Concurrent Validity of PROMIS and LD-SRS Scores in Pediatric Patients With Lower Limb Differences.

BACKGROUND: We sought to assess the concurrent validity of select Patient Reported Outcomes Measurement Information System (PROMIS) domains and Limb Deformity-Scoliosis Research Society (LD-SRS) scores. METHODS: We prospectively administered PROMIS-25 (including anxiety, depression, fatigue, pain interference, peer relationships, and physical function) and LD-SRS questionnaires to 46 consecutive pediatric patients with lower limb differences, presenting to a single surgeon for reconstruction. Concurrent validity between various subdomains of the 2 outcome measures was assessed through Pearson's correlation, with significance defined as P <0.05. The strength of correlation was interpreted by Evans criteria: absolute r value <0.20 indicating very weak correlation; 0.20 to 0.39, weak; 0.40 to 0.59, moderate; 0.60 to 0.79, strong; and 0.8 or greater indicating very strong correlation. RESULTS: The LD-SRS Pain, Function, and Mental Health domains most strongly correlated with the PROMIS pain interference (r=-0.79, P<0.001), physical function (r=0.74, P<0.001), and anxiety (r=-0.68, P <0.001) domains, respectively. In addition, LD-SRS pain strongly correlated with PROMIS physical function (r=0.61, P<0.001) and LD-SRS function with PROMIS pain interference (r=-0.72, P<0.001). All PROMIS domains significantly correlated with total LD-SRS scores. PROMIS pain interference (r=-0.79, P <0.001), physical function (r=0.67, P <0.001), and fatigue (r=-0.60, P <0.001) domains demonstrated the strongest correlations with the total LD-SRS score. CONCLUSIONS: The significant concurrent validity between LD-SRS and multiple PROMIS domains suggests considerable overlap, and perhaps redundancy, between these 2 outcome measures. Given the high degree of concordance and the advantage of computer adaptive testing (CAT) in mitigating administrative burden and survey fatigue, along with the ability to compare outcomes across a wider group of children with a variety of underlying diagnoses, select PROMIS domains may be a viable alternative to LD-SRS score for assessing patient-reported outcomes when treating pediatric patients with lower limb deformities. A larger, multi-center study including pediatric patients with lower limb differences from a diverse background, including age, etiology, native language, and ethnicity, would be helpful to externally validate our findings. LEVEL OF EVIDENCE: Level-I.

What Factors Correlate With Length of Stay and Readmission After Limb Lengthening Procedures? A Large-database Study.

BACKGROUND: Indications and techniques for limb lengthening procedures have evolved over the past two decades. Although there are several case series reporting on the complications and efficacy of these techniques, limited data are available on length of stay and hospital readmission rates after these procedures. QUESTIONS/PURPOSES: (1) What is the median length of stay after lower limb lengthening procedures, and is variability in patient demographics, preoperative diagnosis, and surgical technique associated with length of stay? (2) What is the 1-year readmission rate after lower limb lengthening procedures? (3) Is variability in patient demographics, preoperative diagnosis, and surgical technique associated with varying rates of hospital readmission? METHODS: Patients who underwent femoral or tibial lengthening from 2005 to 2015 in seven states were identified using the Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases. These databases include a large, diverse group of patients across a wide range of hospitals and socioeconomic backgrounds with inclusion of patients regardless of payer. Between 2005 and 2015, there were 3979 inpatient admissions that were identified as involving femoral and/or tibial lengthening procedures based on ICD-9 procedure codes; of those, 2% (97 of 3979) of the inpatient admissions were excluded from analysis because they had ICD-9 procedure codes for primary or revision hip or knee arthroplasty, and 10% (394 of 3979) of the inpatient admissions were excluded because they involved repeated admissions of patients with previous hospitalization data within the database. This yielded 3488 patients for analysis. The median (interquartile range) age of patients was 18 years (12 to 41), and 42% (1481 of 3488) of patients were women. A total of 49% (1705 of 3469) of patients were children (younger than 18 years), 19% (675 of 3469) were young adults (18 to 34 years), 24% (817 of 3469) were adults (35 to 59 years), and 8% (272 of 3469) were seniors (60 years and older). Length of stay and rates of readmission at 1 year after the lengthening procedure were calculated. Univariate analysis was performed to examine associations between age, race, payment method, underlying diagnosis, bone lengthened, and lengthening technique with length of stay and readmission rate. Factors found to be significantly associated with the outcome variables (p < 0.05) were further examined with a multivariate analyses. RESULTS: Included patients had a median (IQR) length of hospital stay of 3 days (2 to 4). Given the poor explanatory power of the multivariate model for length of stay (R 2 = 0.03), no meaningful correlations could be drawn between age, race, underlying diagnosis, lengthening technique, and length of stay. The overall 1-year readmission rate was 35% (1237 of 3488). There were higher readmission rates among adult patients compared with pediatric patients (odds ratio 1.78 [95% confidence interval 1.46 to 2.18]; p < 0.001), patients with government insurance compared with commercial insurance (OR 1.28 [95% CI 1.05 to 1.54]; p = 0.01), and patients undergoing lengthening via external fixation (OR 1.61 [95% CI 1.29 to 2.02]; p < 0.001) or hybrid fixation (OR 1.81 [95% CI 1.38 to 2.37]; p < 0.001) compared with lengthening with internal fixation only. CONCLUSION: When counseling patients who may be candidates for limb lengthening, providers should inform individual patients and their caretakers on the anticipated length of hospital stay and likelihood of hospital readmission based on our findings. Adult patients, those with government insurance, and patients undergoing hybrid or external fixator limb lengthening procedures should be advised that they are at greater risk for hospital readmission. The relationship of specific patient-related factors (such as severity of deformity or associated comorbidities) and treatment-related variables (such as amount of lengthening, compliance with physical therapy, or surgeon's experience) with clinical outcomes after lower limb lengthening and the burden of care associated with hospital readmission needs further study. LEVEL OF EVIDENCE: Level III, therapeutic study.

