What is the role of plastic surgery for incisional closures in pediatric spine surgery? Results from a pediatric spine study group survey.

Current best practice guidelines recommend a plastics-style multilayer wound closure for high-risk pediatric spine surgery. However, plastic surgery closure of spinal incisions remains controversial. This study investigates surgeon perceptions and practice patterns regarding plastic surgery multilayered closure (PMC) in pediatric spine surgery. All surgeons in an international pediatric spine study group received a 30-question survey assessing incisional closure practices, frequency of plastic surgery collaboration, and drain management. Relationship to practice size, setting, geographic region, and individual diagnoses were analyzed. 87/178 (49%) surgeons responded from 79% of participating sites. Plastics utilization rates differed by diagnosis: neuromuscular scoliosis 16.9%, early onset scoliosis 7.8%, adolescent idiopathic scoliosis 2.8% (P < 0.0001). Plastics were used more for early onset scoliosis [odds ratio (OR) 18.5, 95% confidence interval (CI): 8.5, 40.2; P < 0.001] and neuromuscular scoliosis [OR 29.2 (12.2, 69.9); P < 0.001] than adolescent idiopathic scoliosis. Plastics use was unrelated to practice size, setting, or geographic region (P ≥ 0.09). Respondents used plastics more often for spina bifida and underweight patients compared to all other indications (P < 0.001). Compared to orthopaedic management, drains were utilized more often by plastic surgery (85 vs. 21%, P = 0.06) and for longer durations (P = 0.001). Eighty-nine percent of surgeons felt plastics increased operative time (58 ±â€…37 min), and 34% felt it increased length of hospitalization. Surgeons who routinely utilize plastics were more likely to believe PMC decreases wound complications (P = 0.007). The perceived benefit of plastic surgery varies, highlighting equipoise among pediatric spine surgeons. An evidence-based guideline is needed to optimize utilization of plastics in pediatric spine surgery.

Hip Surgery is Not More Painful Than Spine Surgery in Children With Cerebral Palsy.

BACKGROUND: Posterior spinal fusion (PSF) and hip reconstruction are commonly indicated surgeries in children with cerebral palsy (CP), particularly those functioning at GMFCS levels IV and V. These are large and often painful procedures, and previous literature suggests that hip surgery is more painful than spine surgery in this patient population. The purpose of this study is to investigate pain scores and opioid use following hip and spine surgery in a large cohort of children with CP, including many patients who have undergone both types of surgery. METHODS: A retrospective chart review was performed to identify children with CP who underwent hip reconstruction and/or PSF at a tertiary children's hospital between 2004 and 2022. Charts were reviewed for demographic data, pain scores, pain medication usage, duration of hospital stay, and complications. RESULTS: Data were collected for 200 patients (101 male, 99 female) who met inclusion criteria. Eighty-seven patients underwent hip reconstruction, 62 spinal fusion, and 51 both hip and spine surgery asynchronously. Median (interquartile range) age at the time of surgery was significantly older for spinal fusion compared with hip surgery [13.1 (4.9) vs. 8.1 (5.7) y, P<0.0001]. Length of stay was significantly longer after PSF, with a median of 6 (4) days compared with 2 (1) days after hip surgery (P<0.0001). Both maximum and average daily pain scores were similar following hip and spine surgery, with the exception that average pain scores for hip surgery were slightly higher on postoperative day 1, hip=1.73 vs. spine=1.0 (P<0.0001). The amount of opioids used, expressed as morphine milligram equivalents (MME)/kg were similar in the hip and spine surgery groups; however, it was significantly lower in the hip surgery group on postoperative day 0, hip=0.06 versus spine=0.17 (P<0.0001). For the 51 patients who underwent both hip and spine surgery, the amount of opioids used mirrored that for the entire group (similar MME/kg, though only statistically significantly less on POD 0 and 3), and pain scores were not significantly different between the 2 groups except in 2 circumstances. The 2 exceptions in these 51 patients both demonstrated lower pain scores in patients after hip surgery, including lower maximum pain scores on POD 1 (P=0.041), and lower average pain scores on POD3 (P=0.043). CONCLUSIONS: This is the largest series to date comparing postoperative pain in children with CP after hip and spine surgery, including 51 of 200 patients who underwent both types of surgery. The results of this study demonstrate that hip surgery is not more painful than spine surgery in children with CP, and conflict with the traditional belief that hip surgery is more painful. This is important information for health care providers when counseling patients and families regarding these surgeries in children with CP. LEVEL OF EVIDENCE: Level 3.

Is a Three-component Video-based Version of the Foot Posture Index Valid for Assessing Pediatric Patients With Orthopaedic and Neurologic Foot Conditions?

