Recurrence After Surgical Intervention for Infantile Tibia Vara: Assessment of a New Modified Classification.

BACKGROUND: To propose a modified classification of infantile tibia vara based on the morphology of the metaphyseal/epiphyseal tibial slope that better correlates with treatment outcomes than the traditional Langenskiold classification. METHODS: We performed a retrospective review of 82 patients and 115 limbs that underwent surgery for infantile tibia vara over a 22-year period (1990 to 2012) at a single institution. A modified Langenskiold classification was applied to all patients preoperatively and the outcomes were assessed. The modified system created a 3-stage classification (types A, B, and C): type A has a partially lucent medial metaphyseal defect, with or without "beaking"; type B deformity has downward-sloping curvature of the lateral and inferior rim of a completely lucent metaphyseal defect, which then has an upslope at the medial rim, resembling a ski-jump, with no epiphyseal downward slope; type C has vertical, downsloping deformity of both the epiphysis and metaphysis, with no upward curvature projecting medially at the inferior extent, while the epiphysis slopes downward into the metaphyseal defect. RESULTS: Sixty-seven limbs did not develop recurrence following corrective osteotomy, whereas 48 limbs required at least 1 repeat surgery for recurrent deformity. Preoperative mechanical axis deviation, medial proximal tibial angle, lateral distal tibial angle, and body mass index did not differ significantly between those with recurrence and those with without. Mean age at surgery was significantly different for those who developed recurrence compared with those who did not. Patients without recurrence were 4.3 years of age (range, 2.4 to 10.3 y) compared with 6.2 years of age (range, 2.9 to 10.1 y) for those who recurred (P<0.01). Of patients who developed recurrent deformity, there were significantly more patients with type C changes (71.7%, P<0.01) then either type A (22.5%) or type B (20.7%). High rates of recurrence were seen for both Langenskiold stage III (50%) and stage IV (69.6%). CONCLUSIONS: Consistent with prior studies, age 5 seems to be a critical transition in the risk for recurrent deformity after tibial osteotomy. Extreme vertical sloping of the medial metaphyseal defect, as in some classic Langenskiold III lesions and more precisely described by type C in a newer, modified classification, carries a poor prognosis for successful correction by high tibial osteotomy alone or in combination with epiphysiolysis. LEVEL OF EVIDENCE: Level II.

Sex-specific analysis of data in high-impact orthopaedic journals: how are we doing?

BACKGROUND: In 2001, the Institute of Medicine released a report stating that sex must be considered in all aspects and at all levels of biomedical research. Knowledge of differences between males and females in responses to treatment serves to improve our ability to care for our patients. QUESTIONS/PURPOSES: The purpose of our study was to determine (1) if there is an increase in the proportion of sex-specific reporting from 2000 to 2005 and to 2010; and (2) whether there is a proportional difference in such reporting based on journal type: subspecialty versus general orthopaedics. We hypothesize that assessment of the role of sex in outcomes has improved during the past 15 years and that the proportion of studies with of sex-specific analyses has increased with awareness of the role of sex in clinical outcomes and disease states. We additionally hypothesized that the reporting of sex would be similar between subspecialty and general orthopaedic journals. METHODS: Five high-impact orthopaedic journals, consisting of two general and three subspecialty journals, were chosen for review. Issues from even-numbered months during three calendar years (2000, 2005, 2010) were critically assessed for the presence of sex-specific analyses and reporting by two separate reviewers. Retrospective and prospective clinical studies, with a minimum of 20 patients, were included for analysis. Cadaveric, biomechanical, and in vitro studies were excluded. Review articles and clinical studies with less than 20 patients were excluded. A total of 821 studies that met inclusion criteria were analyzed: 206 in 2000, 277 in 2005, and 338 in 2010. RESULTS: Overall, the proportion of sex-specific analyses increased during the three times studied (19%, 40/206, [95% CI, 0.14-0.25] of the studies in 2000; 27%, 77/277, [95% CI, 0.23-0.33] in 2005; and 30%, 102/338, [95% CI, 0.25-0.35] in 2010). The increase in the proportion of sex-specific analysis was significant between 2000 and 2005 (p = 0.033), but was not significant between 2005 and 2010 (p = 0.518). During each of the three specific years studied, general and subspecialty journals increased in the proportions that reported sex-based analyses, but specialty journals had significantly higher reporting rates only in 2000 (2000: 11.9%, 13/109, [95% CI, 0.06-0.18] and 27.8%, 27/97, [95% CI, 0.19-0.37], p = 0.004; 2005: 22.9%, 33/144, [95% CI, 0.16-0.30], and 33.1%, 44/133, [95% CI, 0.25-0.41], p = 0.059; 2010: 28.2%, 51/181, [95% CI, 0.22-0.35] and 32.5%, 51/157, [95% CI, 0.25-0.40], p = 0.390). CONCLUSIONS: Our findings indicate that inclusion of sex-specific analysis and reporting in the orthopaedic literature improved during our study period, but are present in less than 1/3 of the studies. Although subgroup analysis and reporting are required by NIH guidelines, it is important that such analyses be published in non-NIH-funded studies to generate hypotheses regarding sex differences for subsequent research. These data also are important as they can be used in systematic reviews where large independent studies may not be available in the literature. CLINICAL RELEVANCE: Where evaluating conditions that affect males and females, studies should be designed with sufficient sample size to allow for subgroup analysis by sex to be performed, and they should include sex-specific differences among the a priori research questions.

