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BACKGROUND: Slipped capital femoral epiphysis (SCFE) is a disorder of the proximal femoral physis occurring in late childhood and adolescence. Previously postulated risk factors include obesity and endocrinopathies. The purpose of this investigation was to identify risk factors for developing SCFE, as well as postslip osteonecrosis (ON), among the United States pediatric population. METHODS: A national database investigation was performed using PearlDiver Technologies, Inc., queried for SCFE and ON using International Classification of Disease codes (2010 to 2020). Regression analyses to determine the risk of developing a SCFE, and ON after a patient has already been diagnosed with a SCFE ("postslip"). Propensity matching between SCFE and control groups generated a pseudo-randomization model to compare the relative risk. RESULTS: There were 11,465 patients with SCFE available in the database, matched with 134,680 controls. After matching, vitamin D deficiency, obesity, hypothyroidism, and growth hormone use were risk factors for developing SCFE [relative risk ranges from 1.42 (95% CI: 1.21-1.39, vitamin D deficiency) to 3.45 (95% CI: 3.33-3.57, obesity)]. ON risk factors were vitamin D deficiency [1.65 (1.26-2.14)] and hypothyroidism [1.49 (1.10-2.07)]. CONCLUSIONS: This United States national database study quantified risk factors of developing an SCFE and postslip ON. Obesity is the most significant risk factor for the development of a slip, but not ON. Growth hormone use, hypothyroidism, and vitamin D deficiency are also risk factors for SCFE development, whereas only the latter two were associated with ON. These findings demonstrate the public health implications of obesity and comorbid conditions in pediatric hip pathology. LEVEL OF EVIDENCE: Level III.
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Hipotireoidismo , Escorregamento das Epífises Proximais do Fêmur , Deficiência de Vitamina D , Adolescente , Humanos , Criança , Escorregamento das Epífises Proximais do Fêmur/complicações , Fatores de Risco , Obesidade/complicações , Obesidade/epidemiologia , Hipotireoidismo/complicações , Deficiência de Vitamina D/complicações , Hormônio do CrescimentoRESUMO
PURPOSE: Supracondylar humerus (SCH) fractures account for approximately 30% of injuries for those younger than 7 years of age (Cheng et al. in J Pediatr Orthop 19:344-350, 1999). Recent studies examining the association of patient age and SCH fracture outcomes have provided conflicting findings. The purpose of this study is to investigate SCH fracture outcomes in children at different ages of skeletal development. METHODS: Retrospective review of a Level I pediatric trauma center between 2010 and 2014 was conducted. 190 patients with SCH fractures, age < 14 years, fracture type Gartland III or IV (AO/OTA 13-M 3.1 III and IV) were included. Patients were sorted into age groups: < 2 years, 4-6 years, and > 8 years. Patients were treated with either a closed or open reduction with percutaneous fixation. Clinical outcomes including postoperative elbow range of motion, nerve palsy, compartment syndrome, infection, and cubitus varus were assessed. RESULTS: Patients in younger age groups were more likely to obtain postoperative full elbow flexion (< 2 years = 77%; 4-6 years = 66%; > 8 years = 43%) and full elbow extension (< 2 years = 96%; 4-6 years = 88%; > 8 years = 64%). Age was a significant predictor of nerve palsy on admission, mean operative time (< 2 years = 21.8 min; 4-6 years = 43.0 min; > 8 years = 80.7 min), and mean fluoroscopy time (< 2 years = 22.9 s; 4-6 years = 59.5 s; > 8 years = 171.9 s). There were no differences in rates of open reduction, compartment syndrome, pin tract infection, cubitus varus, or reoperation among groups. CONCLUSION: Increasing age is associated with increased elbow stiffness after percutaneous fixation of Gartland Type III and Type IV SCH fractures. Older patients with SCH fractures may benefit from formal rehabilitation. LEVEL OF EVIDENCE: III.
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INTRODUCTION: Parents frequently report retaining unused opioid pills following their child's surgery due to fear of untreated postoperative pain. Assessment of pain in adolescents with neurocognitive disability is challenging. We hypothesized that parents of adolescents with neurocognitive disability may report less opioid use and higher opioid pill retention. METHODS: Adolescents (13-20 y) undergoing elective surgery (posterior spinal fusion, hip reconstruction, arthroscopy, tonsillectomy) were prospectively enrolled from a tertiary children's hospital from 2019 to 2020. Only adolescents prescribed opioids at discharge were included. Parents completed a preoperative survey collecting sociodemographic characteristics and two postoperative surveys at 30- and 90-d. Neurocognitive disability was determined at time of enrollment by caregiver report, and included adolescents with cerebral palsy, severe autism spectrum disorder, and discrete syndromes with severe neurocognitive disability. RESULTS: Of 125 parent-adolescent dyads enrolled, 14 had neurocognitive disability. The median number of opioid pills prescribed at discharge did not differ by neurocognitive disability (29, interquartile range {IQR}: 20.0-33.3 versus 30, IQR: 25.0-40.0, P = 0.180). Parents of both groups reported similar cumulative days of opioid use (7.0, IQR: 3.0-21.0 versus 6.0, IQR:3.0-10.0, P = 0.515) and similar number of opioid pills used (4, IQR: 2.0-4.5 versus 12, IQR: 3.5-22.5, P = 0.083). Parents of both groups reported similar numbers of unused opioid pills (17, IQR: 12.5-22.5 versus 19, IQR: 8.0-29.0, P = 0.905) and rates of retention of unused opioids (15.4% versus 23.8%, P = 0.730). CONCLUSIONS: The number of opioid pills prescribed did not differ by neurocognitive disability and parents reported similar opioid use and retention of unused opioid pills. Larger studies are needed to identify opportunities to improve postoperative pain control for children with neurocognitive disability.