BACKGROUND: The Foot Posture Index-6 (FPI6) is an assessment of foot position that can be useful for patients with orthopaedic complaints. The FPI6 rates six components of foot position from -2 to +2, resulting in a total score on a continuum between -12 (severe cavus or supination) to +12 (severe planus or pronation). The subscores are ratings made by the examiner and are subjective assessments of deformity severity. The FPI6 requires palpation of bony structures around the foot and therefore must be administered live during physical examination. Because it is sometimes impractical to perform these assessments live, such as for retrospective research, a valid and reliable video-based tool would be very useful. QUESTIONS/PURPOSES: This study examines a version of the FPI using three of the original six components to determine: (1) Are scores from the three-component version of the FPI (FPI3) associated with those from the original six-component version (FPI6)? (2) Is the three-component FPI3 as reliable as the original six-component FPI6? (3) Are FPI3 assessments done retrospectively from video as reliable as those done live? METHODS: A retrospective group of 155 participants (106 males; mean age 13 ± 4 years) was studied. All had undergone gait analysis including videotaping and in-person assessment using the FPI6. Ratings for three components (calcaneus inversion/eversion, medial arch congruence, and forefoot abduction/adduction) were extracted yielding an FPI3 score ranging from -6 to +6. The other three components of the FPI6 (talar head palpation, curves above and below the lateral malleolus, talonavicular joint bulge) were excluded from the FPI3. FPI6 and FPI3 scores and side-to-side asymmetry were compared for all participants and for diagnosis subgroups (cerebral palsy and Charcot-Marie-Tooth disease) using a Pearson correlation. Agreement for foot posture categorization between the FPI6 and FPI3 was assessed using weighted kappa. Intra- and interrater reliability of live and video-based assessments for the FPI3 and its components were examined using intraclass correlation coefficients (ICCs) and Bland-Altman analysis. RESULTS: Scores from the FPI3 and FPI6 are highly associated with each other, suggesting the FPI3 is an adequate substitute for the FPI6. FPI6 and FPI3 scores (r = 0.98) and asymmetry (r = 0.96) were highly correlated overall and within the cerebral palsy (r = 0.98 for scores; r = 0.98 for asymmetry) and Charcot-Marie-Tooth (r = 0.96 for scores; r = 0.90 for asymmetry) subgroups (all p < 0.001). Agreement between the FPI6 and FPI3 was high for foot posture categorization (weighted agreement = 95%, weighted κ = 0.88; p < 0.001). Interrater reliability for live ratings was similar for FPI3 and FPI6 and high for both measures (ICC = 0.95 for FPI6 and 0.94 for FPI3; both p < 0.001). High reliability was seen in video versus live ratings for the FPI3 total score and each of its components regardless of whether they were performed by the same (ICC = 0.98) or different (ICC = 0.97) raters (both p < 0.001), and interrater reliability remained high when the FPI3 was scored from video recordings (ICC = 0.96; p < 0.001). CONCLUSION: The FPI3 is valid and reliable when done live or from video or by the same or different examiners. It is suitable for retrospective and multicenter research studies, provided videos are done using standardized protocols. Further research is recommended investigating possible ceiling and floor effects in patients with pathologic conditions.Level of Evidence Level III, diagnostic study.

The Fate of The Broken Tether: How Do Curves Treated with Vertebral Body Tethering Behave After Tether Breakage?

STUDY DESIGN: Retrospective, Multicenter. OBJECTIVE: Assess curve progression and occurrence of revision surgery following tether breakage after vertebral body tethering (VBT). SUMMARY OF BACKGROUND DATA: Tether breakage after VBT is common with rates up to 50% reported. In these cases, it remains unknown whether the curve will progress or remain stable. METHODS: Adolescent and juvenile idiopathic scoliosis patients in a multicenter registry with ≥2 year-follow-up after VBT were reviewed. Broken tethers were listed as postoperative complications and identified by increased screw divergence of >5° on serial radiographs. Revision procedures and curve magnitude at subsequent visits were recorded. RESULTS: Of 186 patients who qualified for inclusion, 84 (45.2%) patients with tether breakage were identified with a mean age at VBT of 12.4±1.4 years and mean curve magnitude at index procedure of 51.8°±8.1°. Tether breakage occurred at a mean of 30.3±11.8 months and mean curve of 33.9°±13.2°. Twelve patients (12/84, 14.5%) underwent 13 revision procedures after VBT breakage, including 6 tether revisions and 7 conversions to fusion. All tether revisions occurred within 5 months of breakage identification. No patients with curves <35° after breakage underwent revision. Revision rate was greatest in skeletally immature (Risser 0-3) patients with curves ≥35° at time of breakage (Risser 0-3: 9/17, 53% vs. Risser 4-5: 3/23, 13%, P=0.01).Curves increased by 3.1° and 3.7° in the first and second year, respectively. By two years, 15/30 (50%) progressed >5° and 8/30 (26.7%) progressed greater than 10°. Overall, 66.7% (40/60) reached a curve magnitude >35° at their latest follow-up, and 14/60 (23.3%) reached a curve magnitude greater than 45°. Skeletal maturity did not affect curve progression after tether breakage (P>0.26), but time to rupture did (P=0.048). CONCLUSION: While skeletal immaturity and curve magnitude were not independently associated with curve progression, skeletally immature patients with curves ≥35° at time of rupture are most likely to undergo additional surgery. Most patients can expect progression at least 5° in the first two years after tether breakage, though longer-term behavior remains unknown. LEVEL OF EVIDENCE: III.