Issues With Big Data: Variability in Reported Demographics and Complications Associated With Posterior Spinal Fusion in Pediatric Patients.

BACKGROUND: Clinical and administrative registries provide large volumes of data that can be used for clinical research. However, there are several limitations relating to the quality, consistency, and generalizability of big data. In this study, we aim to compare reported demographics and certain outcomes in patients undergoing posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS), neuromuscular scoliosis (NS), and Scheuermann kyphosis (SK) between 3 commonly utilized databases in pediatric orthopaedic research. METHODS: We used International Classification of Diseases, Ninth Revision (ICD-9), International Classification of Diseases, 10th Revision (ICD-10), and Current Procedural Terminology (CPT) codes to identify patients in the National Surgical Quality Improvement Program (NSQIP), Healthcare Cost and Utilization Project (HCUP), and Pediatric Health Information System (PHIS) between the ages of 10 to 18 that underwent PSF for AIS, SK, and NS from 2012 to 2015. We compared various demographic factors, such as sex, race/ethnicity, age, and rates of postsurgical infection and 30-day readmissions. Data was analyzed with descriptive and univariate statistics. RESULTS: We identified 9891 patients that underwent PSF in NSQIP, 10,771 patients in PHIS, and 4335 patients in HCUP over the study period. There were significant differences in patient demographics, readmission rates, and infection rates between all patients that underwent PSF across the databases (P<0.01), as well as specifically in patients with AIS (P<0.01). HCUP had the highest proportion of Hispanic patients that underwent PSF (13.5%), as well as patients who had AIS (13.3%) or NS (17.9%). The PHIS database had the highest proportion of patients undergoing PSF for SK. Among patients with NS, there were significant differences in race across the databases (P<0.01), but no significant differences in sex, ethnicity, or readmission (P>0.05). In addition, there were significant differences in race (P=0.04) and readmission (P=0.01) across databases for patients with SK, but no differences in sex or ethnicity (P>0.05). NSQIP reported the highest rate of 30-day readmissions for patients undergoing PSF (17.9%) compared with other databases (HCUP 4.1%, PHIS 12.1%). CONCLUSIONS: There are significant differences in patient demographics, sample sizes, and rates of complications for pediatric patients undergoing PSF across 3 commonly utilized US administrative databases. Given the variability in reported outcomes and demographics, generalizability is difficult to extrapolate from these large data sources. In addition, certain databases should be selected to appropriately power studies focusing on particular patient populations or outcomes.

The Prevalence of Bullying Among Pediatric Orthopaedic Patients.

