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Journal of Pediatric Orthopaedics
Journal Prestige (SJR): 0.913
Citation Impact (citeScore): 2
Number of Followers: 16  
 
  Hybrid Journal Hybrid journal (It can contain Open Access articles)
ISSN (Print) 0271-6798 - ISSN (Online) 1539-2570
Published by LWW Wolters Kluwer Homepage  [301 journals]
  • Outcomes and Complications in Management of Congenital Myopathy
           Early-Onset Scoliosis

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      Authors: Magee; Lacey; Bram, Joshua T.; Anari, Jason B.; Ramo, Brandon; Mayer, Oscar H.; Matsumoto, Hiroko; Brooks, Jaysson T.; Andras, Lindsay; Lark, Robert; Fitzgerald, Ryan; Truong, Walter; Li, Ying; Karlin, Lawrence; Schwend, Richard; Weinstein, Stuart; Roye, David; Snyder, Brian; Flynn, John M.; Oetgen, Matthew; Smith, John; Cahill, Patrick J.; PSSG
      Abstract: imageBackground: Congenital myopathies (CMs) are complex conditions often associated with early-onset scoliosis (EOS). The purpose of this study was to investigate radiographic outcomes in CM patients undergoing EOS instrumentation as well as complications. Secondarily, we sought to compare these patients to a population with higher prevalence, cerebral palsy (CP) EOS patients.Methods: This is a retrospective study of a prospectively collected multicenter registry. The registry was queried for EOS patients with growth-sparing instrumentation (vertical expandable prosthetic titanium ribs, magnetically controlled growing rods, traditional growing rod, or Shilla) and a CM or CP diagnosis with minimum 2 years follow-up. Outcomes included major curve magnitude, T1-S1 height, kyphosis, and complications.Results: Sixteen patients with CM were included. Six (37.5%) children with CM experienced 11 complications by 2 years. Mean major curve magnitude for CM patients was improved postoperatively and maintained at 2 years (P0.05). Ninety-seven patients with CP EOS were included as a comparative cohort. Fewer CP patients required baseline respiratory support compared with CM patients (20.0% vs. 92.9%, P
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Clinical Outcomes of 3-column Osteotomy at Growing Rod Graduation

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      Authors: Cayli; Cem; Dursun, Gokay; Cetik, R. Mert; Ramazanov, Rafik; Demirkiran, H. Gokhan; Ayvaz, Mehmet; Yazici, Muharrem
      Abstract: imageBackground: Several different strategies were described on how to graduate a patient when skeletal maturity is reached after growing rod treatment. A final instrumentation and fusion is commonly performed, but the stiffness of the spine after numerous lenghthenings can be a major problem. When correction is needed in a severe and rigid curve, 3-column osteotomies (3CO) can be used as a method of bringing the spine back to a well-balanced position. This study aims to evaluate the clinical outcomes of 3CO osteotomies at growing rod graduation.Methods: A retrospective search of the database was performed between 1996 and 2018. Inclusion criteria were: diagnosis of early-onset scoliosis, underwent 3CO at the final fusion procedure, and ≥1 year of follow-up. Indications for this osteotomy were: significant sagittal and/or coronal off-balance or severe crankshaft deformity or significant distal and/or proximal adding-on. Clinical, radiographic, and operative data were analyzed. Complications were classified according to the modified Clavien-Dindo-Sink system.Results: Eight patients were included in the study with a mean age of 13.5 at graduation (male/female: 2/6). The mean scoliosis angle significantly reduced from 65.6 to 39 degrees (P=0.012). Mean T1-T12 height increased from 19 to 20.5 (P=0.084) and T1-S1 from 29.6 to 31.6 (P=0.144). Five patients had a staged surgery. Average operative time was 338 minutes and blood loss was 1321 mL. Four grade 1, 1 grade 2, and 1 grade 3 complications occurred.Conclusions: This is the first case-series in the literature reporting on the use of 3CO at growing rod graduation. These procedures can be safely and effectively used to overcome significant multiplanar deformity and/or off-balance in the graduation of patients with early-onset scoliosis and significant correction can be achieved on these severe and rigid curves.Level of Evidence: Level IV—case series.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Use of Vancomycin Powder in the Surgical Treatment of Early Onset
           Scoliosis Is Associated With Different Microbiology Cultures After
           Surgical Site Infection

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      Authors: Dumaine; Anne M.; Du, Jerry Y.; Parent, Stefan; Sturm, Peter; Sponseller, Paul; Glotzbecker, Michael P.; Pediatric Spine Study Group
      Abstract: imageBackground: The use of vancomycin powder has been shown to decrease risk of surgical site infection (SSI) in early onset scoliosis (EOS). While there is potential benefit in SSI reduction, there is also theoretical risk in creating increased bacterial resistance to standard treatment regimens. However, the effects of topical vancomycin powder on microbiology in these patients has not been studied.Methods: A multicenter database for EOS patients was retrospectively analyzed. All patients that underwent surgical treatment with traditional growing rods, magnetically controlled growing rods, vertical expandable prosthetic titanium rib, and Shilla for EOS performed after 2010 were identified (n=1115). Patients that sustained at least 1 SSI after guided growth surgery were assessed (n=104, 9.3%). Patients with culture and antibiotic details were included (n=55). Patients that received vancomycin powder at index surgery were compared with patients that did not. A multivariate regression model was used to control for potential confounders.Results: There were 55 patients included in this study, including 26 males (47%) and 29 females (53%). Mean age at index surgery was 7.2±6.9 years. Vancomycin powder was utilized in 18 cases (33%). Mean time from index surgery to SSI was 2.0±1.3 years. There were 2 cases of wound dehiscence (4%), 7 cases of superficial infection (13%), and 46 cases of deep infection (84%).There were significant differences in overall microbiology results between vancomycin and no vancomycin cohorts (P=0.047). On univariate analysis, the vancomycin powder cohort had a significantly high incidence of cultures without growth (n=7, 39% vs. n=4, 11%, relative risk: 2.063, 95% confidence interval: 0.927-4.591, P=0.028). This association remained significant on multivariate analysis (adjusted odds ratio: 9.656, 95% confidence interval: 1.743-53.494, P=0.009).Conclusions: In EOS patients undergoing procedures complicated by SSI, the use of vancomycin powder was independently associated with increased risk of no culture growth. Surgeons and infectious disease physicians should be aware and adjust diagnostic and treatment strategies appropriately.Level of Evidence: Level III—retrospective cohort study.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Risk of Scoliosis Progression in Nonoperatively Treated Adolescent
           Idiopathic Scoliosis Based on Skeletal Maturity

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      Authors: Johnson; Mitchell A.; Flynn, John M.; Anari, Jason B.; Gohel, Shivani; Cahill, Patrick J.; Winell, Jennifer J.; Baldwin, Keith D.
      Abstract: imageBackground: Hand radiographs for skeletal maturity staging are now frequently used to evaluate remaining growth potential for patients with adolescent idiopathic scoliosis (AIS). Our objective was to create a model predicting a patient’s risk of curve progression based on modern treatment standards.Methods: We retrospectively reviewed all AIS patients presenting with a major curve 25 degrees, whereas patients between 10 and 25 degrees were observed. Treatment success was defined as reaching skeletal maturity with a major curve
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Postoperative Correction in Idiopathic Scoliosis: Which Preoperative
           Imaging Technique Is Most Predictive'

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      Authors: Erkilinc; Mehmet; Dumaine, Anne M.; Du, Jerry Y.; Poe-Kochert, Connie; Thompson, George H.; Liu, Raymond W.; Mistovich, R. Justin
      Abstract: imageIntroduction: Preoperative radiographic assessment of curve flexibility in patients with idiopathic scoliosis is important to determine Lenke classification, operative levels, and potential postoperative correction. However, no consensus exists regarding the optimal technique. We compared measurements from supine side bending (SB) and intraoperative traction radiographs under general anesthesia (TUGA) with actual postoperative correction followed for 1 year.Methods: We identified 235 patients with idiopathic scoliosis who underwent posterior spinal fusion with pedicle screw instrumentation between 2010 and 2018 who had preoperative and postoperative radiographs including standing posterior-anterior (PA) and lateral radiographs, preoperative SB radiographs, and TUGA radiographs. Curves were categorized into proximal thoracic, main thoracic/thoracolumbar (MT), and distal thoracolumbar/lumbar (TL/L) curves. Flexibility was calculated from SB and TUGA radiographs. Correction rates were calculated from 1 month and 1 year radiographs postoperatively. Bending radiographs that correlated significantly with postoperative correction with P
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Area Deprivation Index and Magnitude of Scoliosis at Presentation to a
           Tertiary Referral Scoliosis Clinic in Massachusetts

