Pediatr Orthop Research Articles

FRI0576-HPR Static and dynamic postural control in individuals with chondromalacia patellae

BackgroundChondromalacia patellae is a common cause of anterior Knee pain, especially in young athletes or sedentary [1]. These individuals often have muscle weakness of the quadriceps and gluteus medius, responsible...

Referrals to Pediatric Orthopedics: Always Indicated?

Hsu EY, Schwend RM, Leamon J. How many referrals to a pediatric orthopaedic hospital specialty clinic are primary care problems?. J Pediatr Orthop. 2012; 32( 7): 727- 731; doi: org/10.1097/BPO.0b013e31826994a4[OpenUrl][1][CrossRef][2][PubMed][3] Investigators from Children’s Mercy Hospital in Kansas City, MO sought to determine how many new patient referrals evaluated by pediatric orthopedic surgeons had conditions that a pediatrician could manage if she/he chose to do so. The authors utilized the 2002 American Academy of Pediatrics guidelines for referral1 in conjunction with the American Board of Pediatrics referral criteria2 to distinguish conditions manageable by pediatricians from those requiring pediatric orthopedic management. ### PICO Question : Of new patients referred to a pediatric orthopedic clinic, how many had conditions that could be readily managed by a primary care physician? Question type : Descriptive Study design : Cross-sectional A total of 529 new referrals to the pediatric orthopedic outpatient clinic during the month of August 2010 were evaluated. A total of 246 referrals (47%) … [1]: {openurl}?query=rft.jtitle%253DJournal%2Bof%2Bpediatric%2Borthopedics%26rft.stitle%253DJ%2BPediatr%2BOrthop%26rft.aulast%253DCatena%26rft.auinit1%253DN.%26rft.volume%253D32%26rft.issue%253D7%26rft.spage%253D727%26rft.epage%253D731%26rft.atitle%253DHand%2Band%2Bupper%2Blimb%2Banomalies%2Bin%2Bpoland%2Bsyndrome%253A%2B%2Ba%2Bnew%2Bproposal%2Bof%2Bclassification.%26rft_id%253Dinfo%253Adoi%252F10.1097%252FBPO.0b013e31826994a4%26rft_id%253Dinfo%253Apmid%252F22955538%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/external-ref?access_num=10.1097/BPO.0b013e31826994a4&link_type=DOI [3]: /lookup/external-ref?access_num=22955538&link_type=MED&atom=%2Faapgrand%2F29%2F3%2F29.atom

1325 Intra-Subject Variability on 3T MRI Imaging of Neonatal Hips

BackgroundMRI may have utility for examining neonatal hips. To date, MRI measurements of hip dimensions have only been characterized on post-mortem imaging. The aim of this study was to compare...

Paper 251: Wavelet-EMG Analysis of the Leg Muscles in Fencing During a Flèche Attack

