To define anatomical landmarks on the vertebrae at each spinal level for surgeons to use intraoperatively as a guide for the placement of juxtapedicular screws in the setting of hypoplastic or absent pedicles. Preoperative computed tomography (CT) of patients with adolescent idiopathic scoliosis (AIS) was analyzed for thoracic pedicles ≤ 3 mm wide, measured between the outer cortices at the isthmus, as these may require a juxtapedicular screw for safe placement. For these pedicles, a simulated juxtapedicular screw was placed into the vertebrae using image reconstruction software. The distance from the screw’s insertion point was measured in the axial plane to the medial and lateral borders of the superior articular process (SAP) and to the posterior tip of the transverse process (TP), and in the sagittal plane to the junction of the SAP and TP. Screw trajectory angle was measured between the longitudinal axis of the screw and the sagittal and axial planes. Of 6324 pedicles, a total of 378 pedicles (6.0

Children with neuromuscular scoliosis (NMS) resultant to cerebral palsy (CP) are at a heightened risk for complications following surgical treatment. These children have a reported 22–64

Enhanced Recovery after Surgery (ERAS) pathways have been shown to decrease length of stay (LOS) after posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). The aim of this study was to compare immediate post-operative outcomes following an ERAS pathway with a traditional pathway for AIS. A prospective dual-center study of patients treated using an ERAS pathway (203 patients) or a traditional discharge (TD) pathway (73 patients) was performed with focus on pain at discharge, quality of life at one month, and return to school/work. LOS was 55% less in the ERAS group (4.8 days TD vs. 2.2 days ERAS, p < 0.001). Length of surgery (4.8 h TD vs. 2.8 h, p < 0.001) and EBL (500 cc vs. 240 cc, p < 0.001) were greater in the TD group, likely related to larger curve magnitudes ((62.0° TD vs. 54.0° ERAS, p < 0.001), a higher percentage of patients undergoing osteotomies (94% vs. 46%, p < 0.001) and more levels fused (11.4 ± 1.6 vs. 10.1 ± 2.6, p < 0.001) in the TD group. Regression analysis showed no difference in Visual Analog Score (VAS) score at discharge or quality of recovery using the QOR9 instrument between groups at follow up. There was no difference in return to school (p = 0.43) and parents’ return to work (p = 0.61) between the groups. Patients managed with an ERAS pathway had similar pain scores at discharge than those managed with a TD pathway. Both groups showed evidence of rapid return to normalcy by the first follow up visit.

Study Design: Biomechanical Study. Objective: The search for optimal spinal alignment has led to the development of sophisticated formulas and software for preoperative planning. However, preoperative plans are not always appropriately executed since rod contouring during surgery is often subjective and estimated by the surgeon. We aimed to assess whether rods contoured to specific angles with a French rod bender using a template guide will be more accurate than rods contoured without a template. Methods: Ten experienced spine surgeons were requested to contour two 125 × 5.5 mm Ti64 rods to 40°, 60° and 80° without templates and then 2 more rods using 2D metallic templates with the same angles. Rod angles were then measured for accuracy and compared. Results: Average angles for rods bent without a template to 40°, 60° and 80° were 60.2°, 78.9° and 97.5°, respectively. Without a template, rods were overbent by a mean of 18.9°. When using templates of 40°, 60° and 80°, mean bend angles were 41.5°, 59.1° and 78.7°, respectively, with an average underbend of 0.2°. Differences between the template and non-template groups for each target angle were all significant (p < 0.001). Conclusions: Without the template, surgeons tend to overbend rods compared to the desired angle, while surgeons improved markedly with a template guide. This tendency to overbend could have significant impact on patient outcomes and risk of proximal junctional failure and warrants further research to better enable surgeons to more accurately execute preoperative alignment plans.