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      Authors: Nezwek; Teron A.; Braun, Stuart V.; Menendez, Mariano E.; Grussing, Emily D.; Shabin, Zabrina M.
      Abstract: imageBackground: There is growing interest in identifying predictors of large scoliosis curves at initial presentation, but few data to guide such preventive efforts. The association of neighborhood socioeconomic deprivation with curve magnitude in this context has not been previously evaluated. The purpose of our study was to determine the correlation of socioeconomic deprivation with scoliosis curve magnitude at initial presentation. Secondarily, we assessed the correlation of body mass index (BMI) with curve severity.Methods: We retrospectively identified 202 patients presenting with adolescent idiopathic scoliosis to a single tertiary care center in Massachusetts from January 2015 to August 2018. The Area Deprivation Index (ADI), a validated composite measure of neighborhood socioeconomic deprivation, was calculated for each patient. Curve magnitude, age, sex, BMI, race, and insurance status were recorded. Pearson correlation was used to determine the association of the ADI and BMI with scoliosis severity.Results: There was no correlation between the ADI and the magnitude of scoliosis at presentation (r=0.055; P=0.43). Greater BMI was moderately correlated with increased scoliosis curve magnitude (r=0.28; P
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Getting Them Back in the Game: When Can Athletes With Adolescent
           Idiopathic Scoliosis Safely Return to Sports' A Mixed-effects Study of
           the Pediatric Orthopaedic Association of North America

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      Authors: Ho; Dedi; Du, Jerry Y.; Erkilinc, Mehmet; Glotzbecker, Michael P.; Mistovich, R. Justin
      Abstract: imageBackground: Despite the relative frequency of posterior spinal fusion (PSF) and instrumentation for adolescent idiopathic scoliosis (AIS), there are limited guidelines for postoperative return to sports. Few studies explore factors influencing treating surgeons’ recommendations.Methods: A survey presenting several clinical vignettes of patients who had undergone PSF for AIS was distributed to 1496 Pediatric Orthopaedic Society of North America (POSNA) members. Of the 257 returned surveys, 170 met the inclusion criteria. Mixed-effects models were created to assess the effects of the surgeon and hypothetical patient characteristics on return to jogging, noncontact, contact, and collision sports.Results: Estimated marginal mean time to return to sporting activities increased for more physically demanding sports [jogging: 4.1 mo, 95% confidence interval (CI): 3.8-4.3; noncontact: 4.6 mo, 95% CI: 4.3-4.9; contact: 6.8 mo, 95% CI: 6.4-7.1; collision: 9.8 mo, 95% CI: 9.2-10.4]. Hypothetical patient characteristics (sex, age, obesity, skeletal maturity, levels fused, and fusions ending in thoracic versus lumbar spine) were not associated with changes in return to sport recommendations for jogging, noncontact, contact, or collision activities. Surgeon volume, experience, fellowship type, and practice setting all affected return to all activities (P
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Performing Multiple Posterior Spinal Fusions in 1 Day: A Comparison of
           Perioperative Outcomes Between Morning and Afternoon Cases

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      Authors: O’Neill; Nora P.; Hedequist, Daniel J.; Glotzbecker, Michael; Cook, Danielle; Yang, Troy; McCann, Mary E.; Chacko, Sabeena; Cravero, Joseph; Hresko, Michael Timothy
      Abstract: imageBackground: High-volume centers for idiopathic scoliosis (IS) have difficulty in scheduling posterior spinal fusions (PSFs) due to operating room availability, particularly during school vacation. A solution is for 1 surgeon to perform 2 PSF cases back-to-back. This study aims to compare morning and afternoon PSF cases performed by the same surgeon for perioperative outcomes.Methods: A retrospective review of PSF cases for IS that occurred on the same day as another PSF by the same surgeon between January 2013 and December 2019 was conducted. Perioperative outcomes included surgical time, estimated blood loss, length of stay, and inpatient opioid consumption normalized by the patient’s weight. Postoperative outcomes included complications, revision rate, curve correction, and patient-reported outcomes using the Scoliosis Research Society-30.Results: A total of 95 patients (87% female), mean age 15.6 years, were analyzed, with 48 morning cases and 47 afternoon cases. The median follow-up was 1.9 years (range: 0.3 to 6.1 y). Tests for equivalency determined equivalence in median anesthesia and mean surgical duration (P=0.05). The groups had similar initial curve correction (P=0.43) and rate of complications at 90 days postoperative (2 in each group for a total of 4 complications). No significant differences were seen between Scoliosis Research Society-30 scores at 6 months or in those who have reached 2 years postoperative.Conclusions: Little literature exists on the safety of a surgeon performing 2 PSF cases in 1 day, particularly in regard to pain outcomes, 30- and 90-day complication rates, and quality of life measures. This study indicates that few differences in safety, pain, and quality of life outcomes may appear between morning and afternoon PSF cases.Level of Evidence: Level II.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Minimally Invasive Fusionless Surgery for Scoliosis in Spinal Muscular
           Atrophy: Long-term Follow-up Results in a Series of 59 Patients

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      Authors: Gaume; Mathilde; Saudeau, Etienne; Gomez-Garcia de la Banda, Marta; Azzi-Salameh, Viviane; Mbieleu, Blaise; Verollet, Delphine; Benezit, Audrey; Bergounioux, Jean; Essid, Aben; Doehring, Isabelle; Dabaj, Ivana; Desguerre, Isabelle; Barnerias, Christine; Topouchian, Vicken; Glorion, Christophe; Quijano-Roy, Susana; Miladi, Lotfi
      Abstract: imageBackground: Treatment of spinal muscular atrophy (SMA) scoliosis has evolved in the last decade, with the emergence of fusionless surgical techniques that allow correction of the deformity before the end of growth spurt. These techniques are expected to delay definitive spine fusion and preserve trunk growth.Purpose: The aim was to evaluate long-term clinical, radiologic, and respiratory outcomes of a minimally invasive fusionless surgery (MIFLS) in SMA scoliosis.Methods: All children affected with SMA scoliosis who underwent MIFLS in our department from 2011 to 2019 were included. The instrumentation consisted in a bilateral sliding rod construct from T1 to the sacrum, anchored proximally by double-hook claws and distally by iliosacral screws. Clinical, genetic, respiratory and radiographic data were retrospectively reviewed. A patient’s satisfaction survey was performed.Results: A total of 59 children with genetic confirmation of SMA (9SMA1c, 47SMA2, and 3SMA3) underwent MIFLS at a mean age of 11±1.9 years. All of them were nonwalker at the time of surgery. Twenty-six were treated with intrathecal Nusinersen. Mean follow-up was 5.2 years (2 to 9.6 y). Mean major coronal curve improved from 79±15 to 41±16 degrees and pelvic obliquity decreased from 24±11 to 5.9±4 degrees. Mean space available for lung improved from 77% to 93%. Mechanical or infectious complications occurred in 9 patients, with removal of the implant in 1. 6 children required unplanned surgeries. Postoperative bracing was needed in 13 children. Mean gain weight 3 years after the first surgery was 6 kg. 91.5% of patients had a positive satisfaction of the surgery. There was no significant impact in respiratory function postoperatively. Only 30 children required rod lengthening procedures, with a mean interval between procedures of 1.9 years (0.5 to 3.7 y). No arthrodesis was required at last follow-up in any patient.Conclusion: Bipolar MIFLS in SMA preserves spinal and thoracic growth without interference with respiratory function. It provides a significant correction of spinal deformity and pelvic obliquity, having a reduced rate of complications. The correction of spinal deformity was maintained at long term, not requiring definitive fusion at the end of growth.Level of Evidence: Level IV.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Functional and Clinical Outcomes of Combined Simultaneous Bilateral
           Anterior Distal Femoral Plate Hemiepiphysiodesis and Hamstrings Release in
           Management of Knee Flexion Contractures in Children With Neuromuscular
           Disorders