BACKGROUND: Bullying is destructive and pervasive. Although the literature suggests children with chronic health conditions are at higher risk of being bullied, there is minimal research regarding the prevalence of bullying among children with orthopaedic conditions. Our study aimed to assess the prevalence of bullying among pediatric orthopaedic outpatients and evaluate the association of orthopaedic conditions and use of orthopaedic devices with perceptions of bullying. METHODS: Patients in outpatient pediatric orthopaedic clinics, ages 10 to 17 and their parents were surveyed using the Child-Adolescent Bullying Scale-9. Basic demographic, information about the child's orthopaedic condition, and parent's perception of their child being subject to bullying were also collected. Children were asked if they had used any orthopaedic devices in the last 3 months, whether they were bullied because of their device, and if bullying affected their compliance with device use. The analysis utilized a t test or analysis of variance to compare mean Child-Adolescent Bullying Scale-9 scores across different groups. RESULTS: Among the 198 patients surveyed, 61% (N=121) perceived no-to-minimal exposure to bullying, 36% (N=72) moderate exposure, and 3% (N=5) severe exposure. Children ages 10 to 13 (N=100) and children ages 14 to 17 (N=98) reported similar rates of bullying (P=0.97). Higher rates of moderate to severe bullying were reported by patients with foot deformity (80%), multiple orthopaedic diagnoses (55%), chronic pain (39%), fracture/acute injury (37%), and scoliosis (33%). Moderate to severe bullying was reported by 37% of patients who wore a cast, 40% who wore a brace/orthotic, and 52% who used multiple orthopaedic devices. Parental concern that their child was being bullied was highly correlated with their child's bullying score (P=0.0002). CONCLUSIONS: More than one third of our pediatric orthopaedic outpatients (39%) experience moderate to severe levels of bullying, which is higher than the general population's reported rates of 20% to 35%. Exposure to bullying may be higher in certain diagnoses or with use of certain orthopaedic devices. Further research is needed to delineate who is at highest risk. LEVEL OF EVIDENCE: Level IV.

Telomere length dynamics in early life: the blood-and-muscle model.

Telomere length (TL) trajectories in somatic tissues during human growth and development are poorly understood. We examined a blood-and-muscle model during early life, focusing on TL trajectories in leukocytes, representing the highly proliferative hematopoietic system, and skeletal muscle, a minimally proliferative tissue. Leukocyte TL (LTL) and skeletal muscle TL (MTL) were measured in 28 fetuses and 73 children. LTL and MTL were highly variable across individuals (sd: fetal LTL = 0.72 kb, MTL = 0.72 kb; children LTL = 0.81 kb, MTL = 0.82 kb) but were highly correlated within individuals (fetuses, r = 0.76, P < 0.0001; children, r = 0.87, P < 0.0001). LTL was shorter than MTL in fetuses (10.63 vs. 11.01 kb; P = 0.0004) and children (8.46 vs. 9.40 kb; <0.0001). The LTL-MTL gap was smaller in fetuses than children. TL in children was inversely correlated with body mass index (BMI) (LTL: -0.047 ± 0.016 kb/BMI, P < 0.005; MTL: -0.037 ± 0.017 kb/BMI, P = 0.03). We conclude that variations in TL across adults and differences in TL between somatic tissues are largely established in early life. Because TL plays a significant role in aging-related diseases, insight into the factors that fashion TL in somatic tissues during early development should contribute to an understanding of the relationship of TL with these disease and longevity in humans.-Sabharwal, S., Verhulst, S., Guirguis, G., Kark, J. D., Labat, C., Roche, N. E., Martimucci, K., Patel, K., Heller, D. S., Kimura, M., Chuang, D., Chuang, A., Benetos, A., Aviv, A. Telomere length dynamics in early life: the blood-and-muscle model.

Treatment of Infantile Blount Disease: An Update.

Although the core principles of managing infantile Blount disease generally remain unchanged, treatment modalities have evolved over the years. Consensus has yet to be reached regarding the efficacy of bracing. Children with Blount disease commonly have advanced bone age, which may impact the timing and magnitude of (over) correction of angular deformity. Techniques of growth modulation, based on the tension band principle, continue to gain popularity. Although there are limited reports in the last decade on proximal tibial osteotomy for this developmental disorder, both acute and gradual correction remain viable treatment options in the appropriate setting. In certain older children (>7 y old) with advanced stages of the disease, a medial hemiplateau elevation combined with lateral proximal tibial hemiepiphysiodesis may be needed to address the epiphyseal deformity. Given the possibility of unpredictable proximal tibial physeal activity, all children with Blount disease should be followed at regular intervals till skeletal maturity. To provide sufficient granularity for pooled analyses and help establish evidence-based clinical guidelines, standardization of reporting clinical outcomes among children with Blount disease is encouraged.

Percutaneous Subtrochanteric Osteotomy for Painful Dislocated Hips in Patients With Cerebral Palsy.