Intraoperative methadone has been shown to decrease opioid medication requirement following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). No study to date has investigated the effect of methadone on opioid medication requirement when used in conjunction with an enhanced recovery after surgery (ERAS) protocol following PSF. A retrospective cohort study was performed at a single, tertiary care pediatric hospital. Patients with AIS undergoing PSF were consecutively given a single intra-operative methadone dose and matched 1:2 to a AIS control group without methadone. Patients were matched for age, curve magnitude, levels fused, blood loss, and operating time. All children followed a standard ERAS protocol with methadone being the only change in the post-operative regimen. In-hospital data for opioid and non-opioid medication use, surgical, and patient variables were recorded and compared between cohorts. Twenty-six patients received methadone (average 15.1 ± 1.9 years) and were matched with 52 control patients without methadone (average 14.7 ± 2.2 years). There were no significant differences in total opioid usage at any time-interval prior to hospital discharge or in cumulative opioid usage. Additionally, patients had a similar VAS pain level at discharge (methadone: 4.0 ± 2.3 vs control: 3.8 ± 1.9; P = 0.572). Total opioid usage was correlated with LOS. There were no opioid-related medication complications in either cohort. There was no decrease of in-hospital opioid usage when methadone was used with an ERAS protocol. Total opioid usage is correlated with hospital LOS following PSF.

Robotic assistance in surgical procedures is a valuable tool that enhances the safety and efficacy of invasive surgeries. These devices are divided functionally into surgeon surrogates where the device operates under the direct control of an offsite surgeon, and surgeon adjuncts where the device is an intraoperative guidance tool used in a portion of the procedure. The current state of robotic spine surgery focuses on the latter, addressing the primary task of pedicle screw placement. We would like to share our experience with the Mazor Robotics devices to discuss the underlying concepts, strengths, weaknesses, and results as they pertain to pediatric spine deformity.

Laboratory based study. To compare reduction force and plastic deformation of cobalt–chromium (Co–Cr) spinal rods using a rigid, thoracolumbar spinal deformity model. Pre-contoured spinal rods are growing in their utilization for spinal deformity. Although there are theoretical advantages to pre-contouring rods, no previous studies have compared pre-contoured and manually contoured rods for their ability to maintain sagittal contour and resist mechanical load. A spinal deformity model was utilized, simulating a rigid, thoracolumbar spinal deformity fixated with pedicle screws. Roll-formed pre-contoured and manually contoured 5.5 mm and 6.0 mm Co–Cr rods were reduced to the model with a load cell attached to the apical screw to measure corrective force. Rods remained reduced in the model for 20 min and change in contour was assessed to characterize plastic deformation. Twenty-four rods were tested with six rods per group (Table 1). The load to reduction was significantly lower in the 5.5 mm rods compared to the 6.0 mm rods (95% CI -254.0 to -61.42; p = 0.008). Although there was no difference in the corrective forces for manual and pre-contoured 5.5 mm rods (p = 0.722), the 6.0 mm rod produced significantly less corrective force compared to the manually contoured 6.0 mm rods (95% CI -134.42 to -5.317; p = 0.039). Additionally, rod contour for the manual group showed significantly less plastic deformation than the pre-contoured group in both 5.5 mm and 6.0 mm rods (5.5 mm: 57.1% vs. 61.6%, p = 0.006; 6.0 mm: 54.3% vs. 62.28%, p = 0.003). Roll formed, pre-contoured Co–Cr rods demonstrated significantly greater plastic deformation when compared with manually contoured rods of the same diameter. Furthermore, 6.0 mm pre-contoured rods required significantly lower load for rod reduction, the equivalent of 15 lb-force. Post-manufacturing, roll-formed pre-contouring of larger diameter Co–Cr may impair the rods mechanical properties.

