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首页> 外文期刊>Orthopaedic Journal of Sports Medicine >OPERATIVE DECISION-MAKING FOR PEDIATRIC TIBIAL SPINE FRACTURES: ASSESSING THE EFFECT OF SURGEON EXPERIENCE AND RISK-AVERSION AND PATIENT AGE, SEX, INJURY TYPE, AND ATHLETIC LEVEL USING A MIXED EFFECTS MODEL
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OPERATIVE DECISION-MAKING FOR PEDIATRIC TIBIAL SPINE FRACTURES: ASSESSING THE EFFECT OF SURGEON EXPERIENCE AND RISK-AVERSION AND PATIENT AGE, SEX, INJURY TYPE, AND ATHLETIC LEVEL USING A MIXED EFFECTS MODEL

机译：儿科胫骨脊柱骨折的操作决策：使用混合效应模型评估外科医生经验和风险厌恶和患者年龄，性别，伤害型和运动水平的影响

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Background: Tibial spine fractures most commonly occur in children aged 8 to 14 years and are occasionally seen in adults. Although the annual incidence is 3 per 100,000 children, they account for 2-5% of pediatric knee injuries with effusions and are associated with substantial complications including ACL deficiency and arthrofibrosis. The rise in competitive youth sports has brought increased public attention to this injury. Meyers and McKeever Type II fractures are displaced anteriorly with an intact posterior hinge. This specific subtype of pediatric tibial spine fractures has controversy in the literature whether they should be treated non-operatively or operatively. The purpose of this study was to identify assess for variability amongst pediatric orthopaedic surgeons when treating pediatric type II tibial spine fractures. Methods: A discrete choice experiment was conducted to determine the patient and injury attributes that influence the management of type II pediatric tibial spine fractures by pediatric orthopaedic surgeons. A convenience sample of 14 pediatric orthopaedic surgeons reviewed 40 case vignettes (Figure 1) that included radiographs displaying fractures with varying degrees of displacement (range: 2.5 – 6.0 mm) and a brief description on the patient’s sex, age (8-17), mechanism of injury (fall, collision, hypertension, twist), and predominant sport (swimming, football, basketball, nonathlete). Surgeons were asked whether they would treat the fracture operatively or non-operatively. Physes were blinded. A mixed effects model was used to determine the patient attributes most likely to influence the surgeon’s decision for operative treatment of a tibial spine fracture. In addition, the association between surgeon propensity for operative treatment based on surgeon training, years in practice, and risk-taking behavior based on the Jackson Personality Inventory subscale was assessed. A receiver operating characteristic curve was used to determine probability of surgical treatment based on the degree of fracture displacement. Results: Surgeon demographics are summarized in Table 1. Overall, the 14 respondents selected operative treatment in 75% of the presented cases. The degree of fracture displacement was the only patient attribute that was significantly associated with treatment choice (p&0.001). Surgeons were 29% more likely to treat the fracture operatively with each additional millimeter of displacement. The probability of opting for surgical treatment exceeded 50% when the fracture had 3.5 or more