BACKGROUND: Treatment of a painful, chronically dislocated hip in nonambulatory children with cerebral palsy (CP) is challenging and controversial. Although many surgical options have been described, there is limited information, including patient-centered outcomes, following treatment. The purpose of our study was to evaluate the effect of a percutaneous subtrochanteric valgus osteotomy (SVO) using external fixation (EF) on hip abduction, radiographic parameters, and quality of life (QOL) measures in such patients. METHODS: Fifteen nonambulatory patients (8 male, 7 female) with CP with 19 chronically dislocated hips underwent SVO using EF and adductor tenotomy at an average age of 14.3 years (range, 10.7 to 26.8 y). Changes in hip abduction and radiographic angular correction following surgery were assessed. Caregivers completed 2 surveys detailing differences in the patient's QOL measures, including severity and duration of pain and ease of nursing care, and the modified Child Health Index of Life with Disabilities (CPCHILD). RESULTS: Caregivers of 11 patients completed both surveys at an average follow-up of 50 months (range, 17 to 119 mo) after fixator removal. There was improvement in pain, sitting tolerance, ease of transfers, and perineal care in the majority (9/11) of patients. The modified CPCHILD (possible score, 10 to 50) improved from 27.2 to 16.23 (P=0.05). Hip abduction improved from -7 degrees (range, -32 to 5 degrees) to 24 degrees (range, 0 to 40 degrees) (P<0.0001). The average valgus osteotomy correction was 48.2 degrees (range, 2.2 to 93.2 degrees). The pelvic femoral shaft angle improved from -15.2 degrees (range, -47.7 to 7.4 degrees) to 15.4 degrees (-44.3 to 44.6 degrees). There was some correlation of both, change in hip abduction (R=0.55) and osteotomy angle (R=0.60), with improvement in QOL measures. There were 3 major complications (20%) in 15 patients. CONCLUSIONS: On the basis of preliminary results, percutaneous SVO stabilized with EF improves QOL in the majority of nonambulatory CP patients despite untoward events and is a viable alternative to open osteotomy with internal fixation. More robust comparative studies are needed to further assess the optimal salvage technique in this patient population. LEVEL OF EVIDENCE: Level IV.

The POSNA-COUR International Scholar Program. Results of the First 7 Years.

BACKGROUND: The Pediatric Orthopedic Society of North America (POSNA)-Children's Orthopedics in Underserved Regions (COUR) International Scholar Program was initiated in 2007 to provide educational opportunities for emerging leaders who treat children with orthopaedic conditions in resource-challenged environments worldwide. Financial support is available each year for 4 to 6 orthopaedic surgeons to attend either the POSNA Annual Meeting or the International Pediatric Orthopedic Symposium. The scholars are also encouraged to visit selected centers for observerships during their trip. Since 2007 there have been 41 international scholars who have participated in the program. We wished to assess the impact of the program and to obtain feedback to improve the experience for future participants. METHODS: A 23-question web-based survey was created and sent to 38 past scholars from 22 countries who have participated in the program by July 2013. The responses were gathered online and the data were analyzed for the 24 (62%) respondents from 18 countries who completed the survey. RESULTS: Of the respondents, 16/24 (66%) reported that their current practice is comprised of at least 75% pediatrics. Twelve of 24 (52%) were fellowship trained in pediatric orthopaedics, typically outside of North America. All scholars found the meeting they attended to be very useful and have subsequently made changes to their clinical practice. Nineteen of 24 (82%) did a premeeting or postmeeting observership. Twenty-two of 24 (92%) participants have remained in contact with POSNA members they met at the meeting, with 86% of respondents stating that they have subsequently consulted POSNA members on management of patients. Sixty-two percent of the scholars had a POSNA member visit them following the scholarship and 29% have since returned to visit POSNA members for further clinical observerships. Twenty-one of 24 (91%) have had the opportunity to share the knowledge they gained with others in their region through lectures, surgical demonstrations, and/or clinical training. A common response from the scholars was that the scholarship program was a truly transformative life experience that provided them with an opportunity to receive the highest quality of professional education. The main challenges that these scholars report are lack of available fellowship/subspecialty training in their region, patients' inability to pay, and excessive physician workload. All of the respondents expressed interest in arranging a POSNA cosponsored regional meeting. CONCLUSIONS: Since 2007, the POSNA-COUR international scholar program has been a fruitful resource for orthopaedists practicing in resource-challenged environments worldwide. It has provided unique training for the scholars and has further enabled them to teach others in their region. The program has thus far succeeded in fostering lasting relationships that have led to continued educational exchanges. LEVEL OF EVIDENCE: Level IV-case series.

Addressing the Global Disparities in the Delivery of Pediatric Orthopaedic Services: Opportunities for COUR and POSNA.

The burden of musculoskeletal conditions, especially injuries, is increasing in low-income and middle-income countries. Road traffic injuries have become epidemic. There are multiple barriers to accessing surgical services at both the individual (utilization) and the health system (availability) levels, and deficiencies in education and training of health providers. Specialty societies such as the Pediatric Orthopaedic Society of North America (POSNA) have an opportunity to play an important role through teaching and training. The POSNA Children's Orthopedics in Underserved Regions (COUR) committee has supported the Visiting Scholars Program, which invites surgeons from the developing world to attend a scientific meeting and facilitates the scholar's visit to North American pediatric orthopaedic centers. POSNA members have held global educational courses that support an educational exchange between lecturers and attendees. The COUR web site allows for submission of trip reports that document successes and obstacles experienced by members performing overseas clinical care and teaching. The web site also provides educational resources relevant to providing care in these environments. POSNA collaborates with other societies, such as the American Academy of Orthopaedic Surgeons and the Society of Military Orthopaedic Surgeons, to provide education in disaster management. In addition to increasing member involvement, specialty societies have the opportunity for continued data collection from overseas care, application of US registry data to disease processes in the developing world, and further collaboration with one another.

