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.

Intraoperative Epiphyseal Perfusion Monitoring Does Not Reliably Predict Osteonecrosis Following Treatment of Unstable SCFE.

BACKGROUND: Avascular necrosis (AVN) remains the most dreaded complication of unstable slipped capital femoral epiphysis (SCFE) treatment. Newer closed reduction techniques (with perfusion monitoring) have emerged as a technically straightforward means to address residual SCFE deformity while still minimizing the risk of osteonecrosis. However, limited data exists regarding the reliability of intraoperative epiphyseal perfusion monitoring to predict the development of AVN. The purpose of this study was to evaluate its reliability. METHODS: We retrospectively reviewed all patients with unstable SCFE who underwent closed or open reduction with epiphyseal perfusion monitoring using an intracranial pressure (ICP) probe from 2015 to 2023 at a single institution with a minimum 6-month radiographic follow-up. Demographic, clinical, and radiographic data were recorded, including duration of symptoms, type of reduction, capsulotomy performed, presence of a waveform on ICP monitoring after epiphyseal fixation, and development of AVN on follow-up radiographs. RESULTS: Our cohort included 33 hips (32 patients), of which 60.6% (n=20) were male. The average age was 12.5±1.8 years, with a median follow-up of 15.8 months. Eleven hips were treated with open reduction using the modified Dunn technique (10 hips) or anterior approach (1 hip), and 22 hips were treated with inadvertent (5 hips) or purposeful closed reduction using the Leadbetter technique (17 hips). Overall, 8 of the 33 hips in our series (24.2%) developed AVN, 6 of which (20%) had a pulsatile waveform on intraoperative epiphyseal perfusion monitoring. The overall rate of AVN after closed reductions was 31.8% (7 of 22 hips); the incidence of AVN after closed reduction with a detectable waveform was 30% (6 of 20 hips). There was no significant association between time to surgery ( P =0.416) or type of reduction ( P =0.218) and the incidence of AVN. CONCLUSIONS: In this series, intraoperative epiphyseal perfusion monitoring did not reliably predict the development of osteonecrosis. To our knowledge, this is the first study to report AVN after demonstrable intraoperative epiphyseal perfusion following closed reduction of unstable slips. LEVEL OF EVIDENCE: Level IV: case series-therapeutic study.

New Classification for Pediatric Proximal Fifth Metatarsal Fractures.

Proximal fifth metatarsal fractures are the most common foot fractures in children. Attempts to classify these injuries are misapplied and inadequately predict outcomes. This is the first study to identify factors associated with healing in pediatric fifth metatarsal fractures. In this retrospective cohort study (N = 305), proximal fifth metatarsal fractures were classified on radiographs by location on the bone, alignment (transverse or oblique), displacement (>2 mm), and completion through the bone. Based on the literature, they were secondarily sorted by category: apophyseal, intra-articular metaphyseal, extra-articular metaphyseal, and diaphyseal. Primary outcomes included times to healing, indicated by clinical symptoms, immobilization, and return to sports, as well as radiographic callus formation, bridging, and remodeling. Healing times were compared by ANOVA and linear regression. Location had a significant effect on times of immobilization and return to sports, but alignment, displacement, and completion were not associated with healing. When re-classified, the categories were also associated with immobilization and return to sports. Apophyseal fractures healed fastest and diaphyseal fractures required the most time to heal. There was no difference between extra- and intra-articular fractures. For every year of age, symptoms resolved about 2 days sooner. Neither gender nor body mass index (BMI) was positively or negatively associated with healing times. In conclusion, classifying fractures by apophyseal, metaphyseal, and diaphyseal is the most concise, accurate, and useful system. This is the largest series of nonoperatively treated proximal fifth metatarsal fractures in children and a robust standard to which surgical management can be compared.

What Are the Psychosocial Effects of Pavlik Harness Treatment? A Prospective Study on Perceived Impact on Families and Maternal-Infant Bonding.

