BACKGROUND The purpose of this study is to examine the relationship between preoperative comorbidities, surgical complications, and length of stay (LOS) after hip reconstruction in nonambulatory children with cerebral palsy (CP). METHODS This single-center retrospective cohort study included 127 patients undergoing hip surgery between 2007 and 2016 who were diagnosed with CP (GMFCS IV/V). The cohort was 54% Gross Motor Function Classification System (GMFCS) V with an average age at surgery of 9 years (range, 3-19 y). Preoperative comorbidities included: presence of a gastrostomy tube, respiratory difficulty requiring positive-pressure ventilation or tracheostomy, history of seizures, and nonverbal status. Complications were dichotomized into major and minor complications according to severity. Multivariable general linear modeling was used to identify factors associated with complications and prolonged LOS. RESULTS The median LOS in the hospital was 6 days (intequartile range, 5-9 d). The majority of procedures (72%) involved both the femur and acetabulum and 82% of surgeries were performed bilaterally. Patients who experienced a major complication were mostly GMFCS level V and were more likely to spend time in intensive care unit than postanesthetic care unit (P=0.001). Multivariable analysis for a major complication determined that the addition of each comorbid risk fact increased the odds of developing a major complication by 2.6 times (odds ratio, 2.64; 95% confidence interval, 1.56-4.47; P<0.001) regardless of GMFCS level. Multivariable analysis for prolonged LOS determined that major complications (P<0.001), bilaterality (P=0.01), age (P=0.02), female sex (P=0.01), and GMFCS V (P<0.001) were all factors that increased LOS. Migration percentage, acetabular index odds ratio, and pelvic obliquity were not associated with prolonged LOS or the presence of a major complication. CONCLUSIONS From our analysis, the authors found that a patient's premorbid comorbidities were more predictive of the likelihood of sustaining a major complication than their GMFCS level. Identifying high-risk patients preoperatively may help reduce complications and LOS, which ultimately will improve the quality of care the authors deliver to nonambulatory children with CP undergoing hip reconstruction surgery. LEVEL OF EVIDENCE Level III-retrospective cohort study.

Hip Reconstruction in Nonambulatory Children With Cerebral Palsy: Identifying Risk Factors Associated With Postoperative Complications and Prolonged Length of Stay.

Introduction The study purpose was to determine the safety/efficacy of a split anterior tibialis tendon transfer (SPLATT) to the peroneus tertius or brevis in children with static encephalopathy and varus feet. Methods A retrospective review of short- and long-term complications, change in ankle range of motion, strength, and gait kinematics. Predictors of postoperative varus or valgus were examined. Results One hundred thirty-three patients were included (average age [SD] 10.3 [3.7]), with an average follow-up of 3.9 (3.4) years. Forefoot/hindfoot eversion range of motion improved (P ≤ 0.05), dorsiflexor strength was maintained or improved in 76.9% of patients, and dorsiflexion in swing phase was maintained. Complications occurred in 6 of 133 patients (4.5%) and included 1 transfer failure, 1 wound dehiscence, and four pressure areas from casts. Successful correction was achieved in 77% of patients. Later onset of recurrent varus (14.4%, 10.6% requiring revision surgery) and pes valgus (8.7%, 4.8% requiring revision surgery) occurred. The length of the follow-up predicted the development of the pes valgus (odds ratio 1.28, 95% CI 1.0 to 1.6). Discussion SPLATT to the peroneus tertius or brevis is effective, and complications are rare. Subsequent valgus or recurrent varus deformities may occur, possibly requiring repeat surgery.

Split Tibialis Anterior Tendon Transfer to The Peroneus Brevis or Tertius for the Treatment of Varus Foot Deformities in Children with Static Encephalopathy: A retrospective case series

The Clavien–Dindosink (CDS) classification system provides more treatment-focused granularity than subjective methods of describing surgical complications; however, it has not been validated in posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). The purpose of this study was to modify the CDS system for application in patients with AIS undergoing PSF to assess its inter- and intra-rater reliability for describing complications faced by this population. A review of all complications specific to patients with AIS captured in a large multicenter international database was performed. All complications were classified according to CDS, modified by addition of “prolonged initial hospital stay” as a criterion for Grade II. A survey of this complication list and an additional 20 clinical vignettes (sent out on two occasions) was sent to nine spinal deformity surgeons. Weighted kappa values were used to determine inter- and intra-rater reliability. The Fleiss κ value for interrater reliability among 5 respondents grading all AIS complications was 0.8 (very good). For each grade, interrater reliability was very good, with an overall range of 0.8–1. The overall kappa value for intrarater reliability among eight respondents grading 20 vignettes was between 0.6 (good) and 0.9 (very good). The modified CDS classification system has very good interrater and intrarater reliability in describing complications following PSF in patients with AIS. This system may be of greater utility for reporting outcomes than a “major” versus “minor” complication system and can serve as a valuable tool for improving surgical practices and patient outcomes in this population. IV case series.

Modified Clavien-Dindo-sink classification system for adolescent idiopathic scoliosis.