External fixation for closed pediatric femoral shaft fractures: where are we now?

BACKGROUND: Recent advances in external fixation technique and pin design have sought to minimize complications such as pin site infection and premature removal of the external fixator. Although newer forms of internal fixation have gained popularity, external fixation may still have a role in managing pediatric femoral shaft fractures. QUESTIONS/PURPOSES: We sought to assess the time to healing, limb alignment, and complications observed in a cohort of pediatric patients with closed femoral shaft fractures who were treated with external fixation. METHODS: Over a 15-year period, one surgeon treated 289 pediatric patients with femur fractures, 31 (11%) of whom received an external fixator. The general indications for use of an external fixator during the period in question included length-unstable fractures, metadiaphyseal location, refracture, and pathologic fracture. Six patients (19%) had inadequate followup data and four patients (13%) were treated with a combination of flexible intramedullary nails and external fixation, leaving 21 patients for analysis. Mean age at injury was 10 years (range, 6-15 years) and followup averaged 22 months (range, 5-45 months) after removal of the fixator. Radiographs were examined for alignment and limb length discrepancy. Complications were recorded from a chart review. RESULTS: Mean time in the fixator was 17 weeks (range, 9-24 weeks). One patient sustained a refracture and one patient with an isolated femur fracture had a leg length discrepancy > 2 cm. There were no pin site infections requiring intravenous antibiotics or additional surgery. One patient with Blount disease and previous tibial osteotomy developed transient peroneal nerve palsy. CONCLUSIONS: Despite improvements in pin design and predictable fracture healing, complications such as refracture and leg length discrepancy after external fixation of pediatric femoral shaft fractures can occur. However, external fixation remains a viable alternative for certain fractures such as length-unstable fractures, metadiaphyseal location, pathologic fractures, and refractures. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Is there a difference in sagittal alignment of Blount's disease between radiographic and clinical evaluation?

BACKGROUND: A procurvatum deformity of the proximal tibia often is seen in patients with Blount's disease. If left untreated, it can lead to progressive angulation in the sagittal plane and altered contact stresses across the knee. QUESTIONS/PURPOSES: We asked the following questions: (1) Is the mean angle of procurvatum measured from full-length lateral radiographs of the tibia greater than that of procurvatum measured from clinical photographs of the affected lower extremity? (2) Is there a linear relationship between radiographically measured procurvatum and radiographically measured procurvatum? METHODS: We treated 72 patients surgically for Blount's disease between 1997 and 2012; of those, 29 patients were excluded from this analysis because they did not have adequate photographs or radiographs, leaving 43 patients (60% of the patients treated surgically; 47 limbs total), mean age of 13 years (range, 6-25 years), who underwent surgical realignment for Blount's disease were retrospectively evaluated at a median of 97 months after surgery (range, 24-170 months). Genu procurvatum was measured from full-length lateral radiographs of the tibia and clinical photographs of the affected lower extremity. We then assessed the relationship between radiographically measured procurvatum and clinically measured procurvatum using linear regression analysis. RESULTS: The mean preoperative radiographically measured procurvatum (12.3°; range -3.1° to 55.2°) was larger than the clinically measured procurvatum (6.0°; range, -1° to 45°; p = 0.024). The mean postoperative radiographically measured procurvatum (4.2°; range -4.8° to 30.3°) was larger than the clinically measured procurvatum (2.1°; range, -2° to 20°; p = 0.041). Preoperatively and postoperatively, radiographically measured procurvatum and clinically measured procurvatum were well correlated (linear regression p < 0.001). After surgical realignment, the mean improvement in radiographically measured procurvatum (8.2°) was larger than that measured for clinically measured procurvatum (3.8°) (p = 0.018). CONCLUSIONS: In patients with Blount's disease, visual inspection of the extremity can underestimate the procurvatum deformity of the proximal tibia relative to the measurable deformity on radiographs. Furthermore, surgical correction of proximal tibial procurvatum does not lead to clinical hyperextension of the knee. LEVEL OF EVIDENCE: Level IV, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.

Safe zone for superolateral entry pin into the distal humerus in children: an MRI analysis.