Background: Closed reduction and percutaneous pinning (CRPP) of supracondylar humeral fractures is one of the most common procedures performed in pediatric orthopaedics. The use of full, standard preparation and draping with standard personal protective equipment (PPE) may not be necessary during this procedure. This is of particular interest in the current climate as we face unprecedented PPE shortages due to the current COVID-19 pandemic. Methods: This is a retrospective chart review of 1,270 patients treated with CRPP of a supracondylar humeral fracture at 2 metropolitan pediatric centers by 10 fellowship-trained pediatric orthopaedic surgeons. One surgeon in the group did not wear a mask when performing CRPP of supracondylar humeral fractures, and multiple surgeons in the group utilized a semisterile preparation technique (no sterile gown or drapes). Infectious outcomes were compared between 2 groups: full sterile preparation and semisterile preparation. We additionally analyzed a subgroup of patients who had semisterile preparation without surgeon mask use. Hospital cost data were used to estimate annual cost savings with the adoption of the semisterile technique. Results: In this study, 1,270 patients who underwent CRPP of a supracondylar humeral fracture and met inclusion criteria were identified. There were 3 deep infections (0.24%). These infections all occurred in the group using full sterile preparation and surgical masks. No clinically relevant pin-track infections were noted. There were no known surgeon occupational exposures to bodily fluid. It is estimated that national adoption of this technique in the United States could save between 18,612 and 22,162 gowns and masks with costs savings of $3.7 million to $4.4 million annually. Conclusions: We currently face critical shortages of PPE due to the COVID-19 pandemic. Data from this large series suggest that a semisterile technique during CRPP of supracondylar humeral fractures is a safe practice. We anticipate that this could preserve approximately 20,000 gowns and masks in the United States over the next year. Physicians are encouraged to reevaluate their daily practice to identify safe opportunities for resource preservation. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Back pain and spinal deformity in the pediatric and adolescent patient population are common reasons for presentation to the orthopaedic surgeon, and although most conditions are benign and self-limiting, a standardized approach to the history and physical examination can identify concerning signs and symptoms as well as aid in determining the final diagnosis and a recommended treatment plan. The most common and concerning etiologies of back pain and spinal deformity will be reviewed, along with nonsurgical and surgical management of these conditions.

OBJECTIVE:Posterior 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. METHODS:A 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. RESULTS:A 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. CONCLUSIONS:There 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.