Background Children with neuromuscular complex chronic conditions (NMCCC) frequently undergo hip reconstruction surgery requiring blood transfusion. The purpose of this study is to examine the efficacy of tranexamic acid (TXA) to reduce blood loss and transfusion requirement in NMCCC children undergoing hip reconstruction surgery. Methods Children with NMCCC undergoing hip reconstruction surgery between 2013 and 2018 were identified. Two cohorts were identified: those who received TXA and those who did not. Patient and surgical characteristics between cohorts were used for propensity matching. Patients were matched on the basis of comorbid factors, bilateral involvement, pelvic osteotomy, open reduction, and surgeon. Comparative outcomes between cohorts were analyzed for intraoperative and postoperative blood loss and transfusion requirements and length of hospital stay (LOS). Results A total of 166 patients underwent hip surgery at an average of 9.6 years (SD, 4.0). Propensity matching utilized 72% of the cohort including 47 TXA and 72 non-TXA subjects. There were no differences in patient or surgical characteristics across matched groups. Fifteen (15/47, 32%) TXA subjects required a postoperative blood transfusion compared with the 47% (34/72) of non-TXA subjects who required a transfusion and intraoperative transfusion rates were similar between the 2 groups. There was no significant difference in complication rate (TXA, 79%; non-TXA, 86%), reported estimated blood loss (median=200 mLfor both) or LOS (median=6 d for both). Hematocrit levels were slightly higher in TXA subjects intraoperatively (P=0.047), at the end of surgery (P=0.04), and for the overall lowest perioperative level (P=0.04). The overall percent loss of estimated blood volume was less for those who were given TXA compared with those who were not (P=0.001). Conclusions The use of TXA during hip reconstruction surgery in NMCCC children significantly reduced the percent loss of estimated blood volume and postoperative transfusion rate. Further prospective multicenter studies are needed to verify the positive effects and safety of TXA in the setting of hip reconstruction surgery in NMCCC children. Level of evidence Level III-retrospective comparative study.

The Use of Tranexamic Acid (TXA) in Neuromuscular Hip Reconstruction: Can We Alter the Need for Blood Transfusion?

BACKGROUND Bilateral hip reconstructions with osteotomies are commonly required in patients with severe cerebral palsy (CP) and dysplasia. These procedures can be performed by staging each hip surgery, separated by weeks to months, or by addressing both hips in a single-event surgery. The optimal timing of such surgery is yet to be determined. The purpose of this study was to retrospectively compare major complications between the staged and single-event approaches. METHODS Medical records of patients who underwent bilateral hip osteotomies, with at least one side including a pelvic osteotomy, were retrospectively reviewed. Subjects were identified who had a diagnosis of nonambulatory CP (defined by Gross Motor and Functional Classification System level IV or V), and at least 1 year of clinical follow-up. All hips were treated by 1 of 7 surgeons: 2 surgeons who always performing single-event surgery and 5 who always perform staged surgeries. Complications were stratified by the Modified Clavien-Dindo Classification (grades 1 to 5). The primary outcome was major complications (grade ≥3), while minor complications, readmissions, reoperations, and resource utilization outcomes were investigated secondarily. RESULTS Sixty-five patients met our inclusion criteria: 35 received single-event surgery and 30 received staged surgery. The staged group had a higher rate of major complications per patient (0.30 vs. 0; P=0.013). Unplanned readmissions and reoperations were likewise increased in the staged group. Minor complication rates were high in both groups, with no differences observed between staged and single-event approaches (3.27 per patient vs. 2.91; P=0.952). There were no complications causing permanent disability or death. The total length of stay (6.2 vs. 4.0 d; P<0.001) and mean nonsurgical operating room time (65.7 vs. 45.6 min; P<0.001) were increased in the staged group versus the single-event group. CONCLUSIONS The staged approach to bilateral hip reconstructions in the nonambulatory CP population was associated with a higher rate of major complications compared with a single-event approach. Minor complications were similar for both approaches. Both approaches can have an acceptable safety profile with no observed grade 4 or 5 complications. LEVEL OF EVIDENCE Level III.

Comparison of Staged Versus Same-day Bilateral Hip Surgery in Nonambulatory Children With Cerebral Palsy.

BACKGROUND: The modified Clavien-Dindo (MCD) system is a reliable tool for classifying adverse events (AEs) in hip preservation surgery and has since been utilized in studies involving lower limb surgery for ambulant and nonambulant children with cerebral palsy (CP). However, the profile of AEs recorded in children with CP compared with typically developing children is different, and the reliability of the MCD in CP is unknown. This study aimed to evaluate the interrater and intrarater reliability of the MCD system for classifying AEs following lower limb surgery in children with CP. METHODS: Eighteen raters were invited to participate, including clinicians from surgical, nursing, and physical therapy professions, and individuals with CP. Following a MCD familiarization session, participants rated 40 clinical scenarios on 2 occasions, 2 weeks apart. Fleiss' κ statistics were used to calculate interrater and intrarater reliability. RESULTS: The overall Fleiss' κ value for interrater reliability in the first rating was 0.70 (95% confidence interval, 0.61-0.80), and increased to 0.75 (95% confidence interval, 0.66-0.84) in the second rating. The average Fleiss' κ value for intrarater reliability was 0.78 (range, 0.48 to 1.00). Grading of more severe AEs (MCD III to V) achieved near perfect agreement (κ, 0.87 to 1.00). There was a lower level of agreement for minor AEs (MCD I-II) (κ, 0.53 to 0.55). A κ score of 0 to 0.2 was deemed as poor, 0.21 to 0.4 as fair, 0.41 to 0.6 as good, 0.61 to 0.8 as very good, and 0.81 to 1.0 as almost perfect agreement. CONCLUSIONS: The MCD System demonstrates a very good interrater and intrarater reliability following lower limb surgery in children with CP. The MCD can be used by clinicians from different health care professions with a high level of reliability. The MCD may improve standardization of AE recording with a view to accurate audits and improved clarity in outcome studies for CP. LEVEL OF EVIDENCE: Level II-diagnostic.

/pdf/classifying-adverse-events-following-lower-limb-orthopaedic-y9mx577htl.pdf

Mela Harambasic

Papers

Classifying Adverse Events Following Lower Limb Orthopaedic Surgery in Children With Cerebral Palsy: Reliability of the Modified Clavien-Dindo System.