BACKGROUND: The radial nerve is at risk for iatrogenic injury during placement of pins, screws, or wires around the distal humerus. Unlike adults, detailed anatomic information about the relationship of the nerve to the distal humerus is lacking in children. QUESTION/PURPOSES: This study evaluates the relationship of the radial nerve to the distal humerus in a pediatric population on conventional MRI and proposes an anatomic safe zone using easily identifiable bony landmarks on an AP elbow radiograph. METHODS: To determine the course of the radial nerve at the lateral distal humerus, we reviewed 23 elbow radiographs and MRIs of 22 children (mean age, 9 ± 4 years; range, 3-12 years) obtained as part of their workup for various elbow conditions. We described a technique using distance ratios calculated as a percentage of the patient's own transepicondylar distance, defined as the distance measured between the apices of the medial and lateral epicondyles, on the AP elbow radiograph and the midcoronal MR image. The cross-reference tool on a Picture Archiving and Communication System was then used to identify axial MR image at the level where the transepicondylar distance was measured. On this axial image, a line was drawn connecting the medial and lateral epicondyles (the transepicondylar axis) and its midpoint was determined. The radial nerve angle was measured by a line from the radial nerve to the midpoint of the transepicondylar axis and a line along the lateral half of the transepicondylar axis. On this axial slice, the closest distance from the nerve to the underlying cortex of the distal humerus was measured. To further localize the nerve along the distal humerus, predetermined percentages of the transepicondylar distance were projected proximally from the level of the transepicondylar axis along the longitudinal axis of the humerus on the midcoronal MR image. At these designated heights, the corresponding axial MR image was identified using the cross-reference tool and the nerve was mapped in a similar fashion. We then proposed a simpler method using a best-fit line drawn along the lateral supracondylar ridge on the AP radiograph to define the safe zone for lateral pin entry. RESULTS: On axial MR images, the radial nerve was located in the anterolateral quadrant with a mean radial nerve angle of 54° (range, 35°-87) at 0% transepicondylar distance (23 MRIs), 41° (range, 24°-63°) at 50% transepicondylar distance (23 MRIs), and ≥ 10° at 75% transepicondylar distance (on the 13 MRIs that extended this far cephalad). The mean closest distance between the radial nerve and the underlying humeral cortex was 10 mm (range, 3-26 mm) at 0% transepicondylar distance and 7 mm (3-16 mm) at 50% transepicondylar distance. On the AP elbow radiograph, the height of the lateral supracondylar ridge, determined by a best-fit line drawn along the lateral cortex of the ridge, diverged from the most proximal extent of the ridge at a point located at 60% transepicondylar distance (range, 51%-76%). At the corresponding location on the axial MR image, the nerve was located anterolaterally with a mean radial nerve angle of 39° (range, 15°-61°) and a mean distance of 6 mm (range, 2-10 mm) from the underlying humerus. CONCLUSIONS: Our data suggest that percutaneous direct lateral entry Kirschner wires and half-pins can be safely inserted in the distal humerus in children along the transepicondylar axis, either at or slightly posterior to the lateral supracondylar ridge, when placed caudal to the point located where the lateral supracondylar ridge line diverges from the proximal extent of the supracondylar ridge on AP elbow radiograph.

Do children with Blount disease have lower body mass index after lower limb realignment?

BACKGROUND: Children with Blount disease are typically obese. The goal of our study was to assess whether children with Blount disease had lower body mass index (BMI) after surgical correction of their lower limb deformity. METHODS: A surgical data base was used to identify children with Blount disease. Demographic information including age of disease onset, ethnicity, health insurance status, and laterality was noted. Preoperative and most recent BMI values were documented. Using full-length standing radiographs, the mechanical axis deviation (MAD) and leg length discrepancy (LLD) were measured preoperatively and at latest follow-up. The relationship of the change in BMI with various demographic and radiologic parameters was evaluated. RESULTS: Fifty-one children (32 males, 19 females) with Blount disease (23 early onset, 28 late onset) affecting 70 lower extremities (32 unilateral and 19 bilateral) underwent a variety of surgical procedures. All 47 children who underwent gradual correction with external fixation also underwent nutritional counseling while receiving inpatient rehabilitation. At an average follow-up of 48 months, MAD improved from 80.5 mm medial to 16.1 mm medial (P<0.0001) and LLD improved from 19.6 to 10.9 mm (P=0.0002). During the same time period, the BMI increased from 35 (95% confidence interval, 32-37) to 38 (95% confidence interval, 35-41; P=0.0006). Compared with their preoperative BMI, 76% of the children had an increase in their BMI at the latest follow-up. There was no association of the change in the patient's BMI with their age of disease onset, sex, ethnicity, health insurance status, final MAD, or LLD. There was a tendency for the patient's BMI to increase with longer follow-up (P=0.002). Using multivariate analysis, only the length of follow-up was associated with an increase in BMI (P=0.026). CONCLUSIONS: Despite improvement in limb alignment and LLD after surgery, the BMI of the majority of children with Blount disease increased over time. Other strategies for addressing obesity amongst these children are warranted. LEVEL OF EVIDENCE: Level IV--case series.