Pediatric Outcomes Data Collection Instrument Scores Within Gross Motor Function Classification Scale Levels and Functional Mobility Scale Ratings in Individuals With Cerebral Palsy.

BACKGROUND AND OBJECTIVE: The Pediatric Outcomes Data Collection Instrument (PODCI) is a patient/parent-reported outcome measure used in children with cerebral palsy (CP). PODCI score variability has not been widely examined in patients of Gross Motor Function Classification System (GMFCS) level IV or using the Functional Mobility Scale (FMS). The purpose of this study is to examine the distribution of PODCI scores within patients with CP GMFCS levels I-IV and FMS levels 1-6. METHODS: Retrospectively identified patients with CP whose parent/caregiver had completed the PODCI at their visit were grouped based on GMFCS and FMS level. One-way ANOVA with pairwise Bonferroni-adjusted post hoc tests was performed to compare the effect of GMFCS and FMS levels (1, 2-4, 5, or 6) on PODCI scores. RESULTS: Three hundred sixty-seven patients were included (128 female, 11.7 years, SD 3.6). Global, Sports, Transfer, and Upper Extremity scores differed among all GMFCS levels ( P ≤0.056) and were significantly lower for GMFCS IV compared with all other levels. Happiness, Expectations, and Pain scores did not differ significantly among GMFCS levels including level IV ( P >0.06). Similar trends were seen at all FMS distances (5, 50, and 500âm). At 50âm, Global, Sports, Transfer, and Upper Extremity scores differed significantly among all FMS levels ( P <0.001) except that Upper Extremity Scores were similar between levels 2-4 and level 5 ( P =1.00). Happiness and Pain scores were not different between FMS levels ( P >0.27). Expectations scores differed only between FMS 1 and FMS 6 with FMS 6 being higher at the 50-m distance only ( P =0.03). CONCLUSIONS: Parent-reported outcome measures are important for providing patient-centered care. Providers can examine these measures alongside functional classification systems to create a more complete clinical picture of the patient. Providers should be aware of the score trends seen in our results when evaluating the PODCI for individuals with CP to improve shared decision-making and better monitor their need for future care. LEVEL OF EVIDENCE: Level III-retrospective study.

Does Size Really Matter? Incidence of Periprosthetic Fractures After Femoral Osteotomy in Patients With Cerebral Palsy.

OBJECTIVE: Of children, 30% to 35% with cerebral palsy (CP) develop hip subluxation or dislocation and often require reconstructive hip surgery, including varus derotation osteotomy (VDRO). A recent literature review identified postoperative fractures as the most common complication (9.4%) of VDROs. This study aimed to assess risk factors for periprosthetic fracture after VDRO in children with CP. METHODS: A total of 347 patients (644 hips, 526 bilateral hips) with CP and hip subluxation or dislocation (129 females; mean age at index VDRO: 8.6 y, SD 3.4, range: 1.5 to 17.7; 2 Gross Motor Function Classification System (GMFCS) I, 35 GMFCS II, 39 GMFCS III, 119 GMFCS IV, 133 GMFCS V, 21 unavailable) were included in this retrospective, single-group intervention (VDRO) study at a tertiary referral center. Imaging and clinical documentation for patients age 18 years or younger at index surgery, treated with VDRO were reviewed to determine demographic data, GMFCS level, surgeon, type of hardware implanted, use of anticonvulsants and steroids, type of postoperative immobilization, presence of periprosthetic fractures, fracture location and mechanism, and time from surgery to fracture. Potential determinants of periprosthetic fractures were assessed using mixed effects logistic regression. RESULTS: Of 644 hips, 14 (2.2%, 95% CI: 1.3%, 3.6%) sustained a periprosthetic fracture, at a median of 2.1 years postoperatively (interquartile range: 4.6 y, range: 1.2 mo to 7.8 y). Patients with a fracture had a median age at index surgery of 7.3 years (interquartile range: 4.3, range: 2.8 to 17.8; 1 GMFCS II, 6 GMFCS IV, 7 GMFCS V). Periprosthetic fractures were not significantly related to age at index surgery ( P = 0.18), sex ( P = 0.30), body mass index percentile ( P = 0.87), surgery side ( P = 0.16), anticonvulsant use ( P = 0.35), type of postoperative immobilization ( P = 0.40), GMFCS level ( P = 0.31), or blade plate size ( P = 0.17). Only surgeon volume significantly related to periprosthetic fracture (odds ratio = 5.03, 95% CI: 1.53, 16.56, P = 0.008), with the highest-volume surgeon also using smaller blade plates ( P < 0.01). CONCLUSIONS: Periprosthetic fractures after VDRO surgery in children with CP are uncommon, and routine hardware removal appears unnecessary. The data suggest that the common dogma of putting in the largest blade plate possible to maximize fixation may increase the risk of periprosthetic fracture. Due to the overall low fracture rate, especially when contextualized relative to the risk of hardware removal, a reactive approach to hardware removal appears warranted. LEVEL OF EVIDENCE: Level III-retrospective study (targeting varus derotational osteotomies in children with cerebral palsy).