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      Authors: Zaghloul; Ahmed; Manoukian, Dimitrios; Barrett, Matthew C.; Geronta, Ilektra; Maizen, Claudia
      Abstract: imageBackground: We examined the clinical and functional outcomes of the simultaneous anterior distal femoral 8-plate hemiepiphysiodesis (ADF8PH) and hamstring release, for fixed knee flexion deformity in children with neuromuscular disease. To our knowledge, no published evidence is available that reports the outcomes of this combined techniques.Methods: Electronic medical records were retrospectively reviewed for 19 consecutive children who underwent bilateral ADF8PH and concomitant hamstrings release in our institution from 2012 to 2019. Relevant demographics, Gross Motor Functional Classification Score and preoperative and postoperative knee flexion contractures and popliteal angles were documented.Results: The average age at the time of operation was 12±2.1 years. There were 15 males and 4 females. Diagnoses included cerebral palsy (n=16), Cornelia de Lange syndrome (n=1), hereditary spastic paraplegia type 56 (n=1) and fructose-1,6 bisphosphonate aldose B deficiency (n=1). Mean length of follow-up was 3.8 years (range: 1.5 to 7 y). Mean fixed knee flexion deformity improved from 28.9 to 13.4 degrees (P
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Patient-Reported Outcome Measurement Information System (PROMIS) Scores in
           Pediatric Patients With Arthrogryposis

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      Authors: Hyer; Lauren C.; Carson, Lisa T.; Carpenter, Ashley M.; Westberry, David E.
      Abstract: imageBackground: Arthrogryposis multiplex congenita (AMC) is a clinical term that is used to describe congenital contractures that lead to childhood deformities. Treatment aims are to maximize function while minimizing pain and disability. Few studies have explored patient-reported outcomes in the pediatric arthrogrypotic population, particularly concerning mobility. The aim of this study was to report scores for the Patient-Reported Outcome Measurement Information System (PROMIS) questionnaire for pediatric patients with arthrogryposis with regards to mobility, upper extremity (UE) function, pain interference, and peer relationships.Methods: A retrospective chart review of 76 patients with AMC aged 5 to 17 who completed the PROMIS questionnaire between January 1, 2017 to March 24, 2020 was performed. Results were collected for four domains: mobility, UE function, pain interference, and peer relationships. Outcomes were stratified by type of arthrogryposis: Amyoplasia (Am), Distal Arthrogryposis (DA), and Other Diagnoses (OD). Results of subjects with isolated upper or lower extremity involvement were compared with subjects with involvement of upper and/or lower extremities. Outcomes were correlated with history of surgical intervention.Results: Children with Am and OD demonstrated moderate impairment of mobility (average: 35.2 and 35.9, respectively), while those with DA reported only mild impairment (average: 44.9). UE function was severely impaired for children with Am (average: 23.0), moderately impaired for OD (average: 33.0), and mildly impaired for DA (average: 43.4). All patient groups reported normal ranges of pain interference, as well as good peer relationships. A moderate negative correlation between number of surgical interventions and mobility scores, and a weak negative correlation between number of surgeries and pain interference scores were found.Conclusions: Children with AMC experience limited mobility and UE function, but normal levels of pain interference and good peer relationships. The average values provided in this study will serve as a baseline from which to evaluate the efficacy of both nonoperative and surgical interventions.Level of Evidence: Level II—prognostic study; retrospective study.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Estimating Skeletal Maturity Using Knee Radiographs During Preadolescence:
           The Epiphyseal:Metaphyseal Ratio

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      Authors: Benedick; Alexander J.; Hogue, Bailyn; Furdock, Ryan J.; Uli, Naveen; Liu, Raymond W.
      Abstract: imageBackground: Though skeletal maturity is most relevant during adolescence, it has utility in treatment of younger patients in some circumstances. Accurate estimation of skeletal maturity using knee radiographs would be useful when treating limb length discrepancy and other general medical conditions in preadolescent patients. Currently, a quick, accurate, and reproducible method of estimating skeletal maturity in preadolescents is lacking.Methods: Serial anteroposterior knee radiographs taken at historical growth study visits leading up to the chronological age associated with 90% of final height (an enhanced skeletal maturity standard as compared with peak height velocity) were analyzed in 75 children. Epiphyseal and metaphyseal widths of the distal femur, proximal tibia, and proximal fibula were measured and the epiphyseal:metaphyseal ratio was calculated. Greulich and Pyle (GP) bone ages were also assigned by an experienced pediatric endocrinologist using left hand radiographs. Stepwise linear regression and generalized estimating equation analyses were used to make a skeletal maturity model incorporating demographics (age+sex) and knee epiphyseal:metaphyseal ratios.Results: A total of 258 left knee radiographs from 39 girls (mean age 8.6 y, range: 2.9 to 13 y) and 36 boys (mean age 10.6 y, range: 3.8 to 15 y) were included. The demographics+ratios model had similar prediction accuracy (0.49 vs. 0.48 y, P=0.84) and rate of outliers (11% vs. 9%, P=0.11) as the demographics+GP model. The demographics+ratios model outperformed all other models evaluated, including a demographics-only model (P
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Skeletal Maturity Using Knee X-rays: Understanding the Resilience of 7
           Radiographic Parameters to Rotational Position

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      Authors: Castillo Tafur; Julio C.; Benedick, Alexander; Knapik, Derrick M.; Janes, Jessica L.; Delozier, Sarah J.; Liu, Raymond W.
      Abstract: imageBackground: Recently, a skeletal maturity system using knee radiographs, named the modified Roche-Wainer-Thissen (RWT) system, has been developed using 7 discrete radiographic parameters. While the system has been shown to significantly outperform the Greulich and Pyle atlas, the effect of rotational variation of the knee radiograph on skeletal maturity determinations has not been studied.Methods: Normal knee computed tomography scans of 12 male children ages 10 to 16 years and 8 female children ages 8 to 14 years were obtained retrospectively, converted into 3-dimensional reconstructions, and then used to simulate knee radiographs in 5 different rotational positions. Images were graded using the modified RWT system, and 1-way repeated measures analysis of variance was used to compare skeletal age in the patella centered view versus the other positions. We next retrospectively found 85 pediatric patients with both bilateral standing anteroposterior hip to ankles and separate knee radiograph within 6 months of each other. The skeletal maturity values from the 2 different radiographs were compared in 39 males between the ages of 10 and 16 years and 46 females between 8 and 14 years of age using paired t test and Wilcoxon-signed rank test.Results: On the computed tomography scan-based images, there was no statistically significant effect of rotational position on the modified RWT score using repeat measures analysis of variance (P=0.210). Only the width ratio of the tibial epiphysis and metaphysis and the width ratio of the fibular epiphysis and metaphysis were statistically different between rotational positions (P
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Measuring Proximal Tibial Metaphyseal Width and Lateral Epiphyseal Height
           Improves Determination of Remaining Growth in Children

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      Authors: Kahan; Joseph B.; Li, Don T.; Schneble, Christopher A.; Elabd, Ahmed; Attia, Elsayed; Esparza, Rachel; Cui, Jonathan J.; Li, Eric; Moran, Jay; Smith, Brian G.; Cooperman, Daniel R.
      Abstract: imageBackground: Accurate assessments of skeletal maturity is of critical importance to guide type and timing of orthopaedic surgical interventions. Several quantitative markers of the proximal tibia were recently developed using historical knee radiographs. The purpose of the present study was to determine which marker would be most effective in assessment of full-length radiographs in a modern pediatric patient population.Methods: All full-length radiographs at our institutions between 2013 and 2018 were reviewed. Inclusion criteria for our study required that the child reached final height as defined by 2 consecutive unchanged heights, at least 6 months apart, after age 16 for boys and 14 for girls. Patients with metabolic bone disease, prior surgery such as epiphysiodesis, or previous infections around the knee were excluded. Summary statistics for each of the 3 proximal tibial ratios were calculated and multiple linear regression was performed with percent of growth remaining as a dependent variable. A recommended regression model is presented and evaluated.Results: A total of 692 full-length radiographs met inclusion criteria. Proximal tibial ratios were calculated and averaged values for each percent of growth remaining was presented. Multiple linear regression demonstrated that using all 3 variables led to overfitting of the model so tibial metaphyseal width/lateral tibial epiphyseal height was selected as the optimal ratio for use by clinicians. The optimal model for determining growth was found to have R2=0.723 in the developmental set and R2=0.762 in an excluded validation set.Conclusions: This study demonstrates that the proximal tibial metaphyseal width/lateral tibial epiphyseal height is the ideal measurement for clinicians seeking to determine growth remaining in children. It presents average values between 0% and 25% of growth remaining. This study also develops and validates a multivariable regression model for determining percentage of growth remaining in children that will allow for quantitative determination of growth using full-length radiographs.Level of Evidence: Level III.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Evaluating Perioperative Complications Surrounding Supracondylar Humerus
           Fractures: Expanding Indications for Outpatient Surgery

