Surgeon Recommendations for Physical Activity in Patients With Pediatric Hip Conditions.

BACKGROUND: While physical activity (PA) is important during youth, it is unclear if children and adolescents with developmental dysplasia of the hip (DDH), Legg-Calvé-Perthes disease (LCPD), or slipped capital femoral epiphysis (SCFE) are expected or encouraged to return to PA once they have healed. This study examines the orthopaedic surgeons' role in advising pediatric hip patients on the PA they should engage in, assessing their practice, opinions, and consensus when making recommendations. METHODS: Orthopaedic surgeons were invited from member lists of 4 hip study groups. The survey included demographics, opinions regarding PA, and 10 case scenarios that queried respondents on the duration and intensity of PA as well as the restrictions on activity type that they would recommend for DDH, LCPD, or SCFE patients. Consensus was evaluated on a scale ranging from 0 to 1, with a value of 0 indicating no agreement among respondents and a value of 1 indicating complete agreement. RESULTS: A total of 51 orthopaedic surgeons responded. While 94% agreed that it is important for school-aged hip patients to return to PA after they have healed, 53% believed that PA may compromise the hip and contribute to the development of osteoarthritis. Average standardized consensus was 0.92 for suggesting the patient engage in some amount of PA, 0.44 for suggesting the recommended daily minimum of 60 minutes of moderate-to-vigorous physical activity (MVPA), and 0.33 for suggesting restrictions on activity type. The most frequently selected restrictions included avoiding impact activities (93%, 235/254) and contact activities (58%, 147/254), followed by weight-bearing activities (24%, 62/254). Respondents were not aware of existing PA guidelines, although 57% expressed interest in following guidelines and 39% were uncertain. CONCLUSIONS: While there is consensus among orthopaedic surgeons that children with chronic hip conditions should engage in PA, there is considerable variation when recommending the recommended daily MVPA minimum and placing restrictions on activity type. This study suggests interest among orthopaedic surgeons in developing PA guidelines that optimize outcomes for pediatric hip patients. LEVEL OF EVIDENCE: Level II-Survey study.

Protocol for extracting and isolating porcine bone-marrow-derived macrophages from ribs.

Due to anatomical and biological similarities with humans, pigs are increasingly used for inflammation- and immune-related studies in biomedical research, including the field of osteonecrosis and osteoimmunology. Here, we present a protocol for rib extraction, isolation of the bone marrow by centrifugation, and processing to obtain bone-marrow-derived macrophages (BMDMs). Then, we describe the procedures of in vitro experiments to evaluate the cell phenotype. For complete details on the use and execution of this protocol, please refer to Andre et al.1.

Pathogenic Gene Variants Identified in Patients Presenting With Perthes or Perthes-like Hip Disorder.

AIMS: Legg-Calve-Perthes disease (LCPD) is a diagnosis of exclusion. Various conditions, such as skeletal dysplasias, can closely mimic LCPD and these must be ruled out to provide appropriate treatment, prognosis, and counseling. Traditionally, genetic testing has not been readily available in pediatric orthopaedic practice. Furthermore, the clinical value of genetic testing patients with LCPD is unclear. With the advance of next-generation sequencing (NGS) technology, genetic testing has become clinically available as a lab test. The purposes of this study were to assess the clinical utility of genetic testing in select patients with LCPD and to determine the patient characteristics of those who tested positive for skeletal dysplasia. METHODS: This is an IRB-approved, retrospective study of 63 consecutive patients who presented with Perthes-like symptoms and/or x-ray findings and who had genetic testing. The reason(s) for genetic testing included bilateral hip disease, family history of LCPD, short stature, suspected skeletal dysplasia, atypical radiographic findings, and/or combinations of these reasons. RESULTS: Of the 63 patients, 19 patients (30%) were found to have a pathogenic gene variant. In 8 of the 19, a variety of skeletal dysplasia was diagnosed. The remaining 11 patients were found to be carriers of autosomal recessive disorders. All 19 patients were referred for genetic counseling. Of the 8 patients found to have skeletal dysplasia, 3 had bilateral disease, 3 were <10 percentile in height, 1 had a family history of "LCPD," and 3 had atypical x-ray findings. In addition to the pathogenic variants, numerous genetic variants of unknown significance were found with 2 gene variants showing exactly the same variant found in 2 unrelated patients. CONCLUSIONS: With 30% of the patients showing pathogenic results, genetic testing of select patients with Perthes-like disease is valuable in detecting an underlying genetic disorder or a carrier status of a genetic disorder.