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Transtorno do Espectro Autista , Transtornos Relacionados ao Uso de Opioides , Criança , Humanos , Adolescente , Analgésicos Opioides/uso terapêutico , Projetos Piloto , Transtorno do Espectro Autista/tratamento farmacológico , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Transtornos Relacionados ao Uso de Opioides/etiologia , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/etiologia , Prescrições , Padrões de Prática MédicaRESUMO
BACKGROUND: Relapse rates of clubfoot deformity after initial correction range between 19% and 68% regardless of treatment approach. Most studies focus on relapse before age 4. Little research has focused on late clubfoot relapse. The purpose of this study was to compare the gait characteristics of children with late clubfoot relapse (age ≥5 y) following treatment with the Ponseti method only compared with intra-articular and extra-articular surgeries. METHODS: A retrospective review was conducted of all patients with idiopathic clubfoot ≥5 years old who underwent computerized gait analysis for clubfoot relapse between 2001 and 2021. Joint range of motion, muscle strength, gait kinematics, and kinetics were compared among 3 groups based on prior clubfoot treatment: (1) Ponseti casting, (2) Extra-articular (EA) surgery, and (3) Intra-articular (IA) surgery. RESULTS: Sixty-eight subjects (107 feet) were included (39 bilateral). Thirty-one percent of feet had been treated with Ponseti casting alone; 57% had IA surgery, and 12% had EA surgery. The average age when presenting with late relapse was 8.2 years, 9.0 years and 10.7 years for the Ponseti, and IA and EA groups, respectively. The IA group had greater passive dorsiflexion than the other 2 groups (P<0.002), greater inversion weakness than the other 2 groups (P<0.0001), greater dorsiflexion during the stance phase of gait compared with the Ponseti group (P=0.001), and lower maximum power production at push-off compared with the other 2 groups (P=0.009). CONCLUSION: Late relapse can occur after all types of clubfoot correction. Consistent with existing literature, patients who have undergone posteromedial release surgery have significantly greater plantarflexor weakness resulting in poorer plantarflexor moment and power production during gait. LEVEL OF EVIDENCE: Level III, retrospective comparative study.
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Pé Torto Equinovaro , Criança , Humanos , Lactente , Pré-Escolar , Pé Torto Equinovaro/cirurgia , Análise da Marcha , Estudos Retrospectivos , Resultado do Tratamento , Moldes Cirúrgicos , Marcha , RecidivaRESUMO
INTRODUCTION: Pediatric hip disorders represent a broad range of pathology and remain a significant source of morbidity for children and young adults. Surgical intervention is often required for joint preservation, but when salvage is not possible, joint replacement may be indicated to eliminate pain and preserve function. Although there have been significant updates in the management of both pediatric hip disease and the field of total hip arthroplasty (THA), there is a paucity of literature reflecting advancements in the area of pediatric and young adult (PYA) arthroplasty. No study has investigated the impact of approach on outcomes after PYA THA. The purpose of this study is to describe the indications, techniques, and early outcomes of THA in the PYA population in a modern practice setting. METHODS: We performed a retrospective descriptive analysis of all patients undergoing primary THA performed at a tertiary care children's hospital from 2004 to 2019. Ninety-three hips in 76 patients were evaluated. Demographics, intraoperative variables, postoperative pain and function ratings, and complication and revision rates were collected. RESULTS: Eighty-five hips in 69 patients were included. Patients were aged 12 to 23 years old, with males and females represented equally (33 vs. 36, respectively). The most common cause of hip pain was avascular necrosis (AVN, 56/85, 66%), most commonly due to slipped capital femoral epiphysis (13/56, 23%) idiopathic AVN (12/56, 21%), and chemotherapy (12/56, 21%). Half of all hips had been previously operated before THA (43/85). Thirty-six procedures were performed via the posterolateral approach (36/85, 42%), 33 were performed via direct anterior approach (33/85, 39%), and 16 were performed via the lateral approach (LAT, 16/85, 19%). At final follow-up, 98% (83/85) of patients had complete resolution of pain, 82% (70/85) had no notable limp, and 95% (81/85) had returned to all activities. There were 6 complications and 1 early revision. Average Hip disability and Osteoarthritis Outcomes Score for Joint Replacement scores increased by 37 points from 56 to 93. The overall revision-free survival rate for PYA THA was 98.8% (at average 19-mo follow-up). CONCLUSIONS: Modern PYA THA is dissimilar in indications and surgical techniques to historic cohorts, and conclusions from prior studies should not be generalized to modern practice. In our practice, PYA patients most commonly carry a diagnosis of AVN, and THA can be performed with modern cementless fixation with large cup and head sizes and ceramic-on-cross-linked polyethylene bearings utilizing any approach. Further study is required to better characterize middle-term and long-term results and patient-reported outcomes. LEVEL OF EVIDENCE: Therapeutic Level IV-retrospective case series.