Orthopedic aspects of collagen disorders.

PURPOSE OF REVIEW: The purpose of this article is to provide the pediatrician with a review of disorders that have the orthopedic manifestation of joint hypermobility. Hypermobility, also termed ligamentous laxity, may present in different parts of the body at different times throughout childhood and adolescence. It may be symptomatic or incidentally found on the physical examination. Many conditions that cause joint hypermobility resolve with nonoperative management, but occasionally operative intervention is required for the best patient outcome. RECENT FINDINGS: In addition, hypermobility may be associated with collagen disorders that affect vital organ systems. Recognition of hypermobility combined with a thorough patient evaluation may be the initial opportunity for the pediatrician to uncover disease that may be managed promptly. SUMMARY: Heightened awareness of subtle hypermobility or symptomatic joint laxity on physical examination facilitates optimal management and favorable outcomes in children with this condition.

Pediatric upper extremity stress injuries.

PURPOSE OF REVIEW: To provide primary care physicians with strategies to evaluate and manage pediatric upper extremity stress injuries related to overuse with a focus on anatomic location, patient history, physical examination, and imaging. RECENT FINDINGS: Children are susceptible to stress injuries due to their open physes. The physeal cartilage of epiphyses and apophyses is the weakest structure in the developing skeleton. The differential diagnosis for pediatric stress injuries includes injury to the bone, physis, epiphysis, and apophysis. Most stress injuries in children improve with rest. Missed or misdiagnosed stress injuries can lead to growth abnormalities and potential malalignment. SUMMARY: Awareness of stress injuries is important for timely diagnosis and prevention of sequelae. A thorough history, focused physical examination, and proper imaging studies are crucial steps to identify upper extremity stress injuries in the pediatric population.

Sex and gender considerations in male patients with osteoporosis.

BACKGROUND: Osteoporosis remains underrecognized and undertreated in both men and women, but men who sustain fragility fractures experience greater morbidity and mortality. While men exhibit advanced comorbidity at the time of hip fracture presentation, there are distinct sex- and gender-specific factors related to the pathophysiology and treatment of osteoporosis that further influence morbidity and mortality. QUESTIONS/PURPOSES: With a selective review of the literature, we evaluated sex- and gender-based differences contributing to increased morbidity and mortality in men with osteoporosis. WHERE ARE WE NOW?: Sex-specific differences in bone biology and morphology may affect the pathophysiology of osteoporosis, choice of pharmacotherapy, and surgical implant selection. Additionally, estrogen metabolism may play a key role in both fracture prevention and healing. Gender-based differences in recommendations for screening and prevention between men and women may influence the severity at which osteoporosis is recognized. Primary, secondary, and tertiary prevention efforts in men lag behind those of women. This may be due to a lack of consensus regarding screening guidelines for osteoporosis in men but may be attributed to lack of awareness in the physician and patient about osteoporosis and its potentially debilitating consequences. WHERE DO WE NEED TO GO?: These disparities are a call to action for healthcare providers to raise awareness for early prevention and treatment of this potentially debilitating disease, particularly in men. HOW DO WE GET THERE?: Continued prospective research on the differences between men and women diagnosed with osteoporosis is needed, as well as sex-specific stratification of data in all studies on osteoporosis.