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      Authors: Hockensmith; Lindsay H.; Muffly, Brian T.; Wattles, Mitchell R.; Snyder, Erin N.; McFarland, Braxton J.; Jacobs, Cale; Iwinski, Henry J.; Riley, Scott A.; Prusick, Vincent W.
      Abstract: imageBackground: Supracondylar humerus (SCH) fractures are one of the most common pediatric orthopaedic injuries. Described using the Wilkins modification of the Gartland Classification system, current practice guidelines give moderate evidence for closed reduction and percutaneous pinning of type 2 and 3 injuries, but little evidence exists regarding the appropriate surgical setting for fixation. The goal of this study was to evaluate the perioperative complication profile of type 3 fractures with maintained metaphyseal contact and determine their suitability for outpatient surgery.Methods: Skeletally immature patients with type 2 and 3 SCH fractures treated at a single, Level-1 trauma institution from March 2019 to January 2000 were retrospectively reviewed. A total of 1126 subjects were identified. Open, concomitant injuries, incomplete physical examination, initial neurovascular compromise, flexion-type fractures, ecchymosis, skin compromise, and those managed nonoperatively were excluded. Type 3 fractures were categorized as either “3M” versus type “3” (“M” denoting metaphyseal bony contact). Demographic data, neurovascular changes, and postoperative complications were collected. Categorical variables were evaluated using χ2 or Fisher exact tests, and continuous variables analyzed using analysis of variance, with significance defined as a P-value
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Efficacy of Antibiotics in Supracondylar Fractures

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      Authors: Bhatt; Etasha; Ridley, Taylor J.; Kruckeberg, Bradley; Quanbeck, Zachary; Quanbeck, Deborah S.; Schiffern, Alison
      Abstract: imageBackground: Controversy exists surrounding antibiotic use in the setting of pediatric supracondylar humerus fractures treated with closed reduction and percutaneous Kirschner wire (K-wire) fixation. While the reported incidence of infection in the literature is low, surgeons frequently administer preoperative antibiotics. The purpose of this study was to retrospectively review preoperative antibiotic use and incidence of infection in children with supracondylar humerus fractures treated with closed reduction and K-wire fixation. It was hypothesized that antibiotic administration will not affect the incidence of infection following this procedure.Methods: We performed a retrospective review of 1053 patients with supracondylar humerus fractures treated with closed reduction and K-wire fixation at 3 institutions between 2006 and 2016. Patient demographics, antibiotic administration and follow-up data were reviewed in 905 patients.Results: Of 905 patients, 755 patients received preoperative antibiotics and 150 patients did not. The incidence of infection was 2.5% (n=22) in the group that received preoperative antibiotics and 2.0% in the group that did not receive antibiotics with an overall incidence of infection of 2.4%. The difference between groups did not reach significance (P>0.5). The majority of infections were treated with oral antibiotics with or without early pin removal. Four patients, all in the preoperative antibiotic group, required surgical debridement and intravenous antibiotics.Conclusions: Retrospective review of the incidence of infection in closed reduction and percutaneous pinning of supracondylar humerus fractures found no difference between patients who received preoperative antibiotics and those who did not receive preoperative antibiotics.Level of Evidence: Level III—therapeutic.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Factors That Drive Annual Variation in Pediatric Elbow Fracture
           Occurrence, Severity, and Resource Utilization

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      Authors: Schultz; Jacob D.; Rees, Andrew B.; Wollenman, Lucas C.; McKeithan, Lydia J.; Tadepalli, Vaibhav R.; Wessinger, Bronson C.; Attipoe, Graham; Gay, James C.; Martus, Jeffrey E.; Moore-Lotridge, Stephanie N.; Schoenecker, Jonathan G.
      Abstract: imageBackground: Elbow fractures are the most common pediatric fractures requiring operative treatment. To date, few studies have examined what annual factors drive pediatric elbow fracture incidence and no studies have examined which annual factors drive elbow fracture severity or resource utilization. The goal of this study was to not only document the annual patterns of pediatric elbow fracture incidence and severity but also the impact of these patterns on resource utilization in the emergency department, emergency medical service transportation, and the operating room (OR).Methods: Retrospective cohort study of 4414 pediatric elbow fractures from a single tertiary hospital (2007 to 2017). Exclusion criteria included outside treatment or lack of diagnosis by an orthopaedist. Presentation information, injury patterns, transport, and treatment requirements were collected. Pearson correlations were used to analyze factors influencing fracture incidence, severity, and resource utilization.Results: Pediatric elbow fracture incidence positively correlated with monthly daylight hours, but significantly fewer elbow fractures occurred during summer vacation from school compared with surrounding in school months. While fewer overall fractures occurred during summer break, the fractures sustained were greater in severity, conferring higher rates of displacement, higher risk of neurovascular injury, and greater needs for emergency transportation and operative treatment. Yearly, elbow fractures required 320.6 OR hours (7.7% of all pediatric orthopaedic OR time and 12.3% of all pediatric orthopaedic operative procedures), 203.4 hospital admissions, and a total of 4753.7 miles traveled by emergency medical service transportation to manage. All-cause emergency department visits were negatively correlated with daylight hours, inversing the pattern seen in elbow fractures.Conclusion: Increased daylight, while school was in session, was a major driver of the incidence of pediatric elbow fractures. While summer vacation conferred fewer fractures, these were of higher severity. As such, increased daylight correlated strongly with monthly resource utilization, including the need for emergency transportation and operative treatment. This study provides objective data by which providers and administrators can more accurately allocate resources.Level of Evidence: Level III—Retrospective comparative study.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Treatment Choice of Complete Distal Forearm Fractures in 8 to 14 Years Old
           Children

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      Authors: Liu; Ya; Zhang, Fu-Yong; Zhen, Yun-Fang; Zhu, Lun-Qing; Guo, Zhi-Xiong; Wang, Xiao-Dong
      Abstract: imageBackground: New surgical techniques have challenged traditional guidelines for nonsurgical treatment in pediatric and adolescent distal forearm fractures. This study was performed to compare outcomes and costs between closed reduction with percutaneous pinning (CRPP) and closed reduction with casting in the treatment of complete distal forearm fractures in children 8 to 14 years old.Methods: A retrospective cohort study was performed of 175 displaced distal forearm fractures treated with 2 different methods in the emergency department of a children’s trauma center. One hundred and fourteen children were managed using CRPP. The remaining 61 were treated with closed reduction and casting. All patients had initial follow-up radiographs. The quality of reduction and the residual angulation in both the coronal and sagittal planes were recorded. Outcomes included the angulation after reduction, residual angulation at final follow-up, radiation exposure, total immobilization time, days absent from school, total costs, and postoperative complications.Results: The postreduction sagittal plane angulation was significantly lower in the CRPP group (P=0.037). While residual deformity between the groups at the 6-month final follow-up was not significantly different in either the sagittal or coronal planes (P=0.486, 0.726), patients in the nonoperative group received greater radiation than those in the operative group (P
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • The Impact of Cast Immobilization on Return to Daycare

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      Authors: Heffernan; Michael J.; Barnett, Scott A.; Nungesser, Matthew E.; Song, Bryant M.; Leonardi, Claudia; Gonzales, Joseph
      Abstract: imageBackground: Children who are prohibited from returning to daycare (RTD) after treatment with cast immobilization place an increased burden on parents and caregivers. The purpose of this study was to assess the impact of cast immobilization on RTD. Specifically, we sought to determine the prevalence of RTD after orthopaedic immobilization based on daycare facility policy.Methods: This was a survey study of randomly selected daycare facilities servicing a total of 6662 children within 10 miles of a major metropolitan city center. The 40-question survey included information on daycare policies and experience caring for children treated with orthopaedic immobilization. The survey also included questions about daycare type, enrollment, and geographic location. Photographs of the types of immobilization were embedded in the survey to facilitate understanding. Daycare facilities were randomly selected based on a power analysis to estimate a 50% prevalence of RTD after spica casting within 10% margin of error.Results: Seventy-three daycare facilities completed the survey study. The average child-staff ratio was 5:1 and most daycare facilities (78%) did not have a nurse on staff. Predetermined policies regarding RTD after injury were available at 81% of daycares. Twenty-eight (38.5%) facilities had encountered a child with a cast in the previous year. The rate of RTD for children with upper limb injuries was 90.5% compared with 79% for lower limb injuries (P=0.003). Spica casts showed the lowest RTD rate: single leg (22.5%), 1 and a half leg (18%), and 2 leg (16%) (P5 y) had a higher RTD rate compared with less experienced facilities (P=0.026).Conclusions: The ability to RTD is dependent on immobilization type. Children with long leg and spica casts are disproportionately restricted when compared with other cast types. At minimum, surgeons should consider the socioeconomic implications of orthopaedic immobilization. There is also a need for orthopaedic involvement in policy formation at the local level to provide standardized guidelines for re-entry into childcare facilities following orthopaedic immobilization.Level of Evidence: Level IV.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Results of Early Proximal Femoral Osteotomy at Skeletal Maturity in
           Legg-CalvĂ©-Perthes Disease: Implication for the Bypass of Fragmentation
           Stage