millimeters of displacement. Significant variation in surgeon’s propensity for operative treatment of this fracture was observed (p=0.01). Nine of the 14 surgeons demonstrated a significant propensity for operative treatment of this injury. Surgeon training, years in practice, and risk-taking scores were not associated with the respondent’s preference for surgical treatment. Conclusions / Significance: There is substantial variation among pediatric orthopaedic surgeons when treating type II tibial spine fractures. The decision to operate is significantly based on the degree of fracture displacement. However, there is no standardization regarding how to treat type II tibial spine fractures and therefore better treatment algorithms are needed to optimize patient outcomes. Learning about the current treatment preferences among surgeons given different patient factors can highlight current variation in practice patterns and direct efforts toward promoting the most optimal treatment strategies. Table 1: Surgeon Demographics Age (Mean ± SD) 43.3 ± 6.1 years Sex n (%) ??Male 14/14 (100%) Years of Practice (Mean ± SD) 9.2 ± 6.2 years Practice Geography ??Northeast 8/14 (57.1%) ??Midwest 4/14 (28.6%) ??Southwest 2/14 (14.3%) Practice Type ??Academic 12/14 (85.7%) ??Academic and Private Mix 2/14 (14.3%) Fellowship Training ??Pediatrics 6/14 (42.9%) ??Pediatrics and Sports 7/14 (30%) ??Pediatrics and Hip Preservation 1/14 (7.1%) Avenge Days Per Week On-Cull (Mean ± SD) 1.8 ± 0.6 years Pediatric Tibial Spine Fractures Treated Annually ??1-3 5/14 (35.7%) ??4-6 3/14 (21.4%) ??6-9 4/14 (28.6%) ??10-14 1/14 (7.1%) ??&15 1/14 (7.1%) Adult Tibial Spine Fractures Treated Annually ??Rarely (&1) 6/14 (42.9%) ??1-3 3/14 (21.4%) ??4-6 2/14 (14.3%) ??6-9 2/14 (14.3%) ??10-14 1/14 (7.1%)
机译：背景：胫骨脊柱骨折最常见于8至14岁的儿童，偶尔会在成人中看到。虽然年发病率为每10万人3例，但它们占2-5％的小儿膝关节伤害，患有积液，并与ACL缺乏和关节纤维化，包括缺乏症和关节纤维化有关。有竞争力的青年体育的兴起带来了对这一伤害的高度关注。 Meyers和McKeever II型骨折与完整的后铰链向前移动。除了它们应该是不可操作性的或可操作的，这种特定的儿科胫骨脊柱骨折的亚型在文献中具有争议。本研究的目的是在治疗小儿型II胫骨脊柱骨折时识别儿科骨科外科医生的可变性评估。方法：进行分立选择实验，以确定对儿科骨科外科医生影响II型儿科胫骨骨折的管理的患者和损伤属性。 14个儿科矫形外科医生的便利样品审查了40个案例的小插图（图1），包括显示射线照相，显示骨折，具有不同程度的位移（范围：2.5-6.0 mm）和关于患者性别的简要说明（8-17），损伤机制（秋季，碰撞，高血压，扭曲）和主要运动（游泳，足球，篮球，非运动）。询问外科医生是否会术式或不可操作地对待骨折。物理因素被蒙蔽了。混合效应模型用于确定最有可能影响外科医生的胫骨脊柱骨折的治疗决定的患者属性。此外，根据医生的培训手术治疗，多年的实践，以及冒险行为基础上，杰克逊人格量表外科医生倾向之间的关联进行了评估。接收器操作特征曲线用于根据骨折位移程度确定手术治疗的概率。结果：外科医生人口统计数据总结在表1中。总体而言，14名受访者在75％的案件中选择了手术治疗。骨折位移程度是与治疗选择显着相关的唯一患者属性（P <0.001）。外科医生可能与每个额外的毫米的位移可操作地治疗骨折29％。当骨折具有3.5或更多毫米的位移时，选择外科治疗的可能性超过50％。观察到外科医生对该骨折的操作治疗倾向的显着变化（p = 0.01）。 14个外科医生中的九个表现出对这种损伤的手术治疗的显着倾向。外科医生培训，实践年份，风险评分与受访者对外科治疗的偏好无关。结论/意义：在治疗II型胫骨脊柱骨折时，儿科骨科外科医生存在显着变化。操作的决定是基于裂缝位移程度的显着。然而，对于如何治疗II型胫骨脊柱骨折并没有标准化，因此需要更好的治疗算法来优化患者结果。学习外科医生的当前治疗偏好，不同的患者因素可以突出实践模式的当前变化，直接努力促进最佳的治疗策略。表1：外科医生人口统计年龄（平均值±SD）43.3±6.1年性别N（％）？男性14/14（100％）练习（平均值±SD）9.2±6.2年实践地理？东北8/14 （57.1％）??中西部4/14（28.6％）??西南2/14（14.3％）实践类型？学术12/14（85.7％）？学术和私人组合2/14（14.3％）奖学金培训??儿科6/14（42.9％）??儿科和运动7/14（30％）??儿科和臀部保存1/14（7.1％）每周复仇天（平均值±SD）1.8± 0.6年儿科胫骨脊柱骨折每年治疗吗?? 1-3 5/14（35.7％）?? 4-6 3/14（21.4％）?? 6-9 4/14（28.6％）?? 10-14 1 / 14（7.1％）??＆ 15 1/14（7.1％）每年待治疗的成人胫骨脊柱骨折（＆ 1）6/14（42.9％）？1-3 3/14（21.4％） ）?? 4-6 2/14（14.3％）?? 6-9 2/14（14.3％）?? 10-14 1/14（7.1％）

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