This study aimed to identify factors associated with increased rates of blood transfusion in patients with adolescent idiopathic scoliosis (AIS) treated with posterior spinal fusion (PSF).

A retrospective case-control study was performed for AIS patients treated at a large children's hospital between August 2018 and December 2020. All patients with a diagnosis of AIS were evaluated. Data on patient demographics, AIS, and transfusion parameters were collected. Univariate regression and multivariate logistic modeling were utilized to assess risk factors associated with requiring transfusion. Odds ratios (OR) and 95% confidence interval (CI) were calculated. Surgeries were done by three surgeons and thirty anesthesiologists. To quantify the influence of anesthesia practice preferences a categorical variable was defined as “higher-transfusion practice preference”, for the provider with the highest rate of transfusion.

A total of 157 AIS patients were included, of whom 56 were transfused RBC units (cases), and 101 did not receive any RBC transfusion (controls). On univariate analysis, the following variables were significantly correlated with receiving RBC transfusion: “higher-transfusion practice preference,” “administration of crystalloids,” “receiving fresh frozen plasma (FFP),” “receiving platelets,” “pre-operative hemoglobin,” “cell saver volume,” and “surgical time.” On multiple regression modeling, “pre-operative hemoglobin less than 120 g/L” (OR 14.05, 95% CI: 1.951 to 135.7) and “higher-transfusion practice preference” (OR 11.84, 95% CI: 2.505 to 63.65) were found to be meaningfully and significantly predictive of RBC transfusion.

In this cohort, we identified pre-operative hemoglobin of 120 g/L as a critical threshold for requiring transfusion. In addition, we identified significant contribution from anesthesia transfusion practice preferences. Our multivariate model indicated that these two factors are the major significant contributors to allogenic blood transfusion. Although further studies are required to better understand factors contributing to transfusion in AIS patients, we suggest standardized, peri-operative evidence-based strategies to potentially help reduce variations due to individual provider preferences.

Primary care physicians rely on radiology reports to confirm a scoliosis diagnosis and inform the need for spine specialist referral. In turn, spine specialists use these reports for triage decisions and planning of care. To be a valid predictor of disease and management, radiographic evaluation should include frontal and lateral views of the spine and a complete view of the pelvis, leading to accurate Cobb angle measurements and Risser staging. The study objectives were to determine 1) the adequacy of index images to inform treatment decisions at initial consultation by generating a score and 2) the utility of index radiology reports for appropriate triage decisions, by comparing reports to corresponding images.

We conducted a retrospective chart and radiographic review including all idiopathic scoliosis patients seen for initial consultation, aged three to 18 years, between January 1-April 30, 2021. A score was generated based on the adequacy of index images to provide accurate Cobb angle measurements and determine skeletal maturity (view of full spine, coronal=two, lateral=one, pelvis=one, ribcage=one). Index images were considered inadequate if repeat imaging was necessary. Comparisons were made between index radiology report, associated imaging, and new imaging if obtained at initial consultation. Major discrepancies were defined by inter-reader difference >15°, discordant Risser staging, or inaccuracies that led to inappropriate triage decisions. Location of index imaging, hospital versus community-based private clinic, was evaluated as a risk factor for inadequate or discrepant imaging.

There were 94 patients reviewed with 79% (n=74) requiring repeat imaging at initial consultation, of which 74% (n=55) were due to insufficient quality and/or visualization of the sagittal profile, pelvis or ribcage. Of index images available for review at initial consult (n=80), 41.2% scored five out of five and 32.5% scored two or below. New imaging showed that 50.0% of those patients had not been triaged appropriately, compared to 18.2% of patients with a full score. Comparing index radiology reports to initial visit evaluation with <60 days between imaging (n=49), discrepancies in Cobb angle were found in 24.5% (95% CI 14.6, 38.1) of patients, with 18.4% (95% CI 10.0, 31.4) categorized as major discrepancies. Risser stage was reported in only 14% of index radiology reports. In 13.8% (n=13) of the total cohort, surgical or brace treatment was recommended when not predicted based on index radiology report. Repeat radiograph (p=0.001, OR=8.38) and discrepancies (p=0.02, OR=7.96) were increased when index imaging was obtained at community-based private clinic compared to at a hospital. Re-evaluation of available index imaging demonstrated that 24.6% (95% CI 15.2, 37.1) of Cobb angles were mis-reported by six to 21 degrees.