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Artroplastia de Quadril , Prótese de Quadril , Masculino , Feminino , Humanos , Adulto Jovem , Criança , Adolescente , Adulto , Artroplastia de Quadril/efeitos adversos , Articulação do Quadril/cirurgia , Estudos Retrospectivos , Resultado do Tratamento , Falha de Prótese , Reoperação , Dor Pós-OperatóriaRESUMO
BACKGROUND: There is limited information on the presentation and management of upper extremity septic arthritis (UESA) in children. Our purpose was to report on the characteristics and short-term treatment outcomes of pediatric UESA from a multicenter database. METHODS: Patients with UESA were identified from a multicenter retrospective musculoskeletal infection database. Demographics, laboratory tests, culture results, number of surgeries, and complications were collected. RESULTS: Of 684 patients with septic arthritis (SA), 68 (10%) patients had UESA. Septic arthritis was most common in the elbow (53%), followed by the shoulder (41%) and wrist (4%). The median age at admission was 1.7 years [interquartile range(IQR, 0.8-8.0 y)] and 66% of the cohort was male. Blood cultures were collected in 65 (96%) patients with 23 (34%) positive results. Joint aspirate and/or tissue cultures were obtained in 66 (97%) patients with 49 (72%) positive results. Methicillin-sensitive Staphylococcus aureus (MSSA) was the most common causative organism overall, but Streptococcus was the most common pathogen in the shoulder. Sixty-six (97%) patients underwent irrigation and debridement, with 5 (7%) patients requiring 2 surgeries and 1 patient (1%) requiring 3 surgeries. The median length of stay was 4.9 days (IQR, 4.0-6.3 d). Thirty-one (46%) children had adjacent musculoskeletal infections and/or persistent bacteremia. No patients experienced venous thromboembolism, and 4 patients with associated osteomyelitis experienced a musculoskeletal complication (3 avascular necrosis, 1 pathologic fracture). One child had re-admission and 3 children with associated osteomyelitis had a recurrence of UESA. Comparison between elbow and shoulder locations showed that children with septic arthritis of the shoulder were younger (4.6 vs. 1.0 y, P =0.001), and there was a difference in minimum platelet count (280 vs. 358 ×10 9 cells/L, P =0.02). CONCLUSIONS: UESA comprises 10% of cases of septic arthritis in children. The elbow is the most common location. Shoulder septic arthritis affects younger children. MSSA is the most common causative organism in UESA, but Streptococcus is common in shoulder septic arthritis. Irrigation and debridement result in excellent short-term outcomes with a low complication rate. Re-admissions and repeat surgical interventions are rare. LEVEL OF EVIDENCE: Level IV, prognostic.
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Artrite Infecciosa , Osteomielite , Infecções Estafilocócicas , Criança , Masculino , Humanos , Lactente , Estudos Retrospectivos , Artrite Infecciosa/epidemiologia , Artrite Infecciosa/terapia , Artrite Infecciosa/complicações , Infecções Estafilocócicas/tratamento farmacológico , Staphylococcus aureus , Osteomielite/complicações , Extremidade Superior , Antibacterianos/uso terapêuticoRESUMO
BACKGROUND: Restricted weight bearing is commonly prescribed in Legg-Calvé-Perthes Disease (LCPD), raising concerns of causing overweight or obesity. This study utilizes prospectively collected data to address the following questions: (1) does body mass index (BMI) Z-score increase over the course of LCPD follow-up; (2) is having a BMI category of normal, overweight, or obese at baseline associated with BMI Z-score changes over the course of follow-up; and (3) is the duration of weight bearing restrictions (no restrictions, <3, 3 to <6, 6 to 9, or >9 mo) associated with BMI Z-score changes. METHODS: Data of 130 children aged 5 to 12 years with unilateral early-stage LCPD were extracted from an international database. Nation-specific BMI Z-scores and percentile-based weight categories were determined, and the duration of follow-up and weight bearing restrictions were calculated. Longitudinal changes in BMI Z-scores were evaluated for the 3 study questions using mixed effects linear regression models with surgery as a covariate. Sensitivity analyses were used to determine the influence of socio-cultural background (USA vs. India) for each study question. RESULTS: During the 35.5±15.9 months of follow-up, no statistically significant increase in BMI Z-scores was observed across the entire cohort, or following stratification by baseline weight categories or the duration of the weight bearing restriction. Sensitivity analyses indicated that patients in the USA had no change in their BMI Z-score. When stratified by weight categories, the normal weight of US children had a small increase in their BMI Z-score (0.005 per mo, 95% confidence interval: 0.0002, 0.009), but this was not seen in other BMI categories. The cohort of Indian children had a small but significant decrease in their BMI Z-score (-0.005/mo, 95% CI: -0.009, -0.0002). After stratification by weight categories, a small decrease of the BMI Z-score was observed only in the Indian overweight children (-0.016 per mo, 95% CI: -0.027, -0.005) and no other BMI category. CONCLUSIONS: Weightbearing restrictions over the course of follow-up for our cohort of children with early-stage LCPD were not associated with clinically meaningful increases of BMI Z-scores. Weight gain is multi-factorial and probably not caused by weight bearing restrictions alone. LEVEL OF EVIDENCE: III Diagnostic Study.