BACKGROUND CONTEXT Precontoured spinal rods are growing in their utilization for spinal deformity. Although there are theoretical advantages to precontouring rods, no previous studies have compared precontoured and manually contoured rods for their ability to maintain sagittal contour and resist mechanical load. PURPOSE To compare the biomechanical properties of roll-formed precontoured spinal rods with manually contoured rods of the same diameter. STUDY DESIGN/SETTING Biomechanical study utilizing a rigid, thoracolumbar spinal deformity model. OUTCOME MEASURES Load to reduction, rod plastic deformation METHODS A spinal deformity model was utilized, simulating a rigid, thoracolumbar spinal deformity fixated with pedicle screws. Roll-formed precontoured and manually contoured 5.5 mm and 6.0 mm cobalt chromium (Co-Cr) rods were reduced to the model with a load cell attached to the apical screw to measure reduction force. Rods remained reduced in the model for 20 minutes and change in contour was assessed to characterize plastic deformation. Reduction loads and plastic deformation was compared between rod groups using paired T-tests. RESULTS Twenty-four rods were tested with 6 rods per group. The load to reduction was significantly lower in the 5.5 mm rods compared to the 6.0 mm rods (95% C.I. -254.0 - -61.42; p=0.008). Although there was no difference in the load to reduction for manual and precontoured 5.5 mm rods (437.01 N vs 428.38 N; p=0.722), the precontoured 6.0mm rod required significantly less load to reduction compared to the manually contoured 6.0 mm rods (586.09 N vs 655.97 N; 95% C.I. -134.42 - -5.317; p=0.039). Additionally, rod contour for the manual group showed significantly less plastic deformation than the pre-contoured group in both 5.5mm and 6.0mm rods (5.5mm: 57.1% vs 61.6%, p=0.006; 6.0mm: 54.3% vs 62.28%, p=0.003). CONCLUSIONS Roll formed, precontoured Co-Cr rods demonstrated significantly greater plastic deformation when compared with manually contoured rods of the same diameter. Furthermore, 6.0mm precontoured rods required significantly lower load for rod reduction. Post-manufacturing, roll-formed pre-contouring of larger diameter Co-Cr may impair the rods mechanical properties. FDA DEVICE/DRUG STATUS Unavailable from authors at time of publication. Precontoured spinal rods are growing in their utilization for spinal deformity. Although there are theoretical advantages to precontouring rods, no previous studies have compared precontoured and manually contoured rods for their ability to maintain sagittal contour and resist mechanical load. To compare the biomechanical properties of roll-formed precontoured spinal rods with manually contoured rods of the same diameter. Biomechanical study utilizing a rigid, thoracolumbar spinal deformity model. Load to reduction, rod plastic deformation A spinal deformity model was utilized, simulating a rigid, thoracolumbar spinal deformity fixated with pedicle screws. Roll-formed precontoured and manually contoured 5.5 mm and 6.0 mm cobalt chromium (Co-Cr) rods were reduced to the model with a load cell attached to the apical screw to measure reduction force. Rods remained reduced in the model for 20 minutes and change in contour was assessed to characterize plastic deformation. Reduction loads and plastic deformation was compared between rod groups using paired T-tests. Twenty-four rods were tested with 6 rods per group. The load to reduction was significantly lower in the 5.5 mm rods compared to the 6.0 mm rods (95% C.I. -254.0 - -61.42; p=0.008). Although there was no difference in the load to reduction for manual and precontoured 5.5 mm rods (437.01 N vs 428.38 N; p=0.722), the precontoured 6.0mm rod required significantly less load to reduction compared to the manually contoured 6.0 mm rods (586.09 N vs 655.97 N; 95% C.I. -134.42 - -5.317; p=0.039). Additionally, rod contour for the manual group showed significantly less plastic deformation than the pre-contoured group in both 5.5mm and 6.0mm rods (5.5mm: 57.1% vs 61.6%, p=0.006; 6.0mm: 54.3% vs 62.28%, p=0.003). Roll formed, precontoured Co-Cr rods demonstrated significantly greater plastic deformation when compared with manually contoured rods of the same diameter. Furthermore, 6.0mm precontoured rods required significantly lower load for rod reduction. Post-manufacturing, roll-formed pre-contouring of larger diameter Co-Cr may impair the rods mechanical properties.

Background Children with congenital heart disease (CHD) have been reported to be at increased risk of developing scoliosis following cardiac surgery. Previous sample studies have reported that these patients may safely undergo posterior spinal fusion (PSF) with low complication rates. The goal of this study is to provide an updated analysis of the perioperative complication profile for posterior spinal fusion in a large cohort of pediatric patients with CHD, using a nationwide database. Methods A retrospective cohort study was conducted using 30-day perioperative outcomes data from the NSQIP-P database. Our inclusion criteria were all pediatric patients who underwent posterior spinal fusion by CPT code. Patients were subdivided into two groups: those with a history of cardiac surgery for CHD and those without. Postoperative complications were classified according to the Clavien-Dindo system. Risk factors were assessed in univariate and multivariate logistic regression analyses, with significance set at p < .05. Results Our results included 3,426 pediatric patients (68.2% female, 31.8% male) with a median age at spinal fusion of 13.7 ± 2.87 years. A CHD diagnosis was present in 312 patients, with 128 having had prior cardiac surgery. The overall complication rate was 6.68%, with a 10.9% rate in the prior cardiac surgery cohort (p = .068). The most common overall perioperative complications were unplanned read-mission (3.5%), reoperation (2.6%), and superficial wound dehiscence (2.5%). Patients with a history of cardiac surgery were not at increased risk for postoperative complications; however, blood transfusion (p < .001), bronchopulmonary dysplasia (p < .001), combined bronchopulmonary dysplasia and previous cardiac surgery (p = .004), and a neuromuscular diagnosis (p < .001) were all risk factors for major postoperative complications in this cohort. Conclusions Children with scoliosis who have undergone cardiac surgery to address CHD are not at an increased risk of perioperative complications within 30 days of undergoing a posterior spinal fusion. However, patients who underwent cardiac surgery for CHD who also had bronchopulmonary dysplasia or an associated neuromuscular diagnosis are at increased risk for perioperative complications. It is important for pediatric orthopedic spine surgeons to be familiar with an updated profile of potential perioperative obstacles they may face when treating these patients, as seen in a large and representative cohort. Level of Evidence Level III.