The etiology of short stature affects the clinical outcome of lower limb lengthening using external fixation. A systematic review of 18 trials involving 547 patients.

BACKGROUND AND PURPOSE: Distraction osteogenesis (DO) has been used to gain height in short statured individuals. However, there have been no studies comparing the clinical outcome of limb lengthening based on the etiology of the short stature. We assessed whether different underlying diagnoses are associated with varied clinical outcomes in these patients. METHODS: We performed a systematic review of the literature pertaining to lower limb lengthening using external fixation for short stature. Clinical outcomes including amount of lengthening, healing index (HI), and complications based on the underlying diagnosis for the short stature were documented. RESULTS: 18 clinical studies were included, with 547 patients who underwent 1,581 lower limb segment lengthening procedures. Mean follow-up was 4.3 years. The average age at lengthening was less for individuals with achondroplasia/hypochondroplasia (A/H) (14.5 years) than for those with Turner's syndrome (TS) (18.2 years) or with constitutional short stature (CSS) (21.7 years). Mean height gained was greater in patients with A/H (9.5 cm) than in those with TS (7.7 cm) or CSS (6.1 cm) group. The HI was better in A/H (30.8 days/cm) and CSS (32 days/cm) than in TS (45.1 days/cm). The reported complication rate per segment was lower for A/H (0.68) and TS (0.71) than for CSS (1.06). INTERPRETATION: Patients with A/H tolerated larger amounts of lengthening with fewer complications than those with other diagnoses.

Reuse of Orthopaedic Equipment: Barriers and Opportunities.

¼ Reuse of orthopaedic equipment is one of many potential ways to minimize the negative impact of used equipment on the environment, rising healthcare costs and disparities in access to surgical care.¼ Barriers to widespread adoption of reuse include concerns for patient safety, exposure to unknown liability risks, negative public perceptions, and logistical barriers such as limited availability of infrastructure and quality control metrics.¼ Some low- and middle-income countries have existing models of equipment reuse that can be adapted through reverse innovation to high-income countries such as the United States.¼ Further research should be conducted to examine the safety and efficacy of reusing various orthopaedic equipment, so that standardized guidelines for reuse can be established.

Peer-reviewed publications in orthopaedic surgery from lower income countries: A comparative analysis.

INTRODUCTION: Musculoskeletal (MSK) disease is a substantial global burden, especially in lower income countries. However, limited research has been published on MSK health by scholars from these countries. We aimed to study the distribution of authorships, including trends in peer-reviewed orthopaedic publications based on each author's affiliated institution's country income status. METHODS: Based on a bibliometric search, 119 orthopaedic-related journals were identified using the Journal Citation Reports database. Details of all scientific articles published in these journals between 2012 and 2021 were used to study trends and association between each of the author's affiliated institution's country income status, using the World Bank Classification. RESULTS: Of the 133,718 unique articles, 87.6% had at least one author affiliation from a high-income country (HIC), 7.0% from an upper-middle income country (UMIC), 5.2% from a lower-middle income country (LMIC), and 0.2% from a low-income country (LIC). Overall, these articles were cited 1,825,365 times, with 92.5% of citations from HIC-affiliated authors and < 0.1% from LIC-affiliated authors. Over the 10-year study period, HIC-affiliated articles demonstrated the largest increase in the number of publications (9107-14,619), compared to UMIC-affiliated (495-1214), LMIC-affiliated (406-874), and LIC-affiliated articles (4-28). CONCLUSIONS: There are large and persistent disparities in orthopaedic research publications based on the country income status of the author's affiliated institution, especially in the higher impact orthopaedic journals. Efforts should be made to increase opportunities for scholars from LICs and LMICs to publish their research in high-impact orthopaedic journals.

Limb Lengthening and Reconstruction Society AIM index reliably assesses lower limb deformity.

BACKGROUND: Although several systems exist for classifying specific limb deformities, there currently are no validated rating scales for evaluating the complexity of general lower limb deformities. Accurate assessment of the complexity of a limb deformity is essential for successful treatment. A committee of the Limb Lengthening and Reconstruction Society (LLRS) therefore developed the LLRS AIM Index to quantify the severity of a broad range of lower extremity deformities in seven domains. QUESTIONS/PURPOSES: We addressed two questions: (1) Does the LLRS AIM Index show construct validity by correlating with rankings of case complexity? (2) Does the LLRS AIM Index show sufficient interrater and intrarater reliabilities? METHODS: We had eight surgeons evaluate 10 fictionalized patients with various lower limb deformities. First, they ranked the cases from simplest to most complex, and then they rated the cases using the LLRS AIM Index. Two or more weeks later, they rated the cases again. We assessed reliability using the Kendall's W test. RESULTS: Raters were consistent in their rankings of case complexity (W = 0.33). Patient rankings also correlated with both sets of LLRS AIM ratings (r(2) = 0.25; r(2) = 0.23). The LLRS AIM Index showed interrater reliability with an intraclass correlation (ICC) of 0.97 for Trial 1 and 0.98 for Trial 2 and intrarater reliability with an ICC of 0.94. The LLRS AIM Index ratings also were highly consistent between the attending surgeons and surgeons-in-training (ICC = 0.91). CONCLUSIONS: Our preliminarily observations suggest that the LLRS AIM Index reliably classifies the complexity of lower limb deformities in and between observers.