Neonatal brain structure on MRI and diffusion tensor imaging, sex, and neurodevelopment in very-low-birthweight preterm children.

The neurological basis of an increased incidence of cerebral palsy (CP) in preterm males is unknown. This study examined neonatal brain structure on magnetic resonance imaging (MRI) and diffusion tensor imaging (DTI) at term-equivalent age, sex, and neurodevelopment at 1 year 6 months on the basis of the Amiel-Tison neurological examination, Gross Motor Function Classification System, and Bayley Scales of Infant Development in 78 very-low-birthweight preterm children (41 males, 37 females; mean gestational age 27.6 wks, SD 2.5; mean birthweight 1021 g, SD 339). Brain abnormalities on MRI and DTI were not different between males and females except in the splenium of the corpus callosum, where males had lower DTI fractional anisotropy (p=0.025) and a higher apparent diffusion coefficient (p=0.013), indicating delayed splenium development. In the 26 infants who were at higher risk on the basis of DTI, males had more abnormalities on MRI (p=0.034) and had lower fractional anisotropy and a higher apparent diffusion coefficient in the splenium (p=0.049; p=0.025) and right posterior limb of the internal capsule (PLIC; p=0.003; p=0.033). Abnormal neurodevelopment was more common in males (n=9) than in females (n=2; p=0.036). Children with abnormal neurodevelopment had more abnormalities on MRI (p=0.014) and reduced splenium and right PLIC fractional anisotropy (p=0.001; p=0.035). In children with abnormal neurodevelopment, right PLIC fractional anisotropy was lower than left (p=0.035), whereas in those with normal neurodevelopment right PLIC fractional anisotropy was higher than left (p=0.001). Right PLIC fractional anisotropy correlated to neurodevelopment (rho=0.371, p=0.002). Logistic regression predicted neurodevelopment with 94% accuracy; only right PLIC fractional anisotropy was a significant logistic coefficient. Results indicate that the higher incidence of abnormal neurodevelopment in preterm males relates to greater incidence and severity of brain abnormalities, including reduced PLIC and splenium development.

Radiographic, Pulmonary, and Clinical Outcomes With Halo Gravity Traction.

STUDY DESIGN: Single-center retrospective chart review. OBJECTIVES AND SUMMARY: Halo gravity traction (HGT) is a safe and effective intervention to improve spinal deformity prior to corrective instrumentation. Our study aimed to report on a large series of patients undergoing HGT, demonstrate the correlation between thoracic height achieved and pulmonary function, and evaluate the efficacy of nutritional assessment and intervention while in HGT for these often malnourished or nutritionally compromised patients. METHODS: 107 patients underwent HGT for severe spinal deformity. Major coronal and sagittal Cobb angles, T1-T12 ht, and T1-S1 ht were collected pre-HGT, during HGT, postoperation, and 2 years postoperation. Pulmonary function tests (PFTs) recorded forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1). Nutritional interventions such as formal nutrition consult, resulting nutritional supplementation, or interventions were recorded. RESULTS: Patients were in HGT for mean of 82.1 days and mean maximum percentage body weight in traction was 49.5%. Mean major coronal Cobb angle prior to HGT was 92.6°, improving to 65.8° in maximal traction and to 47° after surgical intervention. Traction accounted for 78% of T1-T12 height and 79% of T1-S1 length gains from pre- to postoperation. We showed a positive correlation between gain in T1-T12 height and percentage predicted changes in FVC and FEV1. Weight Z score for the entire cohort of patients improved from -2.8 pretraction to -2.4 in traction and then to -2.3 postoperative. CONCLUSIONS: Our study again demonstrated that HGT achieves radiographic improvement safely and effectively in severe spinal deformity. We demonstrated a positive correlation between improvement in PFTs and increase in thoracic height seen with HGT. Additionally, improvement in weight Z score was seen in the entire population and the most at risk patients for malnutrition, results that have not been shown before. LEVEL OF EVIDENCE: Level IV.