Most pre-referral paediatric spine radiographs are inadequate for idiopathic scoliosis evaluation. Standardization of spine imaging and reporting should improve measurement accuracy, facilitate triage and decrease unnecessary radiation exposure.

Timely and competent treatment of paediatric fractures is paramount to a healthy future working population. Anecdotal evidence suggests that children travel greater distances to obtain care compared to adults causing economic and geographic inequities. This study aims to qualify the informal regionalization of children's fracture care in Ontario. The results could inform future policy on resource distribution and planning of the provincial health care system.

A retrospective cohort study was conducted examining two of the most common paediatric orthopaedic traumatic injuries, femoral shaft and supracondylar humerus fractures (SCH), in parallel over the last 10 years (2010-2020) using multiple linked administrative databases housed at the Institute for Clinical Evaluative Sciences (ICES) in Toronto, Ontario. We compared the distance travelled by these pediatric cohorts to clinically equivalent adult fracture patterns (distal radius fracture (DR) and femoral shaft fracture). Patient cohorts were identified based on treatment codes and distances were calculated from a centroid of patient home forward sortation area to hospital location. Demographics, hospital type, and closest hospital to patient were also recorded.

For common upper extremity fracture care, 84% of children underwent surgery at specialized centers which required significant travel (44km). Conversely, 67% of adults were treated locally, travelling a mean of 23km. Similarly, two-thirds of adult femoral shaft fractures were treated locally (mean travel distance of 30km) while most children (84%) with femoral shaft fractures travelled an average of 63km to specialized centers. Children who live in rural areas travel on average 51km more than their adult rural-residing counterparts for all fracture care. Four institutions provide over 75% of the fracture care for children, whereas 22 institutions distribute the same case volume in adults.?

Adult fracture care naturally self-organizes with proportionate distribution without policy-directed systemization. There is an unplanned concentration of pediatric fracture care to specialized centers in Ontario placing undue burden on pediatric patients and inadvertently stresses the surgical resources in a small handful of hospitals. In contrast, adult fracture care naturally self-organizes with proportionate distribution without policy-directed systemization. Patient care equity and appropriate resource allocation cannot be achieved without appropriate systemization of pediatric fracture care.

Ten RCTs published between 2000 and 2013 support treating distal radius buckle fractures and other low-risk distal radius fractures with a removable splint and with no orthopaedic follow-up. Application of this evidence has been shown to be variable and suboptimal resulting in unnecessary costs to a strained healthcare system. The Canadian evidence on this topic has been generated by subspecialist physicians working in paediatric hospitals. It is unclear what factors affect the dissemination of this information. We investigated the association of hospital type and physician type with the application of best-evidence treatment for low-risk distal radius fractures in children with the goal of improving our understanding of evidence diffusion in Ontario for this common injury.

We performed a retrospective population-based cohort study using linked health care administrative data. We identified all children aged 2–14 treated in Ontario emergency departments from 2003–2015 with distal radius fractures with no reduction and no operation within a six week period. We excluded refractures and children with comorbidities. We evaluated the followup received – orthopaedic, general practitioner, or none. We examined the data for trends over time. Multivariable log binomial regression was used to quantify associations between hospital and physician type and best-evidence treatment. We adjusted for patient-related variables including age, sex, rural or urban location, and socioeconomic status.

70,801 fractures were analyzed. Best-evidence treatment was more likely to occur in a small (RR 1.86, 95%CI 1.72–2.01), paediatric (RR 1.16, 95%CI 1.07–1.26), or community (RR 1.13, 95%CI 1.06–1.20) hospital compared with treatment in a teaching hospital. Best-evidence treatment was more likely if initial management was by a paediatrician with additional emergency medicine training (RR 1.73, 95%CI 1.56–1.92) or paediatrician (RR 1.22, 95%CI 1.11–1.34). Paediatric and teaching hospitals have improved their use of best-evidence over time while other hospital types have stagnated or deteriorated. Paediatricians, paediatricians with additional emergency medicine training, and emergency medicine residency trained physicians have improved their use of best-evidence over time, while other physician types have stagnated or deteriorated. Overall, only 20% of patients received best-evidence treatment and 70% had orthopaedic follow-up.

