Operative treatment of the young cerebral palsy hip.

Hip dysplasia, subluxation, and eventual hip dislocation are commonly encountered in the cerebral palsy population secondary to spasticity and loss of motor control, especially in those patients with more severe neurologic involvement. The treatment of hip disorders in these patients should take into account the degree of limb and hip involvement, pain severity, and overall functioning. Conservative management focuses on mitigating spasticity and preserving range of motion in order to provide an environment in which the femoral head remains concentrically reduced in the acetabulum. However, operative management, consisting of soft tissue or tendon releases, femoral or pelvic osteotomies, or hip salvage procedures, is sometimes necessary to treat the painful, subluxated, or dislocated hip. Radiographic hip surveillance in the pediatric cerebral palsy population is used to guide operative treatment. Long term hip containment is generally improved when surgical intervention is performed in the earlier stages of dysplasia. Younger patients who demonstrate progressive hip subluxation despite conservative measures may be carefully selected to undergo soft tissue procedures. Bony reconstruction, with adjunctive soft tissue procedures, is often necessary to better contain the proximal femur in patients above the age of four years.

Symptomatic cervical spinal stenosis in spastic cerebral palsy.

AIM: To describe the prevalence of symptomatic cervical spinal stenosis (CSS) in spastic cerebral palsy (CP) and associated characteristics. METHOD: This cross-sectional study of adults (>18y) with CP (2006-2016) at a single institution compared the patient characteristics (demographics, comorbidities, surgical history, medications, Gross Motor Function Classification System [GMFCS] level, and CP type) of patients with and without CSS. RESULTS: Of 424 patients (mean age 33y 4mo, SD 13y 6mo, range 18-78y; 225 females, 199 males), 32 patients (7.5%) had symptomatic CSS. GMFCS levels in the study cohort were distributed as follows: level I, 25%; level II, 25%; level III, 22%; level IV, 19%; level V, 9%. Twenty-five out of 32 (78.1%) patients had spastic CP, two (6.3%) had dystonic CP, and one (3.1%) had mixed characteristics. Individuals with CSS were older (mean age 54y 6mo, SD 10y 5mo vs mean age 31y 7mo, SD 12y 1mo, p<0.05) and had a higher body mass index (26.1, SD 4.8 vs 23.4, SD 6.2, p<0.05) than those without CSS. Presentations included upper-extremity symptoms (73%), ambulation decline (70%), neck pain (53%), and incontinence (30%). Common stenosis levels were C5-C6 (59%), C4-C5 (56%), and C6-C7 (53%). INTERPRETATION: Symptomatic CSS was identified in 7.5% of this adult cohort during the 2006 to 2016 period. Diagnosis in CP is difficult due to impaired communication and pre-existing gait abnormalities and spasticity. Given the high prevalence of symptomatic CSS in adults, we propose developing screening guidelines. Physicians must maintain a high level of suspicion for CSS if patients present with changes in gait or spasticity.

Validation of Pediatric Self-Report Patient-Reported Outcomes Measurement Information System (PROMIS) Measures in Different Stages of Legg-Calvé-Perthes Disease.

OBJECTIVES: Patient-reported outcomes (PRO) assessing health-related quality of life (HRQoL) are important outcome measures, especially in Legg-Calvé-Perthes disease (LCPD) where symptoms (pain and limping), activity restrictions, and treatments vary depending on the stage of the disease. The purpose of this study was to investigate the validity of the Patient-reported Outcomes Measurement Information System (PROMIS) for measuring HRQoL of patients with LCPD in various stages of the disease. METHODS: This is a multicenter validity study. Patients with LCPD between 4 and 18 years old were included and classified into modified Waldenström stages of disease: Early (1 or 2A), Late (2B or 3), or Healed (4). Seven PROMIS domains were collected, including Pain Interference, Fatigue, Mobility, Depression, Anger, Anxiety, and Peer Relationships. Convergent, discriminant, and known group validity was determined. RESULTS: A total of 190 patients were included (mean age: 10.4±3.1 y). All 7 domains showed the worst scores in patients in the Early stage (known group validity). Within each domain, all domains positively correlated to each other (convergent validity). Patients who reported more anxiety, depression, and anger were associated with decreased mobility and increased fatigue and pain. Peer relationships had no to weak associations with other domains (discriminant validity). CONCLUSIONS: PROMIS has construct validity in measuring the HRQoL of patients in different stages of LCPD, suggesting that PROMIS has potential to serve as a patient-reported outcome tool for this population. LEVEL OF EVIDENCE: Diagnostic level III study.

