Practice Variation in the Surgical Management of Children With Acute Hematogenous Osteomyelitis

Abstract

Introduction:The surgical indications to manage children with acute hematogenous osteomyelitis (AHO) remain poorly defined. The purpose of this study was to identify if practice pattern variation exists in the surgical management of pediatric AHO among tertiary pediatric medical centers across the United States. A secondary purpose was to evaluate variables that may impact the rate of surgical intervention among these institutions. Methods: Children with AHO were retrospectively analyzed between January 1, 2010, and December 31, 2016, from 18 pediatric medical centers throughout the United States. The rates of surgery were identified. Admission vitals, labs, weight-bearing status, length of stay, and readmission rates were compared between those who did and did not undergo surgery. Multivariate regression and classification and regression tree analyses were performed to identify the variables that were associated with surgical intervention. Results: Of the 1003 children identified with AHO in this retrospective, multicenter database, 619/1003 (62%) were treated surgically. Multivariate analysis revealed institution, inability to ambulate, presence of multifocal infection, elevated admission C-reactive protein, increased admission platelet count, and location of the osteomyelitis were significant predictors of surgery (P < 0.01). Patients who underwent surgery were more than twice as likely to have a recurrence or readmission and stayed a median of 2 days longer than those who did not have surgery. In the classification and regression tree analysis, 2 distinct patterns of surgical intervention were identified based on institution, with 12 institutions operating in most cases (72%), regardless of clinical factors. A second cohort of 6 institutions operated less routinely, with 47% receiving surgery overall. At these 6 institutions, patients without multifocal infection only received surgery 26% of the time, which increased to 74% with multifocal infection and admission erythrocyte sedimentation rate > 37.5 mm/h. Conclusions: This study is the first to objectively identify significant differences in the rates of surgical management of pediatric AHO across the United States. Variation in the surgical management of AHO appears to be driven primarily based on institutional practice. Twelve institutions operated on 72% of patients, regardless of the severity of disease, indicating that the institution custom or dogma may drive the surgical indications. Six institutions relied more on clinical judgment with significant variability in rates of surgical intervention (26% vs. 74%), depending on the severity of the disease. Surgical intervention is associated with increased recurrence, readmission, and hospital length of stay. As a result of these findings, it is essential to prospectively study the appropriate surgical indications and measure the outcomes in children with pediatric AHO. Level of Evidence: Level III.

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“…[2][3][4]7,12,[16][17][18] Some studies have reported a higher median age of presentation of between 6.7 and 11.1 years. 5,8,14,[19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37] Males appear to be between 1.2 and 3.6 times more affected than females.…”

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“…A recent review of the Children's ORthopaedic Trauma and Infection Consortium for Evidence-based Study (CORTICES, www.cortices.org) database found that significant variation occurs in the surgical management of acute hematogenous osteomyelitis, and that this variation appears to be driven largely by institutional practices. 13 This variation may be explained, in part, by regional and temporal differences in bacterial flora, and local susceptibility patterns make the creation of universal diagnostic protocols or treatment recommendations more challenging than care pathways for more elective type conditions. 14,15 Furthermore, controversies regarding the need and timing of advanced imaging, the use of intravenous contrast for said imaging, and the timing of procedural interventions may have a profound impact on a surgeon's day-to-day practice.…”

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“…The CORTICES (Children’s Orthopedic Trauma and Infection Consortium for Evidence based Studies) Study Group found, in a series of 1,003 patients, that surgeons in 12 participating institutions operated on 72% of patients and surgeons in the other 6 institutions took a more targeted approach, operating on only 26% of patients. The authors concluded that institutional dogma dictated operative interventions more than clinical presentation did 66 .…”