Subscapularis tears and lesser tuberosity avulsion fractures in the pediatric patient.

BACKGROUND: Pediatric subscapularis tears are known to be rare injuries. They are often associated with an avulsion fragment of the lesser tuberosity leading to dual description in the literature of either subscapularis tear or lesser tuberosity avulsion. Historically, they were managed nonoperatively; however, outcomes have improved with operative management. Nonoperative management often led to bony overgrowth at the lesser tuberosity that limited motion. The literature is limited to case reports and a few small case series, often not restricted to pediatric patients. STUDY DESIGN: Case series. LEVEL OF EVIDENCE: Level 5. METHODS: Radiographic and operative databases were retrospectively reviewed to identify pediatric patients with subscapularis tears or lesser tuberosity avulsions in the past 10 years. RESULTS: Five cases of pediatric subscapularis tears were identified that underwent operative management. Of the 5 cases, 4 had delayed presentation. In 1 case, the lesser tuberosity fragment was initially missed on radiographic imaging. All patients underwent operative management. CONCLUSION: These cases add to the body of knowledge of a rare pediatric injury that is commonly missed or diagnosis delayed. The importance of suspicion in the adolescent male patient without instability and unrelenting shoulder pain is stressed. Additionally, the importance of early magnetic resonance imaging with suspicion as well as an axillary view of the shoulder is demonstrated. As with all rare entities, it is important to disseminate information on natural history and interventions for this injury.

20 years of pediatric anterior cruciate ligament reconstruction in New York State.

BACKGROUND: There have been no population-based studies to evaluate the rate of pediatric anterior cruciate ligament (ACL) reconstruction. PURPOSE: The primary aim of the current study was to determine the yearly rate of ACL reconstruction over the past 20 years in New York State. Secondary aims were to determine the age distribution for ACL reconstruction and determine whether patient demographic and socioeconomic factors were associated with ACL reconstruction. STUDY DESIGN: Descriptive epidemiology study. METHODS: The Statewide Planning and Research Cooperative System (SPARCS) database contains a census of all hospital admissions and ambulatory surgery in New York State. This database was used to identify pediatric ACL reconstructions between 1990 and 2009; ICD-9-CM (International Classification of Diseases, 9 Revision, Clinical Modification) and CPT-4 (Current Procedural Terminology, 4th Revision) codes were used to identify reconstructions. Patient sex, age, race, family income, education, and insurance status were assessed. RESULTS: The rate of ACL reconstruction per 100,000 population aged 3 to 20 years has been increasing steadily over the past 20 years, from 17.6 (95% confidence interval [CI], 16.4-18.9) in 1990 to 50.9 (95% CI, 48.8-53.0) in 2009. The peak age for ACL reconstruction in 2009 was 17 years, at a rate of 176.7 (95% CI, 160.9-192.5). In 2009, the youngest age at which ACL reconstruction was performed was 9 years. The rate of ACL reconstruction in male patients was about 15% higher than in females, and ACL reconstruction was 6-fold more common in patients with private health insurance compared with those enrolled in Medicaid. CONCLUSION: This study is the first to quantify the increasing rate of ACL reconstructions in the skeletally immature. Only ACL reconstructions were assessed, and it is possible that some ACL tears in children are not diagnosed or are treated nonoperatively. The rate of ACL tears in New York State is likely higher than the rate of reconstructions reported in this study. SIGNIFICANCE: This study quantifies the increasing rate of ACL reconstruction in the skeletally immature and suggests that there may be some disparities in care based on insurance status.

