title: Clinical Implications of Psychosocial Factors on Pediatric External Fixation Treatment and Recommendations.
abstract: BACKGROUND
  Pediatric limb reconstruction using circular external fixation is a prolonged treatment that interrupts patients' daily function. Patient personality characteristics and expectations may interfere with planned treatment, making complicated medical procedures more challenging. The aims of this study are to identify factors impacting treatment outcome and recommendations for preoperative evaluation and planning.
  
  
  OBJECTIVE
  (1) Are there group differences between patients with and without a preexisting mental health condition(s) in terms of unplanned reoperations? (2) Does the number of surgical procedures before current external fixator placement correlate with the number of unplanned readmissions, unplanned reoperations, and days spent in circular external fixation? (3) Are there group differences between single- compared with two-parent households in terms of inpatient narcotic doses, length of inpatient stay, number of unplanned readmissions, length of readmission(s), and/or unplanned outpatient clinic visits? (4) Does patient age at the time of surgery have an impact on treatment duration, postoperative complications, and treatment outcome?
  
  
  METHODS
  This is a retrospective chart review of pediatric patients who underwent limb reconstruction between 2008 and 2012. Patients with limb length discrepancy > 4 cm or severe angular deformity and who agreed to intervention were treated with circular external fixation. Sixty-seven patients were included; 16 patients were excluded. Statistical analyses included Pearson r correlation and t-test.
  
  
  RESULTS
  Patients who reported preexisting mental health diagnosis (13%) had more unplanned reoperations than patients who did not (no mental health diagnosis; 87%) (mental health diagnosis 3.4 ± 10.3 versus no mental health diagnosis 0.2 ± 0.5 reoperation[s], p = 0.022). Number of previous surgical procedures correlated with number of unplanned reoperations (r = 0.448, p < 0.001), number of unplanned readmissions (r = 0.375, p < 0.001), and number of days in an apparatus (r = 0.275, p = 0.018). Compared with patients from two-parent households, patients from single-parent households received a greater number of inpatient narcotic doses (single-parent 129 ± 118 versus two-parent 73 ± 109 doses, p = 0.039), longer length of inpatient stay (single-parent 73 ± 63 versus two-parent 40 ± 65 days, p = 0.036), more unplanned readmissions (single-parent 0.4 ± 0.1 versus two-parent 0.2 ± 0.2 readmission, p = 0.024), longer hospitalization when readmitted (single-parent 5 ± 11 versus two-parent 1 ± 3 day(s), p = 0.025), and fewer unplanned outpatient visits (single-parent 0.2 ± 0.8 versus two-parent 0.9 ± 1.1 visit, p = 0.005). Apparatus applications with successful outcome had higher average age than those with poor outcome (successful outcome 16 ± 3 versus poor outcome 13 ± 4 years old, p = 0.011). Age at time of apparatus application correlated with number of prescribed antibiotics (r = 0.245, p = 0.036) and number of days in an apparatus (r = 0.233, p = 0.047).
  
  
  CONCLUSIONS
  As a result of the inherent challenges of limb reconstruction, surgical candidates should be preoperatively assessed and mitigating psychosocial factors managed to maximize successful treatment outcome.
  
  
  METHODS
  Level IV, therapeutic study.
authors.affiliation: Texas Scottish Rite Hospital for Children, 2222 Welborn Street, Dallas, TX, 75219, USA, Heather.richard@tsrh.org.
authors.forename: Heather M
authors.initials: HM
authors.lastname: Richard
authors.forename: Dylan C
authors.initials: DC
authors.lastname: Nguyen
authors.forename: John G
authors.initials: JG
authors.lastname: Birch
authors.forename: Sandy D
authors.initials: SD
authors.lastname: Roland
authors.forename: Mikhail K
authors.initials: MK
authors.lastname: Samchukov
authors.forename: Alex M
authors.initials: AM
authors.lastname: Cherkashin
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D016267:External Fixators; D005260:Female; D005592:Fracture Fixation / Q000523:psychology*; D050723:Fractures, Bone / Q000150:complications / Q000601:surgery*; D006801:Humans; D008297:Male; D001523:Mental Disorders / Q000150:complications; D011183:Postoperative Complications / Q000453:epidemiology; D017410:Practice Guidelines as Topic; D012086:Reoperation / Q000706:statistics & numerical data; D012189:Retrospective Studies; D055815:Young Adult
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