Evaluating the Readability of Patient Education Materials for Anterior Vertebral Body Tethering, Distraction-Based Methods, and Posterior Spinal Fusion for the Treatment of Pediatric Spinal Deformity.

BACKGROUND: The Internet is an important source of information for patients, but its effectiveness relies on the readability of its content. Patient education materials (PEMs) should be written at or below a sixth-grade reading level as outlined by agencies such as the American Medical Association. This study assessed PEMs' readability for the novel anterior vertebral body tethering (AVBT), distraction-based methods, and posterior spinal fusion (PSF) in treating pediatric spinal deformity. METHODS: An online search identified PEMs using the terms "anterior vertebral body tethering," "growing rods scoliosis," and "posterior spinal fusion pediatric scoliosis." We selected the first 20 general medical websites (GMWs) and 10 academic health institution websites (AHIWs) discussing each treatment (90 websites total). Readability tests for each webpage were conducted using Readability Studio software. Reading grade levels (RGLs), which correspond to the US grade at which one is expected to comprehend the text, were calculated for sources and independent t tests compared with RGLs between treatment types. RESULTS: The mean RGL was 12.1 ± 2.0. No articles were below a sixth-grade reading level, with only 2.2% at the sixth-grade reading level. AVBT articles had a higher RGL than distraction-based methods (12.7 ± 1.6 vs 11.9 ± 1.9, P = 0.082) and PSF (12.7 ± 1.6 vs 11.6 ± 2.3, P = 0.032). Materials for distraction-based methods and PSF were comparable (11.9 ± 1.9 vs 11.6 ± 2.3, P = 0.566). Among GMWs, AVBT materials had a higher RGL than distraction-based methods (12.9 ± 1.4 vs 12.1 ± 1.8, P = 0.133) and PSF (12.9 ± 1.4 vs 11.4 ± 2.4, P = 0.016). CLINICAL RELEVANCE: Patients' health literacy is important for shared decision-making. Assessing the readability of scoliosis treatment PEMs guides physicians when sharing resources and discussing treatment with patients. CONCLUSION: Both GMWs and AHIWs exceed recommended RGLs, which may limit patient and parent understanding. Within GMWs, AVBT materials are written at a higher RGL than other treatments, which may hinder informed decision-making and patient outcomes. Efforts should be made to create online resources at the appropriate RGL. At the very least, patients and parents may be directed toward AHIWs; RGLs are more consistent.

My radius is broken - do I need a cast or is a splint enough?

PURPOSE OF REVIEW: The treatment of many distal radius fractures has shifted from casting to splinting or the application of a soft dressing. This review includes a review of the types of pediatric distal radius fractures and the most recent literature on the management of these injuries. RECENT FINDINGS: Many nondisplaced distal radius fractures may be treated with removable splints or bandages. This mitigates complications with cast immobilization. Additionally, many of these injuries do not require follow-up treatment and thereby reduce healthcare costs. SUMMARY: This update on distal radius fractures in the pediatric population highlights changes in the treatment paradigm and demonstrates an opportunity to diminish healthcare costs.

Surgical prophylaxis in pediatric orthopedic patients with penicillin allergy: a multicentered retrospective prognostic study.

