Pediatric Orthopaedic Surgeons Research Articles

Temporary hemi-epiphysiodesis with tension band plates in skeletally immature patients with genu valgum: Faster correction in patients with more than 2 years of expected time of growth remaining

Purpose: Hemi-epiphysiodesis procedures in skeletally immature patients are commonly done to correct genu valgum over time. This study seeks to demonstrate the average rate of deformity correction for genu valgum using hinged tension band plates, while examining different age groups and sex-related differences. Methods: A retrospective chart review of patients who underwent hemi-epiphysiodesis with hinged tension band plates for valgus knee deformity from 2012 to 2022 by one pediatric orthopaedic surgeon was performed. Expected time of growth remaining was calculated as the difference between age of skeletal maturity and bone age at time of surgery. The mechanical lateral distal femoral angle, mechanical medial proximal tibial angle, mechanical femoral tibia angle, screw divergence angle, and hinge angle were measured immediately after implant placement and prior to implant removal. Results: 54 skeletally immature patients were treated for pathologic genu valgum. The mean age at time of surgery was 12.5 ± 1.9 years. The radiographic measurement of the valgus deformity between the beginning and end of treatment showed significant correction ( p = 0.002). The lower limb axis of the younger cohort corrected significantly faster (7.5 ± 4.6°/year) than the older cohort (5.3 ± 2.8°/year) ( p = 0.030). The mechanical lateral distal femoral angle correction rate was also significantly different between the two cohorts (7.0 ± 4.7°/year vs. 4.8 ± 2.8°/year, respectively ( p = 0.002)). The group with greater expected time of growth remaining demonstrated a significantly faster rate of correction than the group with less than 2 years of growth remaining ( p < 0.001). Conclusion: This study reaffirms the finding that timing is essential when performing temporary hemi-epiphysiodesis for valgus knee deformity in skeletally immature patients.

Gartland classification concordance of supracondylar fractures among pediatric emergency medicine physicians, radiologists, and orthopedic surgeons.

The modified Gartland classification is the most widely accepted grading method of supracondylar humeral fractures among orthopedic surgeons and is relevant to identifying fractures that may require surgery. To assess the interobserver reliability of the modified Gartland classification among pediatric radiologists, pediatric orthopedic surgeons, and pediatric emergency medicine physicians. Elbow radiographs for 100 children with supracondylar humeral fractures were retrospectively independently graded by two pediatric radiologists, two pediatric orthopedic surgeons, and two pediatric emergency medicine physicians using the modified Gartland classification. A third grader of the same subspecialty served as a tie-breaker as needed to reach consensus. Readers were blinded to one another and to the medical record. The modified Gartland grade documented in the medical record by the treating orthopedic provider was used as the reference standard. Interobserver agreement was assessed using kappa statistics. There was substantial interobserver agreement (kappa = 0.77 [95% CI, 0.69-0.85]) on consensus fracture grade between the three subspecialties. Similarly, when discriminating between Gartland type I and higher fracture grades, there was substantial interobserver agreement between specialties (kappa = 0.77 [95% CI, 0.66-0.89]). The grade assigned by pediatric radiologists differed from the reference standard on 15 occasions, pediatric emergency medicine differed on 19 occasions, and pediatric orthopedics differed on 9 occasions. The modified Gartland classification for supracondylar humeral fractures is reproducible among pediatric emergency medicine physicians, radiologists, and orthopedic surgeons.

Geographic Access to Pediatric Orthopedic Surgeons in the United States: An Analysis of Sociodemographic Factors.

It is unclear how pediatric orthopedic surgeons are geographically distributed relative to their patients. The purpose of this study was to evaluate the geographic distribution of pediatric orthopedic surgeons in the United States. County-level data of actively practicing pediatric orthopedic surgeons were identified by matching several registries and membership logs. Data were used to calculate the distance between counties and nearest surgeon. Counties were categorized as "surgeon clusters" or "surgeon deserts" if the distance to the nearest surgeon was less than or greater than the national average and the average of all neighboring counties, respectively. Cohorts were then compared for differences in population characteristics using data obtained from the 2020 American Community Survey. A total of 1197 unique pediatric orthopedic surgeons were identified. The mean distance to the nearest pediatric orthopedic surgeon for a patient residing in a surgeon desert or a surgeon cluster was 141.9±53.8 miles and 30.9±16.0 miles, respectively. Surgeon deserts were found to have lower median household incomes (P<.001) and greater rates of children without health insurance (P<.001). Multivariate analyses showed that higher Rural-Urban Continuum codes (P<.001), Area Deprivation Index scores (P<.001), and percentage of patients without health insurance (P<.001) all independently required significantly greater travel distances to see a pediatric orthopedic surgeon. Pediatric orthopedic surgeons are not equally distributed in the United States, and many counties are not optimally served. Additional studies are needed to identify the relationship between travel distances and patient outcomes and how geographic inequalities can be minimized. [Orthopedics. 202x;4x(x):xx-xx.].