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      Authors: Kim; Sungmin; Oh, Ho-Seok; Lim, Jun-Hyuk; Cho, Seunghyeon; Jung, Sung Taek
      Abstract: imageBackground: The aim was to assess the long-term radiographic outcomes of patients with Legg-Calvé-Perthes disease following an early proximal femoral osteotomy (PFO) performed in avascular necrosis stage or early fragmentation stage.Methods: In this retrospective study, we analyzed data of 65 patients aged above 6 years at the time of diagnosis with unilateral Legg-Calvé-Perthes disease, following early PFO performed at our institution between 1979 and 2013. We observed the presence of bypassing fragmentation stage, which was classified into complete and incomplete. We compared radiographic outcomes between patients with bypass of fragmentation stage (26 hips) and those without (31 hips). Regarding skeletal maturity, the hips were graded according to the femoral head shapes: spherical, ovoid, or flat.Results: The mean age at diagnosis was 7.9 years (range: 6.0 to 11.9 y). The average follow-up period was 11.8 years (range: 5.9 to 22.9 y). Fragmentation bypass occurred in 40.5% (26/65) of patients, with 8 (12.3%) “undetermined” cases. Patients who completely or partially bypassed fragmentation experienced significantly less severe lateral pillar collapse (P=0.016). The femoral head was also significantly more spherical in patients with bypass (P=0.024).Conclusions: Our results show that 40.5% of patients who underwent early PFO bypassed the fragmentation stage. The degree of lateral pillar collapse was lower in patients with bypass. In addition, there were significantly more patients with more spherical femoral head in the bypass group.Level of Evidence: Level IV—case series.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Feasibility of Magnetic Resonance Angiography in Patients With
           Legg-Calvé-Perthes Disease

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      Authors: Moreno Grangeiro; Patricia; Rodrigues, João C.; de Angeli, Luiz R.A.; Leão Filho, Hilton; Montenegro, Nei B.; Guarniero, Roberto; Dempsey, Molly; Kim, Harry K.W.
      Abstract: imageBackground: The etiology of Legg-Calvé-Perthes disease (LCPD) remains unknown; however, interruption of medial circumflex femoral artery (MCFA) supply to the femoral head is the key pathogenic factor. The main purpose of this study is to determine the feasibility of using magnetic resonance angiography (MRA) to evaluate the course of the MCFA in the normal and affected hips of patients with unilateral LCPD.Methods: We analyzed 24 patients with unilateral LCPD using a time-resolved imaging of contrast kinetics magnetic resonance angiography (TRICKS-MRA). The course of the MCFA was divided into 4 segments in the coronal plane and in 3 segments in the axial plane, based on its location with respect to the femoral neck. The visibility of each segment was studied in the normal and affected sides. The segments were defined as not visible when no contrast was seen within the vessel lumen or visible when the lumen was partially or completely visualized with contrast. The statistical analysis was done using the χ2 test.Results: TRICKS-MRA provided well-defined images of the first 2 segments of the MCFA on both the normal and affected sides of patients with LCPD (P=1). In half of the patients, the third segment was also visible using TRICKS-MRA on both sides (P=1). The fourth segment of the MCFA, which was the ascending lateral epiphyseal segment, was not visible on either side (P=0.49). No significant difference was found between the normal and affected hips in terms of visibility of the 4 segments of the MCFA using TRICKS-MRA. Anastomosis of the MCFA with the inferior gluteal artery was found in 3 hips (2 hips with LCPD and 1 normal hip).Conclusions: TRICKS-MRA provides well-defined images of the arterial supply to the proximal femoral epiphysis in children with LCPD, presenting a noninvasive and radiation-free alternative to conventional angiography. However, the TRICKS-MRA method used did not allow visualization of the ascending lateral epiphyseal segment of MCFA in the affected and the contralateral normal side. We believe that further advancement of this noninvasive imaging technique may open new opportunities for research aimed at evaluating the vascular supply of the femoral head in children.Level of Evidence: Level IV—case-control study.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Reliability and Validity of Visual Estimation of Femoral Head
           Hypoperfusion on Perfusion MRI in Legg-Calve-Perthes Disease

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      Authors: Chong; David Y.; Schrader, Tim; Laine, Jennifer C.; Yang, Scott; Gilbert, Shawn R.; Kim, Harry K.W.; on Behalf of the International Perthes Study Group
      Abstract: imageBackground: Assessing the severity of Legg-Calve-Perthes disease is important for treatment decision-making and determining prognosis. Perfusion magnetic resonance imaging (MRI) scans have improved our ability to assess femoral head hypoperfusion, and the use of an image analysis software called HipVasc (Scottish Rite for Children, Dallas TX) has allowed precise quantification for research purposes. In the clinical setting, using HipVasc software is not practical, and visual estimation is used to assess hypoperfusion. Currently, the reliability of visual estimation is unknown. The purpose of this study was to determine the reliability and validity of visual estimation of hypoperfusion on perfusion MRI and compare the results to measurements obtained with the HipVasc software.Methods: Fourteen pediatric orthopaedic surgeons, divided into 4 groups, participated in this study. Each surgeon completed a 30-minute in-person training on HipVasc before proceeding. Stratified by category of severity, 122 MRIs were randomly assigned to 1 of the 4 groups so that each group member measured the same set of ∼30 MRIs. Each surgeon documented their visual estimation of hypoperfusion first, then used HipVasc to measure the hypoperfusion and recorded their results. Interobserver reliability was assessed at the group level by calculating the intraclass correlation coefficient.Results: Good correlation and reliability was found between the visual estimate and HipVasc measurements with an overall mean intraclass correlation coefficient of 0.87 and mean Pearson coefficient of 0.90. The mean interobserver reliability of visual estimation was 0.84. Observers had a tendency to overestimate hypoperfusion with visual estimation.Conclusions: This study demonstrates the reliability and validity of visual estimation as a clinically applicable method for determining femoral head hypoperfusion. Our study is the first to measure the reliability of visual estimation and HipVasc with a large cohort of clinicians, specifically pediatric orthopaedic surgeons with varied experience in graphical software analysis. We recommend using visual estimation as a clinically applicable method to make treatment decisions, and its accuracy is comparable to HipVasc software analysis.Level of Evidence: Level III—diagnostic.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Stability in Pelvic Triple Osteotomies in Children Using Resorbable PLGA
           Screws for Fixation

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      Authors: Hedelin; Henrik; Larnert, Per; Antonsson, Pavel; Lagerstrand, Kerstin; Brisby, Helena; Hebelka, Hanna; Laine, Tero
      Abstract: imageBackground: The triple pelvic osteotomy (TPO) is a major redirectional osteotomy used to improve the acetabular coverage of the femoral head in selected pediatric patients with hip disorders. Traditionally the iliac osteotomy is stabilized by metal screws that require a second surgery for removal. Despite favorable results for both adults and children in related pelvic osteotomies, resorbable implants have not previously been used for TPOs.This study aims to suggest a novel modified TPO surgical method in children using resorbable poly lactic-co-glycolic acid (PLGA) screws for fixation and to radiographically evaluate the postoperative stability achieved by these implants in a case series.Methods: All patients (n=11) with dysplasia of the hip (2), Perthe disease (5), or Down syndrome (4), who underwent primary TPO surgery during 2013 to 2019, using resorbable PLGA screws for fixation were included. The stability of the osteotomy was evaluated in the postoperative radiograph series using the acetabular index, migration percentage, Sharp’s angle and the center-edge angle. The osteotomy angle was introduced as a parameter to confirm the postoperative integrity of the achieved correction. All cases were evaluated until radiographic healing of the iliac osteotomy. Hospital notes were analyzed for complications or local reactions in relation to the implants.Results: In all studied hips, the overall achieved correction was well maintained. The mean (SD) correction achieved, from the preoperative images to the last measurable postoperative image, was a 16.7 degrees decrease for Sharp angle, a 20.9 degrees decrease in acetabular index and a 24.7 degrees increase for the center-edge angle, respectively. There were no complications related to the bioabsorption of the implants.Conclusion: The present findings suggest that the modified TPO method, using resorbable PLGA screws, provides sufficient stability and appears to be a promising alternative to traditional TPO. Avoiding implant removal is a major benefit in a pediatric population. Resorbable screws enable the surgeon to place implants with more degrees of freedom since later implant removal is not a limiting factor.Level of Evidence: Level IV—case series.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • The Open Triradiate Cartilage: How Young Is Too Young for Total Hip
           Arthroplasty'