Variation Among Pediatric Orthopaedic Surgeons When Treating Medial Epicondyle Fractures.

BACKGROUND: Medial epicondyle fractures are a common pediatric and adolescent injury accounting for 11% to 20% of elbow fractures in this population. This purpose of this study was to determine the variability among pediatric orthopaedic surgeons when treating pediatric medial epicondyle fractures. METHODS: A discrete choice experiment was conducted to determine which patient and injury attributes influence the management of medial epicondyle fractures by pediatric orthopaedic surgeons. A convenience sample of 13 pediatric orthopaedic surgeons reviewed 60 case vignettes of medial epicondyle fractures that included elbow radiographs and patient/injury characteristics. Displacement was incorporated into the study model as a fixed effect. Surgeons were queried if they would treat the injury with immobilization alone or open reduction and internal fixation (ORIF). Statistical analysis was performed using a mixed effect regression model. In addition, surgeons filled out a demographic questionnaire and a risk assessment to determine if these factors affected clinical decision-making. RESULTS: Elbow dislocation and fracture displacement were the only attributes that significantly influenced surgeons to perform surgery (P<0.05). The presence of an elbow dislocation had the largest impact on surgeons when choosing operative care (ß=-0.14; P=0.02). In addition, for every 1 mm increase in displacement, surgeons tended to favor ORIF by a factor of 0.09 (P<0.01). Sex, mechanism of injury, and sport participation did not influence decision-making. In total, 54% of the surgeons demonstrated a preference for ORIF for the included scenarios. On the basis of the personality Likert scale, participants were neither high-risk takers nor extremely risk adverse with an average-risk score of 2.24. Participant demographics did not influence decision-making. CONCLUSIONS: There is substantial variation among pediatric orthopaedic surgeons when treating medial epicondyle fractures. The decision to operate is significantly based on the degree of fracture displacement and if there is a concomitant elbow dislocation. There is no standardization regarding how to treat medial epicondyle fractures and better treatment algorithms are needed to provide better patient outcomes. LEVEL OF EVIDENCE: Level V.

Gross Motor Function Classification System Specific Growth Charts-Utility as a Risk Stratification Tool for Surgical Site Infection Following Spine Surgery.

BACKGROUND: There is currently minimal evidence that preoperative malnutrition increases surgical site infection (SSI) risk in children with cerebral palsy (CP) undergoing spinal deformity surgery. Growth charts specifically for patients with CP have been created to aid in the clinical interpretation of body mass index (BMI) as a marker of nutritional status, but to our knowledge these charts have never been used to risk stratify patients before orthopaedic surgery. We hypothesize that patients with CP who have BMI-for-age below the 10th percentile (BMI≤10) on CP-specific growth charts are at increased risk of surgical site infection following spinal deformity surgery compared with patients with BMI-for-age above the 10th percentile (BMI>10). METHODS: Single-center, retrospective review comparing the rate of SSI in patients with CP stratified by BMI-for-age percentiles on CP-specific growth charts who underwent spinal deformity surgery. Odds ratios with 95% confidence intervals and Pearson χ tests were used to analyze the association of the measured nutritional indicators with SSI. RESULTS: In total, 65 patients, who underwent 74 procedures, had complete follow-up data and were included in this analysis. Ten patients (15.4%) were GMFCS I-III and 55 (84.6%) were GMFCS IV-V; 39 (60%) were orally fed and 26 (40%) were tube-fed. The rate of SSI in this patient population was 13.5% with 10 SSIs reported within 90 days of surgery. There was a significant association between patients with a BMI below the 10th percentile on GMFCS-stratified growth charts and the development of SSI (OR, 13.6; 95% CI, 2.4-75.4; P=0.005). All SSIs occurred in patients that were GMFCS IV-V. There was no association between height, weight, feeding method, or pelvic instrumentation and development of SSI. CONCLUSIONS: CP-specific growth charts are useful tools for identifying patients at increased risk for SSI following spinal instrumentation procedures, whereas standard CDC growth charts are much less sensitive. There is a strong association between preoperative BMI percentile on GMFCS-stratified growth charts and SSI following spinal deformity surgery. LEVEL OF EVIDENCE: Level III-Retrospective Study.

Anesthesia Exposure in Children: Practitioners Respond to the 2016 FDA Drug Safety Communication.