Conception and validation of A 3d printed learning model of supra condylar fracture of children

The supracondylar fracture of the child is a common fracture. Its physiology, physiopathology and treatment use periosteum. As far as we know, there is no 3D printed model of this typical fracture in children with periosteum. The purposes of the research are to present the concept of an educational 3D printed supra condylar model with periosteum of the child and its expert validation. Materials and methodsThe basis for the paediatric elbow model was a 3D scan of a four-year-old girl. Once the data had been extracted, the models were constructed using 3D Slicer®, Autodesk fusion 360® and Ultimaker Cura® software's. The Creality 3D Ender 6 SE Printer® used PLA filaments to print bone and TPU for periosteum. Printing took place at the University Hospital and the steps were modelled by hand. 3D printed bones and 3D printed periosteum were manually assembled. ParticipantsExpert validation with twelve paediatric orthopaedic surgeons took place in three University hospitals of the North of France. ResultsFour Lagrange and Rigault 3D printed models of supracondylar fractures with periosteum were obtained with 200 h of design, printing and manual assembly based on a four-year-old elbow. According to the paediatric orthopaedic surgery experts, the size of the model is very good, but the model itself is of little interest compared to the information provided by the reconstruction of a 3D scanner. In total, with 9 out of 12 questions scoring higher than 8/10, the model was considered to be a good model for informing parents and teaching students. ConclusionsThis study details the design of the first 3D-printed supra condylar fracture model in children with a full-size physeal and periosteum. The model has been validated by paediatric orthopaedic surgery experts.

Evaluating Chat Generative Pre-trained Transformer Responses to Common Pediatric In-toeing Questions.

Chat generative pre-trained transformer (ChatGPT) has garnered attention in health care for its potential to reshape patient interactions. As patients increasingly rely on artificial intelligence platforms, concerns about information accuracy arise. In-toeing, a common lower extremity variation, often leads to pediatric orthopaedic referrals despite observation being the primary treatment. Our study aims to assess ChatGPT's responses to pediatric in-toeing questions, contributing to discussions on health care innovation and technology in patient education. We compiled a list of 34 common in-toeing questions from the "Frequently Asked Questions" sections of 9 health care-affiliated websites, identifying 25 as the most encountered. On January 17, 2024, we queried ChatGPT 3.5 in separate sessions and recorded the responses. These 25 questions were posed again on January 21, 2024, to assess its reproducibility. Two pediatric orthopaedic surgeons evaluated responses using a scale of "excellent (no clarification)" to "unsatisfactory (substantial clarification)." Average ratings were used when evaluators' grades were within one level of each other. In discordant cases, the senior author provided a decisive rating. We found 46% of ChatGPT responses were "excellent" and 44% "satisfactory (minimal clarification)." In addition, 8% of cases were "satisfactory (moderate clarification)" and 2% were "unsatisfactory." Questions had appropriate readability, with an average Flesch-Kincaid Grade Level of 4.9 (±2.1). However, ChatGPT's responses were at a collegiate level, averaging 12.7 (±1.4). No significant differences in ratings were observed between question topics. Furthermore, ChatGPT exhibited moderate consistency after repeated queries, evidenced by a Spearman rho coefficient of 0.55 (P = 0.005). The chatbot appropriately described in-toeing as normal or spontaneously resolving in 62% of responses and consistently recommended evaluation by a health care provider in 100%. The chatbot presented a serviceable, though not perfect, representation of the diagnosis and management of pediatric in-toeing while demonstrating a moderate level of reproducibility in its responses. ChatGPT's utility could be enhanced by improving readability and consistency and incorporating evidence-based guidelines. Level IV-diagnostic.

Ultrasound supports clinical decision-making in determining the Sanders' skeletal maturity score of the hand.

The Sanders Scoring System has revolutionized the way we assess the remaining growth potential of the skeleton. However, because it involves radiation exposure, it must be used with caution in children. The purpose of the study was to evaluate whether the Sanders skeletal maturity score (SMS) could be accurately determined using ultrasound (U). We took radiographs (R) of the hand and performed U of the thumb and index finger in 115 patients between six and 19years of age who were undergoing treatment for scoliosis or limb deformities. Paediatric orthopaedic surgeons, a paediatrician, and a paediatric radiologist were evaluated the blinded images. Those classified images are based on the SMS and the Thumb Ossification Composite Index (TOCI). Intrarater reliability was high for SMS and slightly weaker for TOCI, but still significant. Interrater reliability was clear for R and weaker for U in both staging systems. Ultimately, SMS 3 and 7 achieved the highest percentage of concordance (P) of 71.7% and 66.0%, respectively, when U was performed. Combining the clinically relevant groups of SMS 3&4 and SMS 7&8 also significantly increased peak scores (SMS 3 and 4 P = 76.7%; SMS 7 and 8 P = 79.7%). The probabilities of peak scores were significantly weaker when the TOCI score was examined. Our study shows that U can be used effectively especially to measure stages 3 and 4 and stages 7 and 8 of SMS. The U method is easy to use and therefore may offer advantages in clinical practice without the need for radiation exposure.