Up to 20% of orthopedic surgeons still avoid the use of cephalosporins in patients with penicillin allergies despite its reported safety in the adult and general surgery pediatric population. The primary objective is to determine the incidence of adverse effects and allergic reactions when using cephalosporins in pediatric orthopedic patients labeled as penicillin-allergic as compared to those without previously reported penicillin allergy. A multicenter retrospective chart review was performed across three level 1 trauma centers from January 2013 to February 2020 to identify penicillin-allergic as well as non-penicillin-allergic pediatric patients treated for orthopedic injuries. Data were collected regarding patient demographics, antibiotic administered, timing of antibiotic administration, reported drug allergy, and described allergic reaction. Postoperative or intraoperative allergic reactions to antibiotics, surgical site infections, and complications were recorded. A total of 2289 surgeries performed by four fellowship-trained surgeons were evaluated. Eighty-five patients diagnosed with penicillin allergy were identified and underwent 95 surgeries and 95 patients without previously reported penicillin allergy underwent 95 surgeries. One patient, with a documented history of anaphylaxis to cefazolin, sustained an anaphylactic reaction intraoperatively to cefazolin. There were no other reported reactions, surgical site infections, or complications. There was no statistically significant difference in rate of allergic reaction in patients with previously reported penicillin allergy treated with cefazolin and those with no previous reported reaction (P > 0.05). Prophylaxis with cephalosporins is not associated with increased risk for allergic reaction. Cephalosporins can be safely administered to pediatric patients with penicillin allergy undergoing orthopedic intervention. Level of evidence: Level II, Multicenter Retrospective Prognostic Study.

Telemedicine for pediatric orthopedic visits: evaluating usability and satisfaction.

The purpose of this study is to evaluate usability and patient satisfaction with telemedicine in pediatric orthopedics using validated questionnaires and to identify demographic and clinical factors that may impact these ratings. All caregivers of patients who had telemedicine visits with a single fellowship-trained pediatric orthopedic surgeon between 23 March 2020 and 3 June 2020 were eligible to participate. Patient Satisfaction Questionnaire (PSQ) and the Telehealth Usability Questionnaire (TUQ) rated on a 4-point Likert scale (1 = poor, 2 = fair, 3 = good and 4 = excellent) were used. Additional information regarding the level of education, mode of transportation, technology usage, demographics, visit diagnosis and length of visit were collected. Quantitative analysis was performed. A total of 68.6% (83/121) of the visits were done via telemedicine. Around 46 surveys were completed with a response rate of 55.4% (46/83). The PSQ mean score was 3.63 ± 0.39 with non-English-speaking caregivers scoring lower compared to their English-speaking counterparts (3.4 ± 0.47 vs. 3.72 ± 0.33; P = 0.017). PSQ mean score increased with increasing length of visit (r = 0.352; P = 0.018). A total of 86.8% (839/966) of all TUQ's responses were good to excellent with 89.1% (41/46) of responders were satisfied with telemedicine and 91.3% (42/46) would use it again. Although the topic is an evolving one, and a lot of changes should be expected in the future, certain characteristics such as primary language and length of visit may affect the levels of satisfaction with the use of telemedicine in pediatric orthopedics. Knowledge regarding satisfaction ratings may allow orthopedic surgeons to improve patient care delivered through this technology. Level of Evidence: IV.

Developmental Dysplasia of the Hip: How Does Social Media Influence Patients and Caregivers Seeking Information?

Developmental dysplasia of the hip (DDH) is a common orthopaedic condition affecting newborns. The rapid and vast adoption of social media has changed how we access medical information. The aim of this study was to deepen the understanding of the impact of social media as a tool used by caregivers. A search was performed on the Facebook (FB), Twitter (TW), and YouTube (YT) platforms. Information was quantitatively assessed by category, and number of posts and users. Comments and posts from the social medial platforms were then qualitatively assessed by using a thematic analysis. 16 Facebook pages and groups, 135 YouTube videos, and 5 Twitter accounts related to DDH were identified across 15 countries. A total of 25,471 comments/tweets were recorded. Across the social media platforms, the most common comments theme was "information sharing" (36.1%). Facebook groups had a significantly greater number of comments that were characterized as "social media as a second opinion" in comparison to YouTube videos (p < 0.001), whereas YouTube videos had significantly fewer comments characterized as "sharing information" in comparison to Facebook groups and Facebook pages (p < 0.0001). Orthopaedic surgeons may utilize caregiver presence on social media as an opportunity to help share accurate information and facilitate informed decision-making.

The role of social media in clubfoot: information sharing and social support.

