title: Which Pediatric Orthopaedic Procedures Have the Greatest Risk of Adverse Outcomes?
abstract: BACKGROUND
  Quality improvement in orthopaedic surgery has received increasing attention; however, there is insufficient information available about the perioperative safety of many common pediatric orthopaedic procedures. This study aimed to characterize the incidence of adverse events in a national pediatric patient sample to understand the risk profiles of common pediatric orthopaedic procedures, and to identify patients and operations that are associated with increased rates of adverse outcomes.
  
  
  METHODS
  A retrospective cohort study was conducted using the prospectively collected American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Pediatric database. Pediatric patients who underwent 29 different orthopaedic procedures were identified in the 2012 NSQIP Pediatric database. The occurrence of any adverse event, infection, return to the operating room, and readmission within 30 days, were reported for each procedure. Multivariate regression was then used to identify the association of patient and operative characteristics with the occurrence of each adverse outcome.
  
  
  RESULTS
  A total of 8975 pediatric patients were identified. Supracondylar humerus fracture fixation was the most common procedure performed in this sample (2274 patients or 25.57% of all procedures), followed by posterior spinal fusion (1894 patients or 21.10% of all procedures). Adverse events occurred in 352 patients (3.92% of all patients). Four deaths were noted (0.04% of all patients), which only occurred in patients with nonidiopathic scoliosis undergoing spinal fusion. Infections occurred in 143 patients (1.59%), and 197 patients (2.19%) were readmitted within 30 days. Multiple patient characteristics and procedures were found to be associated with each adverse outcome studied.
  
  
  CONCLUSIONS
  Spinal fusion, multiaxial external fixation, and fasciotomy were procedures associated with increased rates of adverse outcomes within 30 days. Patients with obesity, ASA class ≥3, and impaired cognitive status also had increased rates of adverse outcomes. The results from this study of a large, national sample of pediatric orthopaedic patients are important for benchmarking and highlight areas for quality improvement.
  
  
  METHODS
  Level III-Prognostic.
authors.affiliation: *Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL †Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, CT.
authors.forename: Bryce A
authors.initials: BA
authors.lastname: Basques
authors.forename: Adam M
authors.initials: AM
authors.lastname: Lukasiewicz
authors.forename: Andre M
authors.initials: AM
authors.lastname: Samuel
authors.forename: Matthew L
authors.initials: ML
authors.lastname: Webb
authors.forename: Daniel D
authors.initials: DD
authors.lastname: Bohl
authors.forename: Brian G
authors.initials: BG
authors.lastname: Smith
authors.forename: Jonathan N
authors.initials: JN
authors.lastname: Grauer
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D016208:Databases, Factual; D005260:Female; D006801:Humans; D015994:Incidence; D008297:Male; D019637:Orthopedic Procedures / Q000009:adverse effects / Q000706:statistics & numerical data*; D011183:Postoperative Complications / Q000453:epidemiology*; D011379:Prognosis; D016016:Proportional Hazards Models; D058996:Quality Improvement / Q000458:organization & administration; D012189:Retrospective Studies; D012306:Risk; D016896:Treatment Outcome