A survey of practice in the anesthetic management of adolescent idiopathic scoliosis spine fusion by the North American Pediatric Spine Anesthesiologists Collaborative.

Adolescent Idiopathic Scoliosis (AIS) affects 2%-4% of the general pediatric population. While surgical correction remains one of the most common orthopedic procedures performed in pediatrics, limited consensus exists on the perioperative anesthetic management. To examine the current state of anesthetic management of typical AIS spine fusions at institutions which have a dedicated pediatric orthopedic spine surgeon. A web-based survey was sent to all members of the North American Pediatric Spine Anesthesiologists (NAPSA) Collaborative. This group included 34 anesthesiologists at 19 different institutions, each of whom has a Harms Study Group surgeon performing spine fusions at their hospital. Thirty-one of 34 (91.2%) anesthesiologists completed the survey, with a missing response rate from 0% to 16.1% depending on the question. Most anesthesia practices (77.4%; 95% confidence interval [CI], 67.7-93.4) do not have patients come for a preoperative visit prior to the day of surgery. Intravenous induction was the preferred method (74.2%; 95% CI 61.3-89.9), with the majority utilizing two peripheral IVs (93.5%; 95% CI 90.3-100) and an arterial line (100%; 95% CI 88.8-100). Paralytic administration for intubation and/or exposure was divided (51.6% rocuronium/vecuronium, 45.2% no paralytic, and 3.2% succinylcholine) amongst respondents. While tranexamic acid was consistently utilized for reducing blood loss, dosing regimens varied. When faced with neuromonitoring signal issues, 67.7% employ a formal protocol. Most anesthesiologists (93.5%; 95% CI 78.6-99.2) extubate immediately postoperatively with patients admitted to an inpatient floor bed (77.4%; 95% CI 67.7-93.3). Most anesthesiologists (87.1%; 95% CI 80.6-99.9) report the use of some form of an anesthesia-based protocol for AIS fusions, but our survey results show there is considerable variation in all aspects of perioperative care. Areas of agreement on management comprise the typical vascular access required, utilization of tranexamic acid, immediate extubation, and disposition to a floor bed. By recognizing the diversity of anesthetic care, we can develop areas of research and improve the perioperative management of AIS.

Vitamin D and pediatric bone health: Important information and considerations for the pediatric orthopaedic surgeon

Vitamin D is an essential fat-soluble vitamin produced in the skin during sun exposure. It plays a considerable role in musculoskeletal health and is largely responsible for the regulation of calcium and phosphate metabolism to maintain a healthy, mineralized skeleton. Optimizing bone mineral density in childhood and adolescence is essential to the foundation of skeletal health; however, the literature lacks consensus on values for normal, deficient, and insufficient serum 25-hydroxyvitamin D levels making supplementation and treatment somewhat challenging.The pediatric orthopaedic surgeon is important to optimizing bone health, particularly in the context of bony pathology/injury. Up to 60% of boys and 40% of girls sustain a fracture in childhood. On top of this baseline incidence, children with low vitamin D levels have been noted to be subject to a higher incidence of fractures from normal activities. While the prevalence of vitamin D deficiency in children in the general population has been determined to be 9%, the prevalence of vitamin D deficiency in the pediatric fracture population can be as high as 75% and 61% of the pediatric population has been determined to have vitamin D insufficiency. The pediatric orthopedist also often is the first to diagnose nutritional rickets as these patients can present solely for complaints of limb deformity. Knowledge of appropriate evaluation, vitamin D supplementation, and indications for pediatric endocrinology referral is vital for the treatment of these patients.In the pediatric population, there is a lack of consensus regarding risk factors that warrant screening for vitamin D deficiency, determining insufficient thresholds, and identifying optimal supplementation recommendations and treatment dosages. More research is needed to clarify the ideal amounts of vitamin D necessary through critical growth periods to prevent rickets and to mitigate fracture risk. Regardless, pediatric Orthopaedic surgeons should promote supplementation to all children and treat diagnosed vitamin D deficiency. Key Concepts(1)Vitamin D plays a vital role in musculoskeletal health and optimizing vitamin D levels in childhood and adolescence is crucial to proper bone development.(2)Vitamin D deficiency and insufficiency in the general population is common; 9% of the pediatric population, representing 7.6 million US children and adolescents, are vitamin D deficient and 61%, representing 50.8 million US children and adolescents, are vitamin D insufficient. The prevalence of vitamin D deficiency in the pediatric fracture population can be as high as 75%.(3)Vitamin D deficiency can lead to nutritional rickets which is the most frequent cause of pediatric bone disease in the world, is entirely preventable, and is characterized by deficient mineralization and subsequent architectural disruption of the physis.(4)Vitamin D supplementation is widely recommended and believed to be beneficial, but there are inconsistent guidelines regarding target levels for optimal vitamin D status.

