Can Caregivers Forecast Their Child's Postoperative Disability After Elective Orthopedic Surgery?

Background While there has been a growing emphasis on evaluating the patient's perspective of health outcomes, caregiver expectations of post-orthopedic procedure disability and pain in a pediatric population are yet to be investigated. This study evaluates whether caregivers' preoperative expectations of pain and function differ from their child's early outcomes after surgical orthopedic intervention. Methodology Patients eight to 18 years old undergoing elective orthopedic surgery were enrolled. The caregivers of consented patients completed a survey at the child's preoperative appointment to predict their postoperative pain and disability. The child was given the same survey during their postoperative visit four to six weeks after surgery to assess actual levels of functioning following the procedure. Scores were analyzed to study correlations between patient and caregiver responses (n = 48). Results Caregivers underestimated their child's postoperative psychosocial functioning, as evidenced by the Psychosocial Health Summary Score, and overestimated pain, as demonstrated by the Numeric Pain Rating Scale. The Pediatric Quality of Life Inventory scores showed caregivers had differing expectations of the impact surgery had across various aspects of the physical, emotional, social, and school functioning domains. Higher parental pain catastrophizing was associated with underestimated predictions of their child's psychosocial functioning after surgery. No significant difference was found in the patient's physical functioning, as shown by the Physical Health Summary Score. Conclusions Surgical intervention is a major event that can provoke anxiety for parents and caregivers. Understanding differences in caregiver perspectives and early postoperative patient outcomes provides physicians valuable insights. Explaining to caregivers that patient psychosocial factors and functional outcomes after surgery are commonly better than expected can alleviate anxiety and prevent catastrophizing. This knowledge can help guide caregiver expectations and plans for their child's postoperative pain control and functional recovery.

Conversations About Congenital Clubfoot: Investigating How Parents Share Information About a Structural Diagnosis With Their Children.

Background and objective Clubfoot is a common congenital musculoskeletal condition that is treated with manipulation and casting in the first few weeks of life, followed by bracing that extends into early childhood. While children typically do not recall treatment with Ponseti casting in infancy, childhood treatment and monitoring may result in a sense of heightened awareness. In light of this, this study explores how parents share information about clubfoot diagnosis and guide their children in understanding the importance of treatment. Methods Parents of clubfoot children aged 5-18 years were eligible to participate. Primary recruitment was done through social media via Facebook clubfoot support groups. Participants who gave consent completed an electronic survey and were invited to take part in a semi-structured interview to share additional experiences. Significant themes elicited from study interviews were analyzed along with survey responses. Results Survey responses were received from 74 parents, and 23 participated in the semi-structured interview. Of note, 91% of parents indicated discussing clubfoot with their children, beginning at a median age of three years. The age at which parents first discussed clubfoot with their child was significantly earlier for those who "strongly agree" that their children understand their condition versus those who "agree". Although 68% of parents indicated that receiving guidance from their orthopedic provider would be helpful for these discussions, only 18% noted receiving direct advice. Recurrent themes across interviews included being open and honest about the children's diagnosis and treatment, aiding the children in taking ownership of their diagnosis, and validating emotional responses throughout treatment.  Conclusions This study provides valuable insights into initiating conversations with children about structural diagnoses like congenital clubfoot. Recurrent themes from conversations with families provide information on helpful strategies to encourage early discussions about clubfoot diagnosis and treatment to aid children in taking ownership of their diagnosis.

Parental Concerns Regarding Bracing Compliance for Children With Clubfoot: Seeking Support on Facebook.

