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Impact of tranexamic acid on blood loss and transfusion rate in children with cerebral palsy undergoing hip reconstruction with two or more osteotomies

Masrouha, Karim Z; Shabin, Zabrina M; Bhutada, Kiran; Sala, Debra A; Godfried, David H; Karamitopoulos, Mara S
PURPOSE/OBJECTIVE:Tranexamic acid (TXA), a synthetic lysine analogue, has been used in orthopedic procedures to limit blood loss and prevent allogeneic blood transfusions. However, data are scarce on its use in hip reconstruction of patients with cerebral palsy (CP). This study examines the effect of TXA on patients with CP undergoing hip reconstruction with at least two osteotomies. METHODS:This is a single-center, retrospective study of patients with CP who underwent hip reconstruction with two or more osteotomies from January 2013 to April 2019. There were 43 patients, with a mean age of 9.9 years. Age, procedure, preoperative and postoperative hemoglobin/hematocrit, estimated blood loss (EBL), transfusions and length of stay were recorded. The patients were split into the following two groups: 24 patients who had received intraoperative TXA and 19 who had not. RESULTS:Age, EBL, mean preoperative and postoperative hemoglobin or hematocrit, preoperative to postoperative hematocrit drop, and length of stay were similar for the two groups (p > 0.05). The risk for intraoperative transfusion (21 vs. 17%), postoperative transfusion (26 vs. 8%), and any transfusion (42 vs. 21%) appeared to be greater in the group that did not receive TXA, but this difference did not achieve statistical significance. CONCLUSION/CONCLUSIONS:This pilot study shows patients with CP undergoing hip reconstruction with two or more osteotomies; the use of TXA, while not statistically significant, shows a trend toward a decreased need for allogeneic blood transfusion.
PMID: 33839928
ISSN: 1633-8065
CID: 4845572

Measuring ambulation with wrist-based and hip-based activity trackers for children with cerebral palsy

Sala, Debra A; Grissom, Helyn E; Delsole, Edward M; Chu, Mary Lynn; Godfried, David H; Bhattacharyya, Surjya; Karamitopoulos, Mara S; Chu, Alice
AIM/OBJECTIVE:To assess the accuracy of consumer available wrist-based and hip-based activity trackers in quantitatively measuring ambulation in children with cerebral palsy (CP). METHOD/METHODS:Thirty-nine children (23 males, 16 females; mean age [SD] 9y 7mo [3y 5mo]; range 4-15y) with CP were fitted with trackers both on their wrist and hip. Each participant stood for 3 minutes, ambulated in a hallway, and sat for 3 minutes. The number of steps and distance were recorded on trackers and compared to manually counted steps and distance. Pearson correlation coefficients were determined for the number of steps during ambulation from each tracker and a manual count. Mean absolute error (MAE) and range of errors were calculated for steps during ambulation for each tracker and a manual count and for distance for each tracker and hallway distance. RESULTS:For the number of steps, a weak inverse relationship (r=-0.033) was found for the wrist-based tracker and a strong positive relationship (r=0.991) for the hip-based tracker. The MAE was 88 steps for the wrist-based and seven steps for the hip-based tracker. The MAE for distance was 0.06 miles for the wrist-based and 0.07 miles for the hip-based tracker. INTERPRETATION/CONCLUSIONS:Only the hip-based tracker provided an accurate step count; neither tracker was accurate for distance. Thus, ambulation of children with CP can be accurately quantified with readily available trackers.
PMID: 30883727
ISSN: 1469-8749
CID: 3734892

Percutaneous versus open reduction and fixation for Tillaux and triplane fractures: a multicenter cohort comparison study

Zelenty, William; Yoon, Richard S; Shabtai, Lior; Choi, Paul; Martin, Benjamin; Horn, David; Feldman, David S; Otsuka, Norman Y; Godfried, David H
The goal of this study was to compare open reduction versus percutaneous fixation of adolescent ankle fractures with regards to the incidence of growth disturbance. We performed a retrospective cohort analysis of adolescent patients with triplane or Tillaux fractures. There was an even distribution of triplane fractures and mean initial displacement between cohorts. Analysis of follow-up radiographs revealed no instances of growth disturbance in the percutaneous fixation group and six in the open reduction group (P=0.29). Growth disturbance does not pose a significant concern when selecting a surgical approach. Owing to the rarity of these fractures this study was underpowered.
PMID: 29957617
ISSN: 1473-5865
CID: 3163012