Rare genetic skeletal disorders: Evolving terminology, therapies, education and advocacy

In the US, rare diseases are defined as disorders affecting fewer than 200,000 US residents or disorders for which there is no reasonable expectation that drug development costs will be recoverable by US sales. Almost 800 of the approximately 10,000 defined rare diseases are bone disorders. Until recently, their rarity and heterogeneity have unfortunately hindered their exploration at both clinical and scientific levels. However, wider availability of genetic testing, development of new surgical and pharmaceutical treatment options, and patient advocacy have motivated efforts to study, diagnose, and treat these disorders. Thus, care of the patient with a rare skeletal disorder is now evolving rapidly. This report presents a brief summary of important developments in skeletal disorders impacting bone quality and frequently co-managed by pediatric orthopaedic surgeons. Key Concepts(1)Although a “cure” is not yet available for most rare bone disease patients, new agents are frequently being advanced as new genes and their products are identified as molecules to target.(2)Medical therapies, often combined with surgical interventions and physical therapy, are reducing pain and increasing function in many pediatric orthopaedic patients with rare bone disorders.(3)New tools for physician education and patient management are increasingly available to assist the pediatric orthopaedic surgery community.

Utility of Adult-Based Discoid Lateral Meniscus Diagnostic Criteria in a Pediatric Population.

Commonly cited discoid lateral meniscus (DLM) imaging definitions are based on adult magnetic resonance imaging (MRI) measurements. This pathology commonly presents in pediatric populations; however, whether accepted adult measurements reliably apply to children and adolescents is unknown. This purposes of the study were to determine (1) the utility of applying adult-accepted MRI definitions of DLM to pediatric patients, (2) whether sex differences affect the applicability of the criteria, and (3) whether MRI magnet strength and/or tear presence affect MRI measurements for diagnosing DLM in pediatric patients. It was hypothesized that MRI criteria for DLM would be similar in adults and pediatric patients. Case series; Level of evidence, 4. A total of 100 consecutive MRIs from pediatric patients with DLM were evaluated, with 91 scans included. Two study authors independently reviewed the MRIs, evaluating meniscal height and width on sagittal and coronal images, "bow tie signs" on sagittal images, tibial sagittal and coronal width, and tear presence. For analysis, MRI magnet strength was dichotomized into high (>1.5 T) and low (<1.5 T) groups. The mean age of the patients at MRI evaluation was 12.3 ± 3.4 years; 51% of the patients were male, and 56% of the scans were of left knees. Included patients with DLM showed a mean of 3.68 bow tie signs, a sagittal total anterior to posterior meniscal width/tibial width ratio of 73%, a coronal meniscal width/tibial width ratio of 30%, and a coronal, transverse width of the lateral meniscus at the midportion of the meniscal body of 20.6 ± 7.7 mm. The MRI tesla strength of the images included in this study ranged from 0.3 to 3. It was determined that high- versus low-resolution MRI scans did not affect the inter- or intraobserver reliability of the MRI measurments (P > .05). However, several measurements showed improved intraclass correlation coefficients with increased tesla strength. This study confirms that pediatric patients with DLM, diagnosed by board-certified pediatric sports medicine orthopaedic surgeons, have measurements on MRI consistent with adult DLM diagnostic criteria. This finding held true regardless of sex or MRI tesla strength. Pediatric patients with DLM had >3 bow tie signs, >70% sagittal tibial plateau coverage, >14 mm coronal width, and >20% coronal tibial plateau coverage on MRI.

POSNA Leadership Program (PLP): Developing surgeon leaders for patients, organizations, and our society

POSNA initiated a Leadership Program in 2022. The POSNA Leadership Program (PLP) is designed to enhance emotional intelligence (social skills, empathy, communication, self-regulation, and self-awareness) and in-depth leadership skill development for selected participants in a year-long seminar. Disruptive behaviors detrimental to health care professionals, patients, and care delivery organizations can be identified and lessened through education.Most surgeons rightfully focus their learning intently on specific surgical knowledge and technical expertise, especially in the early and middle career stages. Despite this, surgical errors still occur secondary to limitations of non-technical surgical skills (NOTSS): decision making, communication, leadership and teamwork. More senior surgeons are also prone to leadership and communication errors. By gaining education and expertise in NOTSS, improved team building with more professional staff engagement, empowerment, and trust can result in lower risk.POSNA is focusing on subspecialty specific leadership education for mid-career pediatric orthopaedic surgeons to foster an enhanced future for our local and national organizations. The PLP leaders understand leadership is not about their own “fame and fortune”, but rather the success of “those they are privileged to lead” through career and programmatic development that enhances our mission of improving musculoskeletal care for children. The JPOSNA Leadership series will bring the PLP knowledge and expertise to the entire membership. Key concepts(1)leadership, followership, emotional intelligence, non-technical surgical skills