Predictors of Persistent Limp Following Proximal Femoral Varus Osteotomy for Perthes Disease.

INTRODUCTION: One of the most popular containment procedures for Legg-Calvé-Perthes disease (LCPD) is proximal femur varus osteotomy (PFO). While generally successful in achieving containment, PFO can cause limb length discrepancy, abductor weakness, and (of most concern for families) a persistent limp. While many studies have focused on radiographic outcomes following containment surgery, none have analyzed predictors of this persistent limp. The aim of this study was to determine clinical, radiographic, and surgical risk factors for persistent limp 2 years after PFO in children with LCPD. METHODS: A retrospective review of a prospectively collected multicenter database was conducted for patients aged 6 to 11 years at disease onset with unilateral early-stage LCPD (Waldenström I) who underwent PFO. Limp status (no, mild, and severe), age, BMI, and pain scores were obtained at initial presentation, 3-month, and 2-year postoperative visits. Preoperative and follow-up radiographs were used to measure traditional morphologic hip metrics including acetabular index (AI), lateral center-edge angle (LCEA), and femoral neck-shaft angle (NSA). Univariate analysis as well as multivariate logistic regression models were used to analyze factors associated with mild and severe limp at the 2-year visit. RESULTS: A total of 95 patients met the inclusion criteria, and of these 50 patients underwent concomitant greater trochanter apophysiodesis (GTA) at the time of PFO. At the 2-year visit, there were 38 patients (40%) with a mild or severe limp. Multivariate logistic regression revealed no significant radiographic factors associated with a persistent limp. However, lower 2-year BMI and undergoing GTA were associated with decreased rates of persistent limp regardless of age ( P <0.05). When stratifying by age of disease onset, apophysiodesis appeared to be protective against any severity of limp in patients aged 6 to 8 years old ( P = 0.03), but not in patients 8 years or older ( P = 0.49). CONCLUSIONS: Persistent limp following PFO is a frustrating problem that was seen in 40% of patients at 2 years. However, lower follow-up BMI and performing a greater trochanter apophysiodesis, particularly in patients younger than 8 years of age, correlated with a lower risk of postoperative limp.

Outcomes of Simultaneous Versus Staged Resection for Stage IV Colorectal Cancer with Synchronous Liver Metastases.

INTRODUCTION: Management of stage IV colorectal cancer with synchronous liver metastases remains debated, as colorectal and liver resections can be performed simultaneously or staged apart. OBJECTIVE: This study aims to determine any demographic or outcome differences between simultaneous and staged resection. PARTICIPANTS: Retrospective review was performed on patients diagnosed with synchronous colorectal primary and liver metastases within Southern California Kaiser Permanente (KP) hospitals between 2010 and 2020. Patients with other metastases on diagnosis or those who did not receive both primary and liver resections were excluded. Demographic and outcome data were collected and analyzed. RESULTS: Of the 113 patients who met criteria, 72 (63.7%) received simultaneous and 41 (36.3%) received staged resection. Demographic data were comparable between simultaneous and staged resection, respectively, including median age of diagnosis, sex, and race. Both groups had similar median length of stay, percentage of major colorectal resection, and percentage of major liver resection. Both groups also had similar rates of radiation therapy, chemotherapy, and immunotherapy. There were no statistically significant difference in complications rates, median follow-up time, median overall survival, and median disease-free survival. CONCLUSIONS: Practice patterns within Southern California KP hospitals favor minor colorectal and liver resections. However, there were no significant differences in demographics, treatment rates, or outcomes between simultaneous and staged resection. While not statistically significant, our findings of a 11.9% higher major liver resection rate and 7.5-month longer median disease-free survival in the staged resection group may benefit from further study with higher power datasets.

Obesity impairs revascularization and bone healing in a mouse model of osteonecrosis.