BACKGROUND: The Pavlik harness (PH) is the most common treatment for infants with developmental dysplasia of the hip. Although success rates are high when used appropriately, brace treatment may impact family function and parental bonding. The purpose of this study was to prospectively determine how PH treatment affected these psychosocial variables. METHODS: This is a prospective, single-surgeon study at a tertiary-care, urban, academic children's hospital between November 2022 and March 2023. All patients newly treated with a Pavlik were eligible. Caregivers were administered the Postpartum Bonding Questionnaire and the Revised Impact on Family Scale (rIOFS) at the baseline visit and 2- and 6 weeks following treatment initiation. Demographic and treatment-specific information was collected through surveys and retrospective chart review. Descriptive statistics and bivariate analysis were used. RESULTS: A total of 55 caregiver-child dyads were included in the final analysis. Most patients were female (89%) and/or first-born (73%). Forty (73%) hips were diagnosed as having stable dysplasia. rIOFS scores steadily improved from baseline, through 2- and 6 weeks posttreatment initiation. Six-week rIOFS scores were significantly lower than both baseline ( P= 0.002) and 2 weeks ( P =0.018). Average parental bonding scores also improved steadily throughout treatment and did not surpass the threshold of clinical concern at any time. Neither full-time harness use (24 h/d vs. 23 h/d based upon clinical stability) nor age at treatment initiation had a statistically significant effect on parental bonding or family functioning (all P >0.05). Additional demographic variables such as birth order, parental history of anxiety/depression, and relative socioeconomic disadvantage also had no significant effect on psychosocial outcomes. CONCLUSION: PH treatment did not significantly impact maternal-fetal bonding or family dynamics. Relative to other pediatric diseases, PH treatment has an impact on family life greater than that of single-leg spica, but less than that of school-age children with chronic medical illnesses. As PH treatment is a widely used treatment for infantile developmental dysplasia of the hip, this study provides information that clinicians may use to more accurately counsel families and assuage parental concerns. LEVELS OF EVIDENCE: Level IV-prospective uncontrolled cohort study.

Traumatic hip dislocations in a pediatric cohort: The importance of advanced imaging.

Purpose: Given that pediatric traumatic hip dislocations are relatively rare, the purpose of the current study is twofold: first, to contribute a significant cohort to the existing corpus, and second, to provide evidence toward the role that computed tomography and magnetic resonance imaging could play in identification and management of this type of injury. Methods: A retrospective review was conducted of all patients with traumatic hip dislocation who presented from 2012 to 2022 at a tertiary-level pediatric trauma center. Data regarding demographics, mechanism of injury, imaging, and treatment were tabulated. Outcomes of interest included immobilization length, concomitant injuries, imaging performed and findings, and rates of avascular necrosis, pain, and stiffness. Concomitant injuries were identified using imaging, clinical, and operative notes. Differences between categorical variables were compared using chi-square analysis or Fischer-exact testing, while continuous variables were compared using Student t tests or Wilcoxon rank sum tests when appropriate. Results: Thirty-four patients were identified. Postreduction, 28 patients had a cumulative 17 magnetic resonance imaging, 19 computed tomographies, and 1 intraoperative arthrogram. Of these, 16 patients had 19 injuries identified on advanced imaging that were missed on initial radiographs. Eleven of these patients went on to operative treatment. In eight of these, postreduction advanced imaging helped guide the decision for surgery. In four patients, magnetic resonance imaging was necessary to fully characterize injury to the posterior acetabular rim after initial identification on computed tomography. Magnetic resonance imaging was also used to rule out one computed tomography-diagnosed acetabular fracture. Conclusion: Magnetic resonance imaging is valuable to fully define associated rim and intra-articular injuries following initial treatment of pediatric traumatic hip dislocations. Level of evidence: Level IV diagnostic study.

Socioeconomic Deprivation and its Associations With Follow-up Compliance After In Situ Pinning of Slipped Capital Femoral Epiphysis.