How Reliable Is the Measurement of the Lateral Center Edge Angle on Scoliosis Radiographs for Detecting Acetabular Dysplasia?

Hip dysplasia reportedly occurs in up to 12% of the general population and may be higher in patients with adolescent idiopathic scoliosis (AIS). When using lateral center edge angle (LCEA) measurements to help identify hip dysplasia, it is uncertain if this measurement can be performed reliably on scoliosis radiographs due to parallax. The purpose of this study is to evaluate the reliability of measuring LCEA on scoliosis radiographs compared with standard pelvis radiographs. This study evaluated 40 hips on 20 patients (mean age 12.5 years ± 3.1; 50% Female) who received PA scoliosis radiographs and AP pelvis radiographs within 1 year of each other. Review was performed by 4 pediatric radiologists (2 general, 2 MSK), 2 pediatric orthopaedic surgeons, and 1 research fellow. Radiographic measurement of the LCEA for each hip was first performed on the scoliosis radiograph. After a minimum of 3 days, the LCEA was measured on a pelvis radiograph of the same individual obtained within 1 year of the scoliosis radiograph. Pearson coefficient was used to measure agreement between scoliosis and pelvis radiograph measurements. Intraclass correlation coefficient (ICC) was used to evaluate intraobserver and interobserver agreement. ICC values <0.5 were classified as poor reliability, 0.5 to 0.75 were classified moderate, 0.75 to 0.90 were classified good, and >0.9 indicated excellent reliability. The mean difference between scoliosis and pelvis radiographs was 54 ± 79 days. There was good-to-excellent interobserver agreement on LCEA measurements made between readers on scoliosis radiographs (ICC: 0.94, 95% CI: 0.90-0.96, P<0.001) and pelvis radiographs (ICC: 0.91, 95% CI: 0.83-0.95, P<0.001), and moderate-to-excellent intraobserver agreement for scoliosis radiographs (ICC range: 0.68 to 0.98; P<0.001) and pelvis radiographs (ICC range: 0.62 to 0.96; P<0.001). There was a strong correlation between LCEA measurements made on scoliosis and pelvis radiographs (r2=0.66, P<0.001), and the intermodality agreement between scoliosis and pelvis radiograph LCEA measurements were moderate to good (ICC range: 0.68 to 0.89, P<0.001). Overall, there was good-to-excellent agreement between readers on scoliosis and pelvis radiographs, respectively, and moderate-to-excellent intraobserver agreement between LCEA measurements made on scoliosis radiographs and pelvis radiographs, respectively. LCEA measurements made on scoliosis radiographs strongly correlated to the measurements made on pelvis radiographs, and the intermodality ICC was also considered moderate to good. Dedicated pelvis radiographs may not be necessary during scoliosis workup and follow-up surveillance, thereby decreasing radiation exposure, cost, and improving patient care workflow. Level IV-diagnostic study.

Utility of Follow-up Radiographs in Type 1 Supracondylar Humerus Fractures.

Supracondylar humerus (SCH) fractures are common among pediatric patients, with the severity categorized using the Gartland classification system. Type 1 SCH fractures are nondisplaced and treated with immobilization, while more displaced fractures require surgery. The need for follow-up radiographs, particularly for type 1 fractures, is an area where evidence is lacking. This study investigates the clinical value and financial implications of follow-up radiographs for type 1 SCH fractures, hypothesizing that they do not alter clinical management and, therefore, represent an unnecessary expense. This retrospective cohort study, approved by the Institutional Review Board, focused on patients under 18 with nondisplaced SCH fractures treated nonoperatively. One hundred one type 1 SCH fractures, in which the fracture was visible on presenting radiographs, were chosen from patients presenting between January 2021 and December 2022. Charts were reviewed for demographic information, time of cast removal, and complications. A pediatric orthopaedic surgeon and orthopaedic resident reviewed the radiographs to confirm the injury to be a type 1 SCH fracture. Among the 101 patients, after the initial presentation, 79 attended an interim visit and 101 attended a "3-week follow-up" at an average of 23 days postinjury. All patients underwent radiographs during these visits for a total of 180 radiographs after confirmation of type 1 SCH fracture. No changes in management resulted from follow-up radiographs. One instance of refracture was noted ~3 months after cast removal. There were 180 superfluous follow-up radiographs taken at subsequent clinic visits. The total charge for these radiographs was $76,001.40, averaging $752.49 per patient. Follow-up radiographs for type 1 SCH fractures did not lead to changes in clinical management, aligning with previous findings in more severe SCH fractures. This approach can reduce costs, radiation exposure, and clinic time without compromising patient care. The study can reassure providers and parents about the lack of necessity for follow-up radiographs to document healing. Level-IV.