Fencing is highly demanding on the coordinative skills of athletes. The timing of the muscular activation during a flèche attack is one factor of a successful touch during an attack in a fencing bout. The goal of this study was to analyze the muscular activation sequences of the main leg muscles during flèche attacks and to help to improve training methods in fencing. Kinematics of the whole body [Romkes et al, 2007Romkes et al.J Pediatr Orthop B. 2007; 16: 175-180Crossref PubMed Scopus (67) Google Scholar] (VICON MX, 240 Hz), ground reaction force during the push-off phase (Kistler, 6000 Hz) and EMG data (Biovision, 6000 Hz, SENIAM-Standard) of the M. Tibials anterior, (TA), M. Gastrocnemius Medialis (GM), M. Vastus Medialis (VM), M. Rectus Femoris (RM), M. Semitendinosus (HAM) of both legs and of the M. Vastus lateralis (VL) of the front leg was recorded of 7 volunteer male expert fencers. The data of 10 trials/subject were averaged using EMG Wavelet-Transformation (WT-EMG) [von Tscharner, 2000von Tscharner J Electromyogr Kinesiol. 2000; 10: 433-445Abstract Full Text Full Text PDF PubMed Scopus (271) Google Scholar]. The test setup simulates a competition situation. The subject was doing small vertical bouncing jumps on the 2 force plates. The start for flèche attack was given by a visual signal at the target. The distance between the force plate and the target was 2.5 m. The beginning of the forward movement of the center of mass was set as movement start (t = 0 sec). The movement was initialized by lowering the center of mass and shifting it slightly in direction of the target. The actual push-off movement started with an activation of the RF, VM and GM of the rear leg. After taking off the rear foot a short co-contraction of the RF and HAM occur to stabilize the position of the hip joint. [Nene, 2004Nene A. Gait & Posture. 2004; 20: 1-13Abstract Full Text Full Text PDF PubMed Scopus (91) Google Scholar]. The push-off movement of the front leg started before the muscular activation of the rear leg was finished. It started with the RF, VL, VM, GM and slight co-contraction of the RF and HAM after the foot left the ground. Prior to landing all measured muscles of the rear leg were activated, a co-contraction was seen for the ankle joint by the GM and TA and for the hip and knee-joint by the RF, VM and HAM. The co-contraction of the RF and HAM after take-off of the rear leg is needed to keep the leg in the desired position. While the co-contraction of the RF, VM and HAM and the TA and GM prior to landing is a mus¬cular pre-activation which is needed to con¬trol angular position of the joint and to ab¬sorb the impact force of the landing of the rear foot after hitting the target. The main landing impact was first absorbed by TA and slight later by GM and VM, with a clear higher muscular activation. The result of this study shows that the flèche attack is a highly demanding movement for the muscular coordination.

Supracondylar humerus fractures in children treated with closed reduction and percutaneous pinning

Supracondylar fractures of the humerus in children are important for frequency and type of associated serious complications. The management of this kind of fractures is still controversial (Skaggs et al. in J Bone Joint Surg Am 86:702-707, 2004; Kalllio et al. in J Pediatr Orthop 12:11-15, 1992). We are going to present our experience in the treatment of supracondylar humeral fracture in children. In the Orthopedic Department of Pisa, we treated 150 cases from 1989 to 2006. We are used to perform, emergency or within 12 h, reduction and two lateral-entry percutaneous pins fixation. The mean age was 7.5 years. We checked 125 cases, because we excluded all the cases with follow up less then 5 years. The mean follow up was 8.2 years. We used Gartland classification modified by Wilkins. We evaluated 125 cases by using the Flynn classification: 100 % of patients did not have impairment of the elbow joint mobility. We had seven valgus deviation, one of which was more then 10°. We also had 17 varus deviations, 11 of which were not over 8° and only 2 of them were 15°. The average value of the joint Baumann angle was calculated as great as 16°. The obtained results were classified as very good 80 %, good 11 %, sufficiently good 6 %, and bad 3 %. In our experience, all the fractures type II and III by Gartland have to be treated within 12 h, with closed reduction and stabilization with lateral-entry K-wire technique. The conservative treatment by cast is indicated only in type I fracture. The trans olecranic treatment is not realizable, for the stiffness which can occur, for the risk of iatrogenic ulnar nerve lesion, and for long-time hospitalization. The open reduction remains the first choice treatment for exposed or nonreducible fractures, and in cases of vascular injury.