In December 2016, the US Food and Drug Administration (FDA) issued a drug safety warning stating that 11 commonly used anesthetic and sedative medications had potential neurotoxic effects when used in children under the age of 3 years and in pregnant women during the third trimester. A panel presentation at the sixth biennial Pediatric Anesthesia Neurodevelopmental Assessment (PANDA) symposium addressed the FDA announcement in a session entitled "Anesthesia Exposure in Children During Surgical and Non-Surgical Procedures: How Do We Respond to the 2016 FDA Drug Safety Communication?" Panelists included representatives from pediatric anesthesiology, obstetrics, pediatric surgery, and several pediatric surgical subspecialties. Each panelist was asked to address the following questions: How has the FDA labelling change affected your clinical practice including patient discussions, timing, and frequency of procedures? Has your professional society provided any guidelines for this discussion? Has there been any discussion of this topic at your national meetings? The panelists provided important perspectives specific to each specialty, which generated a lively discussion and a detailed response from the Deputy Director of the Division of Anesthesia and Addiction of the FDA describing the FDA procedures that led to this drug safety warning.

Effect of Preoperative Indications Conference on Procedural Planning for Treatment of Scoliosis.

STUDY DESIGN: This study determines the rate of change in the scoliosis surgery plan in cases presented in preoperative indications conference. OBJECTIVES: To determine the effect of preoperative indications conference on the plan of surgery and to identify characteristics that increased the likelihood of change. SUMMARY OF BACKGROUND DATA: Preoperative indications conferences are used as a teaching and planning tool. Levels of fusion, construct options, and necessity for osteotomies are often debated in the planning of scoliosis surgery. METHODS: Scoliosis surgeries were presented at preoperative indications conference with four attending pediatric orthopedic surgeons present. The operative surgeon committed to a surgical plan before conference. A consensus-based plan was made without knowledge of the operative surgeon's preconference plan. Changes of plan were classified as major, minor, or no change. RESULTS: Of the 107 surgical plans, 50 were index surgeries, 13 were revisions, and 44 were scheduled growing rod lengthenings. There were two major changes, including a change to a growing construct from planned fusion, and a change in fusion levels in an adolescent idiopathic scoliosis (AIS) patient. There were 13 minor changes, which included changes in fusion levels (1 to 3; mean = 1.23) and the addition of an osteotomy. The rate of change was 28% for index surgeries and 7.69% for revisions. Of the 14 changes in the 50 index surgeries, there were 8 AIS, 3 cerebral palsy, 1 congenital scoliosis, 1 Ehlers-Danlos, and 1 patient with an undetermined neuromuscular condition. There was 1 change in 13 revision surgeries. There were no changes for growing rod lengthenings and no cancellations as a result of indications conference. CONCLUSIONS: Although revision scoliosis surgery is complex, index AIS/JIS surgery was most subject to the influence of indications conference. This likely reflects controversy around choosing levels of fusion. LEVEL OF EVIDENCE: IV.

An Independent Evaluation of the Validity of a DNA-Based Prognostic Test for Adolescent Idiopathic Scoliosis.

BACKGROUND: ScoliScore is a DNA-based prognostic test, designed and used to help to predict the risk of curve progression in patients with adolescent idiopathic scoliosis. The role of this test in clinical practice remains unclear as the published results of the ScoliScore have not been validated independently. The purpose of this study was to determine if the ScoliScore effectively predicted the risk of curve progression in patients with mild and moderate adolescent idiopathic scoliosis in two urban academic medical centers. METHODS: One hundred and twenty-six patients with adolescent idiopathic scoliosis who met inclusion criteria at two centers were administered the ScoliScore test. Two groups were created: a progression group (those who had a Cobb angle of >40° or those who had undergone surgical fusion) and a non-progression group (those who had skeletal maturity without curve progression to 40°). ScoliScore values and risk levels were compared between the two groups. The negative predictive value was calculated for low-risk scores and the positive predictive value was calculated for high-risk scores. RESULTS: There was no significant difference (p = 0.706) in the mean ScoliScore (and standard deviation) between patients with curve progression (107 ± 55 points) and those without curve progression (102 ± 62 points). There was also no significant difference (p = 0.399) in curve progression between patients with high-risk scores (26.7%) and those with low-risk scores (12.9%). The positive predictive value of the test was 0.27 (95% confidence interval, 0.09 to 0.55), and the negative predictive value was 0.87 (95% confidence interval, 0.69 to 0.96). ScoliScores and rates of progression were not affected by brace-wear. CONCLUSIONS: ScoliScores did not differ between patients with and without curve progression, and the negative and positive predictive values were lower in our study than in the previously published validation study by the developers of the test. This may be due to differences in our test population, genetic variability, or failure of patients in the non-progression group to follow up.