High Rates of Abnormal Patellofemoral Morphology in Adolescents With Anterior Knee Pain: A Retrospective Review

Background: Anterior knee pain is a common reason for referral to a pediatric orthopedic surgeon. Although previous studies have found that adults with anatomic risk factors for patellofemoral instability (patella dislocation) are predisposed to anterior knee pain, no studies have elucidated the relationship between anatomic risk factors for patellofemoral instability and anterior knee pain in children. Purpose: We sought to characterize common radiographic findings in adolescent patients with a chief complaint of anterior knee pain and to determine the prevalence of abnormal patellofemoral morphology. Methods: We conducted a retrospective review of patients 13 to 18 years old with anterior knee pain at a single tertiary care metropolitan institution from 2016 to 2021. X-rays and magnetic resonance imaging (MRI) were evaluated in those diagnosed with “chondromalacia patellae,” “chondromalacia,” “patellofemoral disorders,” or “anterior knee pain.” Patella alta, tibial tubercle-trochlear groove (TT-TG) distance, tubercle height, Wiberg patella type, patellar tilt, and trochlear dysplasia characterization were recorded. Results: Of the 293 adolescents with anterior knee pain included, 62 had bilateral anterior knee pain. Of the 172 MRIs, 72 (42%) met criteria for patella alta, Caton-Deschamps Index (CDI) &gt;1.3, 35% had a TT-TG distance &gt;15 mm, and 32% had lateral patellar tilt &gt;15°. Magnetic resonance imaging findings included infrapatellar fat pad signal hyperintensity (41%) and patellofemoral dysplasia (23%). Of all 293 adolescents, 74% had images showing abnormal patellofemoral morphology, of which 30% had a history of 1 or more patellar dislocation. Overall, 40% of the adolescents had surgery, most commonly medial patellofemoral ligament (MPFL) reconstruction (18%). Conclusions: In this retrospective review, nearly 3/4 of adolescents with anterior knee pain had images showing abnormal patellofemoral morphology, including patella alta, increased TT-TG distance, trochlear dysplasia, or abnormal lateral patellar tilt; only 18% had MPFL surgery. These findings suggest that primary care providers might consider obtaining X-rays and/or MRIs to evaluate for pathology that warrants orthopedic evaluation.

Pediatric Hip Dysplasia Surgery Outcomes by Pediatric Versus Nonpediatric Orthopedists.

Objectives Developmental dysplasia of the hip (DDH) encompasses a spectrum of abnormalities in the immature hip. Surgical intervention is indicated if conservative management fails. Despite the increased supply of pediatric orthopedic surgeons (POSs) over the last few decades, there continues to be a maldistribution of surgeons. The purpose of this study is to determine outcomes following surgical management of hip dysplasia by POSs compared to non-pediatric orthopedic surgeons. Methods Pediatric patients who underwent surgical treatment for hip dysplasia from 2012 to 2019 were identified using a large national database. Patient demographics, comorbidities, and postoperative complications were compared by pediatric versus nonpediatric-trained orthopedic surgeons. Bivariate and multivariable regression analyses were performed. Results Of the 10,780 pediatric patients who underwent hip dysplasia surgery, 10,206 patients (94.7%) were operated on by a POS, whereas 574 (5.3%) were operated on by a non-pediatric orthopedic surgeon. POSs were more likely to operate on patients with a higher American Society of Anesthesiologists class (p<0.001) and those with a greater number of medical comorbidities, including cardiac (p=0.001), gastrointestinal (p=0.017), and neurological (p<0.001). Following analysis using multivariable regression models to control for patient baseline characteristics, there were no differences in any postoperative complications between patients treated by pediatric-trained and nonpediatric-trained orthopedic surgeons. Conclusions Compared to non-pediatric orthopedic surgeons, POSs were more likely to operate on younger patients with increased medical comorbidities. However, there were no differences in postoperative complications following surgical management for DDH in patients treated by nonpediatric and pediatric orthopedic surgeons.

MRI findings of peroneal tendon tears do not necessarily correlate to clinical findings in paediatric and adolescent patients.