Pediatric Forearm Fractures: Spotting and Managing the Bad Actors

Fractures of the forearm are among the most common fractures in children, 1 Cheng J.C. Ng B.K. Ying S.Y. Lam P.K. A 10-year study of the changes in the pattern and treatment of 6,493 fractures. J Pediatr Orthop. 1999; 19: 344-350 PubMed Google Scholar with the vast majority of these injuries requiring no more than immobilization with or without closed reduction. 2 Creasman C. Zaleske D.J. Ehrlich M.G. Analyzing forearm fractures in children: the more subtle signs of impending problems. Clin Orthop Relat Res. 1984; 188: 40-53 PubMed Google Scholar , 3 Daruwalla J.S. A study of radioulnar movements following fractures of the forearm in children. Clin Orthop Relat Res. 1979; 139: 114-120 PubMed Google Scholar Children with open physes are capable of remodeling mild to moderate posttraumatic deformities, but the remodeling potential depends on the amount of remaining growth at the nearest physis, the proximity of the injury to the physis, and the plane of motion of the nearest joint. Rotational deformities and joint dislocations, however, will not remodel. For forearm fractures that compromise joint congruity or limit forearm rotation, as can occur with both Monteggia- and Galeazzi-type injuries, an anatomic or nearly anatomic reduction should be sought. Treatment decisions are based on the individual circumstances of the patient by weighing the risks of closed, percutaneous, or open management with the likelihood of long-term disability from a nonanatomic reduction. Educational Objectives •State the soft tissue stabilizers of the proximal and distal radioulnar joints. •Discuss the various injuries that can be caused by axial loads applied to the pediatric forearm. •Describe the remodeling potential with reference to age and plane of deformity. •Discuss the complications of intramedullary fixation. •Summarize the risk factors for the development of compartment syndrome following intramedullary fixation. •List the indications for open reduction and rigid fixation. Earn up to 2 hours of CME credit per JHS issue when you read the related articles and take the online test. To pay the $20 fee and take this month’s test, visit http://www.jhandsurg.org/CME/home. •State the soft tissue stabilizers of the proximal and distal radioulnar joints. •Discuss the various injuries that can be caused by axial loads applied to the pediatric forearm. •Describe the remodeling potential with reference to age and plane of deformity. •Discuss the complications of intramedullary fixation. •Summarize the risk factors for the development of compartment syndrome following intramedullary fixation. •List the indications for open reduction and rigid fixation. Earn up to 2 hours of CME credit per JHS issue when you read the related articles and take the online test. To pay the $20 fee and take this month’s test, visit http://www.jhandsurg.org/CME/home. Journal CME QuestionsJournal of Hand SurgeryVol. 37Issue 2Preview Full-Text PDF

Dexamethasone Therapy + Antibiotics for Septic Arthritis in Children

Research Article| June 01 2011 Dexamethasone Therapy + Antibiotics for Septic Arthritis in Children AAP Grand Rounds (2011) 25 (6): 64. https://doi.org/10.1542/gr.25-6-64 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Twitter LinkedIn Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation Dexamethasone Therapy + Antibiotics for Septic Arthritis in Children. AAP Grand Rounds June 2011; 25 (6): 64. https://doi.org/10.1542/gr.25-6-64 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search nav search search input Search input auto suggest search filter All PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP NewsAll AAP Sites Search Advanced Search Topics: bacterial arthritis, dexamethasone Source: Harel L, Prais D, Bar-on E, et al. Dexamethasone therapy for septic arthritis in children: results of a randomized doubleblind placebo-controlled study. J Pediatr Orthop. 2011; 31(2): 211– 215; doi: https://doi.org/10.1097/BPO.0b013e3182092869Google Scholar Investigators from Israel designed this prospective, randomized, double-blind, placebo-controlled study to determine if a four-day course of dexamethasone given at the start of antibiotic treatment in children with septic arthritis is safe, and leads to a more rapid clinical improvement compared to children treated with antibiotics alone. Children with septic arthritis who met the inclusion criteria of 1) an acute swollen, painful, warm joint with limited motion; 2) aspirated joint fluid containing more than 50,000 white blood cells/ mm3; and 3) elevated acute phase reactants, were enrolled. Intravenous cefuroxime 150 mg/kg/dose in three divided doses was initiated in all patients. Study patients were randomized to receive IV dexamethasone, 0.15mg/kg/dose every 6 hours for 16 consecutive doses, or placebo. The primary endpoints of the study were time to clinical and laboratory normalization and duration of hospitalization. The secondary endpoint was evidence of late sequelae. A total of 49 children were enrolled in the study; 25 were randomized to receive dexamethasone and 24 received placebo. The mean patient age was 33 months (range 6–161). The affected joints included hips (21), knees (18), ankles (5), elbows (3), and shoulders (2). There were no significant differences between the two groups in age, duration of symptoms, joint affected, or initial level of acute phase reactants. Bacteria were cultured from the joint fluid in 17 patients (35%) and from the blood in 4 patients (8%). The most common organisms isolated were Kingella kingae in seven patients (41%) and methicillin-sensitive Staphylococcus aureus in three cases (18%). Compared to the placebo group, patients treated with dexamethasone had a significantly earlier mean first day without fever (1.7 vs 2.8 days, P=.021), mean first day without pain (7.2 vs 10.8 days, P=.021), mean first day of full range of motion (7.0 vs 12.2 days, P=.03), faster return of ESR to less than 25 mm/h (3.8 vs 8.4 days, P=.003), faster return of CRP to less than 0.5 mg/dL (3.1 vs 5.5 days, P=.029), shorter duration of IV treatment (9.9 vs 12.6 days, P=.007), and shorter hospital stay. Duration of follow-up ranged from 2 to 12 months and there were no adverse outcomes such as limitation in range of motion or leg length discrepancies. The authors conclude that dexamethasone given during the first four days of antibiotic treatment of children with septic arthritis is safe and leads to more rapid clinical improvement. Dr Hennrikus has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device. This is a spectacular study that may change pediatric practice. In this well-designed study, a four-day course of dexamethasone given to children with septic arthritis was safe, resulted in... You do not currently have access to this content.

