BACKGROUND: Consensus regarding which children within orthopedics would benefit from venous thromboembolism (VTE) prophylaxis is lacking. Our objective was to explore the incidence and epidemiology of VTE within pediatric orthopedics through a multicenter review across the United States. METHODS: Encompassing 13 pediatric centers nationwide, VTE incidence rates with 95% confidence interval (CIs) were determined for all pediatric nonorthopedic patients (PNOPs) in general (age 0-18 years) and compared with pediatric orthopedic patients (POPs) from both inpatient and outpatient settings between 2014 and 2017. Demographics, risk factors, presence of prophylaxis, treatment, and outcomes for POP VTEs were analyzed using descriptive statistics. RESULTS: Of 10,040,937 total unique patients, the overall 4-year VTE incidence for PNOPs was 2.1 per 10,000 patients (CI 2.01-2.19). Of 141,545 POPs, the VTE incidence was 8.0 per 10,000 patients (CI 6.61-9.63). The weighted median age for POP VTEs was higher than that for PNOP VTEs (11.5 vs. 8.0 years, p = 0.001). Of the 113 POP VTEs, 97 eligible patients (median age 13.3 years, 56% male) with complete data were further analyzed: 85% (82/97) underwent orthopedic surgery for trauma, infection, or an elective procedure. Orthopedic procedures (49%), bacteremia (46%), central venous catheters (38%), and trauma (28%) were the most common risk factors associated with VTE development, mostly occurring during the initial hospitalization (65%). Thirty-four percent (33/97) of VTE cases had received prophylaxis, predominantly pharmacological (26/33, 79%), administered postoperatively. Ninety-seven percent (94/97) of POP VTEs were treated with anticoagulation, most frequently low-molecular-weight heparin (79%). Twenty-two percent of POP VTEs experienced complications, 2 (2%) of which were deaths, with one having received postoperative VTE prophylaxis. CONCLUSIONS: Although relatively rare, the true incidence of pediatric orthopedic-related VTE may be greater than that of nonpediatric orthopedic VTE, with child mortality occurring in a small minority of cases. In children diagnosed with VTE, one third had received VTE prophylaxis. Identifying at-risk children undergoing orthopedic surgery and establishing best practice safety protocols for VTE prevention are critical to prevent associated morbidity and mortality. LEVEL OF EVIDENCE: Level III-Retrospective comparative study. See Instructions for Authors for a complete description of levels of evidence.

Purpose

Risk factors for congenital upper limb differences (CoULDs) are often studied at the general population level. The CoULD registry provides a unique opportunity to study prenatal risk factors within a large patient sample.

Methods

All patients enrolled between June 2014 and March 2020 in the prospective CoULD registry, a national multicenter database of patients diagnosed with a CoULD, were included in the analysis. We analyzed self-reported, prenatal risk factors, including maternal smoking, alcohol use, recreational drug use, prescription drug use, gestational diabetes mellitus (GDM), and gestational hypertension. The outcome measures included comorbid medical conditions, proximal involvement of limb difference, bilateral involvement, and additional orthopedic conditions. Multivariable logistic regression was used to analyze the effect of the risk factors, controlling for sex and the presence of a named syndrome.

Results

In total, 2,410 patients were analyzed, of whom 72% (1,734) did not have a self-reported risk factor. Among the 29% (676) who did have at least 1 risk factor, prenatal maternal prescription drug use was the most frequent (376/2,410; 16%). Maternal prescription drug use was associated with increased odds of patient medical comorbidities (odds ratio [OR] = 1.43, P = .02). Gestational diabetes mellitus was associated with increased odds of comorbid medical conditions (OR = 1.58, P = .04), additional orthopedic conditions (OR = 1.51, P = .04), and proximal involvement (OR = 1.52, P = .04). Overall, reporting 1 or more risk factors increased the odds of patient comorbid medical conditions (OR = 1.42, P < .001) and additional orthopedic conditions (OR = 1.25, P = .03).

Conclusions

Most caregivers (72%) did not report a risk factor during enrollment. However, reporting a risk factor was associated with patient medical and orthopedic comorbidities. Of note, GDM alone significantly increased the odds of both these outcome measures along with proximal limb differences. These findings highlight the ill-defined etiology of CoULDs but suggest that prenatal risk factors, especially GDM, are associated with a higher degree of morbidity.

Type of study/level of evidence

Prognostic III.