Osteonecrosis of the femoral head (ONFH) is a devastating bone disease that is caused by a disruption of blood supply leading to necrotic cell death. Clinically, it was found that obesity has a high prevalence with ONFH. However, it remains unclear how obesity may directly affect tissue regeneration and bone healing in osteonecrosis (ON). The purpose of this study is to investigate the effects of obesity and weight loss (WL) on ON healing. In this study, we induced obesity and WL in an established surgery-induced ON mouse model via feeding a high-fat diet (HFD) and altering the diet respectively. All mice received a surgical induction of ON of distal femoral epiphysis at the age of 12 weeks. HFD was switched to normal diet (ND) after ON surgery to induce WL. Mouse body weight was recorded weekly. Mouse body composition was scanned by DEXA (Dual-energy X-ray absorptiometry) right after sacrifice at the age of 16 weeks. The distal femoral bone samples were fixed and embedded for histology such as H&E, immunohistochemistry, and TRAP staining. In this study, we found that HFD-induced obesity impaired revascularization and bone remodeling showing decreased vessel areas and reduced osteoblast and osteoclast numbers. WL could rescue obesity-induced bone healing defects. Our study is the first to test the direct effects of obesity and WL on ON bone healing. We believe our work may provide new concepts for osteonecrosis treatment in obese patients.

Fully automatic system to detect and segment the proximal femur in pelvic radiographic images for Legg-Calvé-Perthes disease.

This study aimed to develop a method using computer vision techniques to accurately detect and delineate the proximal femur in radiographs of Legg-Calvé-Perthes disease (LCPD) patients. Currently, evaluating femoral head deformity, a crucial predictor of LCPD outcomes, relies on unreliable categorical and qualitative classifications. To address this limitation, we employed the pretrained object detection model YOLOv5 to detect the proximal femur on over 2000 radiographs, including images of shoulders and chests, to enhance robustness and generalizability. Subsequently, we utilized the U-Net convolutional neural network architecture for image segmentation of the proximal femur in more than 800 manually annotated images of stage IV LCPD. The results demonstrate outstanding performance, with the object detection model achieving high accuracy (mean average precision of 0.99) and the segmentation model attaining an accuracy score of 91%, dice coefficient of 0.75, and binary IoU score of 0.85 on the held-out test set. The proposed fully automatic proximal femur detection and segmentation system offers a promising approach to accurately detect and delineate the proximal femoral bone contour in radiographic images, which is essential for further image analysis in LCPD patients. Clinical significance: This study highlights the potential of computer vision techniques for enhancing the reliability of Legg-Calvé-Perthes disease staging and outcome prediction.

Percutaneous transphyseal screw induces varus proximal femoral growth modulation in a growing pig model-A three-dimensional analysis.

Bone and joint angular deformities are common pediatric orthopedic problems that are often corrected surgically. Previous studies successfully demonstrated proximal femoral growth modulation in animal models, however outcome measurements were limited by two-dimensional analysis. In this study, six Yorkshire cross male piglets were treated with unilateral percutaneous transphyseal screw placement across the medial aspect of the proximal femoral physis and analyzed using three-dimensional (3D) techniques. Three primary outcome measures were considered-physis angle, version, and femoral length. Compared to paired controls, all treated femurs displayed varus correction and shortening after an average treatment period of 10 weeks. The amount of varus change was 11.6 ± 2.8° (mean ± SD) (p = 0.0002, 95% confidence interval [CI] [8.659, 14.589]) and shortening was 4.3 ± 1.6 mm (p = 0.0011, 95% CI [2.672, 5.942]). Four animals demonstrated retroversion and two demonstrated anteversion compared to controls (4.1 ± 5.4° retroversion, p = 0.1169, 95% CI [-1.483, 9.765]). The amount of varus correction was strongly correlated with the orientation of the screw relative to the medial/lateral axis of the physis (r = -0.887, p = 0.0183, 95% CI [-0.988, -0.271]). The amount and direction of version was strongly correlated with how eccentrically anterior or posterior the screw was placed relative to the center of the physis (r = -0.850, p = 0.0322, 95% CI [-0.983, -0.123]) as well as the angle of the screw relative to the posterior condylar axis of the femur (r = -0.980, p = 0.0006, 95% CI [-0.998, -0.822]). This study is the first to use 3D analysis to quantify proximal femur growth modulation and identify associations between the growth modulation outcomes and screw placement parameters.