Extremity Surgery in Ambulatory Children with CP

Research Article| April 01 2010 Extremity Surgery in Ambulatory Children with CP AAP Grand Rounds (2010) 23 (4): 44. https://doi.org/10.1542/gr.23-4-44 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Share Icon Share Twitter LinkedIn Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation Extremity Surgery in Ambulatory Children with CP. AAP Grand Rounds April 2010; 23 (4): 44. https://doi.org/10.1542/gr.23-4-44 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search nav search search input Search input auto suggest search filter All AAP SitesAll PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP News Search Advanced Search Topics: cerebral palsy, gait, limb, orthopedics, leg Source: Gorton GE, Abel MF, Oeffinger DJ, et al. A prospective cohort study of the effects of lower extremity orthopaedic surgery on outcome measures in ambulatory children with cerebral palsy. J Pediatr Orthop. 2009; 29(8): 903– 909; doi: https://doi.org/10.1097/BPO.0b013e3181c11c0cGoogle Scholar This multicenter study assessed whether lower extremity orthopaedic surgery improves function and quality of life in ambulatory children with cerebral palsy (CP). Study subjects were part of a larger six-year prospective multicenter study at seven US pediatric orthopaedic facilities. Children 4 to 18 years of age with Gross Motor Functional Classification System (GMFCS) levels I–III (I: normal; II: walks with limitation; III: walks with hand-held mobility) were eligible. Patients were excluded if they had had dorsal rhizotomy, previous orthopaedic surgery, botulinum toxin A injections, or a functioning... Copyright © 2010 by the American Academy of Pediatrics2010 You do not currently have access to this content.

The use of a professional graphics editing program for the preoperative planning in deformity correction surgery: A technical note

Preoperative planning for lower limb deformity correction surgery used to be performed manually on long standing radiographs with the help of a pencil, transparent goniometer and a long ruler. 2 Feldman D.S. Henderson E.R. Levine H.B. et al. Interobserver and intraobserver reliability in lower-limb deformity correction measurements. J Pediatr Orthop. 2007; 27: 204-208 Crossref PubMed Scopus (29) Google Scholar , 4 Hankemeier S. Gosling T. Richter M. et al. Computer-assisted analysis of lower limb geometry: higher intraobserver reliability compared to conventional method. Comput Aided Surg. 2006; 11: 81-86 PubMed Google Scholar , 7 Paley D. Principles of deformity correction. 1st edition. Springer-Verlag, Berlin/Heidelberg/New York2002 Crossref Google Scholar , 8 Paley D. Herzenberg J.E. Tetsworth K. et al. Deformity planning for frontal and sagittal plane corrective osteotomies. Orthop Clin North Am. 1994; 25: 425-465 PubMed Google Scholar Moreover, simulations for corrective cuts and osteotomies are usually made by copying the radiographs on tracing papers and making the required cuts and corrections on these papers.