PURPOSE: Clubfoot is the most common congenital foot deformity in children. Caregivers often seek medical information on the internet. The aim of the study was to characterize how social media is used by caregivers to access medical information. METHODS: A search was performed on Facebook, Twitter and YouTube platforms. Information was quantitatively assessed. Comments were qualitatively assessed, and the Kruskal-Wallis test was used to study thematic comment distribution. RESULTS: In total, 58 Facebook groups and pages, 109 YouTube accounts and ten Twitter accounts related to clubfoot were discovered from 2007 to 2019. Facebook groups and pages had a collective 56 123 members and 80 544 total likes, respectively. YouTube had a collective 3 280 454 views, with 54 969 total comments throughout the accounts. Comment themes most commonly included sharing information and advice (38.7%), appreciation and success stories (12.8%), emotional support (12.7%) and social media as a second opinion (11.9%). Facebook groups contained a significantly higher number of comments related to 'social media as a second opinion' compared with Facebook pages (p = 0.001), Twitter (p = 0.016) and YouTube (p < 0.0001) while YouTube contained a significantly lower number of comments related to 'sharing information' compared with Facebook groups, pages and Twitter (p < 0.0001). CONCLUSION: Social media continues to be a growing tool for information sharing and the findings of this study highlight the importance placed by caregivers on the advice of their peers. The online presence of caregivers may represent an opportunity for orthopaedic surgeons to communicate with patients and help them make informed decisions. LEVEL OF EVIDENCE: IV.

46,XY DSD and limb abnormalities in a female with a de novo LHX9 missense mutation.

Differences in sex development (DSD) are a group of rare conditions involving genes, hormones and reproductive organs, including genitals. Although these disorders are common, information about the molecular causes remain limited. Many genes have been identified in association with DSD but in many cases the causative gene could not be identified. The Lhx9 gene has been studied in mice and birds, and biallelic mutations in this gene have been found to cause 46,XY DSD and limb abnormalities. So far two variants of LHX9 have been identified in 46,XY individuals with testicular regression, micropenis and hypospadias. We report a de novo heterozygous missense variant in LHX9 in a girl with 46,XY DSD and finger and toe abnormalities. It was previously predicted that a mutation in LHX9 would not cause extragenital anomalies in light of prior animal studies, but our report adds to the limited knowledge of the phenotype observed in humans with a variant in LHX9. To the best of our knowledge this is the first reported case with this combination of abnormalities.

Biomechanical Comparison of Two Pediatric Blade Plate Designs in Proximal Femoral Osteotomies.

BACKGROUND: Blade plates are frequently used for internal fixation following proximal femoral varus rotational osteotomy to treat hip dysplasia in children with cerebral palsy. Recently, cannulated blade plates with the option for a proximal locking screw have demonstrated ease of insertion and low complication rates. Although there are two commonly used blade plates with a proximal screw option, no comparison of their biomechanical profiles has been undertaken. QUESTIONS/PURPOSES: Our study sought to compare the structural properties under axial loading, as well as the biomechanical contribution of a proximal screw, of two different 90° cannulated blade plates designed for pediatric proximal femurs. Plate A has a hole distal to the blade designed to attach a plate inserter, through which a 3.5-mm non-locking cortical screw could be placed. Plate B has a threaded hole distal to the blade designed to accept a 3.5-mm locking screw. METHODS: Plate A and plate B were inserted into 33 left pediatric synthetic proximal femurs. Axial loading to failure of plate A with and without a proximal screw was compared to that of plate B with and without a proximal screw. An additional 10 samples using plate B, with and without a proximal locking screw, were tested in tension to quantify the effect of the proximal screw on pullout strength. RESULTS: Plate B failed at a higher axial load than plate A. The addition of a proximal screw did not affect the axial load to failure for either plate. Pullout testing revealed that blade plates fixed with the proximal screw failed in tension at a significantly higher load (856.3 ± 120.9 N) than those without proximal fixation (68.1 ± 9.3 N, p < 0.001). CONCLUSIONS: Plate B failed at a higher axial load in biomechanical testing, likely related to differences in its design. The addition of a proximal screw did not increase the axial loading properties of the blade plate construct but did increase the pullout strength by a factor of 12. These results may be used to influence implant selection and post-operative rehabilitation following proximal femoral osteotomies in children.