Does Screening Ultrasound Timing in Developmental Dysplasia of the Hip Need to be Adjusted for Moderate Preterm and Near-term Infants: A Prospective Study.

INTRODUCTION: An initial screening ultrasound is essential for patients at higher risk of developmental dysplasia of the hip (DDH) due to breech presentation or a family history of DDH. The American Academy of Pediatrics recommends screening ultrasounds to be performed after 6 weeks of age to reduce the rate of false positives. However, there is limited evidence regarding whether these screening ultrasounds need to be adjusted for gestational age in prematurity. The purpose of this study was to evaluate the influence of moderate preterm and near-term births on screening hip ultrasounds for high-risk DDH populations. METHODS: We identified all prospectively enrolled patients in a single-center database referred for screening hip ultrasound for DDH. We included those hips referred for risk factors of DDH, including breech presentation, family history of DDH, or hip click, and excluded those with known dysplasia or referral for hip instability. Each ultrasound was measured by a pediatric radiologist to determine the alpha angle and femoral head coverage. Patients were classified as "premature" if born at <37 weeks gestation or "full term" if born at ≥37 weeks gestation. All patients underwent screening hip ultrasound between 5 and 8 weeks of age. Sonographic markers of dysplasia and the incidences of abnormal ultrasound and Pavlik harness treatment were compared between cohorts. Significance was set at P <0.05. RESULTS: A total of 244 hips in 122 patients were included, 58 hips in the premature cohort and 186 hips in the full-term cohort. The premature cohort had a significantly decreased gestational age compared with the full-term cohort (35.4 ± 1.1 vs 38.5 ± 1.1 wk, respectively, P < 0.001). However, there was no difference between premature and full-term cohorts in sex distribution (69% vs 75%, females, P = 0.39), unadjusted age at the time of ultrasound (6.6 ± 0.7 vs 6.8±0.7 wk, respectively, P = 0.07), or referral reason ( P = 0.14). On hip ultrasound, there was no difference between premature and full-term cohorts with respect to alpha angle (62.6 ± 3.3 vs 62.2 ± 5.3 degrees, P = 0.41), femoral head coverage (54.9 ± 6.3 vs 55.1 ± 10.6, P = 0.19), rate of abnormal ultrasound (18.3% vs 20.7%, respectively, P = 0.68), or the rate of Pavlik harness treatment (0% vs 5.3%, respectively, P = 0.12). DISCUSSION: There was no significant difference in alpha angle or femoral head coverage between premature and full-term patients at 5 to 8 weeks of unadjusted age. This preliminary data suggests that screening ultrasounds can be performed without adjusting for prematurity. LEVEL OF EVIDENCE: Level II, prognostic study.

Does brace treatment following closed reduction of developmental dysplasia of the hip improve acetabular coverage?

Aims: Abduction bracing is commonly used to treat developmental dysplasia of the hip (DDH) following closed reduction and spica casting, with little evidence to support or refute this practice. The purpose of this study was to determine the efficacy of abduction bracing after closed reduction in improving acetabular index (AI) and reducing secondary surgery for residual hip dysplasia. Methods: We performed a retrospective review of patients treated with closed reduction for DDH at a single tertiary referral centre. Demographic data were obtained including severity of dislocation based on the International Hip Dysplasia Institute (IHDI) classification, age at reduction, and casting duration. Patients were prescribed no abduction bracing, part-time, or full-time wear post-reduction and casting. AI measurements were obtained immediately upon cast removal and from two- and four-year follow-up radiographs. Results: A total of 243 hips underwent closed reduction and 82% (199/243) were treated with abduction bracing. There was no difference between those treated with or without bracing with regard to sex, age at reduction, severity of dislocation, spica duration, or immediate post-casting AI (all p > 0.05). There was no difference in hips treated with or without abduction brace with regard to AI at two years post-reduction (32.4° (SD 5.3°) vs 30.9° (SD 4.6°), respectively; p = 0.099) or at four years post-reduction (26.4° (SD 5.2°) vs 25.4° (SD 5.1°), respectively; p = 0.231). Multivariate analysis revealed only IHDI grade predicted AI at two years post-reduction (p = 0.004). There was no difference in overall rate of secondary surgery for residual dysplasia between hips treated with or without bracing (32% vs 39%, respectively; p = 0.372). However, there was an increased risk of early secondary surgery (< two years post-reduction) in the non-braced group (11.4% vs 2.5%; p = 0.019). Conclusion: Abduction bracing following closed reduction for DDH treatment is not associated with decreased residual dysplasia at two or four years post-reduction but may reduce rates of early secondary surgery. A prospective study is indicated to provide more definitive recommendations.