Osteochondroma after Hematopoietic Stem Cell Transplantation in Childhood. An Italian Study on Behalf of the AIEOP-HSCT Group

A retrospective study was conducted among Italian children treated with hematopoietic stem cell transplant (HSCT) to evaluate the incidence and risk factors in the development of osteochondroma (OC). OC occurred in 27 patients who received autologous or allogeneic HSCT. The estimated 5-, 10-, and 15-year cumulative risk of developing OC was 0.5%, 3.2%, and 6.1%, respectively. Analysis of cumulative risk stratified by the various risk factors revealed that male sex (P=.026), autologous HSCT (P=.001), age at HSCT (< or =3 years) (P < .0001), and total body irradiation (TBI) (P <.0001) significantly affected the risk of OC. Multivariate analysis, restricted only to tumor types with at least 1 case of OC, showed that earlier age at HSCT (P =.0004) and TBI (P < .0001) were the only factors that were significantly associated with OC.

ACR Appropriateness Criteria® on Developmental Dysplasia of the Hip—Child

Developmental dysplasia of the hip (DDH) affects 1.5 of every 1,000 caucasian Americans and less frequently affects African Americans. Developmental dysplasia of the hip comprises a spectrum of abnormalities, ranging from laxity of the joint and mild subluxation to fixed dislocation. Early diagnosis of DDH usually leads to low-risk treatment with a harness. Late diagnosis of DDH in children may lead to increased surgical intervention and complications. Late diagnosis of DDH in adults can result in debilitating end-stage degenerative hip joint disease. Screening decreases the incidence of late diagnosis of DDH. Clinical evaluation for DDH should be performed periodically at each well-baby visit until the age of 12 months. There is no consensus on imaging screening for DDH. Consideration for screening with ultrasound is balanced between the benefits of early detection of DDH and the increased treatment and cost factors. In addition, randomized trials evaluating primary ultrasound screening did not find significant decrease in late diagnosis of DDH. In the United States, hip ultrasound is selectively performed in infants with risk factors, such as family history of DDH, breech presentation, and inconclusive findings on physical examination. Ultrasound for DDH should be performed after 2 weeks of age because laxity is common after birth and often resolves itself. A pelvic radiograph can optimally be performed after the age of 4 months, when most infants will have ossification centers of the femoral heads.

An 11-year-old Boy with Ankle Trauma

An 11-year-old Boy with Ankle Trauma

How Not to Wear a School Backpack

Orthopaedics| November 01 2008 How Not to Wear a School Backpack AAP Grand Rounds (2008) 20 (5): 58–59. https://doi.org/10.1542/gr.20-5-58 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation How Not to Wear a School Backpack. AAP Grand Rounds November 2008; 20 (5): 58–59. https://doi.org/10.1542/gr.20-5-58 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search toolbar search search input Search input auto suggest filter your search All PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP NewsAll AAP Sites Search Advanced Search Topics: pain, pressure-physical agent, shoulder region, skin, lower back, shoulder pads, shoulder pain Source: Macias BR, Murthy G, Chambers H, et al. Asymmetric loads and pain associated with backpack carrying by children. J Pediatr Orthop. 2008;28(5):512–517. This study from Children’s Hospital and Health Center, San Diego, described the contact pressures under backpack shoulder straps of children while they carried varying loads under different wearing conditions. Healthy young teens were recruited to carry a standard backpack loaded at 10%, 20%, and 30% of body weight (BW). Four different standardized backpack positions were tested for skin surface contact pressures under the shoulder straps utilizing sensors positioned under each strap. The backpack was placed with both shoulder straps equally adjusted for (1) a high back position between the scapula and above the pelvis as well as (2) a low back position resting on the pelvis with the shoulder straps equally adjusted. These high and low back positions were then tested with (3) the backpack carried over the left shoulder and with (4) the pack carried over the right shoulder. Contact pressures were measured while the child was standing as well as walking. Pressure thresholds greater than 30 mm Hg were assumed to occlude skin blood flow. The children rated their pain using the Borg Visual Analog Scale (BVAS: 0= no pain, 10=worst pain).1 Five girls and five boys participated. Subjects’ mean age, height, and weight were 13.2 years, 136.5 cm, and 62 kg respectively. For each of the four testing conditions the mean surface contact pressure was significantly higher with the use of one strap on the right shoulder compared to the left, with use of a low back position compared to high back position, and at 30% BW load compared to 10% or 20% BW. The least skin pressure was noted under the left shoulder strap (38 mm Hg SD ± 12 mmHg) for a 10% BW load, high back position, with both straps secured. The highest skin pressure was measured under the right shoulder strap (235 mm Hg SD ± 68) for a 30% BW load, low back position with only one strap secured. Perceived pain on the BVAS was significantly higher with the backpack in the low back position, with backpack loads of 30% BW compared to either 10% or 20%, and with use of one shoulder strap compared to two. The highest pain score (BVAS 6) was noted with a 30% BW load when one shoulder strap was used. At a 10% BW pack load the perceived pain score was <1, regardless of whether one or both shoulder straps were used. The authors conclude that children should carry backpacks in the high-back position with two straps placed over both shoulders to minimize high local pressures. Dr. Schwend has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device. Although this study evaluated only 10 healthy volunteer children, it was well controlled for age and used rigidly applied testing conditions. A skin surface pressure... You do not currently have access to this content.