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Doença de Legg-Calve-Perthes , Criança , Humanos , Aumento de Peso , Índice de Massa Corporal , Sobrepeso/epidemiologia , Obesidade , Suporte de CargaRESUMO
BACKGROUND: Acute hematogenous osteomyelitis (AHO) is a relatively common condition in children, and identifying the offending pathogen with blood or tissue cultures aids in diagnosis and medical management while reducing treatment failure. Recent 2021 AHO clinical practice guidelines from the Pediatric Infectious Disease Society recommend obtaining routine tissue cultures, particularly in cases with negative blood cultures. The purpose of this study was to identify variables associated with positive tissue cultures when blood cultures are negative. METHODS: Children with AHO from 18 pediatric medical centers throughout the United States through the Children's ORthopaedic Trauma and Infection Consortium for Evidence-based Study were evaluated for predictors of positive tissue cultures when blood cultures were negative. Cutoffs of predictors were determined with associated sensitivity and specificity. RESULTS: One thousand three children with AHO were included, and in 688/1003 (68.6%) patients, both blood cultures and tissue cultures were obtained. In patients with negative blood cultures (n=385), tissue was positive in 267/385 (69.4%). In multivariate analysis, age ( P <0.001) and C-reactive protein (CRP) ( P =0.004) were independent predictors. With age >3.1 years and CRP >4.1 mg/dL as factors, the sensitivity of obtaining a positive tissue culture when blood cultures were negative was 87.3% (80.9-92.2%) compared with 7.1% (4.4-10.9%) if neither of these factors was present. There was a lower ratio of methicillin-resistant Staphylococcus aureus in blood culture-negative patients who had a positive tissue culture 48/188 (25.5%), compared with patients who had both positive blood and tissue cultures 108/220 (49.1%). CONCLUSION: AHO patients with CRP ≤ 4.1 mg/dL and age under 3.1 years are unlikely to have clinical value from tissue biopsy that exceeds the morbidity associated with this intervention. In patients with CRP > 4.1 mg/dL and age over 3.1 years, obtaining a tissue specimen may add value; however, it is important to note that effective empiric antibiotic coverage may limit the utility of positive tissue cultures in AHO. LEVEL OF EVIDENCE: Level III-Retrospective comparative study.
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Staphylococcus aureus Resistente à Meticilina , Osteomielite , Criança , Humanos , Pré-Escolar , Proteína C-Reativa/análise , Hemocultura , Estudos Retrospectivos , Antibacterianos/uso terapêutico , Osteomielite/diagnóstico , Osteomielite/tratamento farmacológico , Osteomielite/complicações , Doença AgudaRESUMO
INTRODUCTION: The failure rate of Pavlik harness treatment for developmental dysplasia of the hip (DDH) has been reported as high as 55%. The purpose of this study is to investigate the effect of an inverted acetabular labrum on outcomes of Pavlik harness treatment for DDH. METHODS: A retrospective review was conducted on DDH patients at a tertiary care pediatric hospital from 2004 to 2016. DDH patients that underwent index treatment with Pavlik harness and had minimum 12 months follow-up were included. Medical charts were reviewed for demographics, treatment, and outcomes. Outcomes were compared between patients with an inverted labrum versus those without an inverted labrum. RESULTS: A total of 156 patients with 229 dysplastic hips were included. The mean age at initiation of Pavlik harness treatment was 1.9±1.4 months and mean follow-up was 37.7±23.0 months. Bilateral DDH was diagnosed in 46% (73/156) of patients. In all, 37% (75/229) of hips failed Pavlik harness index treatment. Second-line treatment was rigid hip abduction bracing in 91% (68/75) of hips, closed reduction in 5% (4/75) of hips, and open reduction in 4% (3/75) of hips. An inverted labrum was present in 10% (22/229) of all hips. The incidence of Pavlik harness treatment failure was 91% (20/22) in the inverted labrum group compared with 27% (55/207) in the control group (P<0.001). Closed or open reduction was required in 86% (15/22) of the inverted labrum group compared with 3% (7/207) of hips in the control group (P<0.001). The incidence of avascular necrosis was 18% (4/22) in hips with an inverted labrum compared with 0.4% (1/207) in the control group (P<0.001). CONCLUSIONS: In children with DDH undergoing index treatment in a Pavlik harness, the presence of an inverted acetabular labrum is strongly predictive of treatment failure. Dysplastic hips with an inverted labrum also have a significantly higher risk of requiring closed or open reduction and developing avascular necrosis compared with those without an inverted labrum. LEVEL OF EVIDENCE: Level III.