Ipsilateral Osteochondritis Dissecans-like Distal Femoral Lesions in Children with Blount Disease: Prevalence and Associated Findings.

PURPOSE: Our goal was to assess the prevalence of ipsilateral distal femoral osteochondritis dissecans (OCD)-like lesions in children with Blount disease, including factors associated with this finding. MATERIALS AND METHODS: Characteristics of patients with an OCD-like lesion on an imaging study [(X-ray and/or magnetic resonance imaging (MRI)] were compared with those without such a finding. RESULTS: Over a 12-year period, 6/63 (10%) skeletally immature patients (9/87 limbs) with Blount disease had an OCD-like lesion visible on plain radiographs. Based on available MRI, 7/37 (19%) patients or 10/53 (19%) limbs had an OCD-like distal femoral lesion. All lesions were noted in the posterior third of the weight-bearing portion of the medial femoral condyle with intact overlying articular cartilage. All patients with OCD-like lesions were followed for an average of 1.9 years (range: 1-2.6 years), and complete radiographic resolution of lesion was noted in 7/9 limbs (78%). There was no association of the presence of OCD-like lesion with early- vs late-onset disease, gender, age at imaging, laterality, magnitude of deformity [mean mechanical axis deviation (MAD) 63.3 vs 71.9 mm], mean mechanical lateral distal femoral angle (mLDFA; 91.3 vs 89.7°), and mean medial proximal tibial angle (MPTA; 71.7 vs 71.8°). Children with an OCD-like lesion tended to have a lower mean body mass index (BMI; 21 vs 36, p = 0.003). CONCLUSION: The overall prevalence of OCD-like lesions in the medial femoral condyle in children with Blount disease lesions is 10% using plain radiographs and at least 19% on MRI. Based on the numbers available, we were unable to demonstrate any associations between the presence of such lesions and the patient's age, gender, or magnitude of varus deformity. Further research is needed to fully ascertain the aetiology and natural history of these benign appearing osteochondral imaging findings in children with Blount disease. Our current data support that these lesions do resolve with time and that no surgical intervention targeted at the femoral OCD-like lesion is warranted. LEVEL OF EVIDENCE: Diagnostic study Level III. HOW TO CITE THIS ARTICLE: Edobor-Osula F, Wenokor C, Bloom T, et al. Ipsilateral Osteochondritis Dissecans-like Distal Femoral Lesions in Children with Blount Disease: Prevalence and Associated Findings. Strategies Trauma Limb Reconstr 2019;14(3):121-125.

Secondary ossification centers in the development of the medial malleolus.

BACKGROUND: Accessory ossicles of the medial malleolus have been reported, however, these have not been linked to a pattern of development and are considered anomalies. Here, we describe a pattern of ossification of the medial malleolus in children including a secondary ossification center. METHODS: Twenty anteroposterior (AP) and mortise x-rays of each sex and age from 4 to 12 were randomly selected from skeletally immature patients identified at our institution. X-rays were excluded if there was a cast or splint, fracture, hardware, or obvious tibial deformity. Each x-ray was evaluated and categorized to a 4-part stage of development. These stages were then applied to randomly selected AP hip to ankle films from the same age groups. RESULTS: Four distinct stages of medial malleolus ossification were identified on ankle x-rays. Stage 1 consists of the widening of the epiphysis that did not reach the medial border of the metaphysis. In stage 2, the epiphysis had widened medially to the level of the metaphysis, however, had not extended distally to the level of the dome of the talus. In stage 3, the proximal portion of the medial malleolus has ossified distal to the dome of the talus with ossification centers at this level identified. Stage 4 consisted of a completely fused ossification center extending distally to a mature medial malleolus. The stages were reconfirmed on AP standing hip to ankle to have a similar distribution, secondary ossification centers were more common in females aged 6 to -9 and males aged 8 to 11 years. CONCLUSIONS: The medial malleolus develops in predictable stages which may involve a secondary ossification center in the final stages of development. These findings were initially described on AP and mortise views, then confirmed on AP hip to ankle radiographs were evaluated to exclude potentially confounding ankle pain. These secondary ossification centers were seen at similar ages on both ankle and hip to ankle x-rays. LEVEL OF EVIDENCE: Level III.