Venous thromboembolism in children: details of 46 cases based on a follow-up survey of POSNA members.

INTRODUCTION: On the basis of a recent survey of Pediatric Orthopedic Society of North America members, 59% of the respondents acknowledged having encountered at least 1 child with the diagnosis of venous thromboembolism (VTE). The current survey sought further information including patient demographics, underlying diagnosis, presence of certain risk factors for VTE, and the clinical outcome. METHODS: A follow-up web-based questionnaire was sent to 121 active members of Pediatric Orthopedic Society of North America who had provided their contact information in the prior survey. Thirty-eight respondents provided clinical details on 46 children. RESULTS: The mean age of the affected patients was 14.3 (95% confidence interval, 13.3-15.3) years and 61% were males. The average body mass index was 28 (95% confidence interval, 25-31). Forty-four percent of the patients were diagnosed with deep venous thrombosis (DVT) only, 26% with pulmonary embolism (PE) only, and 30% with both DVT and PE. Majority of the children had DVT involving the popliteal area or thigh (16 cases each). Lower extremity surgery (29 cases, including proximal femoral/tibial osteotomies, internal fixation of long bone fractures, anterior cruciate ligament reconstruction, and resection of osteochondroma around the knee) and adolescence (28 cases) were the 2 most commonly cited associations. Other cases were noted with spinal surgery (8 children) and musculoskeletal infections (7 children). Three patients developed a postphlebitic syndrome, 1 had recurrent DVT and 2 children died. Both deceased children were diagnosed with DVT and PE including a 9-year-old child with a positive family history of antithrombin-3 deficiency that was not noted preoperatively. CONCLUSIONS: Although uncommon, potentially fatal VTE can occur among children with a variety of musculoskeletal ailments. Obtaining a family history suggestive of thrombophilia preoperatively should be encouraged. Further investigation is warranted to ascertain the role of prophylaxis against VTE among children in an orthopaedic practice. LEVEL OF EVIDENCE: Level IV-case series.

Venous thromboembolism in children: preliminary results of a survey of POSNA members.

BACKGROUND: The term venous thromboembolism (VTE) includes deep venous thrombosis of the extremity and pulmonary embolism, a potentially fatal clinical entity. Although the prevalence of VTE may be lower in children compared with adults, recent reports suggest a possible rise in this diagnosis among pediatric patients, especially in association with certain risk factors. We assessed the clinical experience and practice of members of the Pediatric Orthopaedic Society of North America (POSNA) related to VTE among their pediatric patients. METHODS: A 36-question online survey was sent to all 636 active POSNA members. The proportion of surgeons who had encountered at least 1 child with VTE and the respondents' practice of using thromboprophylaxis in children (<18 y old) was assessed. The relationship of responders' experience with VTE among pediatric patients with various practice characteristics was evaluated. RESULTS: The response rate was 56% (354/636). More than half (55%) [95% confidence interval (CI), 50%-60%] of the respondents could recall at least 1 (median, 2 cases/member) pediatric patient with deep venous thrombosis and 29% (95% CI, 24%-34%) could recall ≥1 child with pulmonary embolism. Approximately one quarter (23%) (95% CI, 18%-27%) of all respondents reported never using mechanical prophylaxis and almost one half (45%) (95% CI, 40%-50%) of respondents reported never using pharmacologic prophylaxis against VTE in children. Only 16% (95% CI, 12%-20%) of the respondents had a thromboprophylaxis protocol for pediatric patients. Respondent characteristics such as being in clinical practice <5 years (P=0.01) and having a surgical volume of <100 cases/y (P=0.03) were associated with a lower likelihood of encountering a pediatric patient with VTE. CONCLUSIONS: More than half of responding active POSNA members reported having come across at least 1 case of VTE among pediatric patients during their practice. The routine use of VTE prophylaxis for children is uncommon among pediatric orthopaedists. Further studies aimed at determining the prevalence of VTE and developing specific guidelines for prophylaxis among pediatric patients seeking orthopaedic care are warranted. LEVEL OF EVIDENCE: IV.