Update on the reliability of gait analysis interpretation in cerebral palsy: Inter-institution agreement.

BACKGROUND: Studies have shown good reliability for gait analysis interpretation among surgeons from the same institution. However, reliability among surgeons from different institutions remains to be determined. RESEARCH QUESTION: Is gait analysis interpretation by surgeons from different institutions as reliable as it is for surgeons from the same institution? METHODS: Gait analysis data for 67 patients with cerebral palsy (CP) were reviewed prospectively by two orthopedic surgeons from different institutions in the same state, each with > 10 years' experience interpreting gait analysis data. The surgeons identified gait problems and made treatment recommendations for each patient using a rating form. Percent agreement between raters was calculated for each problem and treatment, and compared to expected agreement based on chance using Cohen's kappa. RESULTS: For problem identification, the greatest agreement was seen for equinus (85% agreement), calcaneus (88%), in-toeing (89%), and out-toeing (90%). Agreement for the remaining problems ranged between 66-78%. Percent agreement was significantly higher than expected due to chance for all issues (p ≤ 0.01) with modest kappa values ranging from 0.12 to 0.51. Agreement between surgeons for treatment recommendations was highest for triceps surae lengthening (89% agreement), tibial derotation osteotomy (90%), and foot osteotomy (87%). Agreement for the remaining treatments ranged between 72-78%. Percent agreement for all treatments was significantly higher than the expected values (p ≤ 0.002) with modest kappa values ranging from 0.22 to 0.52. SIGNIFICANCE: Previous research established that computerized gait analysis data interpretation is reliable for surgeons within a single institution. The current study demonstrates that gait analysis interpretation can also be reliable among surgeons from different institutions. Future research should examine reliability among physicians from more institutions to confirm these results.

Changes in Sports Participation, Specialization, and Burnout From 7th to 12th Grade: Final Results From a 6-Year Longitudinal Study.

BACKGROUND: Previous studies show alarming rates of burnout and dropout from sports participation and physical activity in the youth population. Early sports specialization may increase the risk of injury, burnout, and eventual dropout from sports. HYPOTHESIS: Sports participation will decrease, specialization will increase, and burnout will increase from junior high to high school. STUDY DESIGN: Prospective longitudinal study. LEVEL OF EVIDENCE: Level 2b. METHODS: The graduating class of 2023 was surveyed longitudinally in the fall of each school year from 7th to 12th grade (n = 35-77 from middle to high school based on new enrollment participants and attrition). Survey questions asked about sports participation, specialization, and burnout. Responses were analyzed by grade level using mixed effects linear and logistic regression accounting for repeated measures. RESULTS: The number of days per week in which students engaged in at least 60 minutes of strenuous exercise progressively decreased from 7th through 12th grade from 4.0 to 2.3 days per week (P < 0.01). The percentage of students participating in sports also decreased from 7th to 12th grade from 82% to 39% (P < 0.01). More students stopped participating in a sport (38% vs 22% to 29%, P = 0.04), quit a sport to focus on a single sport (60% vs 46% to 49%, P = 0.01), or reported that 1 sport was most important to them (71% vs 54% to 67%, P = 0.06) in 9th grade. Burnout in sports did not differ significantly by grade level (19% to 23%, P > 0.99). In contrast, burnout in school was significantly more common in high school (54% to 69%) compared with middle school (36%, P < 0.01). Burnout in school was higher in female students compared with male students (68% vs 38%, P < 0.01). CONCLUSION: Organized sports participation and general physical activity decreased from middle to high school, with the entry into high school at 9th grade being a time at which a significant number of students dropped other sports to specialize in a single sport or stopped participating. Burnout in sports did not appear to increase with age; however, there was an increase in school-related burnout as students transitioned from middle to high school. CLINICAL RELEVANCE: Our results highlight the need for continued research into sports participation, specialization, and burnout in adolescents. In addition, health professionals and the community (parents, coaches, teachers) supporting youth athletes may consider positive interventions during the periods of transition from middle to high school to include facilitating different tracks of sports participation (including a developmental or recreational model of play) to reduce dropout from sport and supportive measures to lessen burnout from sports and from school.

Anterior Distal Femoral Hemiepiphysiodesis Does Not Change Pelvic Tilt in Children With Cerebral Palsy.