Combined Tibial Tubercle Fracture and Patellar Tendon Avulsion: Surgical Technique and Case Report

Behery, Omar A; Feder, Oren I; Beutel, Bryan G; Godfried, David H
Introduction/UNASSIGNED:Isolated tibial tubercle fractures or patellar tendon ruptures are common injuries in adolescents. However, combined tubercle fractures with patellar tendon ruptures are rare, and hence, there are no definitive methods of surgical fixation or post-operative protocols. Case Report/UNASSIGNED:A 13-year-old healthy girl sustained an extensor mechanism injury after the left knee hyperflexion during a fall from skateboarding. On examination, the extensor mechanism was not functional against gravity. Radiographic imaging revealed a displaced tibial tubercle fracture with patella alta, and magnetic resonance imaging revealed a concomitant patellar tendon avulsion from the tubercle. From a supine position on a radiolucent table, under general anesthesia and a femoral nerve block, the tibial tubercle fracture was fixed using two fully-threaded cortical screws. The patellar tendon was repaired with Fiber Wire through the Krakow method and secured through a tibial transosseous tunnel. A supplemental Fiber Wire was passed through a patellar tunnel and into a tibial tunnel to mitigate tension on the tendon repair. Post-operative knee motion was limited for 1 week to 60° of passive flexion, and full weight-bearing was permitted in a knee immobilizer. Conclusion/UNASSIGNED:Given the rarity of this combined extensor mechanism injury in adolescents and despite several different fixation methods reported in the literature, there is no clearly superior surgical technique. This case demonstrates a technique allowing for stability of the tubercle fracture and robust repair of the patellar tendon that permits early range of motion and weight-bearing.
PMCID:6298703
PMID: 30584509
ISSN: 2250-0685
CID: 3560092

Accuracy of activity monitors for measuring walking activity in ambulatory children with cerebral palsy [Meeting Abstract]

Sala, D; Grissom, H; Delsole, E; Chu, M; Godfried, D; Karamitopoulos, M; Bhattacharyya, S; Chu, A
Background and Objective(s): Commercially available activity tracking devices present the opportunity to quantify functional changes in ambulatory status of patients with cerebral palsy (CP). The purpose of this study was to assess the accuracy of a waist-based and a wrist-based wearable device for tracking steps and walking distance of children with CP in a controlled setting. Study Design: Prospective cohort study. Study Participants & Setting: Participants were 27 children, mean age of 9.6 years (range, 4-15), with CP and a Gross Motor Function Classification System (GMFCS) score between I and III. Thirteen children were diagnosed with hemiplegia (48%), 13 with diplegia (48%), and 1 with quadriplegia (4%). Seventeen were classified as GMFCS I (63%), 3 as II (11%), and 7 as III (26%). Fourteen children wore ankle-foot orthoses (52%), one wore HKAFO (4%) and 12 wore no orthotics (44%). Four patients used Lofstrand crutches (15%), two used posterior rollators (7%), and 21 patients used no assistive devices (78%). Materials/Methods: Each participant was outfitted with both a waist-based activity tracker, FitBitTM One, and a wrist-based tracker, FitBitTM Flex. They ambulated at a self-selected speed for 670 feet in a hallway. Orthotics and assistive devices were utilized as per the child's normal routine. Number of steps and distance were collected from both trackers. A researcher simultaneously used a tally counter to manually count total number of steps. Pearson correlation coefficients were determined for number of steps from each tracker and the manual count. Mean absolute percent error (MAPE) was calculated for steps for each tracker and the manual count, and for the distance from each tracker and the hallway distance. Results: For number of steps, a strong positive correlation was found between the waist tracker and the manual count (r=0.997), whereas a weak positive correlation was found between wrist tracker and manual count (r=0.223). MAPE for steps was 1% for the waist tracker and 12% for the wrist tracker. For distance, MAPE was 56% for the waist tracker and 41% for the wrist tracker. Conclusions/Significance: The waist-based activity tracker provided an accurate step count. Neither waist-based nor wristbased tracker was accurate for distance measurement. Thus, the walking ability of ambulatory children with CP can be accurately quantified with a readily available inexpensive activity tracker. This has the potential to enable clinicians to assess the effects of various treatments on the real-world activity level of patients with CP
EMBASE:618469751
ISSN: 1469-8749
CID: 2723772