BACKGROUND::Orthotic treatment for adolescent idiopathic scoliosis is a mainstay in nonoperative treatment to prevent progressive spinal deformity. OBJECTIVE::To determine the effectiveness of the Providence orthosis in the treatment of adolescent idiopathic scoliosis. STUDY DESIGN::Retrospective review. METHODS::Patients treated with a Providence orthosis for adolescent idiopathic scoliosis were reviewed. Inclusion criteria included the following: age of 10-18 years; curve magnitude of 25°-40°; Risser stage of 0-2; and, if female, <1 year post menarche at the time of brace initiation. Failure was defined as curve magnitudes progressing >5° or to >45° or surgery. Radiographs and clinical information were recorded and compared between treatment success and failure cohorts. RESULTS::56 patients (51 female and 5 male; average of 12.26 years) were identified with average of 2.21-year follow-up and a 57.1% success rate for preventing curve progression. Factors associated with successful treatment included curve apex T10 and caudal and Risser sign ⩾ 1. Multivariate analysis identified Risser ⩾ 1 and curve apex T10 and caudal as independent predictors of successful treatment. CONCLUSION::The Providence nighttime orthosis can be an effective treatment for adolescent idiopathic scoliosis. Curve Apex at T10 or caudal was an independent predictors of treatment success. CLINICAL RELEVANCE:This study identifies variables associated with treatment success using the Providence nighttime orthosis in a consecutive series of adolescent idiopathic scoliosis patients. This information provides the foundation for identifying ideal patients for nighttime bracing to guide clinical treatment.

Magnetically controlled growing rods (MCGR) are a novel treatment option for early onset scoliosis (EOS). Although the complication profile with MCGR use has been reviewed, these reviews do not take into account important implants modifications, termed iterations, that were made due to early on postoperative complications is not well reported or understood.To assess the effect of MCGR implant iterations on post-operative complications in EOS.A systematic review was performed to identify studies investigating MCGR specifically for the treatment of EOS, refined to those reporting the implant iteration, specifically the incorporation of the keeper plate to the implant design. Articles with mixed implant iteration usage were excluded. Complications following surgery were recorded as well as potential risk factors and compared between implant cohorts.Although 20 articles were identified for inclusion, 5 included mixed implant iteration leaving a total of 271 patients identified through 15 clinical studies that met inclusion criteria. The average follow-up was 25.4-mo. Pre-keeper plate implants were utilized in 3 studies with a total of 49 patients. Overall, 115 (42.4%) post-operative complications were identified, with 87% defined as major. The addition of the keeper plate significantly decreased the rate of post-operative complications per study (35.7% vs 80.6%, P = 0.036), and the rate of distraction failure (8.1% vs 40.8%, P = 0.02). Unplanned reoperation occurred in 69 (26.7%) patients but was not different between implant iteration cohorts (25.5% without keeper plate vs 27.1% with keeper plate, P = 0.92).MCGR for EOS has a cumulative complication rate of 42.4% but this is significantly reduced to 35.7% when reviewing only keeper-plate enabled implants. However, 25% of published articles included mixed implant iterations. Future studies should discern between implants iterations when reporting on the usage of MCGR for EOS.