BACKGROUND: Anterior distal femoral hemiepiphysiodesis (ADFH) is a surgical treatment choice to correct flexed knee gait and fixed knee flexion deformities in children with cerebral palsy who are skeletally immature. Increased anterior pelvic tilt has been reported after surgeries that correct knee flexion deformities, including hamstring lengthening (HSL) and distal femoral extension osteotomies, but anterior pelvic tilt has not been studied after ADFH. We hypothesized that anterior pelvic tilt would increase after ADFH, especially when combined with HSL, and it would correlate with the change in minimum knee flexion in stance and dynamic hamstring lengths. METHODS: Thirty-four eligible participants (age: 13.0, SD: 2.0) were included. Change in mean pelvic tilt across the gait cycle was compared as a function of clinical and gait parameters using linear mixed models. The relationship of change in pelvic tilt to change in other variables was examined using Pearson correlation. RESULTS: Overall, anterior pelvic tilt increased significantly after ADFH by 4.4 degrees ( P = 0.02). Further, the analysis revealed anterior pelvic tilt only increased significantly in the group that had concurrent HSL (11.1 degrees, P < 0.001). Overall, minimum knee flexion significantly decreased (increase in knee extension) in stance (-19.1 degrees, P < 0.001) and there was an increase in maximum normalized dynamic hamstring lengths (0.03, P < 0.001). The anterior pelvic tilt increased significantly in Gross Motor Function Classification System levels III to IV (5.9 degrees, P = 0.02) but did not change significantly in Gross Motor Function Classification System I to II (2.5 degrees, P = 0.37). Change in pelvic tilt was correlated with change in maximum dynamic hamstring lengths ( r = 0.87, P < 0.0001) and change in minimum knee flexion in stance ( r = -0.71, P < 0.0001). CONCLUSIONS: Anterior distal hemiepiphysiodesis without concurrent HSL for flexion knee deformities does not result in increased anterior pelvic tilt. Surgeons should consider anterior distal hemiepiphysiodesis in patients with cerebral palsy and flexed knee gait, who preoperatively have long dynamically modeled hamstrings, are skeletally immature, and when maintenance of pelvic tilt is desired. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Lower-extremity kinematics and kinetics differ based on drop vertical jump variation: An assessment of methodology for a return-to-play protocol using motion analysis.

BACKGROUND: The drop vertical jump (DVJ) is commonly used in return-to-play evaluations to assess movement quality and risk during a dynamic task. However, across biomechanics literature, a multitude of DVJ variations have been used, influencing the generalizability and potential interpretation of the reported findings. RESEARCH QUESTION: The purpose of this study was to identify differences in lower extremity kinematics and kinetics between DVJ variations that differ based on horizontal jump distance, verbal instructions, and the use of a jump target. METHODS: A single-group repeated measures design was used in a laboratory setting. Twenty participants were tested, and three-dimensional angles and moments of the pelvis, hip, knee, and ankle were computed. Wilcoxon signed rank tests were performed to determine differences between DVJ variations. RESULTS: Reduced knee flexion at initial contact and greater knee extensor moments across the descent phase were observed with increased horizontal jump distance. Additionally, both verbal instructions and a jump target influenced movement strategies at the pelvis, hip, and knee. Ground reaction forces were found to be similar across conditions and jump height following the first landing increased with a target. SIGNIFICANCE: Although subtle, the biomechanical differences observed between task variations emphasize the importance of standardizing motion analysis protocols for research and clinical decision-making. Given the findings of the current study, the authors recommend using the Half Height variation in patients treated for a knee injury as it will likely be the most indicative of movement quality.

Dedicated Early Morning Orthopaedic Trauma Operating Room Is Associated With Shorter Time to Surgery and Decreased Length of Hospital Stay for Children Undergoing Surgical Treatment of Supracondylar Humerus Fractures: A Retrospective Cohort Study.

INTRODUCTION: The purpose of this study was to investigate whether the use of a dedicated early morning orthopaedic trauma operating room (OR) resulted in shorter wait times, decreased surgical times, decreased length of stay (LOS), and decreased complications in children treated with urgent surgical intervention for supracondylar humerus fractures. METHODS: This retrospective comparative cohort study at a level I pediatric trauma center included patients younger than 12 years with supracondylar humerus fractures urgently treated with closed or open reduction and percutaneous pinning. Index surgical cases from April 28, 2013, to February 26, 2020, were included. Patients with prior humerus fracture, concomitant injuries, open fracture, pulseless supracondylar fracture, or missing data were excluded. Patients were analyzed based on the type of OR: dedicated early morning orthopaedic trauma OR or typical daytime orthopaedic OR. The primary outcome was time from presentation to surgery. Secondary outcomes included surgical time, complications, and LOS. RESULTS: A total of 401 patients with a mean age of 5 ± 2 (range: 1 to 11) years and a mean follow-up of 2.0 ± 2.1 (range: 0.5 to 25.0) months were included, of whom 137 patients (34%) underwent surgery in the early morning dedicated orthopaedic trauma OR. The dedicated early morning orthopaedic OR group had significantly less time from presentation to surgery (7.5 versus 9.4 hours; P = 0.0002) and shorter LOS (21.0 versus 24.0 hours; P = 0.004) compared with children treated in the typical daytime orthopaedic OR. Surgical time (31.1 versus 32.6 minutes; P = 0.40) and complication rates (5.8% versus 4.9%; P = 0.65) were similar between the groups. No revision surgery was required in either group. DISCUSSION: Surgical wait times were diminished with use of the dedicated early morning OR, as was LOS. Surgical times and complication rates were similar between groups. Institutions may consider adopting a dedicated early morning orthopaedic trauma OR to improve surgical wait times and decrease LOS. LEVEL OF EVIDENCE: III.