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      Authors: Rainer; William; Shirley, Matthew B.; Trousdale, Robert T.; Shaughnessy, William J.
      Abstract: imageBackground: There is, to our knowledge, no published literature regarding primary total hip arthroplasty (THA) in pediatric patients with an open triradiate cartilage. The purpose of this study was to report the outcomes following primary THA in pediatric patients with open triradiate cartilage at a single intuition.Methods: Using a single institution’s Total Joint Registry, 12 patients (13 hips) were identified as having undergone primary THA with open triradiate cartilage between the years of 2000 and 2019. The mean age and body mass index of this group were 13.1 years and 25.5 kg/m2, respectively. The cohort was composed of 10 males, and the mean follow up was 5.5 years. Indications for surgery, functional outcomes, and radiographic signs of stable fixation were analyzed.Results: The most common indication for surgery was avascular necrosis secondary to corticosteroid use (31%), followed by avascular necrosis after operative management of slipped capital femoral epiphysis (23%). The proportion of patients able to achieve independent, gait-aid free, ambulation improved from 23% to 100%. Mean postoperative Harris Hip Score was 92.3. All constructs were cementless, and bearing surfaces included ceramic-on-ceramic in 62% and ceramic on highly crosslinked polyethylene bearings in the remainder. Radiographic review at final follow up demonstrated osseointegration in 12 of 13 (92%) acetabular components. Although 1 patient experienced both acetabular component loosening and instability, on separate occasions, there were no incidences of infection, wound dehiscence, thromboembolic events, or failure secondary to wear.Conclusions: In this study, THA in patients with an open triradiate cartilage yielded significant clinical improvement, low complication rates and good initial implant survivorship at early follow up. Awaiting closure of the triradiate cartilage for concerns of decreased fixation and implant survivorship may be unnecessary.Level of Evidence: Level IV—case series.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Hip Displacement in MECP2 Disorders: Prevalence and Risk Factors

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      Authors: Kanashvili; Bidzina; Rogers, Kenneth J.; Shrader, Michael Wade; Miller, Freeman; Dabney, Kirk W.; Howard, Jason J.
      Abstract: imageBackground: Methyl-CpG binding protein 2 (MECP2) disorders, including Rett syndrome and MECP2 duplication syndrome, are typified by profound intellectual disability, spasticity, and decline in gross motor function. Unlike scoliosis, linked to disease severity, little has been reported regarding the hip. The aim of this study was to report the prevalence and risk factors of hip displacement (HD) in MECP2 disorders.Methods: This was a retrospective, comparative study. Children with a genetically confirmed MECP2 disorder were included. The primary outcome measure was the prevalence of HD (migration percentage>30%). Secondary outcomes included age at HD onset, ambulatory status, presence of clinically relevant scoliosis, genetic severity, presence of seizures, and associated comorbidities. Analysis of proportions of categorical variables was performed using χ2 testing (P=0.05).Results: Fifty-six patients (54 Rett syndrome and 2 MECP2 duplication syndrome), diagnosed at 6.6 (SD: 4.7) years, met the inclusion criteria. The prevalence of HD was 36% [onset, 7.7 (SD: 3.8) y]. Risk factors for HD were nonwalker status (P=0.04), scoliosis (P=0.001), and refractory epilepsy (P=0.04).Conclusions: The prevalence of HD in MECP2 disorders is comparable to cerebral palsy, associated with proxy measures of disease severity. These results can be used to develop hip surveillance programs for MECP2 disorders, allowing for timely management.Level of Evidence: Level III.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Surgical Management of Medial Discoid Meniscus in Pediatric and Adolescent
           Patients

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      Authors: Feroe; Aliya G.; Hussain, Zaamin B.; Stupay, Kristen L.; Kocher, Sophia D.; Williams, Kathryn A.; Micheli, Lyle J.; Kocher, Mininder S.
      Abstract: imageBackground: Medial discoid meniscus (MDM) is an exceedingly rare anatomic abnormality that presents similarly to other meniscal pathologies. Symptomatic MDM is typically managed arthroscopically with mixed short-term and long-term outcomes, although the existing knowledge about MDM is limited. The purpose of this study was to describe the presentation and surgical treatment of MDM in pediatric and adolescent patients.Methods: Medical records of 12 knees with MDM in 8 pediatric and adolescent patients treated between 1991 and 2016 were reviewed retrospectively for patient characteristics, clinical manifestations, radiographic findings, operative techniques, and surgical outcomes.Results: Of the 446 knees diagnosed arthroscopically with discoid menisci, lateral discoid meniscus was noted in 434 knees (97.3%) and MDM was present in 12 knees (2.7%). The MDM series included 8 patients of mean age 13.8 years (range: 7.8 to 19.8), of which 5 were males (63%), and 4 (50%) had bilateral involvement. Of the 11 knees with available clinical records, all cases presented symptomatically (pain, mechanical symptoms); 10 (91%) had concurrent physical exam findings. On intraoperative examination, discoid morphologies were described as complete in 4/8 knees (50%) or incomplete in 4/8 (50%), with associated instability in 6/12 (50%). Meniscal tears were reported in 9 cases (75%)—primarily, horizontal cleavage tears. Saucerization was performed in 11 knees (92%), with medial meniscal repair in 7 (58%), when indicated. Retear of the medial meniscus occurred in 4/11 knees (36%) at a mean of 25.8 months postoperation; 2 knees required revisions. One knee developed arthrofibrosis and underwent arthroscopic lysis of adhesions.Conclusions: MDM is a rare diagnosis, representing 3% of all discoid menisci, with a nonspecific clinical manifestation. Operative management of symptomatic MDM typically involves saucerization and meniscal repair, when indicated, for concurrent tears. Symptom resolution is common short-term, but long-term outcomes include recurrent meniscal tears. Subsequent observational studies are important to evaluate long-term outcomes, such as arthritic changes, with the advancement of arthroscopic techniques for meniscal preservation.Level of Evidence: Level IV—retrospective case series.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Long-term Minimum 15-Year Follow-up After Lateral Discoid Meniscus Rim
           Preservation Surgery in Children and Adolescents

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      Authors: Lins; Laura A.B.; Feroe, Aliya G.; Yang, Brian; Williams, Kathryn A.; Kocher, Sophia D.; Sankarankutty, Saritha; Micheli, Lyle J.; Kocher, Mininder S.
      Abstract: imageBackground: Discoid meniscus is a congenital variant typically affecting the lateral meniscus of the knee. Historically, surgical intervention when symptomatic consisted of total meniscectomy; however, after degenerative changes were observed, current treatments now focus on rim preservation with arthroscopic saucerization and meniscal repair for instability, when indicated. The purpose of our study was to examine long-term patient-reported outcomes of lateral discoid meniscus (LDM) treated with meniscal-preserving techniques.Methods: Ninety-eight patients treated arthroscopically for LDM at a single institution at a minimum of 15 years ago were retrospectively identified and contacted by mailers and telephone to participate. Subjective functional outcomes and patient satisfaction data were collected using a questionnaire that included the validated International Knee Documentation Committee Subjective Knee Evaluation Form, Lysholm Score, Marx Activity Rating Scale, Tegner Activity Score, and Western Ontario and McMaster University Osteoarthritis Index Osteoarthritis Index. Patient and surgical characteristics and patient-reported outcomes were summarized by mean and SD, median and interquartile range (interquartile range), or frequency and percent, as appropriate.Results: Of the 46 patients contacted (response rate of 46/98 eligible), 25 (54%) completed the questionnaires. The mean (±SD) age at initial surgery was 10.8 (±3.4) and 30.3 (±3.7) years at final follow-up. The mean (±SD) follow-up time from initial surgery was 19.5 (±2.8) years (range, 16 to 27). Patient-reported outcomes included: International Knee Documentation Committee 77.4±17.2, Lysholm 78.6±21, Western Ontario and McMaster University Osteoarthritis Index 7.6±11.3, Tegner Activity 7 (of 10), and Marx Activity Rating Scale 8 (of 10). Eleven (44%) cases underwent subsequent LDM-related surgery on the ipsilateral knee(s). There were no cases of total knee replacement.Conclusions: Overall, patient-reported outcomes were favorable at a minimum of 15-year follow-up after rim-preserving saucerization of LDM. While two thirds of patients were satisfied with their surgical outcomes, nearly half of patients underwent revision saucerization with or without meniscal repair. Subsequent long-term follow-up studies with objective outcome measures are important to further elucidate the natural history of LDM and understand how rim-preserving procedures may prevent the development of degenerative processes.Level of Evidence: Level IV—case series, prognostic study.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Congenital Posteromedial Bowing of Tibia: Comparison of Early and Late
           Lengthening