BACKGROUNDMagnetically controlled growing rods (MCGR) are a novel treatment option for early onset scoliosis (EOS). Although the complication profile with MCGR use has been reviewed, these reviews do not take into account important implants modifications, termed iterations, that were made due to early on postoperative complications is not well reported or understood.AIMTo assess the effect of MCGR implant iterations on post-operative complications in EOS.METHODSA systematic review was performed to identify studies investigating MCGR specifically for the treatment of EOS, refined to those reporting the implant iteration, specifically the incorporation of the keeper plate to the implant design. Articles with mixed implant iteration usage were excluded. Complications following surgery were recorded as well as potential risk factors and compared between implant cohorts.RESULTSAlthough 20 articles were identified for inclusion, 5 included mixed implant iteration leaving a total of 271 patients identified through 15 clinical studies that met inclusion criteria. The average follow-up was 25.4-mo. Pre-keeper plate implants were utilized in 3 studies with a total of 49 patients. Overall, 115 (42.4%) post-operative complications were identified, with 87% defined as major. The addition of the keeper plate significantly decreased the rate of post-operative complications per study (35.7% vs 80.6%, P = 0.036), and the rate of distraction failure (8.1% vs 40.8%, P = 0.02). Unplanned reoperation occurred in 69 (26.7%) patients but was not different between implant iteration cohorts (25.5% without keeper plate vs 27.1% with keeper plate, P = 0.92).CONCLUSIONMCGR for EOS has a cumulative complication rate of 42.4% but this is significantly reduced to 35.7% when reviewing only keeper-plate enabled implants. However, 25% of published articles included mixed implant iterations. Future studies should discern between implants iterations when reporting on the usage of MCGR for EOS.

OBJECTIVE The aim of this study was to evaluate the effect of postoperative admission status on 30-day perioperative complications in patients with growing spinal instrumentation undergoing surgical lengthening. METHODS This retrospective case-control study of records from the 2014-2015 National Surgical Quality Improvement Program-Pediatric database was performed to identify surgical lengthening procedures of spinal implants in patients with growing instrumentation by Current Procedural Terminology code. The 30-day postoperative complications were classified according to the Clavien-Dindo system. Patients were subdivided according to their postsurgical admission status. Admission status, American Society of Anesthesiologists (ASA) Physical Status classification, tracheostomy, neuromuscular diagnosis, ventilator dependence, and nutritional support were considered as possible risk factors in univariate and multivariate logistic regression analyses. RESULTS A total of 796 patients were identified (mean age 9.09 ± 3.44 years; 54% of patients were female), of whom 73% underwent lengthening on an inpatient basis. Patients with a tracheostomy or ventilator dependence were more likely to be admitted postoperatively. The overall rate of major complications was 3.5% and did not differ based on admission status (2.8% inpatient vs 3.8% outpatient, p = 0.517). On univariate analysis, ventilator dependence (9.5% vs 2.7%, p = 0.002), need for nutritional support (7.1% vs 2.5%, p = 0.006), and ASA class > II (4.8% vs 1.3%, p = 0.04) placed patients at a higher risk for any postoperative complications. Multivariate analysis identified only ventilator dependence as an independent risk factor for any perioperative complication. CONCLUSIONS Postoperative admission status did not affect the rate of 30-day perioperative complications, readmission, or rate of unplanned operations following lengthening of growing spinal instrumentation. Outpatient lengthening appears to be safe; however, consideration for postoperative admission should be given for those who are ventilator dependent.