Ultrasonic assessment of extracellular matrix content in healing Achilles tendon.

Although several imaging modalities have been utilized to observe tendons, assessing injured tendons by tracking the healing response over time with ultrasound is a desirable method which is yet to be realized. This study examines the use of ultrasound for non-invasive monitoring of the healing process of Achilles tendons after surgical transection. The overall extracellular matrix content of the transection site is monitored and quantified as a function of time. B-mode images (built from successive A-scan signatures) of the injury site were obtained and compared to biomechanical properties. A quantitative measure of tendon healing using the extracellular matrix (ECM) content of the injury site was analyzed using linear regression with all biomechanical measures. Contralateral tendons were used as controls. The trend in the degree of ECM regrowth in the 4 weeks following complete transection of excised tendons was found to be most closely paralleled with that of linear stiffness (R(2) = 0.987, p < .05) obtained with post-ultrasound biomechanical tests. Results suggest that ultrasound can be an effective imaging technique in assessing the degree of tendon healing, and can be used to correlate structural properties of Achilles tendons.

Unipedicular balloon kyphoplasty for the treatment of osteoporotic vertebral compression fractures: early results.

INTRODUCTION: The traditional bipedicular kyphoplasty was proved to be safe and effective for the treatment of pain associated with osteoporotic vertebral compression fractures (VCFs). Nevertheless, unilateral kyphoplasty would be an attractive alternative to the traditional bipedicular kyphoplasty owing to theoretical speed, safety, and less expense; thus far, the biomechanical testing showed that experimental unilateral kyphoplasty had properties comparable with bipedicular kyphoplasty. To date, no clinical data are available regarding the efficacy and safety of unilateral balloon kyphoplasty. In this prospective observational study, the clinical and radiographic outcomes of the unipedicular (unilateral) balloon kyphoplasty in osteoporotic VCFs are evaluated. METHODS: Three hundred and seventeen kyphoplasty procedures were performed in 142 patients with osteoporotic VCFs using the unilateral technique. This technique involves the unilateral cannulation of the center of the vertebral body and the placement of a single balloon tamp. To evaluate improvement in pain and physical function, preoperative and postoperative scores of visual analog scale (VAS), SF-36, and Oswestry Disability Index (ODI) were compared at 3 and 12 months postoperatively. Complications related to the procedure and cement extravasation rates were recorded. Height restoration and overall coronal and sagittal spinal alignment were assessed preoperatively and postoperatively. RESULTS: Significant improvement on the VAS, SF-36 scores, and ODI was noted at 3 months postoperatively; these results were preserved at the 12-month follow-up for the 30 patients who completed the SF-36 questionnaire (VAS/ODI scores were available only for 19 of the 30 patients also showing sustained improvement). No complication was recorded; 34 cases (10.73%) of cement extravasation were all asymptomatic. Mean middle height restoration was found 48.9%; when vertebral levels treated were stratified into 2 groups, with or without height restoration (90.1% and 9.9% of all levels, respectively), corrected mean middle height restoration was found 54%. No lateral wedging or changes in the coronal alignment was observed in the unipedicular group. CONCLUSIONS: Unipedicular (unilateral) extrapedicular kyphoplasty is both a safe and efficacious alternative to the traditional bipedicular kyphoplasty for the treatment of painful osteoporotic VCFs. As a technique, it is faster, less expensive, and involves less radiation exposure for the surgical suite personnel.