Significant over-utilization of resources for low-risk distal radius fractures continues decades after the first randomized trials showed it to be unnecessary. Physician type and hospital rurality are most strongly associated with best-evidence treatment. Physician types involved in generating, presenting, and publishing best-evidence for this fracture type are successfully implementing it, while others have failed to change their practices. Rural hospitals are excellent resource stewards by necessity, but are deteriorating over time. Our results strongly indicate the need for targeted implementation strategies to explicitly apply clinical evidence in clinical practice Canada-wide, with the goal of providing more cost-effective care for common children's fractures.

Distal femoral physeal fractures can cause of growth distrurbance which frequently requires further surgical intervention. The aim of this study was to determine if tibial tuberosity ossification at the time of injury can predict further surgery in patients who have sustained a physeal fracture of the distal femur.

We retrospectively investigated all patients who had operative treatment for a distal femoral physeal fracture at a paediatric level one trauma center over a 17 year period. Logistic regression analysis was performed investigating associations between the need for further surgery to treat growth disturbance and tibial tuberosity ossification, age, Salter Harris grade, mode of fixation or mechanism of injury.

74 patients met the inclusion criteria. There were 57 boys (77%) and 17 girls (23%). The average age at time of injury was 13.1 years (range 2.-17.1 years). Following fixation, 30 patients (41%) underwent further surgery to treat growth disturbance. Absence of tibial tuberosity fusion to the metaphysis was significantly associated with need for further surgery (p = < 0 .001). Odds of requiring secondary surgery after tibial tuberosity fusion to metaphysis posteriorly (compared with not fused) were 0.12, 95% CI (0.04, 0.34). The estimate of effect of tibial tuberosity ossification on reoperation rates did not vary when adjusted for gender, mechanism, fixation and Salter Harris grade. When accounting for age, the odds of further operation if the tibial tuberosity is fused to the metaphysis posteriorly (compared with not fused) were 0.28, 95% CI (0.08, 0.94).

Tibial tuberosity ossification stage at time of injury is a predictor of further surgery to treat growth disturbance in paediatric distal femoral fractures. Children with distal femoral physeal fractures whose tibial tuberosity was not fused to the metaphysis posteriorly were 8.3 times more likely to require further surgery.

Purpose: In skeletally immature children with acceptably angulated (< = 15 degrees angular deformity at presentation) distal radius and/or ulnar fractures, to determine if a pre-fabricated wrist splint is at least as effective as a cast. The primary outcome was recovery of physical function six weeks after the injury as measured by the validated Activities Scale for Kids. Secondary objectives included determining differences in angulation of fracture, wrist range of motion, wrist strength, pain with movement, return to baseline activities, and patient preferences at six weeks.

Method: A randomized controlled, non-inferiority, single (evaluator) blinded, single-centre trial in a tertiary care pediatric emergency department. Minimal required sample size of 76 patients with was based on testing the null hypothesis (H0) that the brace is 7% less effective at the 2.5% level. Physical function was tested by a t-test for a non-zero difference. For the other outcomes, proportions and means were compared with the Fisher Exact and Student s t-test, respectively.

Results: Of the 100 randomized patients, 3 were excluded due to non-eligibility on radiographic review. 93 of the 97 completed full clinical, radiographic, and patient determined followup. ASK scores at six weeks were 92.8 in the splint group and 91.4 in the cast group, neither clinically nor statistically significantly different. Among patients treated in a cast, the average angular deformity at followup was 11.0 degrees and compared with an average of 6.6 degrees angulation among patients treated in a splint (p=.02, t-test). These groups were equal at baseline, with an average of 7.5 degrees of angulation in the cast group and 6.7 degrees in the splint group. Complications did not differ between groups, nor did range of motion with the exception that pronation was slightly better (84 versus 74 degrees) in the splint group at the end of treatment. No patient required any operative procedure. Parents preferred splinting over casting (p< 0.001) and children preferred splinting over casting (p=0.028).