Interobserver and intraobserver reliability of the modified Waldenström classification system for staging of Legg-Calvé-Perthes disease.

BACKGROUND: The absence of a reliable classification system for Legg-Calvé-Perthes disease has contributed to difficulty in establishing consistent management strategies and in interpreting outcome studies. The purpose of this study was to assess interobserver and intraobserver reliability of the modified Waldenström classification system among a large and diverse group of pediatric orthopaedic surgeons. METHODS: Twenty surgeons independently completed the first two rounds of staging: two assessments of forty deidentified radiographs of patients with Legg-Calvé-Perthes disease in various stages. Ten of the twenty surgeons completed another two rounds of staging after the addition of a second pair of radiographs in sequence. Kappa values were calculated within and between each of the rounds. RESULTS: Interobserver kappa values for the classification for surveys 1, 2, 3, and 4 were 0.81, 0.82, 0.76, and 0.80, respectively (with 0.61 to 0.80 considered substantial agreement and 0.81 to 1.0, nearly perfect agreement). Intraobserver agreement for the classification was an average of 0.88 (range, 0.77 to 0.96) between surveys 1 and 2 and an average of 0.87 (range, 0.81 to 0.94) between surveys 3 and 4. CONCLUSIONS: The modified Waldenström classification system for staging of Legg-Calvé-Perthes disease demonstrated substantial to almost perfect agreement between and within observers across multiple rounds of study. In doing so, the results of this study provide a foundation for future validation studies, in which the classification stage will be associated with clinical outcomes.

Pediatric surgeons and anesthesiologists expand the dialogue on the neurotoxicity question, rationale for early and delayed surgeries, and practice changes while awaiting definitive evidence.

The Pediatric Anesthesia NeuroDevelopment Assessment team at Columbia University Medical Center Department of Anesthesiology convened its fourth biennial Symposium to address unresolved issues concerning potential neurotoxic effects of anesthetic agents and sedatives on young children and to assess study findings to date. Dialogue initiated at the third Symposium was continued between anesthesiologists, researchers, and a panel of expert pediatric surgeons representing general surgery and dermatology, orthopedic, and urology specialties. The panel explored the need to balance benefits of early surgery using improved technologies against potential anesthetic risks, practice changes while awaiting definitive answers, and importance of continued interprofessional dialogue.

The effect of rod diameter on correction of adolescent idiopathic scoliosis at two years follow-up.

STUDY DESIGN: The review of multicenter national pediatric scoliosis database. OBJECTIVE: The purpose of this study was to compare the radiographic outcomes of patients who underwent scoliosis surgery utilizing different rod diameter constructs by the posterior approach. BACKGROUND: Little attention has specifically been focused on the effect of rod diameter on correction of spinal deformity after posterior spinal instrumentation and fusion in children with adolescent idiopathic scoliosis (AIS). METHODS: The review of national database comprised of 1125 patients, of which 352 patients had a minimum follow-up of 2 years. Of these, 163 patients received 5.5 mm and 189 patients received 6.35 mm diameter rods for posterior spinal instrumentation. RESULTS: The 6.35 mm rods were used more often for patients who were male, taller, heavier, with larger coronal curves, and more flexible curves. Larger diameter rods were also more likely to be stainless steel, implanted with an increased number of implants per level, and an increased number of pedicle screws used on the concavity of the curve. Univariate analysis of coronal curve showed a significant difference between 5.5 and 6.35 mm rods in correction (67.0% vs. 57.3%) at 2 years. Multivariate analysis revealed that the most significant factors affecting coronal curve correction at 2 years were rod diameter, the patient's preoperative coronal major curve and flexibility, and the implant density. In the sagittal plane, preoperative sagittal curve and rod diameter are the predictors of sagittal correction at 2 years. CONCLUSIONS: The study did not support our hypothesis that larger rods would be associated with a greater correction of frontal and sagittal plane in patients with AIS. In addition to rod diameter, implant density and the inherent flexibility and deformity of the patient were found to be influential factors contributing for the correction and maintenance of coronal and sagittal curves in AIS.