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Displasia do Desenvolvimento do Quadril , Luxação Congênita de Quadril , Criança , Luxação Congênita de Quadril/diagnóstico por imagem , Luxação Congênita de Quadril/terapia , Humanos , Lactente , Aparelhos Ortopédicos , Estudos Retrospectivos , Falha de Tratamento , Resultado do Tratamento , UltrassonografiaRESUMO
BACKGROUND: Early containment surgery has become increasingly popular in Legg-Calvé-Perthes Disease (LCPD), especially for older children. These procedures treat the proximal femur, the acetabulum, or both, and most surgeons endorse the same surgical option regardless of an individual patient's anatomy. This "one-surgery-fits-all" approach fails to consider potential variations in baseline anatomy that may make one option more sensible than another. We sought to describe hip morphology in a large series of children with newly diagnosed LCPD, hypothesizing that variation in anatomy may support the concept of anatomic-specific containment. METHODS: A retrospective review of a prospectively collected multicenter database was conducted for patients aged 6 to 11 at diagnosis. To assess anatomy before significant morphologic changes secondary to the disease itself, only patients in Waldenström stages IA/IB were included. Standard hip radiographic measurements including acetabular index, lateral center-edge angle, proximal femoral neck-shaft angle (NSA), articulotrochanteric quartiles, and extrusion index (EI) were made on printed anteroposterior pelvis radiographs. Age-specific percentiles were calculated for these measures using published norms. Significant outliers (≤10th/≥90th percentile) were reported where applicable. RESULTS: A total of 168 patients with mean age at diagnosis of 8.0±1.3 years met inclusion criteria (81.5% male). Mean acetabular index for the entire cohort was 16.8±4.1 degrees; 58 hips (34.5%) were significantly dysplastic compared with normative data. Mean lateral center-edge angle was 15.9±5.2 degrees at diagnosis; 110 (65.5%) were ≤10th percentile indicating dysplasia (by this metric). Mean NSA overall was 136.5±7.0 degrees. Fifty-one (30.4%) and 20 (11.9%) hips were significantly varus (≤10th percentile) or valgus (≥90th percentile), respectively. Thirty-five hips (20.8%) were the third articulo-trochanteric quartiles or higher suggesting a higher-riding trochanter at baseline. Mean EI was 15.5%±9.0%, while 63 patients (37.5%) had an EI ≥20%. CONCLUSIONS: The present study finds significant variation in baseline anatomy in children with early-stage LCPD, including a high prevalence of coexisting acetabular dysplasia as well as high/low NSAs. These variations suggest that the "one-surgery-fits-all" approach may lack specificity for a particular patient; a potentially wiser option may be an anatomic-specific containment operation (eg, acetabular-sided osteotomy for coexisting dysplasia, varus femoral osteotomy for valgus NSA). LEVEL OF EVIDENCE: Level IV.
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Acetábulo/patologia , Cabeça do Fêmur/patologia , Doença de Legg-Calve-Perthes/patologia , Doença de Legg-Calve-Perthes/cirurgia , Acetábulo/diagnóstico por imagem , Acetábulo/cirurgia , Variação Anatômica , Criança , Bases de Dados Factuais , Epífises/diagnóstico por imagem , Epífises/patologia , Epífises/cirurgia , Feminino , Cabeça do Fêmur/diagnóstico por imagem , Cabeça do Fêmur/cirurgia , Luxação do Quadril/complicações , Luxação do Quadril/diagnóstico por imagem , Luxação do Quadril/cirurgia , Articulação do Quadril/diagnóstico por imagem , Articulação do Quadril/patologia , Articulação do Quadril/cirurgia , Humanos , Doença de Legg-Calve-Perthes/complicações , Doença de Legg-Calve-Perthes/diagnóstico por imagem , Masculino , Radiografia , Estudos RetrospectivosRESUMO
Congenital tibial pseudarthrosis is a rare condition seen in neurofibromatosis type 1 (NF1), and treatment is complex. A randomized, placebo-controlled trial of bone morphogenetic protein (rhBMP-2; INFUSE bone graft) at time of tibial surgery was developed by the Neurofibromatosis Clinical Trials Consortium. Patients were randomized to receive rhBMP-2 that would, or would not, be added to the standard surgical procedure consisting of resection of pseudarthrosis tissue, insertion of a rigid intramedullary rod, and placement of autogenous iliac crest bone graft. Despite involvement of 16 centers with wide experience with NF1 orthopaedic management, only 5 patients (of 54 required) were able to be enrolled in the study during a 3-year time period. Because of the inability to recruit sufficient patients, this study was closed in June 2019, with plans to terminate. The obstacles that were encountered during the study are summarized. The authors question whether a randomized, placebo-controlled trial of a rare pediatric orthopaedic condition is possible to accomplish. Recommendations are provided to guide future studies of orthopaedic manifestations of NF1.Level of Evidence: Level V.
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Proteína Morfogenética Óssea 2/farmacologia , Neurofibromatose 1/cirurgia , Procedimentos Ortopédicos/métodos , Seleção de Pacientes , Pseudoartrose , Ensaios Clínicos Controlados Aleatórios como Assunto/métodos , Fator de Crescimento Transformador beta/farmacologia , Proteínas Morfogenéticas Ósseas/farmacologia , Humanos , Neurofibromatose 1/complicações , Pseudoartrose/congênito , Pseudoartrose/cirurgia , Doenças Raras , Proteínas Recombinantes/farmacologia , Tamanho da Amostra , Tíbia/anormalidades , Tíbia/cirurgiaRESUMO
OBJECTIVE: To evaluate rates and characteristics of slipped capital femoral epiphysis (SCFE) in children who are not obese to prevent missed diagnoses and subsequent complications. STUDY DESIGN: A multicenter, retrospective review identified all patients with SCFE from January 1, 2003 to December 31, 2012. Patients were excluded if they received previous surgery at an outside institution, had no recorded height and weight, or had medical co-morbidity associated with increased risk of SCFE. Body mass index (BMI) percentile for age was calculated and categorized for each patient (patients without obesity vs with obesity). RESULTS: In total, 275 patients met inclusion criteria. Average BMI was 91.2 percentile (range: 8.4-99.7). Thirteen percent (34 patients) were considered "normal weight" (BMI 5%-85%), 17% (48 patients) were considered "overweight" (BMI 85%- 95%), and 70% (193 patients) were considered "obese" (BMI >95%). Average BMI percentile was higher in male than female patients (93.2 ± 12.7 vs 88.5 ± 21.4, P = .034). Patients without obesity were older compared with patients with obesity (12.2 ± 1.7 vs 11.7 ± 1.6 years, P = .015). Fewer patients without obesity were seen at the hospital in the southwest. The southwest had fewer patients without obesity than the northeast (18.3% vs 36.1%, P = .002). Patients without obesity were more likely to present with a severe slip as graded by Wilson percent displacement (27.2% vs 11.4%, P = .007) and an unstable slip (32.9% vs 14.7%, P = .001). CONCLUSION: Rates of nonobese SCFE in this study are higher than reported in the previous literature. Normal weight patients with SCFE are more likely to be older, female, and present with a severe and unstable SCFE.