Conclusion: Splinting was non-inferior to casting, and in fact may be superior to casting, for maintaining the position of a minimally displaced distal radial metaphyseal fracture. Significance: The benefits of splinting over casting have been previously established for undisplaced distal radius and ulnar fractures (Plint), this is the first study which extends these benefits to the large group of children with minimally displaced distal radius fractures. Splint treatment simplifies care for children, reduces cost, and improves short term outcomes.

Purpose: Sports and leisure is the second leading cause of severe childhood injury after road traffic. Severe fractures from school playgrounds are common and preventable. Falling height and impact absorbing surface determine risk. We compared two loose fill surfaces (sand versus engineered wood fibre) to determine arm fracture risk.

Method: Twenty eight elementary schools in the same urban public school board were scheduled for playground replacement and consented to random assignment of either sand (14) or wood fibre (14) beneath the new playground. Two and a half school years of injury data were collected. Arm fractures were defined a priori as the primary outcome of interest.

Results: 267,864 student-months of followup data were collected; 84824 with sand and 183040 with wood fibre. Schools complied (surface installed as randomized) for 73% of the total followup time. Fracture rates were 4.1 per 100,000 student months on sand playgrounds and 13.0 per 100,000 student months on wood fibre playgrounds (p=0.112, analysis adjusted for clustering). Time for play, counts of children playing, weather, and completeness of injury reporting did not differ between groups.

Conclusion: Children at schools with sand surfaces had a lower arm fracture rate related to playground equipment falls. Using sand surfaces instead of engineered wood fibre surfaces is a simple and effective way of reducing arm fractures from playgrounds. This is the only randomized trial we are aware of regarding playground surfacing, and the finding is novel.

Purpose: A retrospective review of 180 consecutive luque unit rod instrumentations for neuromuscular scoliosis revealed a low rate (7%) of reoperation for hardware related issues. The results of this cost effective instrumentation are good, and we question whether moving to more expensive systems (eg pedicle screws) will provide benefit to patients.

Method: A retrospective clinical and radiographic review of 180 consecutive patients, treated with the unit rod and sublaminar wires for progressive neuromuscular scoliosis and cerebral palsy, between 1994 and 2004 was done. Preoperative, intraoperative, and outcome data were obtained from hospital and clinic records with 2 to 12 years of followup.

Results: Mean age at surgery was 13 years. Of 180 patients, 158 were full time wheelchair users. 112 patients underwent isolated posterior surgery, 68 underwent anterior & posterior surgeries. Allograft was used in 96%. Mean surgical time was 5 hours 45 minutes, blood loss was 1325 cc. Mean cobb angles improved from 72° to 32°, pelvic obliquity improved from 20° to 9°. Overall postoperative complications were 222, with 36 (20%) of 180 patients experiencing no complication. Only 13 patients of 180 required revision surgery for hardware related problems. Pseudoarthrosis was seen in 7 patients. 18 patients had prominence of the rod. Of 22 ambulatory patients, 3 became wheelchair dependent. 8 showed coronal decompensation. Medical complications included respiratory in 52 patients, deep or superficial infection in 29, ileus in 23, UTI in 19, SMA syndrome in 5, and other in 18.

Conclusion: Although overall complications were high in this patient group, hardware related complications of the unit rod were low. Respiratory and other medical problems were most of the complications and would not be minimized with different hardware. The unit rod achieved and maintained spinal balance and fusion with only 13 hardware related revisions in 180 patients (7%).

Injuries to the ankle are common in children. We investigated whether decreased dorsiflexion predisposes to such fractures and sprains. Passive dorsiflexion in children with ankle injuries was compared with that in a control group of patients with a normal ankle. The uninjured side was examined to determine flexibility in those patients with ankle injuries. In 82, the mean dorsiflexion was 5.7° with the knee extended and 11.2° with the knee flexed. In 85 controls, the mean dorsiflexion was 12.8° with the knee extended and 21.5° with the knee flexed (p < 0.001, Student’s t-test). There was a strong association between decreased ankle dorsiflexion and injury in children. A flexible triceps surae appeared to absorb energy and protect the bone and ligaments, while stiffness predisposed to injury. We suggest that children with tight calf muscles should undergo a regimen of stretching exercises to improve their flexibility.