Journal Scan: Journal of Pediatric Orthopaedics

Here is my view of the top-10 most potentially influential papers from the Journal of Pediatric Orthopaedics from 2007. Included are the papers that were thought to provide the most useful examinations of treatments and outcomes.

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There is no doubt that ejaculation after bladder exstrophy-epispadias complex (EEC) reconstruction cannot be normal. Even after functional bladder neck reconstruction, the prostate is not surrounding the urethra circumferentially, 1 Gearhart J.P. Yang A. Leonard M.P. et al. Prostate size and configuration in adults with bladder exstrophy. J Urol. 1993; 149: 308-310 PubMed Google Scholar and the lack of a normal functioning bulbospongiosus muscle prohibits forceful ejaculation. 2 Woodhouse C.R.J. Prospects for fertility in patients born with genitourinary anomalies. J Urol. 2001; 165: 2354-2360 Abstract Full Text Full Text PDF PubMed Google Scholar Additionally, surgical injury and malposition of the verumontanum could contribute greatly to ejaculatory disorders in patients with EEC. 3 Hanna M.K. Williams D.I. Genital function in males with vesical exstrophy and epispadias. Br J Urol. 1972; 44: 169-174 Crossref PubMed Scopus (31) Google Scholar However, the effect and the role of the pelvic floor reconstruction on ejaculation in EEC is still unknown. To a certain extent, the reappearance of the pubic gap is constant, regardless of the pelvic ring reconstruction method used, in particular, after all variations of osteotomy 4 Satsuma S. Kobayashi D. Yoshiya S. et al. Comparison of posterior and anterior pelvic osteotomy for bladder exstrophy complex. J Pediatr Orthop B. 2006; 15: 141-146 Crossref PubMed Scopus (19) Google Scholar With regard to this insight, we are convinced that in most cases of classic bladder exstrophy, osteotomy is not necessary to achieve better results whether in antegrade ejaculation or continence.

Reliability and validity of the Edinburgh Visual Gait Score for cerebral palsy when used by inexperienced observers

The Edinburgh Visual Gait Score (EVGS) for cerebral palsy has been validated for observer reliability and validity for observers experienced in gait analysis. This study investigated the reliability and validity of the EVGS for observers inexperienced in gait analysis. Six medical students used the score to analyse videotapes from the original study by Read et al. [Read HS, Hazlewood ME, Hillman SJ, Prescott RJ, Robb JE. Edinburgh visual gait score for use in cerebral palsy. J Pediatr Orthop 2003;23:296–301]. These were viewed on two separate occasions to provide inter- and intra-observer reliability, and the results of the numerical items were compared to those from three-dimensional (3D) gait analyses for validity. Observer agreement was tested using Coefficient of Repeatability (CoR), percentage of complete agreement and the kappa statistic. The CoR for inter-observer agreement for inexperienced observers was 5.99/5.07 (Session 1/Session 2) compared to 4.60/3.95 (Session 1/Session 2) for experienced observers. The CoR for intra-observer agreement for inexperienced observers was 5.15 compared to 4.21 for experienced observers. There was complete agreement for 52% of the 10 numerical items with 3D-gait analysis data for inexperienced observers compared to 64% for experienced observers. Ranking of reliability of individual items was similar between the two groups and was generally best for events occurring at the foot and ankle. Observations of gait events by the inexperienced observers using the EVGS were reasonably reliable but not very accurate when compared to experienced observers and 3D-gait analysis.