The management of extensor mechanism complications in total knee arthroplasty. AAOS exhibit selection.

Complications involving the knee extensor mechanism and patellofemoral joint occur in 1% to 12% of patients following total knee arthroplasty and have major negative effects on patient outcomes and satisfaction. The surgeon must be aware of intraoperative, postoperative, and patient-related factors that can increase the rate of these problems. This review focuses on six of the most commonly encountered problems: patellar tendon disruption, quadriceps tendon rupture, patellar crepitus and soft-tissue impingement, periprosthetic patellar fracture, patellofemoral instability, and osteonecrosis of the patella. The goals of this report are to (1) review the relevant anatomy of the knee extensor mechanism, (2) present risk factors that may lead to extensor mechanism complications, (3) provide a diagnostic and treatment algorithm for each of the aforementioned problems, and (4) review the specific surgical techniques of Achilles tendon allograft reconstruction and synthetic mesh augmentation. Extensor mechanism disorders following total knee arthroplasty remain difficult to manage effectively. Although various surgical techniques have been used, the results in patients with a prior total knee arthroplasty are inferior to the results in the young adult without such a prior procedure. Surgical attempts at restoration of the knee extensor mechanism are usually warranted; however, the outcomes of treatment of these complications are often poor, and management of patient expectations is important.

The impact of preoperative coronal plane deformity on proximal humerus fixation with endosteal augmentation.

OBJECTIVES: To examine the impact of preoperative coronal plane deformity on functional and radiographic outcomes on endosteal strut augmentation of proximal humerus fracture fixation. DESIGN: Single surgeon, retrospective analysis of a prospective database. Case series. SETTING: Academic level 1 trauma center. PATIENTS/PARTICIPANTS: Seventy-two patients with isolated proximal humerus fractures fulfilled all inclusion/exclusion criteria with a minimum follow-up of 12 months. INTERVENTION: Proximal humerus open reduction internal fixation with a laterally placed proximal humeral locking plate and endosteal placement of an allograft fibula treated through the anterolateral approach. MAIN OUTCOME MEASUREMENTS: Global functional outcome as determined by the Disabilities of the Arm, Shoulder and Hand (DASH) score and Short Form 36 physical function. Shoulder-specific functional outcome as determined by the Constant-Murley and the University of California Los Angeles shoulder scores. RESULTS: The mean age was 62 years old (range, 26-90 years). There were 32 varus fractures (neck-shaft angle, 110.8 degrees) and 40 valgus fractures (neck-shaft angle, 168.9 degrees). There was no significant difference in the initial postoperative (varus: 132.5 degrees, valgus: 135.5 degrees) and final (varus: 129.9 degrees, valgus: 132.2 degrees) neck-shaft angles or change in humeral height (varus: 0.94 mm, valgus: 1.48 mm). There were no significant differences in functional outcomes [Constant (varus: 85.2, valgus: 88.7) DASH (varus: 21.4, valgus: 13.9), University of California Los Angeles (28.6, varus 30.4), and Short Form 36 (varus: 66.8, valgus: 59.1)]. There were 2 patients in the valgus group and 3 patients in the varus group with an asymptomatic humeral head screw penetration (mean Constant 84.5, DASH 9.5). There was 1 deep infection in the varus group and 2 in the valgus group necessitating implant removal after fracture union. There was 1 case of avascular necrosis in the valgus group (DASH 19.4, Constant 73). CONCLUSIONS: There were no significant differences in complication rates, radiographic, or clinical outcomes between fractures presenting with preoperative varus coronal displacement compared with those presenting with valgus coronal displacement. The equivalent outcomes may be attributed to the uniform operative technique and fibular strut augmentation used by the primary surgeon. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Evaluation and management of proximal humerus fractures.