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Obesidade Infantil/complicações , Escorregamento das Epífises Proximais do Fêmur/diagnóstico , Adolescente , Índice de Massa Corporal , Peso Corporal , Criança , Pré-Escolar , Comorbidade , Feminino , Hospitais Pediátricos , Humanos , Lactente , Recém-Nascido , Masculino , Sobrepeso/complicações , Estudos Retrospectivos , Fatores de Risco , Escorregamento das Epífises Proximais do Fêmur/complicações , Centros de Atenção TerciáriaRESUMO
BACKGROUND: To prospectively evaluate a displacement-based classification system and an outcome-derived algorithm in the treatment of children with lateral condyle fractures. METHODS: All children with a lateral condyle fracture were prospectively enrolled at our institution between 2013 and 2016. Fractures were classified and treated on the basis of the following classification system: type 1: <2 mm; treated with long arm casting, type II: 2 to 4 mm; treated with closed reduction and percutaneous pinning (CRPP), and type III: >4 mm; open reduction and percutaneous pinning (ORPP). Functional outcomes were assessed at 6 to 12 weeks and at 1-year follow-ups using the Pediatric Outcomes Data Collection Instrument (PODCI). RESULTS: A total of 55 patients (mean age, 6 y; range 2 to 12 y) were prospectively enrolled. There were 17 (31%) type I fractures treated with a long arm cast, 8 (15%) type II treated with CRPP, and 30 (54%) type III treated with ORPP. Postoperative complications included delayed union (N=5) and pin site infection (N=3). Delayed unions on the basis of fracture type was type I (1/17, 6%), type II (1/8, 13%), and type III (3/30, 10%) (P=0.85). The rate of delayed unions in type II and III fractures fixed with k-wires was 11% (4/38). Four patients required a second operation with screw fixation. No significant differences were found across PODCI domains at 1-year follow-up when comparing our study population with normative data. CONCLUSIONS: This is the first prospective study of a treatment protocol for pediatric lateral condyle fractures and validates the use of displacement as a guide for best evidence-based treatment. Children with a lateral condyle fracture can achieve excellent functional outcomes in all classification types with comparable complication rates when radiographic fracture displacement is used to guide surgical and clinical decision making. LEVEL OF EVIDENCE: Level II.
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Fraturas do Úmero/cirurgia , Parafusos Ósseos , Criança , Pré-Escolar , Protocolos Clínicos , Feminino , Fixação Intramedular de Fraturas/métodos , Humanos , Fraturas do Úmero/classificação , Fraturas do Úmero/diagnóstico , Úmero/lesões , Masculino , Redução Aberta , Complicações Pós-Operatórias/epidemiologia , Estudos Prospectivos , Resultado do Tratamento , Lesões no CotoveloRESUMO
OBJECTIVE: To examine the relationship between socioeconomic factors and outcomes of developmental dysplasia of the hip (DDH). STUDY DESIGN: A retrospective review of patients with DDH at a tertiary pediatric hospital from 2003 to 2012 with 2 years minimum follow-up was conducted. The relationship between socioeconomic factors with late presentation, treatment, and outcomes was examined. Socioeconomic factors included insurance status, language, and ethnicity. RESULTS: In total, 188 patients met criteria. Patients with late presentations were more likely to be Hispanic (P = .02). However, public insurance and a non-English language were not associated with late presentation. Hispanic patients (P = .01) and patients with a non-English language (P = .01) had a lower nonoperative treatment success rate. Hispanic patients had more surgical procedures performed than non-Hispanic patients (P = .04). Patients with range of motion limitations were more likely to have public insurance (P = .05) and be Hispanic (P = .04). On multiple logistic regression analysis controlling for late presentation, patients with public insurance had increased odds of range of motion limitations (OR 2.22, P = .04). Patients with public insurance (OR 0.44, P = .04), a non-English primary language (OR 0.30, P < .01), and Hispanic ethnicity (OR 0.37, P = .01) had decreased odds of successful nonoperative treatment. CONCLUSIONS: Public insurance, a non-English language, and Hispanic ethnicity are risk factors for inferior outcomes for DDH. When controlling for late presentation, these were significant risk factors for nonoperative treatment failure.