The authors performed a retrospective study on 796 children undergoing growing spinal implants and concluded that postoperative admission status did not affect the rate of 30-day perioperative complications, readmission, or rate of unplanned operations following lengthening of growing spinal instrumentation.The authors should be congratulated for performing a well-designed study on an important topic (e.g., hospital admission) in pediatric patients. 2,5 In addition, the current emphasis on the need to reduce healthcare costs makes the topic very relevant in perioperative medicine. 3 Although the study of Shaw et al. was well conducted, there are questions regarding the study that need to be clarified by the authors.First, the authors did not account for the impact from the immediate postoperative complications on the decision to admit the patients. 1It is plausible that patients who were not doing well in the postanesthesia care unit were admitted.This fact significantly limits the disposition planning of these patients.Moreover, the authors did not account for specific factors that could lead to higher rates of admission (e.g., patients with chronic pain).Last, the authors should present 95% confidence intervals for the outcomes so that clinical practitioners can make more informed decisions.Although complications were similar between the groups, patients who were admitted and develop complications had better support and care than those who developed complications at home.

Objectives: To describe a midshaft forearm fracture pattern that places the ulnar nerve at risk in the pediatric population and provide 7 clinical case examples describing the injury pattern and treatment methods. Design: Retrospective observational case series, review of literature, cadaver dissection, and treatment recommendations. Setting: Multi-institutional, Southeast United States. Patients: Seven pediatric patients (5 male and 2 female) with mean age of 8.7 years (range, 3–14) who sustained a significantly displaced closed, or grade I open, middle to distal one-third both-bone forearm fracture with subsequent ulnar nerve dysfunction. Interventions: Manual reduction and casting of both-bone forearm shaft fractures, operative debridement, fracture fixation, nerve exploration, neurolysis, nerve repair, and nerve grafting. Main Outcome Measurements: Radiographic fracture union, clinical ulnar nerve motor and sensory function testing, along with selective electric nerve testing and advanced imaging were monitored throughout follow-up postinjury. Results: Five of 7 patients underwent surgical treatment and 2 others were treated with conservative measures. The ulnar nerve was entrapped within the fracture site of one patient with an open fracture along with partial nerve transection, and 4 patients were found to have the nerve encased in hypertrophic scar tissue or bony callus upon surgical exploration at 3–12 months postinjury. Conclusions: The ulnar nerve lies in a precarious position in the middle to distal one-third forearm and is bound by anatomic constraints that place the nerve at risk of injury. This article offers a treatment algorithm that includes conservative treatment, acute exploration, early exploration (≤3 months), and late exploration (>3 months). Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND:Screw malpositioning is an identifiable cause of intraoperative neurophysiologic changes. Although triggered screw electromyography (t-EMG) has been found to exhibit high sensitivity for identifying malpositioned screws, no previous study has assessed the utility of combining t-EMG with robotic-assisted pedicle screw placement for identifying malpositioned screws. We sought to evaluate the utility of t-EMG used in combination with robotic-assisted pedicle screw placement for identifying malpositioned screws in patients with adolescent idiopathic scoliosis (AIS).METHODS:Patients undergoing robotic-assisted posterior spinal fusion with pedicle screw fixation for AIS underwent retrospective review from a single surgeons prospectively collected database. Preoperative demographic data and curve characteristics were recorded. Computed tomography (CT) scans were reviewed, measuring pedicle width and classifying pedicle morphology using the channel classification system. Pedicle data was compared against intra-operative t-EMG data, with a minimal threshold of 8 mA used for screw removal and screw path examination and the rate of screw re-direction recorded. All pedicle screws were verified using image intensification.RESULTS:Forty-nine patients (11 males, 38 females, average age 14.49 years) with an average curve magnitude of 51 degrees and placement of 844 pedicle screws to attain an average curve correction of 67.7%. The incidence of an absent pedicle (type C or D morphology) was 2%. Overall, 24 screws (2.8%) were identified with an abnormal t-EMG threshold. All screws were found to have an intact medial wall upon probing and were reinserted without re-direction. No patient or curve characteristic was predictive of abnormal t-EMG amplitude but smaller pedicles correlated with smaller amplitudes.CONCLUSIONS:With precise pre-operative planning, robotic-assisted pedicle screw placement has shown to be a safe and effective method in treating AIS patients as shown by the lack of medial pedicle breach and malpositioned screws. We found no evidence to support combined use of t-EMG for identifying medially malpositioned screws.