Abduction Bracing Following Anterior Open Reduction for Developmental Dysplasia of the Hip Does Not Improve Residual Dysplasia or Reduce Secondary Surgery.

BACKGROUND: Abduction bracing is commonly used following open reduction and spica casting of developmental dysplasia of the hip. However, there is little evidence to support or refute this practice that carries associated cost and burden for families. The purpose of this study was to determine the efficacy of abduction bracing after open reduction in improving the acetabular dysplasia and reducing the rate of secondary surgery for residual dysplasia. METHODS: This is a retrospective study of patients treated with open reduction at a single tertiary referral center. Demographic data, severity of dislocation [International Hip Dysplasia Institute (IHDI) class], age at reduction, and casting duration were obtained. Patients were prescribed no bracing, part-time (≤18 h/d), or full-time (≥20 h/d) brace wear based on surgeon preference. Acetabular index (AI) measurements were obtained at cast removal and at 2- and 4-year follow-up. RESULTS: A total of 146 hips underwent open reduction with 61% (89/146) of hips treated with abduction bracing. There was no difference between braced and nonbraced cohorts with regards to sex, age at time of reduction, dislocation severity, cast duration, immediate postcasting AI, or incidence of medial open reduction. There was no difference in hips treated with or without brace following open reduction with regards to AI at 2 years postreduction (31.8±6.7 vs. 30.4±6.1 degrees, P =0.27) or at 4 years postreduction (24.9±6.5 vs. 24.7±6.5 degrees, P =0.97). However, further analysis showed lower mean AI at 2-year follow-up for braced versus nonbraced patients following medial open reduction (30.0±5.7 vs. 34.5±7.0 degrees, P =0.02). This difference was no longer present at 4-year follow-up (26.6±6.8 vs. 24.2±6.6 degrees, P =0.44). However, 4/19 (21%) nonbraced hips underwent secondary surgery for residual dysplasia and were consequently excluded from the AI measurement at 4 years postreduction (compared with 4/39 [10%] braced hips within the same time period). There was no difference in the rate of secondary surgery between braced and nonbraced hips (30% vs. 33%, respectively, P =0.70). Multivariate analysis demonstrated that neither IHDI classification, bracing, nor age at reduction predicted residual dysplasia. CONCLUSIONS: Abduction bracing following anterior open reduction for developmental dysplasia of the hip is not associated with decreased residual dysplasia at 2/4 years postreduction or with decreased secondary surgery. These results suggest that abduction bracing following anterior open reduction may not provide clinical benefit. However, abduction bracing may be beneficial following medial open reduction. A prospective study is necessary to provide more definitive recommendations. LEVEL OF EVIDENCE: Level III-therapeutic study.

Local BMP2 hydrogel therapy for robust bone regeneration in a porcine model of Legg-Calvé-Perthes disease.

Legg-Calvé-Perthes disease is juvenile idiopathic osteonecrosis of the femoral head (ONFH) that has no effective clinical treatment. Previously, local injection of bone morphogenetic protein-2 (BMP2) for ONFH treatment showed a heterogeneous bone repair and a high incidence of heterotopic ossification (HO) due to the BMP2 leakage. Here, we developed a BMP2-hydrogel treatment via a transphyseal bone wash and subsequential injection of BMP2-loaded hydrogel. In vitro studies showed that a hydrogel of gelatin-heparin-tyramine retained the BMP2 for four weeks. The injection of the hydrogel can efficiently prevent leakage. With the bone wash, the injected hydrogel had a broad distribution in the head. In vivo studies on pigs revealed that the BMP2-hydrogel treatment produced a homogeneous bone regeneration without HO. It preserved the subchondral contour and restored the subchondral endochondral ossification, although it increased growth plate fusions. In summary, the study demonstrated a promising BMP2-hydrogel treatment for ONFH treatment, especially for teenagers.