Background Clubfoot treatment requires a period of bracing until early childhood to maintain the initial correction achieved by Ponseti casting and serial manipulations. During this period, bracing compliance is the most important factor in preventing the relapse of clubfoot deformity. This period can be challenging for parents, given several factors that affect treatment adherence. In recent years, social media has opened up new ways to seek guidance from an online community, including health-focused areas such as congenital clubfoot. This study examines bracing-related concerns that arise during clubfoot treatment that lead caregivers to seek support from online forums like Facebook. Methodology Six Facebook clubfoot support groups with the highest number of clubfoot posts were evaluated to identify the relative proportion and content of posts related to bracing compliance during December 2021. Bracing-related concerns across all identified posts were then organized into the following six domains that may affect the child's bracing adherence: physical, psychological, commercial, social, bracing device-related, and parental. Results In December 2021, there were 442 total posts across the six clubfoot-focused Facebook groups analyzed. Of these, 23.1% of posts were directly related to bracing compliance. Approximately 22% of these posts had responses where at least one fellow parent suggested seeking advice from a healthcare professional. When these root concerns were organized into six domains that can affect the child's bracing compliance, we found 49 physical, 26 psychological, 5 commercial, 0 social, 14 bracing device-related, and 8 parental factors. Conclusions In this study, 23.1% of all analyzed Facebook posts involved discussion about brace-related concerns, making this a significant topic of discussion on online parental forums. Facebook groups create a community and provide emotional support to parents that support bracing compliance. Clubfoot physicians should be aware of key parental concerns related to bracing compliance, and physicians can provide education on bracing that provides accurate information and anticipatory counseling during regular check-ups with patients and their families.

Evaluating Information About Osteochondritis Dissecans Shared Across Social Media Platforms.

BACKGROUND: With the rise of social media, patients are using a variety of online resources to gather information about medical conditions and connect with others for support. Osteochondritis dissecans (OCD) occurs most commonly among children and adolescents, necessitating early diagnosis and management. The purpose of this study is to evaluate content on social media about OCD to quantify the reach of information shared and themes of discussion surrounding this condition. METHODS: A search was performed across Facebook, Instagram, YouTube, and TikTok using the term "osteochondritis dissecans" to identify information shared related to this topic which was then analyzed based on engagement using number of followers, posts, and/or views. RESULTS: Facebook groups provided a forum for online support and information sharing among patients with OCD and their families. The 4 identified groups had a cumulative following of over 4000 people with posts that shared personal recovery stories, solicited treatment advice, and provided updates on patient progress. Review of related Instagram hashtags revealed over 4500 posts, many of which shared personal accounts of living with OCD. The top 5 most viewed YouTube videos collectively had over 189,000 views and were focused on educational information about OCD, relevant surgical techniques, and pertinent anatomy. The top 3 OCD-related TikTok hashtags had over 4 million total views centered on factual knowledge and sharing changes before and after surgical treatment. CONCLUSION: Patients with OCD and their families seek information about their condition and treatment on online sources including social media. Although social media provides a supportive community to share and receive advice, the quality of information shared in these groups is a subject for concern. Increasing physician involvement and awareness of the information shared across social media platforms may improve accuracy of information and content available to patients. CLINICAL RELEVANCE: It is important for physicians treating patients with OCD to be aware of all sources of information and support, including content shared on social media as these platforms allow for the sharing of personal stories, recommendations for treatment, and educational content.

Orthopaedic Surgery Boot Camp: An Immersion Course for Medical Students.

Introduction There is a substantial need for orthopaedic surgery-specific boot camps due to the limited orthopaedic and musculoskeletal education in medical school, which inadequately prepares medical students for their orthopaedic surgery sub-internships. The aim of this study is to identify the impact of the novel orthopaedic surgery boot camp on medical students' confidence with key orthopaedic topics. Methods A cross-sectional study was conducted using an anonymous online survey distributed to medical students attending the novel orthopaedic surgery boot camp. The boot camp consisted of a four-day immersion course into the basics of orthopaedic surgery principles through both didactic and skills-based educational series. The medical students' confidence in orthopaedic surgery clinical and technical skills were assessed by comparing the students' survey responses before and after attending each of the sessions. Results Twelve fourth-year medical students and 15 second-year medical students attended the boot camp. All the sessions attended by the medical students were statistically significant in improving their confidence in the subject matter and skills-based training. Hundred percent (100%) of the fourth-year medical students recommend future orthopaedic surgery-bound medical students to attend this boot camp. Conclusion A dedicated orthopaedic surgery boot camp focused on clinical and technical skills plays a key role in increasing medical students' confidence with key orthopaedic topics by providing an opportunity to practice these skills in a supervised environment with real-time feedback. This novel boot camp can provide a framework for creating a longitudinal course for medical students to augment the musculoskeletal education taught in medical school education.