Use of Surgical Adjuvants Does Not Decrease Recurrence of Aneurysmal Bone Cysts in Surgical Intervention With Pediatric Patients.

BACKGROUND: Aneurysmal bone cysts (ABCs) are benign active tumors often requiring intralesional curettage with or without adjuvants. The primary aim of this study was to analyze whether recurrence is influenced by the use of surgical adjuvants in pediatric patients with ABCs. Secondary aims examined recurrence rates based on age, sex, and physeal contact. METHODS: A retrospective review was performed at a tertiary pediatric hospital from 2004 to 2020. Inclusion criteria consisted of patients treated surgically for histologically confirmed ABCs with a minimum of 6 months follow-up. Patients with treatment for a recurrent tumor or incomplete records were excluded. Patient demographics, location of the lesion, treatment technique, and incidence of recurrence were collected. Statistical analyses were performed using STATA. RESULTS: There were 129 patients (74 males and 55 females) with a mean age of 11.5 ± 4.1 years and an average follow-up of 29.0 ± 25.4 months. The most common locations for ABCs were the femur and tibia. Of the patients, 53.5% had tumors abutting the physis, 28.7% had no physeal contact, and 17.8% had insufficient imaging to evaluate physeal contact. Surgical adjuvants (high-speed burr, coagulation, liquid nitrogen, and/or hydrogen peroxide) were used in 91 of the 129 cases (70.5%). There was no significant difference in recurrence when comparing those who received an adjuvant and those who did not (25.3% vs 23.7%, P = 1.000). Physeal contact was also not significantly associated with recurrence ( P = 0.146). Finally, patients younger than 6 years old were significantly more likely to have recurrence compared with those 6 years old or older (66.7% vs 21.7%, P = 0.007). CONCLUSION: Our study found no association between the use of surgical adjuvants and the risk of recurrence after intralesional curettage for ABCs. Although our study did demonstrate that patients 6 years old or younger had an increased rate of recurrence, no significant association was found regarding physeal contact or sex. These data indicate that surgical adjuvant may not affect the recurrence rates of pediatric patients with ABCs. LEVEL OF EVIDENCE: Level III. This retrospective review compares rates of recurrence based on the choice of surgical adjuvant.

Feasibility of temperature monitoring smart socks in adolescents and young adults with spina bifida.

PURPOSE: The purpose of the study was to determine if the use of continuous temperature monitoring smart socks is feasible in adolescents with spina bifida (SB) by obtaining user feedback on comfort. METHODS: Participants were provided temperature monitoring socks and a 4 G hub. Follow-up phone calls were performed to answer questions or discuss barriers. Sock temperatures were monitored throughout four weeks. Following sock wear, participants were asked to complete a satisfaction survey. RESULTS: Seventeen of the 33 participants enrolled (eight males, nine females) with a mean age of 14.8 years completed the study. Average sock wear was 8.0 hours per day for four weeks. The mean temperature was 83.4°F with a mean temperature differential between feet of -0.74°F (left-right). The duration of sock wear varied from 14.6 to 595.9 hours over the four-week period. Lastly, eleven participants (84.6%) reported that the socks were comfortable and very easy to put on. CONCLUSION: Continuous temperature monitoring smart socks are an option for monitoring risk for developing pressure injuries in adolescents with SB. Future directions would include increasing sample size, obtaining normative data for temperature ranges in this population, and correlating to clinical outcomes.

Predictors of Changes in Pelvic Rotation after Surgery with or without Femoral Derotational Osteotomy in Ambulatory Children with Cerebral Palsy.

Asymmetry of pelvic rotation affects function. However, predicting the post-operative changes in pelvic rotation is difficult as the root causes are complex and likely multifactorial. This retrospective study explored potential predictors of the changes in pelvic rotation after surgery with or without femoral derotational osteotomy (FDRO) in ambulatory children with cerebral palsy (CP). The change in the mean pelvic rotation angle during the gait cycle, pre- to post-operatively, was examined based on the type of surgery (with or without FDRO) and CP distribution (unilateral or bilateral involvement). In unilaterally involved patients, pelvic rotation changed towards normal with FDRO (p = 0.04), whereas patients who did not undergo FDRO showed a significant worsening of pelvic asymmetry (p = 0.02). In bilaterally involved patients, the changes in pelvic rotation did not differ based on FDRO (p = 0.84). Pelvic rotation corrected more with a greater pre-operative asymmetry (ß = -0.21, SE = 0.10, p = 0.03). Sex, age at surgery, GMFCS level, and follow-up time did not impact the change in pelvic rotation. For children with hemiplegia, internal hip rotation might cause compensatory deviation in pelvic rotation, which could be improved with surgical correction of the hip. The predicted changes in pelvic rotation should be considered when planning surgery for children with CP.

Using a mobile health app in a weight management program for overweight and obese adolescents and young adults with spina bifida.

