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.