Pathologic abnormality of the peroneal tendons are thought to be an under-appreciated source of vague ankle and hindfoot pain in paediatric patients, partly because they can be difficult to diagnose and differentiate from lateral ankle ligament injuries. While magnetic resonance imaging (MRI) is the primary imaging modality used to detect peroneal tendon pathology, previous studies in adults have found that positive MRIs demonstrate a positive predictive value (PPV) of associated clinical findings around 48%. There are no similar known published studies in the paediatric population. Our objective was to determine the positive predictive value of peroneal tendon pathology as diagnosed by MRI as related to positive clinical exam findings in the paediatric and adolescent population. This IRB approved retrospective study was conducted at a tertiary children's hospital. Inclusion criteria included patients under 18years from our tertiary care institution with (a) ankle MRI findings indicating pathology of the peroneus brevis/longus tendons confirmed by a board certified paediatric musculoskeletal radiologist and (b) formal review of the clinical examination by a fellowship trained paediatric orthopaedic surgeon. Patients with congenital deformities or previous surgical intervention of the lateral ankle were excluded. Forty-seven patients (with 48 MRIs) met inclusion criteria over a tenyear period. The majority of the positive MRI scans (70%) demonstrated a peroneus brevis split tear. Of the patients with positive findings on MRI, 17 patients had an associated positive clinical exam. The positive predictive value of MRI for peroneal tendon tears with positive clinical findings was 35.41% (95% confidence interval = 31.1% to 41.6%). There were 31 patients with MRI positive findings with a negative clinical exam. Despite having a negative clinical exam, a high percentage of patients had positive MRI findings suggestive of peroneal tendon pathology which confirms findings of adult populations demonstrating a high rate of incidental finding of peroneal tendon pathology on MRI in paediatric patients.

Sex related difference in postoperative pain and opioid use following posterior spinal fusion for adolescent idiopathic scoliosis

PurposeThis project aims to evaluate the relationship between biological sex and postoperative pain and in patients receiving posterior spinal fusion for adolescent idiopathic scoliosis.MethodsThis is a retrospective study of patients (n=137) aged 10-17 receiving posterior spinal fusion for adolescent idiopathic scoliosis between 01/2018 and 09/2022. Each patient received surgery by the same pediatric orthopedic surgeon with identical postoperative pain management regimen at a children’s hospital or a tertiary referral center with a pediatric spine program.ResultsThere were no significant differences in any background characteristics between the male and female patients, including age, BMI, number of levels fused, preoperative degree of scoliosis, and length of surgery and anesthesia (p>0.05). There were no differences in amount given of any intraoperative medications, nor in amount of postoperative scheduled analgesics (p>0.05). Female patients demonstrated higher average pain scores on Visual Analogue Scale evaluations during the first 24 hours postoperatively (5.0 vs 3.6, p<0.0001), 24-48 hours postoperatively (4.9 vs 4.0, p=0.03), and at the first physical therapy evaluation (5.3 vs 3.8, p<0.001). These patients received significantly greater amounts of morphine milligram equivalents in the first 24 hours postoperatively (42.2 vs 31.5, p=0.01) and for the hospitalization in total (63.8 vs 51.3, p=0.048). There was no difference in hours until hospital discharge (44.3 vs 42.6, p=0.62) nor until first ambulation (20.1 vs 21.3, p=0.24) between the female and male patients.ConclusionThe influence of biopsychosocial factors on postoperative pain in adolescents is complex. This study adds to the existing pool of literature suggesting differences in pain perception between adolescent female and male patients. Female patients undergoing posterior spinal fusion for adolescent idiopathic scoliosis may benefit from increased preoperative counseling and more aggressive intra- and postoperative pain management regimens.

Preventing of nonunion in congenital pseudarthrosis of the tibia cases of Crawford Type I and II through the use of allograft bypass and a brace: Midterm findings.

Congenital pseudarthrosis of the tibia is a limb deformity, which can be distressing for the affected patients and the pediatric orthopedic surgeons involved. We hypothesized that the modified McFarland procedure would avoid fractures and even have a corrective effect on the affected tibia in congenital pseudarthrosis of the tibia patients. Toward this end, we evaluated the midterm results of treating congenital pseudarthrosis of the tibia patients of Crawford Type I and II with allograft bypass combined with long-term bracing. This study retrospectively evaluated 7 patients with congenital pseudarthrosis of the tibia who were treated with allograft bypass combined with long-term bracing between 2009 and 2018. The median follow-up was 7.0 years (range 3.8-10.0 years). The medical records and radiographs were reviewed for demographic data, clinical characteristics, outcomes, and complications. At the time of the last follow-up, all allografts revealed complete consolidation in the patients' tibiae at both ends. All patients presented no functional restriction of the lower limbs and no amputation or non-union has occurred. Most of the obvious deformities of the tibia diaphysis or ankle joint were corrected. Two complications occurred that required successful revision surgery. In this series of seven congenital pseudarthrosis of the tibia patients, the allograft bypass technique showed satisfactory midterm results and validated our hypothesis. For congenital pseudarthrosis of the tibia patients of Crawford Type I and II, this procedure combined with long-term bracing, which involves the affected leg only, can delay or possibly prevent fractures, decrease tibial malalignment, and preserve leg length. level IV.