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Luxação Congênita de Quadril/epidemiologia , Luxação Congênita de Quadril/terapia , Diagnóstico Tardio , Feminino , Seguimentos , Luxação Congênita de Quadril/fisiopatologia , Hispânico ou Latino , Humanos , Lactente , Idioma , Masculino , Assistência Médica , Amplitude de Movimento Articular/fisiologia , Estudos Retrospectivos , Fatores de Risco , Fatores Socioeconômicos , Falha de TratamentoRESUMO
OBJECTIVE: To evaluate whether the time from symptom onset to diagnosis of slipped capital femoral epiphysis (SCFE) has improved over a recent decade compared with reports of previous decades. STUDY DESIGN: Retrospective review of 481 patients admitted with a diagnosis of SCFE at three large pediatric hospitals between January 2003 and December 2012. RESULTS: The average time from symptom onset to diagnosis of SCFE was 17 weeks (range, 0-to 169). There were no significant differences in time from symptom onset to diagnosis across 2-year intervals of the 10-year study period (P = .94). The time from evaluation by first provider to diagnosis was significantly shorter for patients evaluated at an orthopedic clinic (mean, 0 weeks; range, 0-0 weeks) compared with patients evaluated by a primary care provider (mean, 4 weeks; range, 0-52 weeks; r = 0.24; P = .003) or at an emergency department (mean, 6 weeks, range, 0-104 weeks; r = 0.36; P = .008). Fifty-two patients (10.8%) developed a second SCFE after treatment of the first affected side. The time from the onset of symptoms to diagnosis for the second episode of SCFE was significantly shorter (r = 0.19; P < .001), with mean interval of 11 weeks (range, 0-104 weeks) from symptom onset to diagnosis. There were significantly more cases of mildly severe SCFE, as defined by the Wilson classification scheme, in second episodes of SCFE compared with first episodes of SCFE (OR, 4.44; P = .001). CONCLUSION: Despite reports documenting a lag in time to the diagnosis of SCFE more than a decade ago, there has been no improvement in the speed of diagnosis. Decreases in both the time to diagnosis and the severity of findings for the second episode of SCFE suggest that the education of at-risk children and their families (or providers) may be of benefit in decreasing this delay.
Assuntos
Diagnóstico Tardio/tendências , Escorregamento das Epífises Proximais do Fêmur/diagnóstico , Adolescente , Criança , Pré-Escolar , Feminino , Humanos , Masculino , Estudos Retrospectivos , Fatores de Tempo , Estados UnidosRESUMO
BACKGROUND: Previous studies have identified that children with public insurance have limited access to orthopaedic care. The purpose of this study was to explore the relationship between insurance status and curve magnitude at the time of presentation to an orthopaedic surgeon and time to treatment at a tertiary pediatric medical center. METHODS: This study was retrospective review of all patients with idiopathic scoliosis over 10 years, who have not had previous spine surgery. Data were collected on demographics, insurance type, curve magnitude at presentation, source of referral, treatment initiated, and time from recommendation for surgery to surgical intervention. RESULTS: Of the 642 patients included in this study, 53% were publicly insured and 45% were privately insured. Privately insured patients were significantly more likely to be seen as a second opinion (30% vs. 10%, P<0.001), and were significantly more likely to have received previous treatment (8% vs. 4%, P=0.011). Publicly insured patients were significantly more likely to be referred by their primary care doctor (64% vs. 50%, P=0.001) or as a part of school screening program (20% vs. 13%, P=0.036). At the time of presentation, there was no significant difference detected in major Cobb angles in the privately insured group [(private=28.7 (±15.4) degrees vs. public=26.4 (±16.8) degrees, P=0.076)]. There was no significant difference between the 2 groups in the number of patients who were recommended for operative treatment (public=11% vs. private 16%, P=0.072). However, in a multivariate regression analysis, publicly insured patients waited an average of 2.6 months longer for surgery than privately insured patients (P=0.010). CONCLUSIONS: Patients with private insurance presenting for evaluation of idiopathic adolescent scoliosis were significantly more likely to present as a second opinion than those with government insurance. In this group of 642 patients, no significant differences were found in major Cobb angle at presentation or eventual need for surgery. LEVEL OF EVIDENCE: Level III.
Assuntos
Acessibilidade aos Serviços de Saúde/economia , Cobertura do Seguro , Seguro Saúde , Escoliose , Adolescente , California , Criança , Feminino , Humanos , Cobertura do Seguro/economia , Cobertura do Seguro/estatística & dados numéricos , Seguro Saúde/classificação , Seguro Saúde/estatística & dados numéricos , Masculino , Análise Multivariada , Ortopedia/economia , Pediatria/economia , Encaminhamento e Consulta/economia , Estudos Retrospectivos , Escoliose/economia , Escoliose/cirurgia , Tempo para o Tratamento/economiaRESUMO
BACKGROUND: The purpose of this study was to determine the early factors associated with the need for surgical interventions in patients with idiopathic clubfoot treated with the Ponseti method. METHODS: All patients with idiopathic clubfoot treated with Ponseti method at our institution with >3 years of follow-up were evaluated. Age at presentation, history of previous treatment, number of casts used, need for percutaneous Achilles tenotomy (PAT), age of initiation of foot abduction orthosis (FAO), compliance with FAO, and need for additional casts were recorded. Dimeglio/Bensahel and Catterall/Piriani scores were recorded at initial presentation, at initiation of FAO, at 1, 2, 3 years of follow-up, and at the most recent follow-up. RESULTS: Since 2000, 86 patients (134 feet) had >3 years of follow-up from time of initial presentation, and 43 of these feet (32%) had undergone surgery beyond a PAT. Patients who were noncompliant with the FAO were 7.9 times more likely to need surgery than those who were compliant [confidence interval (CI), 2.8-22.0; P<0.001]. Female patients were 5.4 times more likely to need surgery than male patients (CI, 1.8-16.6; P=0.003). For every 1 point increase in Dimeglio/Bensahel score at presentation, patients were 1.3 times more likely to need surgery (CI, 1.0-1.5; P=0.033). For every 1 point increase in Dimeglio/Bensahel score at initiation of the FAO, patients were 1.5 times more likely to need surgery (1.1-2.0, P=0.005). Moreover, for each additional cast required before the initiation of the FAO, patients were 1.5 times less likely to need surgery (CI, 1.1-2.7; P=0.030). No other variable significantly contributed to predicting the need for surgery. CONCLUSIONS: There are early factors that can be used to predict increased risk for surgical intervention in patients undergoing treatment for idiopathic clubfoot. Female patients and those patients with higher Dimeglio/Bensahel scores at presentation and at initiation of the FAO are at increased risk for needing surgical intervention. Noncompliance with the FAO is associated with the highest risk for surgical intervention. LEVEL OF EVIDENCE: Level III.