Proximal humerus fractures are common injuries, especially among older osteoporotic women. Restoration of function requires a thorough understanding of the neurovascular, musculotendinous, and bony anatomy. This paper addresses the relevant anatomy and highlights various management options, including indication for arthroplasty. In the vast majority of cases, proximal humerus fractures may be treated nonoperatively. In the case of displaced fractures, when surgical intervention may be pursued, numerous constructs have been investigated. Of these, the proximal humerus locking plate is the most widely used. Arthroplasty is generally reserved for comminuted 4-part fractures, head-split fractures, or fractures with significant underlying arthritic changes. Reverse total shoulder arthroplasty is reserved for patients with a deficient rotator cuff, or highly comminuted tuberosities.

Temporal-spatial parameters of the upper limb during a Reach & Grasp Cycle for children.

The objective of this study was to characterize normal temporal-spatial patterns during the Reach & Grasp Cycle and to identify upper limb motor deficits in children with cerebral palsy (CP). The Reach & Grasp Cycle encompasses six sequential tasks: reach, grasp cylinder, transport to self (T(1)), transport back to table (T(2)), release cylinder, and return to initial position. Three-dimensional motion data were recorded from 25 typically developing children (11 males, 14 females; ages 5-18 years) and 12 children with hemiplegic CP (2 males, 10 females; ages 5-17 years). Within-day and between-day coefficients of variation for the control group ranged from 0 to 0.19, indicating good repeatability of all parameters. The mean duration of the Cycle for children with CP was nearly twice as long as controls, 9.5±4.3s versus 5.1±1.2s (U=37.0, P=.002), partly due to prolonged grasp and release durations. Peak hand velocity occurred at approximately 40% of each phase and was greater during the transport (T(1), T(2)) than non-transport phases (reach, return) in controls (P<.001). Index of curvature was lower during transport versus non-transport phases for all children. Children with CP demonstrated an increased index of curvature during reach (U=46.0, P=.0074) and an increased total number of movement units (U=16.5, P<.0001) compared to controls, indicating less efficient and less smooth movements. Total duration of the Reach & Grasp Cycle (rho=.957, P<.0001), index of curvature during reach and T(1) (rho=.873, P=.0002 and rho=.778, P=.0028), and total number of movement units (rho=.907, P<.0001) correlated strongly with MACS score. The consistent normative data and the substantial differences between children with CP and controls reflect utility of the Reach & Grasp Cycle for quantitative evaluation of upper limb motor deficits.

Three-dimensional kinematics of the upper limb during a Reach and Grasp Cycle for children.

The ability to reach, grasp, transport, and release objects is essential for activities of daily living. The objective of this study was to develop a quantitative method to assess upper limb motor deficits in children with cerebral palsy (CP) using three-dimensional motion analysis. We report kinematic data from 25 typically developing (TD) children (11 males, 14 females; ages 5-18 years) and 2 children with spastic hemiplegic CP (2 females, ages 14 and 15 years) during the Reach and Grasp Cycle. The Cycle includes six sequential tasks: reach, grasp cylinder, transport to mouth (T(1)), transport back to table (T(2)), release cylinder, and return to initial position. It was designed to represent a functional activity that was challenging yet feasible for children with CP. For example, maximum elbow extension was 43+/-11 degrees flexion in the TD group. Consistent kinematic patterns emerged for the trunk and upper limb: coefficients of variation at point of task achievement for reach, T(1), and T(2) for trunk flexion-extension were (.11, .11, .11), trunk axial rotation (.06, .06, .06), shoulder elevation (.13, .11, .13), elbow flexion-extension (.25, .06, .23), forearm pronation-supination (.08, .10, .11), and wrist flexion-extension (.25, .21, .22). The children with CP demonstrated reduced elbow extension, increased wrist flexion and trunk motion, with an increased tendency to actively externally rotate the shoulder and supinate the forearm during T(1) compared to the TD children. The consistent normative data and clinically significant differences in joint motion between the CP and TD children suggest the Reach and Grasp Cycle is a repeatable protocol for objective clinical evaluation of functional upper limb motor performance.