Interleukin-6 receptor blockade improves bone healing following ischemic osteonecrosis in adolescent mice.

Objective: Juvenile ischemic osteonecrosis (JIO) of the femoral head is one of the most serious hip disorders causing a permanent deformity of the femoral head in childhood. We recently reported that interleukin 6 (IL-6) is significantly increased in the hip synovial fluid of patients with JIO and that articular chondrocytes are primary source of IL-6. Adolescent JIO is particularly challenging to treat and has poor outcome. This study determined if IL-6 receptor blockade prevents bone loss and improves the bone healing in adolescent JIO. Method: Adolescent mice (12-week-old) surgically induced with JIO were treated with either saline or MR16-1, an IL-6 receptor blocker. Results: Micro-CT assessment showed significantly increased bone volume (p â€‹< â€‹0.001, Cohen's d â€‹= â€‹2.0) and trabecular bone thickness (p â€‹< â€‹0.001, d â€‹= â€‹2.3) after the MR16-1 treatment. Histomorphometric assessment showed significantly increased osteoblast number (p â€‹< â€‹0.01, d â€‹= â€‹2.3), bone formation rate (p â€‹< â€‹0.01, d â€‹= â€‹4.3), and mineral apposition rate (p â€‹< â€‹0.01, d â€‹= â€‹4.1) after the MR16-1 treatment. The number of osteoclasts was unchanged. Histologic assessment showed significantly increased revascularization (p â€‹< â€‹0.01) and restoration of the necrotic marrow with new hematopoietic bone marrow (p â€‹< â€‹0.01). Vascular endothelial growth factor (VEGF) expression was increased in the revascularized area and the articular cartilage, and in the cultured chondrocytes treated with IL-6 receptor inhibitor. Conclusion: IL-6 blockade in adolescent mice with JIO enhanced bone formation and revascularization. The findings suggest IL-6 receptor blocker as a potential medical therapy for adolescent JIO.

The impact of music, play, and pet therapies in managing pain and anxiety in paediatric patients in hospital: a rapid systematic review.

Background: Hospitalized children face pain and anxiety associated with the environment and procedures. Objective: This review aimed to assess the impact of music, play, pet and art therapies on pain and anxiety in hospitalized paediatric patients. RCTs assessing the impact of music, play, pet, and/or art therapies on pain and/or anxiety in hospitalized paediatric patients were eligible. Methods: Database searching and citation screening was completed to identify studies. A narrative synthesis was used to summarize study findings and certainty of evidence was assessed using GRADE. Of the 761 documents identified, 29 were included spanning music (n = 15), play (n = 12), and pet (n = 3) therapies. Results: A high certainty of evidence supported play in reducing pain and moderate certainty for music and pet. A moderate certainty of evidence supported music and play in reducing anxiety. Conclusion: Complementary therapies utilized alongside conventional medical treatment may mitigate pain and anxiety in hospitalized paediatric patients.

Reliability of the Modified Method for Sphericity Deviation Score Using Only the Involved Hip Radiographs in the Patients With Legg-Calve-Perthes Disease.