Low-energy femoral shaft fractures associated with alendronate use.

OBJECTIVE: Increasing evidence suggests long-term alendronate use may overly suppress bone metabolism, limiting repair of microdamage and creating risk for insufficiency fractures. The purpose of this study is to demonstrate an association between alendronate use and a specific pattern of low-energy femoral shaft fracture. DESIGN, SETTING, AND PATIENTS: A retrospective review was performed of patients with femoral shaft fractures admitted to a Level 1 trauma center between January 2002 and March 2007. Seventy low-energy fractures were identified. MAIN OUTCOME MEASURE: The medical records were reviewed, and the incidence and duration of alendronate use were recorded. The incidence of a specific femoral shaft fracture in those patients taking alendronate compared with those not being treated was determined. RESULTS: There were 59 females and 11 males. The average age was 74.7 years. Twenty-five (36%) were being treated with alendronate. None of the patients had used or were using other bisphosphonates. Nineteen (76%) of these 25 patients demonstrated a simple, transverse fracture with a unicortical beak in an area of cortical hypertrophy. This fracture pattern was seen in only 1 patient (2%) not being treated with alendronate. Alendronate use was a significant risk factor for the fracture pattern (odds ratio [OR]) 139.33, 95% CI [19.0-939.4], P < 0.0001). This pattern was 98% specific to alendronate users. The average duration of alendronate use in those with the pattern was significantly longer than those who did not exhibit the pattern but were taking alendronate, 6.9 years versus 2.5 years of use, respectively (P = 0.002). Only 1 patient with the fracture pattern had been taking alendronate for less than 4 years. CONCLUSIONS: Low-energy fractures of the femoral shaft with a simple, transverse pattern and hypertrophy of the diaphyseal cortex are associated with alendronate use. This may result from propagation of a stress fracture whose repair is retarded by diminished osteoclast activity and impaired microdamage repair resulting from its prolonged use.

Unsuspected lymphoma diagnosed with use of biopsy during kyphoplasty.

BACKGROUND: Vertebral augmentation procedures are currently widely performed to treat vertebral compression fractures. In selecting appropriate patients for these procedures, it is important to distinguish the pain caused by a fracture from other causes of back pain. The purpose of this study was to determine the frequency of underlying, previously unrecognized malignant tumors in a consecutive series of patients undergoing kyphoplasty to treat vertebral compression fractures. Our hypothesis was that an unsuspected malignant tumor will exist and that a bone-marrow aspiration from the iliac crest would enhance our ability to detect a malignant tumor. METHODS: A prospective histological evaluation of vertebral body biopsy specimens from presumed osteoporotic vertebral compression fractures and a concurrent bone-marrow aspiration from the iliac crest were performed in order to identify latent hematopoietic dyscrasias. Over a four-year period, vertebral body biopsies from 523 vertebral levels as well as iliac crest bone-marrow aspirations were performed in 238 patients. Both specimens were evaluated histologically, and the prevalence of an underlying occult malignant neoplasm was determined. RESULTS: All specimens from the vertebral bodies showed signs of bone-remodeling and/or fracture-healing. However, in three patients, both the bone biopsy specimen and the bone-marrow aspirate showed evidence of B-cell lymphoma. The bone-marrow aspirate did not provide any additional information compared with the vertebral body biopsy specimen, and multiple myeloma was not identified in any patient. CONCLUSIONS: Lymphoma is an uncommon cause of a vertebral compression fracture, but on the basis of our experience in this series, we recommend that vertebral body biopsy specimens be obtained in all patients managed with kyphoplasty and vertebroplasty to rule out an unsuspected malignant tumor. However, we do not recommend the routine use of an additional bone-marrow aspiration from the iliac crest during vertebral augmentation procedures because doing so did not appear to enhance our ability to detect a malignant tumor.