Posterior Sloping Angle of the Capital Femoral Physis

The management of the contralateral hip after unilateral slipped capital femoral epiphysis (SCFE) is controversial. The aims of this study were to assess the interobserver and intraobserver reliability of the posterior sloping angle (PSA) as described by Barrios et al (J Pediatr Orthop. 2005;25:445-449) and whether it can be used as a predictor of need for prophylactic pinning of the contralateral hip. The PSA was measured by 4 different surgeons on 2 separated occasions in 47 unaffected contralateral hips after unilateral SCFE. The interobserver intraclass correlation coefficient (ICC) was 0.83 (excellent) for the first set of measurements and 0.74 (fair to good) for the second set of measurements. Measurement of the intraobserver ICC revealed an excellent agreement (ICC > 0.75) in 3 of the 4 surgeons and fair to good agreement in 1 of the surgeons (ICC between 0.4 and 0.74). Comparison of the PSA measurements of the first author (M.Z.) with a control group of 20 hips revealed that the PSA was significantly higher (P < 0.05) in the group of patients that eventually had a contralateral slip when compared with the PSA of patients in the study group who did not slip and with normal hips in the control group. Patients with contralateral SCFE that did not slip had a significantly higher PSA (P < 0.05) when compared with normal individuals. A PSA of 14.5 degrees or more is recommended for prophylactic pinning of the contralateral hip. The number needed to treat (NNT) at this cut off to avoid 1 future slip was calculated to be 1.9.

Slipped Capital Femoral Epiphysis at Young Age Predicts Bilaterality

Source: Riad J, Bajelidze G, Gabos PG. Bilateral slipped capital femoral epiphysis: predictive factors for contralateral slip. J Pediatr Orthop. 2007.27;411–414.Slipped capital femoral epiphysis (SCFE) is characterized by instability of the proximal femoral growth plate. Investigators from the Alfred I. duPont Hospital for Children in Wilmington, Delaware, sought to determine predictors of contralateral slip in children with unilateral SCFE. The authors retrospectively reviewed the records of 235 patients with SCFE seen between 1990 and 2002. Children were excluded from analysis if they had bilateral disease on initial presentation, had incomplete radiographic data, were treated previously or elsewhere, had known endocrinopathies, or experienced comorbidities necessitating prophylactic screw fixation.The authors identified 70 patients with unilateral disease at presentation. Of these, 16 (23%) went on to develop bilateral disease. The mean age of both boys and girls who later developed bilateral SCFE was less than the mean age of those who did not develop bilateral disease (11.0 vs 11.9 for girls and 12.1 vs 14.2 for boys): 25% of girls younger than 12 years and 37% of boys younger than 14 years developed a contralateral slip. All girls younger than 10 (n=2) and boys younger than 12 (n=5) developed bilateral disease. Bivariate and subsequent multivariate correlation demonstrated a significant association between the development of contralateral SCFE and age (P<.01). For every one year increase in age at initial presentation, the patients were less likely to develop a contralateral slip (OR=.344). The authors conclude that in girls younger than 10 and boys younger than 12 years of age who present with unilateral SCFE, contralateral prophylactic screw fixation should be strongly consideredDr. Raszka has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of a commercial product/device. This commentary does not contain a discussion of an unapproved/ investigative use of a commercial product/device.SCFE is one of the most common adolescent hip disorders. Boys are more commonly affected than girls.1 Several studies have demonstrated that between 40% and 80% of those who present with unilateral SCFE go on to develop bilateral disease.2–3 Reported predictive factors for contralateral involvement include sex, chronologic age, bone age, race, and obesity, although only age and skeletal maturity were looked at specifically in this study.4–5 Predicting who will develop contralateral disease has important implications for follow-up or the use of prophylactic fixation at the time of surgery for the involved hip. However, data accurately predicting who will develop bilateral disease are lacking.Clinical decision analysis models have reached different conclusions about whether to perform prophylactic fixation because of different assumptions about the risks of developing contralateral disease.6–7 This study adds to the body of evidence that suggests young age at presentation is a risk factor for bilateral SCFE. Unfortunately, the authors could not evaluate the relative contribution of body mass index to the risk of SCFE development as height, and even weight, were often not recorded. Based on this and other studies, the younger the child at the time of presentation with SCFE, the more seriously prophylactic fixation of the uninvolved side should be entertained. Children with SCFE, particularly young adolescents, need to be monitored for contralateral involvement with serial examinations and radiographs.

