated with a Charleston bending brace for JIS was undertaken. The patients were analyzed in three groups including:

success;

Of twenty-three patients meeting the inclusion criteria, nine achieved success, seven progressed, and seven required surgery. Success correlated with best in brace correction radiograph but not with initial curve magnitude. Part-time bracing is as successful as full-time bracing in JIS and better than the natural history.

In order to determine the effectiveness of part-time bracing in JIS, a retrospective review of thirty-four patients treated with a Charleston bending brace for JIS was undertaken.

Twenty-three patients met the inclusion criteria which included: curves greater than twenty degrees at initiation of bracing, Risser zero, bracewear more than twelve months, completion of the bracing program and Risser greater than or equal to four at final follow-up. Patients were analyzed in three groups, including

success (progression less than five degrees or less);

There were seven boys and sixteen girls with thirty-seven curves analyzed. Age at referral averaged 8.3 years. Average curve at time of bracing was thiry degrees. Length of bracing averaged 4.2 years with follow-up averaging 6.2 years. Nine patients met the criteria for success with seven patients progressing and seven patients requiring surgery. Of all curves, nineteen (51%) were successfully managed in the brace. Magnitude of curvature at initiation of bracing was not related to ultimate success, whereas success did correlate with higher best in brace correction radiographs.

Part-time bracing offers potential psychosocial and compliance benefits considering the length of treatment necessary in patients with juvenile idiopathic scoliosis. Although previous bracing studies have included some JIS patients, no authors have dealt specifically with the part-time bracing for JIS.

Part-time bracing is as successful as full-time bracing in JIS and better than the natural history.

To determine the effect of cordotomy on the function of the bladder during surgical correction of congenital kyphosis in myelomeningocele, we reviewed 13 patients who had this procedure between 1981 and 1996.

The mean age of the patients at operation was 8.9 years (3.7 to 16) and the mean follow-up was 4.8 years (1.3 to 10.8). Bladder function before and after operation was assessed clinically and quantitatively by urodynamics.

The mean preoperative kyphosis was 117° (52 to 175) and decreased to 49° (1 to 89) immediately after surgery. At the latest follow-up, a mean correction of 52% had been achieved.

Only one patient showed deterioration in bladder function after operation. Eight out of the nine patients who had urodynamic assessment had improvement in bladder capacity and compliance, and five showed an increase in urethral pressure. One patient developed a spastic bladder and required subsequent surgical intervention.

Cordotomy, at or below the level of the kyphosis, allows excellent correction of the structural deformity.

Seat-belt fractures of the lumbar spine in adolescents and adults are well recognised but there are few reports of these injuries in young children. We reviewed all seat-belt injuries in skeletally immature patients (Risser 0), seen at a tertiary referral centre between 1974 and 1991. There were ten cases, eight girls and two boys, with an average age of 7.5 years (3 to 13). Four distinct patterns of injury were observed, most commonly at the L2 to L4 level. Paraplegia, which is thought to be uncommon, occurred in three of our ten cases. Four children had intra-abdominal injuries requiring laparotomy. There was a delay in diagnosis either of the spinal or of the intra-abdominal injury in five cases, although all had contusion of the abdominal wall, the 'seat-belt sign'. Treatment of the fractures was conservative, by bed rest and then hyperextension casts. The incidence of this potentially devastating injury can be reduced by the optimal use of restraints, but there is often a delay in diagnosis. Our classification system may aid in the early detection and evaluation of this injury.