A novel approach to leveraging electronic health record data to enhance pediatric surgical quality improvement bundle process compliance

Fisher, Jason C; Godfried, David H; Lighter-Fisher, Jennifer; Pratko, Joseph; Sheldon, Mary Ellen; Diago, Thelma; Kuenzler, Keith A; Tomita, Sandra S; Ginsburg, Howard B
PURPOSE: Quality improvement (QI) bundles have been widely adopted to reduce surgical site infections (SSI). Improvement science suggests when organizations achieve high-reliability to QI processes, outcomes dramatically improve. However, measuring QI process compliance is poorly supported by electronic health record (EHR) systems. We developed a custom EHR tool to facilitate capture of process data for SSI prevention with the aim of increasing bundle compliance and reducing adverse events. METHODS: Ten SSI prevention bundle processes were linked to EHR data elements that were then aggregated into a snapshot display superimposed on weekly case-log reports. The data aggregation and user interface facilitated efficient review of all SSI bundle elements, providing an exact bundle compliance rate without random sampling or chart review. RESULTS: Nine months after implementation of our custom EHR tool, we observed centerline shifts in median SSI bundle compliance (46% to 72%). Additionally, as predicted by high reliability principles, we began to see a trend toward improvement in SSI rates (1.68 to 0.87 per 100 operations), but a discrete centerline shift was not detected. CONCLUSION: Simple informatics solutions can facilitate extraction of QI process data from the EHR without relying on adjunctive systems. Analyses of these data may drive reductions in adverse events. Pediatric surgical departments should consider leveraging the EHR to enhance bundle compliance as they implement QI strategies.
PMID: 26995516
ISSN: 1531-5037
CID: 2051882

Periosteal chondrosarcoma in a 9-year-old girl with osteochondromatosis [Case Report]

Weinberg, Jacob; Miller, Theodore T; Handelsman, John E; Kahn, Leonard B; Godfried, David H; Kenan, Samuel
A 9-year-old girl with multiple osteochondromatosis presented with a 1 year history of a gradually enlarging surface lesion originating from the midsection of the right humerus, distal to an osteochondroma. Radiographically and histologically this lesion proved to be a periosteal chondrosarcoma adjacent to an osteochondroma
PMID: 15723209
ISSN: 0364-2348
CID: 95706

The halo-Milwaukee brace. Case series of a revived technique [Case Report]

Godfried, D H; Amory, D W; Lubicky, J P
STUDY DESIGN: A case series in which the halo-Milwaukee brace was used for postoperative immobilization in children with complex congenital and developmental spinal deformities. OBJECTIVES: To describe the use of halo-Milwaukee orthosis in a pediatric population for stabilization of the cervical and upper thoracic spine. SUMMARY AND BACKGROUND DATA: Postoperative immobilization of the neck and upper thorax can be achieved with cervical orthoses, cervicothoracic lumbar orthosis, halo cast, Minerva jacket, or halo vest. In the young child or in individuals with severe deformities, prefabricated braces often do not provide adequate stability or predictable fit. The halo-Milwaukee brace has proven to be an effective and versatile technique in the management of complex pediatric spinal deformities. METHODS: Halo-Milwaukee brace immobilization was used in 12 patients after surgical stabilization of the upper thoracic or cervical spine. Technique and indications are discussed in this report. Surgical outcomes and complications were reviewed retrospectively in all cases. RESULTS: Application of the halo-Milwaukee brace was a clinically effective and safe means of controlling the upper thoracic and cervical spine. The orthosis was well tolerated and allowed access to the posterior incision. The brace is easily converted to a standard Milwaukee brace with neck ring. The pelvic segment of the brace is molded before surgery, and in most instances did not require postoperative modification. CONCLUSION: The halo-Milwaukee brace is a simple and convenient method of intraoperative and postoperative immobilization. The technique is applicable in patients who cannot be treated with more conventional off-the-shelf orthoses. The brace was well tolerated and allowed for early patient mobilization.
PMID: 10562996
ISSN: 0362-2436
CID: 394472