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      Authors: Sagade; Bhushan; Jagani, Naeem; Chaudhary, Ishani; Chaudhary, Milind
      Abstract: imageBackground: Congenital posteromedial bowing of tibia (CPMBT), a rare anomaly, is characterized by a decreasing deformity and a gradually increasing limb shortening. Lengthening in CPMBT has not been studied extensively. Our series compares the duration and complications of lengthening in younger versus older children to determine early lengthening safety and benefits.Methods: We studied 28 tibial lengthenings performed by a single surgeon in 23 patients, divided into 2 equal groups of 14 segments: group A 5 years or younger (preschool) and group B above 5 years. All were lengthened with circular external fixators, of which 3 were lengthened over a nail. We measured preoperative (bo) and postoperative (po) sagittal, coronal, and oblique plane deformities, initial limb length discrepancy (LLD), percentage LLD (% LLD), amount of lengthening (AmtL), percentage lengthening (%L), external fixator duration (EFD), and external fixator index (EFI). We graded complications by Lascombes’ criteria, results by Association for the Study and Application of the Methods of Ilizarov bone score.Results: The mean age was 8.8±7.1 years; the mean follow-up was 7.9 years. Group A had significantly greater bo-sagittal, coronal, and oblique plane deformities. Mean LLD (3.4 cm in group A vs. 4.1 cm in group B) was similar in both. Expected LLD at maturity (LLDM) using the multiplier method was greater than previously reported (mean, range in group A: 7.2 cm, 4.4 to 9.5 cm; group B: 5 cm, 2.5 to 9.7 cm). Though AmtL (3.5 and 4.1 cm) was similar in both, %L was 24% in group A and 15.7% in group B (P=0.002). EFD (116.6 days) and EFI (33.7 days/cm) were lesser in group A compared with group B (200.3 days, P=0.001; 50.2 days/cm, P=0.01). Lascombes’ triple contract was fulfilled in 11/14 lengthenings in group A versus 3/14 in group B. Association for the Study and Application of the Methods of Ilizarov bone score was good and excellent in both groups (P=0.44).Conclusions: In a large series of lengthenings in CPMBT, we found younger children presenting with large deformities and large projected length discrepancies could be safely lengthened with significantly lesser EFD and complications than in older children.Level of Evidence: Level IV—therapeutic study.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Terminal Syme Amputation of the Great Toe in the Pediatric Population

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      Authors: Gibson; Thomas W.; Westberry, David E.; Carpenter, Ashley M.; Colucciello, Nicholas; Carson, Lisa
      Abstract: imageBackground: In the pediatric population, chronic ingrown toenails (onychocryptosis) can cause infection (paronychia), debilitating pain, and may be unresponsive to conservative treatments. Following multiple failed interventions, a terminal Syme amputation is one option for definitive treatment of chronic onychocryptosis. This procedure involves amputation of the distal aspect of the distal phalanx of the great toe with complete removal of the nail bed and germinal center, preventing further nail growth and recurrence.Methods: A retrospective review was performed to determine outcomes of a terminal Syme amputation in the pediatric population. Inclusion criteria included treatment of onychocryptosis involving terminal Syme amputation with a minimum follow-up of 1 year. The medical record was reviewed to assess previous failed treatment efforts, perioperative complications, radiographic outcomes, and the need for additional procedures.Results: From 1984 to 2017, 11 patients (13 halluces) with onychocryptosis were treated with a terminal Syme amputation. There were no intraoperative complications. One hallux had a postoperative infection requiring antibiotics as well as partial nail regrowth following the terminal Syme procedure that required subsequent removal of the residual nail. Following partial nail ablation, the patient had no further nail growth. An additional patient also developed a postoperative infection requiring oral antibiotic treatment. All patients returned to full weight-bearing physical activities within 6 weeks of surgery.Conclusions: Terminal Syme amputation was successful in treating pediatric patients who have recalcitrant onychocryptosis and paronychia. There was little functional consequence following terminal Syme amputation of the great toe in this patient population, making it an effective salvage procedure.Level of Evidence: Level IV—retrospective comparative study.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Prospective Evaluation of Tarsal Coalition Excision Show Significant
           Improvements in Pain and Function

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      Authors: Mahan; Susan T.; Miller, Patricia E.; Kasser, James R.; Spencer, Samantha A.
      Abstract: imageBackground: Excision of pediatric tarsal coalition has been successful in most patients. However, some patients have ongoing pain after coalition excision. This study prospectively assessed patient-based clinical outcomes before and after surgical excision of tarsal coalition, with particular emphasis on comparison to radiologic imaging.Methods: We prospectively studied 55 patients who had symptomatic coalition excision for 2 years postoperatively. Patients filled out the modified American Orthopaedic Foot and Ankle Society score, the University of California Los Angeles activity score, and the simple question “does foot pain limit your activity” at 4 different time points: preoperative, 6 months postoperative, 12 months postoperative, and 24 months postoperative. Comparisons were done utilizing patient demographics, imaging parameters, and patient-reported outcomes.Results: Compared with preoperative levels, patients showed improvements in all outcome parameters. Patients with calcaneonavicular coalitions showed initial rapid improvement with later slight decline, while patients with talocalcaneal coalitions showed more steady improvement; both were similar at 2 years postoperatively.Conclusions: This prospective study demonstrated remarkable clinical improvements after tarsal coalition excision regardless coalition type, though postoperative courses differed between calcaneonavicular and talocalcaneal types. Finally, a subset of patients has ongoing activity limiting foot pain after coalition excision which could not be explained by the data in this study.Level of Evidence: Level II—prospective cohort study.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Assessment of the Viability and Union Feature of Diaphysis Reconstruction
           Using Pasteurized Tumor Bone and Intramedullary Free Fibular After Tumor
           Resection

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      Authors: Ji; Tao; Li, Yuan; Xing, Zhili; Tang, Xiaodong; Yang, Rongli; Guo, Wei
      Abstract: imageBackground: Reconstruction using pasteurized tumor bone (PTM) and intramedullary-placed vascularized free fibular (VFG) has the combined advantages of mechanical strength and biological activity. The aims of this study were to investigate scintigraphic viability and radiographic union patterns of composite grafts after surgery, union rates, functional outcomes, and complication rates.Methods: Seventeen patients underwent intercalary composite reconstruction using PTM and VFG (12 male, 2 female, mean age: 10.9 y). Retrospective evaluation of radiography and bone scintigraphy was performed. The most common diagnosis was osteosarcoma (12/14, 85.7%). All radiography and bone scintigraphy was reviewed for bone healing and tracer uptake semiquantitatively using the ratio of the reconstructed portion to the contralateral side. Complications and oncological and functional outcomes were recorded.Results: At a mean follow-up of 33.1 months, primary union was achieved in all 28 host-graft junctions in all 14 patients. The respective mean times to proximal and distal junction bone union were 6.9 and 6.5 months. Metaphyseal junctions healed faster than diaphysis junctions (5.2 vs. 8.0 mo, P=0.02). Free fibular was integrated with surrounding bone after a mean of 10.1 months. The mean tracer uptake ratio was 1.1 after a mean of 4.8 months postoperatively. Half patients (50%) had higher uptake on bone scan than contralateral side. There was no significant correlation between uptake value and bone healing time. Five complications occurred in 4 patients (28.6%), and 1 patient (7.1%) contracted an infection. No fractures or breakages were observed. The mean Musculoskeletal Tumor Society 93 score was 87.6%.Conclusions: Reconstruction using PTM combined with VFG is associated with good short-term biological activity as indicated by bone scintigraphy, a high union rate, and an acceptable complication rate. The technique is a useful reconstruction option for large segmental bone defects after tumor resection in lower extremities.Level of Evidence: Level IV—therapeutic study.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Physeal Abnormalities in Children With High-risk Neuroblastoma Intensively
           Treated With/Without 13-Cis-Retinoic Acid

