A small number of surgical procedures account for the majority of adverse events experienced by pediatric surgical patients in the 30 days following orthopaedic procedures, according to a large study presented by Brian G. Smith, MD, at the 2015 annual meeting of the Pediatric Orthopaedic Society of North America (POSNA). The study garnered the Peter Armstrong, MD, Shriners Hospital for Children Award.

“The results from this study of a large, national sample of pediatric orthopaedic patients are important for benchmarking and highlighting areas for quality improvement,” wrote the authors.

Conducting the study
The researchers obtained prospectively collected data from the 2012 American College of Surgeons National Surgical Quality Improvement Program (NSQIP) pediatric database. In all, 8,975 pediatric patients underwent 29 different orthopaedic surgical procedures. For each procedure, researchers identified the following factors:

• patient demographics
• occurrence of an adverse event
• mortality
• surgical site infection
• readmission within 30 days of surgery

Analyzing results
Supracondylar humerus fracture fixation was the single most commonly performed procedure among all pediatric patients (2,274 patients, or 25.57 percent of all procedures), with posterior spinal fusion second (1,916 patients, or 21.55 percent of all procedures).

The investigators found that 352 patients (3.92 percent) experienced an adverse event associated with surgery, while four pediatric patients died (0.04 percent). The patients who died all had neuromuscular disease and were undergoing posterior spinal fusion.

The researchers also found that surgical site infections occurred in 143 patients (1.59 percent). In total, 197 patients (2.19 percent) were readmitted within 30 days.

The greatest absolute number of adverse events (defined as mortality, surgical site infection, or readmission within 30 days) was associated with posterior spinal fusion (170 patients, or 48.30 percent). Supracondylar humerus fracture fixation (46 patients, or 13.07 percent of all adverse events) was linked to the second highest number of adverse events, followed by revision of spinal fusion (27 patients, or 7.67 percent). Table 1 shows the complete list of “top ten” procedures linked to adverse events.

Drawing conclusions
The researchers were surprised to find that “neuromuscular disease status itself did not predispose to complications,” said Dr. Smith.

“We were also surprised to find that anterior spinal fusions were associated with a high complication rate; however, relatively few of these procedures were performed in this sample, and most were combined anterior and posterior spinal fusions,” he noted. “It was not unexpected that spinal fusions would have a higher complication profile, in general, or that obesity would be associated with complications.

“Recent literature substantiates the association of complications with obesity, which suggests that weight loss prior to elective spinal fusion surgery may truly be beneficial,” continued Dr. Smith.

Overall, the findings are important because these data “educate pediatric orthopaedists about the rates of complications associated with common procedures, thus enabling them to better inform their patients’ families about risks of these surgical procedures and to develop strategies to reduce those risks,” said Dr. Smith.

According to Jonathan N. Grauer, MD, the study’s senior author, the findings point to “areas for quality improvement” when it comes to common procedures.

“We look forward to conducting further research on perioperative safety as it relates to pediatric orthopaedic procedures,” said Dr. Grauer.

Co-authors with Drs. Smith and Grauer on “Which Common Pediatric Orthopaedic Procedures are the Most Dangerous?” included Bryce A. Basques, BS; Daniel D. Bohl, MPH; and Nicholas S. Golinvaux, BA.

Details of the authors’ disclosures may be accessed at www.aaos.org/disclosure

Jennie McKee is a senior science writer for AAOS Now. She can be reached at mckee@aaos.org

Bottom Line

• Based on data on 8,975 pediatric orthopaedic patients from a national database, supracondylar humerus fracture fixation was the most commonly performed procedure with posterior spinal fusion rating second.
• Posterior spinal fusion was linked to the greatest absolute number of adverse events, followed by supracondylar humerus fracture fixation and revision of spinal fusion.
• The study’s findings shed light on possible areas for quality improvement and enhanced communication with patients and families regarding risks of various pediatric orthopaedic procedures.