Quantifying the Relationship Between the Medial Quadriceps Tendon-Femoral Ligament and Patellar Borders: A Pediatric Cadaveric Study.

BACKGROUND: The medial patellofemoral complex (MPFC) is a structure composed of the medial quadriceps tendon-femoral ligament (MQTFL) superiorly and the medial patellofemoral ligament (MPFL) inferiorly. The pediatric MPFL anatomy has been well described, but the precise anatomy of the MQTFL has only recently been described and studied in skeletally immature patients. PURPOSE: To describe the anatomic relationship between the MQTFL and its insertion on the quadriceps tendon and patella in pediatric specimens. STUDY DESIGN: Descriptive laboratory study. METHODS: A total of 22 pediatric cadaveric knee specimens were dissected to analyze attachment of the MQTFL to the quadriceps tendon and patella. Dissection was facilitated using lateral parapatellar arthrotomy followed by eversion of the extensor mechanism to evaluate MQTFL fibers from its undersurface. RESULTS: The mean specimen age was 7.4 years. Specimens were divided based on age into a younger cohort (1-2 years), middle cohort (4-8 years), and older cohort (9-12 years). The quadriceps tendon attachment (QTA) of the MQTFL proximal to the patella extended a median of 5.0 mm in the younger cohort, 11.4 mm in the middle cohort, and 12.0 mm in the older cohort, with significant differences found between the younger and middle cohorts (P < .047) and the younger and older cohorts (P < .001). The QTA as a percentage of patellar articular height averaged 44.4% across all specimens. The vertical height of the patella measured a median of 14.0 mm, 22.3 mm, and 27.3 mm in the younger, middle, and older cohorts, respectively. CONCLUSION: This study expands on the recently described anatomy of the pediatric MPFC to quantify the anatomic relationship between the MQTFL attachment to the quadriceps tendon and patella in a more clinically relevant cohort of donor specimens. CLINICAL RELEVANCE: As access to pediatric cadaveric tissue is extremely limited, a better understanding of MPFC and MQTFL anatomy will support surgeons in preoperative planning and intraoperative considerations for their approach to MQTFL and MPFL reconstruction. This may facilitate improved anatomic surgical stabilization of the patellofemoral joint in pediatric patients.

What is New in Pediatric Orthopaedic Foot and Ankle.

BACKGROUND: This paper aims to report on the last 5 years of relevant research on pediatric foot and ankle pathology with specific focus on clubfoot, congenital vertical talus, toe walking, tarsal coalitions, pes planovalgus with or without accessory navicular, foot and ankle trauma, and talar dome osteochondritis dessicans. METHODS: The Browzine platform was used to review the table of contents for all papers published in the following target journals related to the treatment of pediatric foot and ankle conditions. Search results were further refined to include clinical trials and randomized controlled trials published from March 1, 2015 to November 15, 2021. RESULTS: A total of 73 papers were selected for review based on new findings and significant contributions in treatment of clubfoot, congenital vertical talus, toe walking, tarsal coalitions, pes planovalgus with or without accessory navicular, foot and ankle trauma, and talar dome osteochondritis dessicans. Also included were several papers that did not fit into any of these categories but provided new insight into specific foot and ankle pathologies. CONCLUSIONS: Treatment strategies for children with foot and ankle pathology are continually evolving. We review many of the most recent publications with the goal of improving understanding of these pathologies and highlighting current best practices. LEVEL OF EVIDENCE: Level III.

Tibialis Anterior and Posterior Tendon Transfer for Clubfoot Relapse in a Child with Duchenne Muscular Dystrophy: A Case Report.

CASE: A boy with bilateral congenital clubfoot, Kleefstra syndrome, and Duchenne muscular dystrophy (DMD) developed clubfoot relapse after excellent initial correction with the Ponseti method and maintenance abduction bracing. A traditional clubfoot tibialis anterior transfer was augmented with a tibialis posterior tendon transfer, given underlying DMD at ages 7 and 10 years for the right foot and left foot, respectively. CONCLUSION: This case illustrates successful maintenance of correction using combined tibialis anterior and tibialis posterior tendon transfer. Tibialis posterior tendon transfer may be useful for clubfoot relapse in conditions that weaken the tibialis anterior or in failed tibialis anterior tendon transfers.