Are Breech Rates for Pedicle Screws Higher in the Upper Thoracic Spine?

STUDY DESIGN: A case-control study. OBJECTIVES: To evaluate pedicle screw placement in pediatric patients with various etiologies of scoliosis, and to identify predictors of misplacement. SUMMARY OF BACKGROUND DATA: Accuracy of placement of pedicle screws has not been well documented for posterior spinal instrumentation and fusion performed in the non-idiopathic population. METHODS: A total of 54 patients (29 idiopathic, 16 neuromuscular, and 9 congenital/syndromic scoliosis), ages 5-19 years, were included. Computed tomography scans were obtained on patients postoperatively to assess screw position. Three pediatric orthopedic surgeons evaluated screw placement, and risk factors for misplacement were examined. RESULTS: Of 1,042 pedicle screws, 8.3% were misplaced. Among all etiologies, screws placed at T1 (28.6%) and T2 (18.2%) had higher misplacement rates. T2 screws and curve correction greater than 75% had higher misplacement rates in congenital/syndromic patients; screws at T3, screws at upper end of construct, and proximal screws had significantly higher misplacement rates in neuromuscular patients; and no variables predicted misplacement in idiopathics. Screws placed at the most proximal end of the screw/rod construct also had a higher misplacement rate (14.1%) compared with all remaining levels (7.8%). Nonidiopathic patients had higher anterior misplacement compared with idiopathic. No screws were removed or revised, and no screw-related complications were observed. CONCLUSIONS: Pedicle screw instrumentation in the thoracolumbar spine was safe for pediatric patients. We found that pedicle screws placed at top levels are at higher risk for misplacement among all pediatric scoliosis patients. Nonidiopathic patients are at higher risk for anterior screw misplacement, and the predictive effect of vertebral level is more profound in nonidiopathic patients. Because of these findings, we routinely use fluoroscopic guidance for the placement of T1 and T2 screws, and screws at the proximal end of construct.

Does ScoliScore provide more information than traditional clinical estimates of curve progression?

STUDY DESIGN: Retrospective study comparing ScoliScore and clinical risk estimates. OBJECTIVE: The purpose of this study was to compare risk stratification between ScoliScore and traditional clinical estimates to determine whether ScoliScore provides unique information. SUMMARY OF BACKGROUND DATA: ScoliScore is a genetic prognostic test designed to evaluate the risk of curve progression in skeletally immature patients with adolescent idiopathic scoliosis with Cobb angles of 10° to 25°. Clinicians are currently trying to better understand the role this test may play in guiding clinical decision making because current standards of curve progression are largely based on radiographical markers, such as curve magnitude and bone age. METHODS: Ninety-one patients who received ScoliScore testing at our center and met study inclusion criteria were identified. Patients were given a "clinical risk" level using their Risser sign and Cobb angle. Assigned clinical risk levels were compared with the ScoliScore risk levels reported by the manufacturer's scoring algorithm. RESULTS: ScoliScore risk distribution in our population was 36% low risk, 55% intermediate risk, and 9% high risk. This compares with 2%, 51%, and 47%, respectively, for comparable clinical risk groupings. Only 25% of patients were in the same risk category for both systems. There were no significant correlations between ScoliScore and age, race, menarcheal status, Risser sign, or sex. There was a positive correlation between the Cobb angle and the ScoliScore (r = 0.581, P < 0.001). Cobb angle remained significant in the multivariate regression model (P < 0.001), and Cobb angle was found to account for 33.3% of ScoliScore's variance. CONCLUSION: Only Cobb angle showed significant correlation with ScoliScore among the socioclinical variables studied. The risk distribution of the 2 risk estimation systems examined differed markedly: ScoliScore predicted nearly 16 times more low-risk patients and more than 5 times fewer high-risk patients. This demonstrates that ScoliScore provides unique information to traditional predictors of curve progression, advancing our understanding of the role of ScoliScore in the clinical setting.

The incidence of congenital scoliosis in infants with tetralogy of Fallot based on chest radiographs.