BACKGROUND: Slipped capital femoral epiphysis (SCFE) is a common cause of hip pain in adolescents and is most often treated by in situ screw fixation. Orthopaedic follow-up is critical after treatment for SCFE due to risks of complications and subsequent contralateral slip. Recent studies have shown that socioeconomic deprivation is associated with decreased fracture care compliance, but no studies have explored this relationship with SCFEs. The study aims to determine the relationship between socioeconomic deprivation and SCFE follow-up care compliance. METHODS: This study included pediatric patients treated with in situ pinning of SCFE between 2011 and 2019 at a single tertiary-care urban children's hospital. Demographic and clinical information were obtained from electronic medical records. The Area Deprivation Index (ADI) was used to quantify the socioeconomic deprivation of each. Outcome variables included patient age and status of physeal closure at the most recent appointment, in addition to the length of follow-up (mo). Statistical relationships were evaluated using nonparametric bivariate analysis and correlation. RESULTS: We identified 247 evaluable patients; 57.1% were male, and the median age was 12.4 years. Most slips were stable (95.1%) and treated with isolated unilateral pinning (55.9%). Median length of follow-up was 11.9 months (interquartile range, 4.95 to 23.1) with median patient age at final visit of 13.6 years (interquartile range, 12.4 to 15.1). Only 37.2% of patients were followed until physeal closure. The mean ADI spread in this sample was similar to the national distribution. However, patients in the most deprived quartile were lost to follow-up significantly earlier (median, 6.5 mo) than those in the least deprived quartile (median, 12.5 mo; P <0.001). Throughout the entire cohort, there was a significant, inverse relationship between deprivation and follow-up length ( rs (238) = -0.3; P <0.001), with this relationship most pronounced in the most deprived quartile. CONCLUSIONS: In this sample, ADI spread was representative of national trends, and the incidence of SCFE was distributed evenly across deprivation quartiles. However, follow-up length does not mirror this relationship; increased socioeconomic deprivation is associated with an earlier loss to follow-up (often well before physeal closure). LEVEL OF EVIDENCE: Level II-retrospective prognostic study.

A novel quantitative approach to evaluate femoral head perfusion by contrast-enhanced ultrasound: A pilot study in infants with developmental dysplasia of the hip.

Avascular necrosis (AVN) is a major morbidity that can occur after surgical reduction of a hip with developmental dysplasia. Early detection of changes in femoral head perfusion during surgery may help detect a hip at risk for AVN and guide intraoperative management. Contrast-enhanced ultrasound (CEUS) can be employed for visualization of femoral head perfusion. In this study we evaluate a quantitative CEUS technique to assess femoral head perfusion pre- and post-surgical reduction. CEUS images were obtained following a bolus injection of an ultrasound contrast agent, prior to and again following surgical reduction and casting. An image processing technique called delta projection was used to quantify hip perfusion, measuring peak enhancement (PE) and perfusion index (PI). We analyzed CEUS images of the hips of eight patients, including seven females, whose ages ranged from 4 months to 1 year. In five hips, perfusion increased following surgery, with a mean pre-surgery PE of 6.7 ±2.5(± SE) and PI of 10.5 ±6.3; and a post-reduction PE of 13.1±6.1 (p=0.07) and PI of 14.2 ±6.2 (p=0.008). The change in contrast visualization was observed to be greater within the central aspect of the cartilaginous femoral epiphysis. The proposed technique can quantify pre- and post-surgical perfusion changes on CEUS images in patients with developmental dysplasia. This quantitative technique may provide a more objective and accurate assessment of changes in femoral head perfusion that may have the potential to be indicative of the risk of developing AVN.

Distal Adductor Magnus Avulsion Fracture Treated with Excision After Failure of Nonoperative Management: A Case Report.

CASE: In this case report, we discuss a skeletally immature gymnast who presented with an isolated distal femoral adductor tubercle avulsion fracture that went on to develop a painful nonunion. After the failure of extensive nonoperative intervention, she had resolution of her symptoms with bony excision and soft-tissue repair. CONCLUSION: It is important for clinicians to be aware of this atypical injury pattern and that surgical intervention may be necessary because conservative treatment may not always resolve symptoms.

Radiographic Evaluation of Pediatric Patients with Patellofemoral Instability.

PURPOSE OF REVIEW: The purpose of this review is to highlight the radiographic assessments of utility in the evaluation of a pediatric patient with patellofemoral instability to facilitate a thorough work-up. Understanding of these measures is useful in understanding evolving research in this field, providing accurate patient risk assessment, and appropriately directing surgical decision-making. RECENT FINDINGS: Recent literature has broadened the radiographic characterization of the pediatric patellar instability and its anatomic risk factors. Knee MRI can inform the assessment of skeletal maturity and novel axial alignment measurements may enhance our identification of patients at increased risk of recurrent instability. Additional improvements have been made in the objective measurement and classification of trochlear dysplasia. Knee MRI-based skeletal age assessments may obviate the need for hand bone age assessments in growing children with patellofemoral instability. Novel objective measures exist in the evaluation of pediatric patellar instability both in the assessment of axial alignment and trochlear dysplasia. Future work should focus on how these measures can aid in guiding surgical decision-making.