Dynamic Supination in Congenital Clubfoot: A Modified Delphi Panel Approach to Standardizing Definitions and Indications for Treatment.

BACKGROUND: Dynamic supination is a well-recognized cause of congenital clubfoot deformity relapse. However, there is no consensus on how to diagnose it and there are varied approaches in its management. This study aims to define dynamic supination and indications for treatment by presenting consensus from an international panel of experts using a modified Delphi panel approach. METHODS: An international panel of 15 pediatric orthopaedic surgeons with clinical and research expertise in childhood foot disorders participated in a modified Delphi panel on dynamic supination in congenital clubfoot. Panelists voted on 51 statements using a 4-point Likert scale on dynamic supination, clinical indications for treatment, operative techniques, and postoperative casting and bracing. All panelists participated in 2 voting rounds with an interim meeting for discussion. Responses were classified as unanimous consensus (100%), consensus (80% or above), near-consensus (70% to 79%), and indeterminate (69% or less). RESULTS: Consensus was achieved for 34 of 51 statements. Panelists agreed dynamic supination is present when the forefoot is supinated during swing phase of gait with initial contact on the lateral border of the foot. There was also agreement that dynamic supination results from muscle imbalance between the tibialis anterior and the peroneus longus and brevis. There was no consensus on observation of hindfoot varus in dynamic supination, operative indications for posterior release of the ankle joint, or incisional approach for tibialis anterior tendon transfer. Reference to the calcaneopedal unit concept, planes of movement, and phases of gait were deemed important factors for consideration when evaluating dynamic supination. CONCLUSIONS: Consensus statements from the Delphi panel can guide diagnosis and treatment of dynamic supination in clubfoot deformity relapse, including clinical decision making regarding preoperative casting, surgical approach, and postoperative immobilization. Near-consensus and indeterminate statements may be used to direct future areas of investigation. LEVEL OF EVIDENCE: Level V.

Clubfoot Activity and Recurrence Exercise Study (CARES).

BACKGROUND: Approximately half of treated clubfoot patients initially corrected with the Ponseti method experience relapse that requires additional treatment. The consequences of relapse on childhood activity levels have not been well studied. Ponseti noted lower functional ratings at 18-year follow-up in clubfoot patients who had undergone tibialis anterior tendon transfer for relapse. METHODS: Clubfoot Activity and Recurrence Exercise study (CARES) is an observational, prospective cohort study that compares physical activity in 30 clubfoot patients without and with relapse. Eligible participants were 5 to 10 years old, diagnosed with idiopathic clubfoot at birth, and had not received any clubfoot treatment for at least 6 months before study. Recruitment for this study occurred in-person and through Facebook clubfoot groups. Consented participants wore Fitbits secured to their wrists for at least 14 days, and completed a demographic survey, Child Health Questionnaire (CHQ), and the clubfoot disease-specific instrument (CDSI). Participants' daily activity was monitored through Fitabase. RESULTS: Participants without and with clubfoot relapse had similar daily step counts, distance walked, and step intensities, except for moderately active step intensity, which was higher in the clubfoot relapse group. Total steps, total distance, distances (very active, moderately active), minutes (very active, fairly active), and lightly active intensity of steps were significantly higher for participants whose families earn more than $100,000 per year. Various physical activities and sports were reported by both groups in daily activity sheets. Neither demographics nor the CDSI or the CHQ scores significantly differed between the 2 groups. Step counts of children with clubfoot with or without relapse were similar to published levels for healthy children. CONCLUSION: Children with clubfoot initially treated with the Ponseti method who undergo treatment for relapse have comparable physical activity to those who have not relapsed. They also have comparable step counts to that of the general pediatric population. These reassuring findings can guide conversations with parents when addressing concerns regarding their children's physical activity after treatment for relapse of clubfoot deformity. LEVEL OF EVIDENCE: Level II-therapeutic studies-investigating the results of treatment.

The Impact of the Digital Age and Social Media on Connecting the Clubfoot Community.