CONTEXT: Adolescents and young adults (AYA) with spina bifida (SB) are more susceptible to obesity due to impaired mobility. There is limited access to physical activity for this population. OBJECTIVE: The primary aim of this study was to evaluate the feasibility of a mobile health app in a weight management program for AYA with SB. This was determined by measuring program adherence, active use of the app (defined as ≥3 uses per week), and user rating of the Pt Pal™ mobile app. Secondary outcomes were changes in BMI, quality of life, and health behavior, and the number of active participants over time. METHODS: Patients from the SB Clinic of a large metropolitan hospital between the ages of 11-21 years and overweight were invited to participate. The program consisted of group nutrition sessions and an individualized exercise plan using a mobile app with coaching. Outcome measures were program adherence, changes in BMI, and validated survey responses. Descriptive statistical analysis was performed. RESULTS: Fifteen participants enrolled, and ten participants completed the program. Five of the ten participants attended the nutrition sessions. The number of active app users declined after the first week. Seventy percent of participants decreased their BMI. Most participants reported the program improved their ability to exercise regularly, eat a healthier diet and feel more self-confident. Peds QL™ psychosocial health domains increased postintervention. The YRBS showed increased physical activity and less sedentary time postintervention. CONCLUSIONS: This mobile app-based weight management program with coaching implemented may not be feasible for adoption in the general population of AYA with SB; however, it was well received by some, and further testing is needed to determine how to improve feasibility. This study provides useful information to guide future programs utilizing digital health and coaching.

Comparison of kinematics between Theia markerless and conventional marker-based gait analysis in clinical patients.

BACKGROUND: Markerless motion capture systems have the potential to make clinical gait analysis more efficient and convenient. Theia3D is a commercially available markerless system that may serve as an alternative to traditional gait analysis for clinical gait laboratories. RESEARCH QUESTION: What is the concurrent validity of markerless gait analysis using Theia3D compared to traditional marker-based gait analysis in pediatric clinical gait patients? METHODS: Thirty-six patients (20 male, age 2-25 years) with a range of diagnoses underwent clinical gait analysis with data being captured concurrently by a traditional marker-based motion capture system (Vicon Nexus) and a commercial markerless system (Theia3D). Multiple left strides were averaged for each subject, and the difference in kinematics (Theia - Vicon) was calculated over the gait cycle and evaluated using root mean square difference (RMSD), mean difference, and RMSD after subtracting the mean value across the gait cycle (RMSDoffset). Sub-analysis was performed for 25 patients with foot deformities, 9 wearing ankle-foot orthoses, and 6 walking with assistance (cane, crutches, walker, or handheld). RESULTS: Kinematics showed similar patterns between the marker-based and markerless systems. RMSD was < 6° except for pelvic tilt, hip flexion, ankle inversion, foot progression, and transverse plane rotation of the hip, knee, and ankle. These measures mainly differed due to an offset between the curves. After adjusting for offsets, all RMSDoffset were < 6°. RMSD was larger for patients with foot deformities, wearing orthoses, or using assistive devices, but all RMSDoffset were still < 8°. In some cases, however, the markerless system had greater trial-to-trial variability, showed a larger knee varus "bump" in swing, or failed to track the subject. SIGNIFICANCE: This study provides preliminary evidence of concurrent validity of Theia3D for pediatric patients with abnormal gait. However, some questions remain regarding identification of the knee axis and for patients with foot deformity or assistive devices.

The effects of sport, setting, and demographics on sunscreen use and education in young athletes.

Participation in outdoor sports increases exposure to ultraviolet radiation, necessitating mitigation through sunscreen use. This prospective study examined the effects of sport, setting (practice vs. competition), gender, age and geographic location on sunscreen use and education among youth athletes in various sports. Six hundred and twelve athletes ≤18 years old completed an online survey on sunscreen education and use during competitions and practices. Regardless of sport, reported sunscreen use was higher during practices than competition (p < 0.0001). Sunscreen was used most by swimmers/divers (odds ratio: OR ≥ 1.9, p < 0.001) and least by American football players (OR ≤ 0.57, p ≤ 0.001). Coaches mentioned sunscreen use the most in track and field (OR 1.84, p = 0.001) and the least in American football (OR 0.67, p = 0.03). Athletes used sunscreen more if they were female (OR ≥ 1.9 1.38, p ≤ 0.06) and younger (age OR ≤ 0.88, p < 0.001). In conclusion, youth athletes differ in sunscreen use by sport and setting, highlighting the need for continued photoprotective education.

Persistent increase in anterior pelvic tilt after hamstring lengthening in children with cerebral palsy.