Early diagnosis is critical in patients with congenital scoliosis to identify vertebral defects that have a high risk for progression. A review of the medical records and chest radiographs for 562 patients who underwent corrective surgery for tetralogy of Fallot (TOF) at our institution between 1992 and 2007 was conducted. Of the 364 patients examined in the study, 12 patients (3.3%), six girls and six boys, had a positive diagnosis of congenital scoliosis confirmed by examination of radiographs. This incidence is significantly higher than both the incidence reported in prior studies (0-1.4%) and in the general population (0.05-0.10%). Given that patients with TOF routinely undergo chest radiograph, physicians examining chest radiographs of TOF patients should be aware of the potential for congenital scoliosis to provide early diagnosis and referral for orthopaedic evaluation and treatment.

Electronic monitoring improves brace-wearing compliance in patients with adolescent idiopathic scoliosis: a randomized clinical trial.

STUDY DESIGN: Randomized controlled trial. OBJECTIVE: To assess whether monitoring increases brace-wearing compliance in patients with adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: Noncompliance is a barrier to brace treatment of AIS. Studies have demonstrated that monitoring improves medication compliance; however, this has not been investigated in spinal braces. METHODS: Twenty-one patients (mean age = 12.4 ± 2.0 years) with AIS were prescribed treatment with a custom-made Thoraco-Lumbo-Sacral-Orthosis for 18 hours a day using a standardized script. Before beginning treatment, 10 patients were randomized to be informed that their compliance was monitored, whereas 11 patients were unaware. Compliance was measured via a temperature probe embedded within the Thoraco-Lumbo-Sacral-Orthosis hidden from view. RESULTS: Patients who were notified that they had a monitor in their brace demonstrated significantly increased compliance during the first 14 weeks of treatment compared with those who were uninformed (85.7% vs. 56.5%, P = 0.029), corresponding to a mean difference of 5.24 hours of daily brace wear. CONCLUSION: Electronic monitoring can improve compliance with orthoses in patients with spinal deformity during a short observation period.

Development and initial validation of the assessment of caregiver experience with neuromuscular disease.

BACKGROUND: Orthopaedic intervention can have a wide range of functional and psychosocial effects on children with neuromuscular disease (NMD). In the multihandicapped child (Gross Motor Classification System IV/V), functional status, pain, psychosocial function, and health-related quality of life also have effects on the families of these child. The purpose of this study is to report the development and initial validation of an outcomes instrument specifically designed to assess the caregiver impact experienced by parents raising severely affected NMD children: the Assessment of Caregiver Experience with Neuromuscular Disease (ACEND). METHODS: In the first part of this prospective study, 61 children with NMD and their parents were administered a range of earlier validated pediatric health measures. A framework technique was used to select the most appropriate and relevant subset of questions from this large set. Sensitivity analyses guided the development of a master question list measuring caregiver impact, excluding items with low relevance, and modifying unclear questions. In the second part of the study, the ACEND was administered to the caregivers of 46 children with moderate-to-severe NMD. Statistical analyses were conducted to determine validity of the instrument. RESULTS: The resulting ACEND instrument included 2 domains, 7 subdomains, and 41 items. Domain 1, examining physical impact, includes 4 subdomains: feeding/grooming/dressing (6 items), sitting/play (5 items), transfers (5 items), and mobility (7 items). Domain 2, which examines general caregiver impact, included 3 subdomains: time (4 items), emotion (9 items), and finance (5 items). Mean overall relevance rating was 6.21 ± 0.37 and clarity rating was 6.68 ± 0.52 (scale 0 to 7). Multiple floor effects in patients with GMFCS V and ceiling effects in patients with GMFCS III were identified almost exclusively in motor-based items. Virtually no floor or ceiling effects were identified in the time, emotion or finance domains across GMFCS level. CONCLUSIONS: The initial validation demonstrated that ACEND is a valid, disease-specific measure to quantify experience on caregivers of children with NMD. Larger groups of patients across NMD disease type are currently being tested to strengthen validity findings. Additionally, the ACEND is now being administered before and after orthopaedic interventions to determine responsiveness, which is critical to health outcomes research. LEVEL OF EVIDENCE/RELEVANCE: IIc.

Impact of fractures on school attendance.