Femoral head avascular necrosis after interlocking nail of a femoral shaft fracture in a male adult: a case report

Reamed interlocking nail through the piriformis fossa remains the golden standard for treatment of femoral shaft fracture. Fracture healing rates are 95-99%, and infection rates less than 1% (Clawson et al. in J Bone Joint Surg (Am) 53:681-692, 1971; Winquist et al. in J Bone Joint Surg (Am) 66:529-539, 1984; Brumback et al. in J Bone Joint Surg (Am) 70:1453-1462, 1988). Previous reports recognize avascular necrosis of the femoral head as a complication of antegrade interlocking nail in the adolescent (Beaty et al. in J Pediatr Orthop 14:178-183, 1994; Mileski et al. in J Bone Joint Surg (Am) 76:1706-1708, 1994; O'Malley et al. in J Pediatr Orthop 15:21-23, 1995; Buckaloo et al. in J Southern Orthop Assoc 6(2):97-100, 1997). This report describes a male adult who developed avascular necrosis of the femoral head after an open antegrade interlocking nail of a proximal third femoral shaft fracture. To our knowledge, there is no similar report in the English medical literature.

Spontaneous regression of postoperative ossification about the elbow: A case report

Heterotopic ossification is defined as the presence of trabecular bone in a location in the body where it does not normally exist. Its presence in the hip, knee, shoulder, and elbow has been well documented in the literature, and it usually forms as a reaction to trauma, burns, or surgery. 1 Ayers D.C. Pellegrini Jr, V.D. Evarts C.M. Prevention of heterotopic ossification in high-risk patients by radiation therapy. Clin Orthop Relat Res. 1991; : 87-93 PubMed Google Scholar , 2 Berg E.E. Ciullo J.V. Heterotopic ossification after acromioplasty and distal clavicle resection. J Shoulder Elbow Surg. 1995; 4: 188-193 Abstract Full Text PDF PubMed Scopus (45) Google Scholar , 3 Carlson W.O. Klassen R.A. Myositis ossificans of the upper extremity: a long-term follow-up. J Pediatr Orthop. 1984; 4: 693-696 Crossref PubMed Scopus (16) Google Scholar , 4 Degreef I. Debeer D.P. Heterotopic ossification of the supraspinatus tendon after rotator cuff repair: case report. Clin Rheumatol. 2006; 25: 251-253 Crossref PubMed Scopus (12) Google Scholar , 5 Ring D. Jupiter J.B. Operative release of ankylosis of the elbow due to heterotopic ossification. J Bone Joint Surg Am. 2004; 85: 849-857 Google Scholar , 6 Sferopoulos N. Anagnostopoulos D. Ectopic bone formation in a child with a head injury: complete regression after immobilisation. Int Orthop. 1997; 21: 412-414 Crossref PubMed Scopus (9) Google Scholar , 7 Spencer J.D. Missen G.A. Pseudomalignant heterotopic ossification (“myositis ossificans”) Recurrent after excision with subsequent resorption. J Bone Joint Surg Br. 1989; 71: 317-319 PubMed Google Scholar It is postulated that the stimulation of pluripotent mesenchymal cells by the inciting event initiates the sequence of events leading to endochondral ossification and heterotopic bone formation. We report the case of a patient in whom heterotopic ossification formed adjacent to the elbow after surgery and resolved spontaneously. This patient gave permission for data concerning his case to be submitted for publication.