BACKGROUND: The sphericity deviation score (SDS) is a validated radiographic outcome measure that quantifies the severity of the femoral head deformity in the healed stage of Legg-Calve-Perthes disease (LCPD). The current method requires radiographs of both hips regardless of unilateral involvement to standardize radiographic magnification. As LCPD affects the unilateral hip in 85% to 90% of cases, the current method imposes unnecessary radiation exposure to most of the patients and having to exclude patients from research studies who only had unilateral hip radiographs. We thus modified the SDS method to use unilateral hip radiographs. The purpose of this study was to investigate the reliability of the modified SDS method using the radiographs containing only one hip. METHODS: This retrospective study involved 40 patients with LCPD with unilateral involvement in the healed stage of LCPD. We modified the SDS measurement method by using the distance between the teardrop and the lateral acetabulum for magnification correction and providing a clear anatomic description of reference points on the femoral head. Three independent observers performed measurements using radiographs containing the affected hip only (modified method) and both hips (conventional method). The intraclass correlation (ICC) estimates were calculated. To verify clinical relevance, the correlation of the SDS with the Stulberg classification and hip range of motion (ROM) were also investigated. RESULTS: Measurements using the modified SDS showed excellent inter-/intra-observer ICCs (0.903 to 0.978). The ICCs between the modified and conventional methods were also excellent: 0.940 to 0.966 within the same observer and 0.897 to 0.919 between different observers. The modified SDS showed moderate-to-strong correlations with the Stulberg classification (Spearman ρ=0.650) and hip ROM (Pearson r =-0.661). CONCLUSION: The modified SDS measurement method showed excellent inter-/intra-observer reliability and moderate-to-strong correlations with the Stulberg classification and hip ROM. This method will help reduce unnecessary radiation exposure in patients with unilateral LCPD and prevent the exclusion of patients with unilateral radiographs from future research studies. LEVEL OF EVIDENCE: Level III-diagnostic study.

Patient Adherence to Wide Abduction Brace Treatment for Legg-Calvé-Perthes Disease.

BACKGROUND: A wide abduction brace called the A-frame brace is used to contain the deformed femoral head and improve femoral head remodeling in patients with Legg-Calvé-Perthes disease (LCPD). While there is some data showing the efficacy of brace treatment, little is known about patient adherence. The purpose of this study was to measure A-frame brace adherence using temperature sensors and to identify factors that influence adherence. METHODS: This is an IRB-approved retrospective study of 61 patients with LCPD treated with an A-frame brace between ages 5 and 11. Brace wear was measured using built-in temperature sensors. Pearson correlation coefficient and multiple regression were used to determine relationships between patient characteristics and brace adherence. RESULTS: Of 61 patients, 80% were male. Mean age at LCPD onset was 5.9±1.8 years and the mean age at initiation of brace treatment was 7.1±1.5 years. Fifty-eight patients (95%) were in the fragmentation or reossification stage at the start of bracing, with 23 patients (38%) having lateral pillar B, 7 (11%) lateral pillar B/C, and 31 (51%) lateral pillar C. Forty-two (69%) patients were treated with a Petrie cast for 6 weeks before the A-frame brace. Mean adherence, defined as the ratio of measured over prescribed brace wear, was 0.69±0.32. Mean adherence improved with age ( P <0.05), increasing from 0.57 in patients less than 6 to 0.84 in patients aged 8 to 11. Patients first treated with a Petrie cast had significantly better adherence than those without (0.77 vs. 0.50; P <0.005). Adherence was negatively associated with the amount of prescribed brace wear per day ( P <0.005). Adherence did not change significantly between the start and end of treatment and was not significantly associated with sex or attention deficit hyperactivity disorder. CONCLUSIONS: A-frame brace adherence was significantly associated with age at treatment, prior Petrie casting, and the amount of daily prescribed brace wear. These findings provide new insight into A-frame brace treatment, which will lead to better patient selection and counseling to optimize adherence. LEVEL OF EVIDENCE: III Therapeutic Study.

The Significance of Isolated Hip Click as a Sign of DDH: Implications on Referral Guidelines.