MRI of the Spine in Patients who Toe Walk: Is There a Role?

Little is known about the prevalence of intraspinal pathology in children who toe walk, but magnetic resonance imaging (MRI) may be part of the diagnostic workup. The purpose of this study was to examine the role of MRI for children who toe walk with a focus on the rate of positive findings and associated neurosurgical interventions performed for children with said MRI findings. A single-center tertiary hospital database was queried to identify a cohort of 118 subjects with a diagnosis of toe walking who underwent spinal MRI during a 5-year period. Patient and MRI characteristics were summarized and compared between subjects with a major abnormality, minor abnormality, or no abnormality on MRI using multivariable logistic regression. Major MRI abnormalities included those with a clear spinal etiology, such as fatty filum, tethered cord, syrinx, and Chiari malformation, while minor abnormalities had unclear associations with toe walking. The most common primary indications for MRI were failure to improve with conservative treatment, severe contracture, and abnormal reflexes. The prevalence of major MRI abnormalities was 25% (30/118), minor MRI abnormalities was 19% (22/118), and normal MRI was 56% (66/118). Patients with delayed onset of toe walking were significantly more likely to have a major abnormality on MRI ( P =0.009). The presence of abnormal reflexes, severe contracture, back pain, bladder incontinence, and failure to improve with conservative treatment were not significantly associated with an increased likelihood of major abnormality on MRI. Twenty-nine (25%) subjects underwent tendon lengthening, and 5 (4%) underwent neurosurgical intervention, the most frequent of which was detethering and sectioning of fatty filum. Spinal MRI in patients who toe walk has a high rate of major positive findings, some of which require neurosurgical intervention. The most significant predictor of intraspinal pathology was the late onset of toe walking after the child had initiated walking. MRI of the spine should be considered by pediatric orthopedic surgeons in patients with toe walking who present late with an abnormal clinical course. Level III Retrospective Comparative Study.

Perfusion magnetic resonance imaging correlates with the duration of stages and lateral pillar class in Legg-Calvé-Perthes disease

BackgroundLegg-Calvé-Perthes disease (LCPD) progresses through 4 stages characterized by unique radiographic features, and stage duration is recognized as an important prognostic factor. Newer perfusion magnetic resonance imaging (pMRI) allows for the evaluation of vascularity early in the disease process. This study aims to describe the relationship between global and regional perfusion patterns on early pMRI and the duration of Waldenström stages. A secondary aim was to verify the relationship between hypoperfusion and subsequent lateral pillar class. MethodsThrough a prospectively collected multicenter international cohort, patients with early LCPD (Waldenström Stage I) and pMRI were followed with serial radiographs at 3-month intervals for a minimum of 2 years. Epiphyseal hypoperfusion was quantified by HipVasc Software for the entire epiphysis and regional thirds of the femoral head. Waldenström stages and lateral pillar class were determined by mode assessments from 3 pediatric orthopedic surgeons. Duration of the stage was defined as the interval between the first radiograph demonstrating features of stage IIa and stage IIIa for fragmentation and between IIIa and IV for reossification. ResultsOne-hundred and seven patients (88.8% male, median age 8.0 years) met the study criteria. The average global hypoperfusion was 73.7%. Poorer global perfusion was predictive of a longer duration of fragmentation (rho = 0.34, P < .001) and of reossification (rho = 0.38, P = .003). The average regional hypoperfusion of the medial, central, and lateral third of the femoral head was 65.3%, 83.7%, and 61.3% respectively, and was similarly related to the duration of fragmentation (rho = 0.26, 0.24, and 0.31, respectively) and of reossification (rho = 0.31, 0.43, and 0.39, respectively) (P < .05 for all). Similar to previous studies, we found a significant positive association between hypoperfusion in the lateral third of the femoral head and lateral pillar class (P = .037). ConclusionsThe degree of both global and regional hypoperfusion correlated with the duration of fragmentation and reossification stages in LCPD. Lateral epiphyseal hypoperfusion is predictive of lateral pillar class. Taken together, the information provided by perfusion magnetic resonance imaging can provide crucial prognostic information for children with LCPD. Key Concepts1.Amount of hypoperfusion both globally and regionally on perfusion MRI correlates with the duration of fragmentation and reossification stages in LCPD.2.Lateral epiphyseal hypoperfusion correlates with lateral pillar class.3.Perfusion information offered by contrast MRI can offer crucial prognostic information in children with LCP. Level of EvidenceII Prognostic Study