BACKGROUND: Hamstring lengthening has traditionally been the surgical treatment of choice to correct flexed knee gait in children with cerebral palsy (CP). Improved passive knee extension and knee extension during gait are reported post hamstring lengthening, but concurrent increased anterior pelvic tilt also occurs. RESEARCH QUESTION: Does anterior pelvic tilt increase after hamstring lengthening in children with CP both in the short-term and mid-term, and what predicts increased post-operative anterior pelvic tilt? METHODS: 44 participants were included (age 7.2, SD 2.0 years; 5 GMFCS I, 17 GMFCS II, 21 GMFCS III, 1 GMFCS IV). Mean pelvic tilt was compared between visits, and the effect of potential predictors of change in pelvic tilt was examined using linear mixed models. The relationship of change in pelvic tilt to change in other variables was examined using Pearson correlation. RESULTS: Anterior pelvic tilt increased significantly post-operatively by 4.8° (p < 0.001). It remained significantly higher by 3.8° at 2-15 years follow-up (p < 0.001). Change in pelvic tilt was not affected by sex, age at surgery, GMFCS level, assistance during walking, time since surgery, or baseline values of hip extensor strength, knee extensor strength, knee flexor strength, popliteal angle, hip flexion contracture, step length, walking speed, maximum hip power in stance, or minimum knee flexion in stance. Pre-operative dynamic hamstring length was associated with greater anterior pelvic tilt at all visits but did not affect amount of change in pelvic tilt. Patients in GMFCS I-II showed a similar pattern of change in pelvic tilt to GMFCS III-IV. SIGNFICANCE: When considering hamstring lengthening for ambulatory children with CP, surgeons should weigh increased mid-term anterior pelvic tilt post-operatively with the desired outcome of improved knee extension in stance. Patients with neutral or posterior pelvic tilt and short dynamic hamstring lengths pre-operatively have lowest risk of excessive post-operative anterior pelvic tilt.

Natural history of ankle function during gait in youth with Charcot-Marie-Tooth disease types 1 and 2.

BACKGROUND: Charcot-Marie-Tooth disease (CMT) can cause progressive muscle weakness and contracture, leading to gait abnormalities such as increased and delayed peak ankle dorsiflexion and reduced ankle power generation in terminal stance. Understanding strength loss on ankle function during gait is important for interpreting treatment outcomes and evaluating new therapies designed to improve gait. RESEARCH QUESTION: Do ankle kinematics and kinetics vary as a function of age, disease progression with associated loss of muscle strength and CMT type in youth with CMT types 1 and 2? METHODS: A prospective convenience sample of 45 participants with CMT1 and 2, ages 7-22 years, underwent comprehensive gait analysis. Seventeen patients underwent repeat analyses totaling 67 tests. Generalized mixed effects linear modeling was used to compare CMT1 versus CMT2 and to examine the effects of age on ankle strength, range of motion, kinematics, and kinetics within each CMT type. RESULTS: Plantarflexor and dorsiflexor strength were less in CMT2 compared with CMT1 (p ≤ 0.05), while peak dorsiflexion in terminal stance (TST) was greater (p = 0.02). Peak plantarflexion moment and power generation were also less in CMT2 (p ≤ 0.02). In CMT1, peak dorsiflexion in TST increased with age through 13 years (p = 0.004); then plateaued in the normal range (p = 0.73). Peak ankle angle in mid-swing was closely related to the angle in TST (p < 0.001) following a similar pattern with age. In CMT2, no significant associations were observed between age, peak dorsiflexion in TST, and peak ankle angle in mid-swing (p ≥ 0.19). There were no consistent trends with age for individual patients with repeat tests. SIGNIFICANCE: The heterogeneity of joint level impairments and gait kinematics and kinetics point to the importance of having an in-depth understanding of gait at the individual patient level using comprehensive gait analysis including valid and reliable strength measures.

Exposed Intramedullary Fixation Produces Similar Outcomes to Buried Fixation for Acute Pediatric Monteggia Fractures.

BACKGROUND: Treatment of acute pediatric Monteggia fractures requires ulnar length stability to maintain reduction of the radiocapitellar joint. When operative care is indicated, intramedullary ulna fixation can be buried or left temporarily exposed through the skin while under a cast. The authors hypothesized that treatment with exposed fixation yields equivalent results to buried fixation for Monteggia fractures while avoiding secondary surgery for hardware removal. METHODS: A retrospective review of children with acute Monteggia fractures at our Level 1 pediatric trauma center was performed. Patient charts and radiographs were evaluated for age, fracture type, fracture location, Bado classification, type of treatment, complications, cast duration, time to fracture union, time to hardware removal, and range of motion. RESULTS: Out of 59 acute Monteggia fractures surgically treated (average age 6 y, range 2 to 14), 15 (25%) patients were fixed with buried intramedullary fixation and 44 (75%) with exposed intramedullary fixation under a cast. There were no significant differences between buried and exposed intramedullary fixation in cast time after surgery (39 vs. 37 d; P =0.55), time to fracture union (37 vs. 35 d; P =0.67), pronation/supination (137 vs. 134 degrees; P =0.68) or flexion/extension (115 vs. 114 degrees; P =0.81) range of motion. The exposed fixation had a return to OR of 4.5% (2 out of 44), and the buried fixation returned to the OR for removal on all patients. CONCLUSION: Exposed intramedullary fixation yielded equivalent clinical outcomes to buried devices in the treatment of acute pediatric Monteggia fractures while eliminating the need for a second surgery to remove hardware, reducing the associated risks and costs of surgery and anesthesia, but had a higher complication rate. Open Monteggia fractures or patterns with a known risk of delayed union may benefit from buried instead of exposed intramedullary fixation for earlier mobilization. LEVEL OF EVIDENCE: III.