BACKGROUND: The clinical significance of an isolated hip click remains unclear. The rates of developmental dysplasia of the hip (DDH) in those referred for hip click vary from 0% to 28%. The purpose of this study was to evaluate the rate of DDH in patients prospectively referred for isolated hip click. METHODS: We prospectively enrolled patients referred to a single pediatric orthopaedic center with concern for DDH secondary to isolated hip click felt by the pediatrician on examination. Patients with known sonographic abnormalities or risk factors for DDH (breech presentation or positive family history) were excluded. Ultrasounds were obtained upon initial presentation and defined as abnormal if alpha angle <60 degrees and/or femoral head coverage (FHC) <50%. Mild dysplasia, analogous to Graf IIa physiological immaturity, was defined as alpha angle 50<α<60 and/or <50% FHC in a patient <3 months age. Severe dysplasia was defined as ≤33% FHC, which has been proposed to be sonographically consistent with a hip dislocation. RESULTS: Two hundred fifty-five children were referred for isolated hip click. One hundred eighty-nine patients (74%) had normal ultrasound whereas 66 patients (26%) had sonographic abnormalities (mean age 6.5±6.2 wk at initial ultrasound). Fifty patients (19.6%) demonstrated physiological immaturity, 3 patients (1.2%) demonstrated moderate sonographic dysplasia, and 13 patients (5.1%) had sonographic findings consistent with severe dysplasia or dislocated hip. Hips with severe dysplasia were younger than the remaining population (2.8±2.4 wk vs. 6.6±6.2 wk, P <0.001) with no difference in sex distribution ( P =0.07) or first-born birth order ( P =0.36). For those with sonographic abnormality, 18 (27%) patients were treated with Pavlik harness, 1 (2%) was treated with abduction orthosis, and the remainder (71%) were observed for resolution of physiological immaturity. CONCLUSIONS: Infants with isolated hip click identified by their pediatrician may have higher rates of dysplasia than previously reported. We recommend screening ultrasound and/or orthopaedic referral for all infants with isolated hip click. LEVEL OF EVIDENCE: Level II-prospective prognostic study.

Local Administration of Bone Morphogenetic Protein-2 Using a Hydrogel Carrier for Robust Bone Regeneration in a Large Animal Model of Legg-Calvé-Perthes disease.

Legg-Calvé-Perthes disease is juvenile idiopathic osteonecrosis of the femoral head (ONFH) that has no effective clinical resolutions. Previously, local injection of bone morphogenetic protein-2 (BMP2) for ONFH treatment showed a heterogeneous bone repair and a high incidence of heterotopic ossification (HO) due to the BMP2 leakage. Here, we developed a BMP2-hydrogel treatment via a transphyseal bone wash and subsequential injection of BMP2-loaded hydrogel. In vivo studies showed that a hydrogel of gelatin-heparin-tyramine retained the BMP2 for four weeks. The injection of the hydrogel can efficiently prevent leakage. With the bone wash, the injected hydrogel had a broad distribution in the head. In vivo studies on pigs revealed that the BMP2-hydrogel treatment produced a homogeneous bone regeneration without HO. It preserved the subchondral contour and restored the subchondral endochondral ossification, although it increased growth plate fusions. In summary, the study demonstrated a promising BMP2-hydrogel treatment for ONFH treatment, especially for teenagers.

Ex vivo study of detergent-assisted intraosseous bone wash treatment of osteonecrosis.

Avascular necrosis (AVN) involves ischemic cell death of the bone. AVN leaves an abundance of necrotic lipids and debris in the bone marrow, which instigates inflammatory bone repair. Consequently, the necrotic bone microenvironment stimulates excessive bone resorption, leading to joint deformities and osteoarthritis. Here, we performed a detergent-assisted bone wash using poloxamer 407 (P407) to clean the necrotic bone environment by removing lipids and necrotic debris. The new concept was tested using an established ex vivo AVN model of porcine cadaver humeral heads. The P407 wash was performed using P407 solution and followed with saline via two intraosseous needles. Visual inspection and image analyses of average pixel light intensity showed that the P407 wash produced a better-cleaned bone than the saline wash. Analyses of the collected bone wash solution showed a two-fold increase in triglycerides (101 vs. 53 mmol/head, p = 0.006) and a 10-fold increase in the dry weight of the removed debris (1.34 vs. 0.13 g/head, p = 0.02) with the P407 wash compared to saline. The histological evaluation showed significantly decreased Oil-Red-O (fats) staining in the P407-washed bone compared with the saline-washed bone. The in vitro assays of Alizarin red and qPCR showed the P407 wash neither altered the osteogenic behaviors of porcine bone marrow-derived mesenchymal cells (pBMMCs) nor raised inflammatory responses of porcine bone marrow-derived macrophages (pBMMs). In conclusion, detergent-assisted bone wash using P407 produced a better removal of nonsoluble debris from the bone marrow space than the saline wash without causing changes to osteogenesis or inflammatory reactions.