Assuntos
Tendão do Calcâneo , Pé Torto Equinovaro , Procedimentos Ortopédicos , Tendão do Calcâneo/patologia , Tendão do Calcâneo/cirurgia , Pré-Escolar , Pé Torto Equinovaro/etiologia , Pé Torto Equinovaro/cirurgia , Pé Torto Equinovaro/terapia , Feminino , Humanos , Lactente , Masculino , Avaliação das Necessidades , Procedimentos Ortopédicos/métodos , Procedimentos Ortopédicos/estatística & dados numéricos , Aparelhos Ortopédicos/estatística & dados numéricos , Cooperação do Paciente/estatística & dados numéricos , Prognóstico , Medição de Risco/métodos , Fatores de Risco , Fatores Sexuais , Tenotomia/métodos , Tenotomia/estatística & dados numéricos , Fatores de TempoRESUMO
Purpose: Developmental hip dysplasia is a prevalent pediatric musculoskeletal condition that lacks international standardized screening. We sought to characterize developmental hip dysplasia screening practices in countries with the top global health indices. We also explored diverse definitions in reported epidemiologic rates of this condition. Methods: We performed a scoping review of developmental hip dysplasia screening protocols utilizing countries ranked in the top 25 of the Bloomberg Global Health Index using a protocolized search strategy, progressing from academic to layperson sources. A reference was eligible for inclusion if it mentioned the countries' screening program and developmental hip dysplasia was the pathology of concern. Incidence rates, when present, were also recorded. The United States Census Bureau's International Database tool provided countries' populations. We compiled the data and performed descriptive statistics and appropriate validation methods. Results: Twenty countries (80%) had searchable screening programs. Clinical screening with selective universal screening was the most commonly observed (n = 16). Four countries had universal ultrasound screening: Switzerland, Austria, Germany, and Slovenia. Five countries did not have searchable programs. No countries employed radiographic screening. Incidence rates were expressly stated in the literature for nine countries; however, the cohort of interest varied from developmental hip dysplasia versus severity of developmental hip dysplasia versus miscellaneous (e.g. requiring hospitalization). Conclusion: The findings of this investigation highlight international inconsistencies regarding developmental hip dysplasia screening and epidemiologic data. Screening variations exist despite consensus statements calling for uniformity. We agree with prior literature advocating for increasing consistency in developmental hip dysplasia management or, at a minimum, increasing transparency regarding how we manage these young patients.
RESUMO
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.
RESUMO
BACKGROUND: Femoral fractures in children have the highest probability for abuse after skull fractures and humeral shaft fractures. However, the reported proportion of pediatric femur fractures that result from nonaccidental trauma (NAT) varies in the literature from 2% to 60%. The purpose of this study was to determine the patient characteristics associated with a physician's decision to conduct a NAT workup and challenge universal clinical practice guidelines stating that all children younger than 3 years with a diaphyseal femur fracture be evaluated for NAT. METHODS: A retrospective review was conducted on patients aged 0 to 36 months diagnosed with a femur fracture between January 1, 2004, and April 9, 2019, at our institution. NAT was defined as a diagnosis of trauma that was nonaccidental in the medical chart after a positive workup by skeletal survey, ophthalmological examination, or other appropriate referral made by the institution's child abuse and neglect team. Patients with incomplete medical records were excluded. RESULTS: A total of 299 patients were identified, and 22 were excluded. 71% (197/277) were screened for NAT. Patients younger than 1 year were significantly more likely to undergo a NAT workup (P = 0.009; Odds Ratio [OR], 2.3; 95% CI, 1.2 to 4.4) and receive a positive result from the NAT workup (P < 0.0005; OR, 11.3; 95% CI, 4.6 to 27.4). Additional injuries were also a significant predictor of a positive NAT workup (P < 0.001; OR, 5.3; 95% CI, 2.4 to 11.9). Patient race/ethnicity, sex, and fracture type were not markedly associated with the physician's decision to conduct a NAT workup. CONCLUSIONS: Infants younger than 1 year with a femur fracture and children younger than 3 years presenting with a femur fracture and another injury are at increased risk of possible NAT. While clinical practice guidelines may minimize racial bias in NAT evaluation, this study demonstrates that universal NAT workups for walking-age children in the absence of other evidence of abuse may be unnecessary. LEVEL OF EVIDENCE: This is a Level III retrospective cohort study.