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      Authors: Koh; Kyung-Nam; Jeon, Ji Young; Park, Soo-Sung; Im, Ho Joon; Kim, Hyery; Kang, Michael Seungcheol
      Abstract: imageBackground: This study aimed to investigate the presence of physeal abnormality and its effect on growth in children with high-risk neuroblastoma treated by intensive multimodal treatment with/without 13-cis-retinoic acid (13-CRA).Methods: Fifteen patients diagnosed with high-risk neuroblastomas at the age of 1 to 10 years, who received treatment such as high-dose chemotherapy and autologous stem cell transplantation with/without 13-CRA, and with complete data during their>2-year follow-up were retrospectively reviewed. The physeal abnormalities were investigated by whole-body magnetic resonance imaging, serially performed every 3 to 6 months. The patients’ height growth was also investigated and compared with that of age-and-sex-matched patients with brain tumors who also underwent high-dose chemotherapy and autologous stem cell transplantation.Results: Six of 15 patients presented multifocal physeal abnormalities during follow-up, and all lesions occurred in patients with 13-CRA use. The lesions in 3 patients completely resolved spontaneously without any adverse effect on growth, but some lesions in the other 3 patients progressed to disturb the bony growth. Height growth of matched patients with brain tumors were not significantly different, and none of the matched controls showed definite bony deformity during the follow-up.Conclusions: Some children who were treated for high-risk neuroblastomas experienced multifocal physeal insults, probably due to the use of 13-CRA. Most lesions resolved spontaneously, but some led to bony deformity. If the lesions are not followed by premature physeal closure, there seems to be no further adverse effect of 13-CRA on leg length growth. Routine periodic screening for physeal status is needed for the patients with high-risk neuroblastomas using 13-CRA.Level of Evidence: Level IV—prognostic study.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • An Analysis of Online Ratings of Pediatric Orthopaedic Surgeons

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      Authors: Jay; Jordan H.; Runge, Nicholas E.; Vergara, Franz H.; Sabatini, Coleen S.; Oni, Julius K.
      Abstract: imageBackground: Patients continue to utilize physician review websites (PRWs) to assist in their selection of a health care provider. Studies on PRWs and how they affect patient care have recently become popular in the literature. This study analyzes PRW ratings of a previously unexamined subspecialty, pediatric orthopaedic surgeons.Methods: Three hundred ninety-nine randomly selected Pediatric Orthopaedic Society of North America member’s PRW ratings were examined from May 4, 2020 to July 18, 2020. Healthgrades.com, Vitals.com, RateMDs.com, and Google.com were reviewed. Number of ratings and average ratings (0 to 5.0) were recorded. Provider sex, years in practice (0 to 10, 11 to 20, and 21+), practice type (academic, private), geographic location (Northeast, Southeast, Midwest, Southwest, West), degree (Medical Doctor, Doctor of Osteopathic Medicine), and fellowship training (yes, no) were recorded. Kruskal-Wallis testing was performed to determine factors affecting positive surgeon ratings.Results: 98.5% (393) of Pediatric Orthopaedic Society of North America surgeons were rated on a PRW at least once and were highly rated with an average rating of 4.14 of 5.0. Surgeons in practice 1 to 10 years had higher ratings than those in practice 11 to 20 and 21+ years, on Healthgrades.com (P=0.049) and RateMDs.com (P=0.011). Academic surgeons were found to have higher ratings than those in private practice on Google.com (P=0.007). Sex, region of practice, degree type, and fellowship training status did not have an effect on online ratings across all PRWs.Conclusions: Pediatric orthopaedic surgeons are frequently and highly rated, similar to other orthopaedic subspecialties. Surgeons in practice 1 to 10 years were found to have statistically higher ratings on some websites. Academic surgeons were found to have statistically higher ratings on some websites.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Determining C2 Pedicle Screw Placement Feasibility in the Pediatric
           Population: A Computed Tomographic Safe Zone Analysis

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      Authors: Hirase; Takashi; Zhuge, Wu; Phelps, Christopher I.; Kushwaha, Vivek P.; Marco, Rex A.W.
      Abstract: imageBackground: Due to high rates of anatomic variability of the C2 pedicle, thin-sliced pedicular-oriented computed tomography (CT) and 3-dimensional reconstructive CT technologies have been introduced to predict safe C2 pedicle screw placement. However, this technology may not be readily available in all centers. The purpose of this study was to perform a C2 pedicle safe zone analysis using standard sagittal CT scans to predict the feasibility of C2 pedicle screw placement in a pediatric population and to compare the results with our previously obtained safe zone analysis from the adult population.Methods: A retrospective analysis was performed at a single level I trauma center of pediatric patients who completed CT scans of the cervical spine. The feasibility of C2 pedicle screw placement was analyzed using our previously described C2 pedicle safe zone analysis technique. The risk profiles were compared with our previously obtained safe zone analysis from the adult population.Results: Thirty-nine consecutive patients with a mean age of 7.8±4.4 years and 78 total pedicles were included in the study. Fourteen pedicles (18%) were considered low risk, 37 (47%) were moderate risk, and 27 (35%) were high risk for vertebral artery injury. Individual patients were found to have a significant amount of side-to-side variability between pedicles with 21 patients (54%) having left and right pedicles with different risk profiles. Four patients (10%) demonstrated low risk profiles in bilateral pedicles. There was no significant difference between the risk profiles of pediatric and adult patients.Conclusions: There is a considerable amount of anatomic variability within the pediatric C2 pedicles. Using this simple and accessible technique during the review of preoperative imaging, C2 pedicle screw placement may be considered in appropriately selected pediatric patients.Level of Evidence: Level III.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Primary Bacterial Pyomyositis in Children: A Systematic Review

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      Authors: Vij; Neeraj; Ranade, Ashish S.; Kang, Paul; Belthur, Mohan V.
      Abstract: imageBackground: Tropical pyomyositis has had a recent increase in the United States, Europe, and other nontropical areas. The purpose of this study was to provide an accurate description of the demographics, presenting features, sites of involvement, microbiology, imaging modalities, medical and surgical management, complications, and predictors of clinical course.Methods: We searched PubMed, Cochrane, Web of Science Collection, Scopus, and Embase databases yielding 156 studies. Of these, 23 articles were selected for statistical analysis.Results: The average age at presentation was 8.4±1.9 years with males more commonly affected. Fever, painful limp, and localized pain were the most common presenting symptoms. Pelvis, lower extremity, trunk and spine, in descending order, were the most commonly affected locations. Iliopsoas, obturator musculature, and gluteus musculature were the most commonly affected muscle groups. The mean time to diagnosis was 6.6±3.05 days. Staphylococcus aureus was the most common offending organism. The mean length of hospital stay was 12.0±4.6 days. Medical management alone was successful in 40% of cases (143/361) with an average duration of 9.5±4.0 and 22.7±7.2 days of intravenous and oral antibiotics, respectively. Surgical management consisted of open drainage in 91.3% (199/218) or percutaneous drainage in 8.7% (19/218) of cases. Painful limp, fever, and larger values of white cell count and erythrocyte sedimentation rate were associated with an increased need for surgery. Obturator and calf muscle involvement were strongly associated with multifocal involvement. There were 42 complications in 41 patients (11.3%). Methicillin-resistant S. aureus was associated with an increased risk of complications. The most common complications were osteomyelitis, septicemia, and septic arthritis.Conclusions: Primary pyomyositis should be considered in cases suggesting pediatric infection. Magnetic resonance imaging is the most commonly used imaging modality; however, ultrasound is useful given its accessibility and low cost. Medical management alone can be successful, but surgical treatment is often needed. The prognosis is favorable. Early diagnosis, appropriate medical management, and potential surgical drainage are required for effective treatment.Level of Evidence: Level IV—systematic review.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Bruegel and the Cost of the Bended Knee

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      Authors: Rebello; Gleeson; Joseph, Benjamin
      Abstract: imageIn Pieter Bruegel’s painting, “The Seven Acts of Charity” he portrays 2 subjects with flexed knees. One of them cannot walk while the other can walk but does so with excessive energy expenditure.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Obese Children Have Different Forearm Fracture Characteristics Compared
           With Normal-weight Children

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      Authors: Rehm; Andreas; Thahir, Azeem
      Abstract: No abstract available
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
 
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