Background Internet chat rooms played an important role in the late 1990s promoting the Ponseti method as the preferred initial treatment for congenital clubfoot. The social media boom has created multiple new methods for caregivers to seek support from a global community using a variety of platforms that are now easily available. This study assesses the reach of information shared across social media platforms about congenital clubfoot and analyzes topics most commonly discussed among members in these groups. Methodology Posts and pages across Facebook, Instagram, Twitter, and TikTok were evaluated to identify the top clubfoot-related hashtags and accounts. In addition, content themes were analyzed for posts across all platforms. Results There were 122 clubfoot-focused Facebook groups for parent support, and the five Facebook groups with the highest number of posts during the study period were found to frequently discuss the following topics: successful treatment stories, questions about casting, bracing, relapse, and commercial items compatible with clubfoot treatment. Twitter pages contained information about live webinars, educational resources for parents and providers, and the impact of the coronavirus disease 2019 pandemic on clubfoot treatment. A search across visual platforms using "#clubfoot" yielded over 59,000 cumulative posts on Instagram and over 34.7 million total views on TikTok. Conclusions Parents of clubfoot patients are increasingly connecting through digital social media platforms, relying on them for information on clubfoot, and utilizing them as a network for social support. Clubfoot physicians should be aware of this content on social media to promote education and discussion that addresses parent concerns, provides accurate information, and guides expectations.

New advances in our understanding of the "unique" RNase L in host pathogen interaction and immune signaling.

Ever since the discovery of the existence of an interferon (IFN)-regulated ribonuclease, significant advances have been made in understanding the mechanism and associated regulatory effects of its action. What had been studied initially as a "unique" endoribonuclease is currently known as ribonuclease L (RNase L where "L" stands for latent). Some of the key developments include discovery of the RNase L signaling pathway, its structural characterization, and its molecular cloning. RNase L has been implicated in antiviral and antibacterial defense, as well as in hereditary prostate cancer. RNase L is activated by 2'-5' linked oligoadenylates (2-5A), which are synthesized by the oligoadenylate synthetases (OASs), a family of IFN-regulated pathogen recognition receptors that sense double-stranded RNAs. Activated RNase L cleaves single stranded RNAs, including viral RNAs and cellular RNAs. The catalytic activity of RNase L has been found to lead into the activation of several cellular signaling pathways, including those involved in autophagy, apoptosis, IFN-ß production, NLRP3 inflammasome activation leading to IL-1ß secretion, inhibition of cell migration, and cell adhesion. In this review, we will highlight the newest advances in our understanding of the catalytic role of RNase L in the context of different cellular pathways and extend the scope of these findings to discussion of potential therapeutic targets for antimicrobial drug development.

RNase L is a negative regulator of cell migration.

RNase L is a regulated endoribonuclease that functions in the interferon antiviral response. Activation of RNase L by 2', 5'-oligoadenylates has been linked to apoptosis, autophagy and inflammation. Genetic studies have also suggested the possible involvement of the RNase L gene (RNASEL) on chromosome 1q25.3 in several types of cancer. Here we report that ablation of RNase L in human prostate cancer PC3 cells by CRISPR/Cas9 gene editing technology enhanced cell migration as determined both by transwell assays and scratch wound healing assays. In addition, RNase L knockdown by means of RNAi increased migration of PC3 and DU145 cells in response to either fibronectin or serum stimulation, as did homozygous disruption of the RNase L gene in mouse embryonic fibroblasts. Serum or fibronectin stimulation of focal adhesion kinase (FAK) autophosphorylation on tyrosine-397 was increased by either knockdown or ablation of RNase L. In contrast, a missense mutant RNase L (R667A) lacking catalytic activity failed to suppress cell migration in PC3 cells. However, a nuclease-inactive mutant mouse RNase L (W630A) was able to partially inhibit migration of mouse fibroblasts. Consistent with a role for the catalytic activity of RNase L, transfection of PC3 cells with the RNase L activator, 2', 5'-oligoadenylate, suppressed cell migration. RNase L knockdown in PC3 cells enhanced tumor growth and metastasis following implantation in the mouse prostate. Our results suggest that naturally occurring mutations in the RNase L gene might promote enhanced cell migration and metastasis.