BACKGROUND: The purpose of this study was to determine the average prevalence of children across the nation who experience difficulty in attending school after an acute orthopaedic injury. METHODS: A survey was created to obtain information on school absence for children with acute orthopaedic injuries. All members of the Pediatric Orthopaedic Society of North America were invited to complete the survey. RESULTS: The survey was sent by e-mail to 936 members of the Pediatric Orthopaedic Society of North America. A total of 283 surgeons from 45 states responded to the survey, which resulted in a response rate of 30.2%. The survey found a correlation with difficulty in attending school with a cast and the size of the population served. Communities with the larger populations are less likely to permit children to attend school with a cast. The most common reasons given by schools for a child not being permitted to attend school with a cast were concern for the safety of the child and inability to accommodate the needs of the child. CONCLUSIONS: Most physicians participating in the survey reported no difficulty with their patients attending school with a cast. There was more difficulty with children in attending school with a cast in metropolitan areas and in communities with greater than 1 million people. To decrease or to eliminate absence from school, it may be best to identify schools in a physician's community that do not allow attendance of children with a cast. Once individual schools are identified, advocacy can be targeted. At the very least, when it is known which schools are involved, the surgeon can anticipate difficulties and plan accordingly. As a child's absence from school has substantial negative consequences, we strongly support intervention to enable injured children to appropriately return to a regular educational setting in a timely manner. Future studies with school participation would help to identify reasons for school absence after a musculoskeletal injury. LEVEL OF EVIDENCE: Level V, Prognostic.

Can parents rate their children's quality of life? Perspectives on pediatric orthopedic outcomes.

The ultimate goal of treatment for children with orthopedic problems is to improve their health-related quality of life. Because children may lack the abilities to effectively interpret and answer the questions used to assess a patient's health-related quality of life, parent proxies have been used in such pediatric cases. Unfortunately, previous studies exploring the efficacy of these parent proxies have been inconsistent. It is therefore important to determine the level of agreement between child-parent dyads and whether agreement is mediated by variables such as disease type, demographics, instrument, and the domain being assessed. The purpose of this study was to examine the degree of agreement between children and their parents' ratings in the Child Health Questionnaire (CHQ) and the Pediatric Orthopaedic Data Collection Instrument (PODCI), two instruments commonly used to assess health-related quality of life in children. The CHQ, PODCI, and standard demographic and clinical data were collected from parents and children between the ages of 5 and 18 years with a wide range of musculoskeletal problems. There was a strong level of agreement between child and parent responses for most of the domains in both instruments. Exceptions included Physical Functioning (PF), General Health (GH), and Mental Health (MH) in the CHQ, and Expectations in the PODCI. All four of these domains exhibited significant differences between the two respondent groups and had medium effect sizes. Children reported a higher level of PF and lower levels of both GH and MH than their parents. Additionally, parents reported significantly higher expectations for treatment than children did. None of the regressions yielded significant ß values for child age, parent sex, match/no match between parent-child sex, and scoliosis/nonscoliosis diagnosis. These significant discrepancies were not driven by specific subsamples; therefore, we concluded that these discrepancies can be generalized to the pediatric orthopedic population. Our results also indicate that the CHQ is more sensitive than the PODCI to the rating differences between children and parents. The results of this study can serve clinicians in pediatric orthopedic surgery as a guide for not only selecting the most appropriate instruments for assessment but also for interpreting treatment outcomes most meaningfully. Level of Evidence is the Level II Prognostic Study.

Child abuse: the role of the orthopaedic surgeon in nonaccidental trauma.

BACKGROUND: Child abuse presents in many different forms: physical, sexual, psychological, and neglect. The orthopaedic surgeon is involved mostly with physical abuse but should be aware of the other forms. There is limited training regarding child abuse, and the documentation is poor when a patient is at risk for abuse. There is a considerable risk to children when abuse is not recognized. QUESTIONS/PURPOSES: In this review, we (1) define abuse, (2) describe the incidence and demographic characteristics of abuse, (3) describe the orthopaedic manifestations of abuse, and (4) define the orthopaedic surgeon's role in cases of abuse. METHODS: We performed a PubMed literature review and a search of the Department of Health and Human Services Web site. The Pediatric Orthopaedic Surgery of North America trauma symposium was referenced and expanded to create this review. RESULTS: Recognition and awareness of child abuse are the primary tasks of the orthopaedic surgeon. Skin trauma is more common than fractures, yet fractures are the most common radiographic finding. Patients with fractures who are younger than 3 years, particularly those younger than 1 year, should be evaluated for abuse. No fracture type or location is pathognomonic. Management in the majority of fracture cases resulting from abuse is nonoperative casting or splinting. CONCLUSIONS: The role of the orthopaedic surgeon in suspected cases of child abuse includes (1) obtaining a good history and making a thorough physical examination; (2) obtaining the appropriate radiographs and notifying the appropriate services; and (3) participating in and communicating with a multidisciplinary team to manage the patients.