The favorable outcome of Bernese periacetabular osteotomy for the hip osteoarthritis in multiple epiphyseal dysplasia.

BACKGROUND: Multiple epiphyseal dysplasia (MED) is a rare congenital bone dysplasia. Patients with MED develop secondary hip osteoarthritis as early as the third to the fourth decade. Currently, there is no consensus on the prevention of the progressive hip osteoarthritis secondary to MED. The Bernese periacetabular osteotomy (PAO) is a joint-preserving surgery to reshape acetabulum and extend femoral head coverage. However, there is no documentary evidence for the effect of the procedure on MED hips. PATIENTS AND METHODS: We analyzed the preliminary outcomes following the Bernese PAO in 6 MED hips. The average age at the time of surgery was 14.3 years (range from 11.4 to 17.2 years). For our study interest of time efficiency, radiographic parameters were analyzed preoperatively and 1 year postoperatively. The hip function was evaluated by the Harris Hip Score (HHS) before and after surgery. RESULTS: The mean follow-up time was 1.7 years. The mean lateral center-edge angle increased from 3.8° to 47.1° (p = 0.02), anterior center-edge angle increased from 7.3° to 35.1° (p = 0.02), and acetabulum index decreased from 27.8° to 14.6° (p = 0.04). The femoral head coverage ratio increased from 66.8% to 100% (p = 0.02). The post-operative anteroposterior pelvic radiograph demonstrated all preoperative broken Shenton lines were reversed. The mean HHS improved from 67.3 to 86.7 (p = 0.05). CONCLUSION: Bernese PAO is a feasible treatment for hip disorders in MED patients. It reshapes acetabular and femoral morphology efficiently. In our study, the preliminary results showed the procedure not only improved radiographic outcomes but also hip function.

Definition of hip displacement and dislocation by acetabular dysplasia in children with cerebral palsy.

Purpose: The acetabulum interacts with the femoral head in daily activities and may exhibit structural changes in the presence of hip disorders. This study aims to redefine hip disorders in children with cerebral palsy by structural characteristics of the acetabulum in relation to the degree of the migration percentage. Methods: The clinical and radiographic data of 70 patients (36 males, 34 females; mean age 8.2 years) with spastic cerebral palsy were retrospectively analyzed. The acetabular structure was measured by the acetabular index on reconstructed three-dimensional computerized tomography for precision of measurement. Any significant change in acetabular index measured on the reconstructive computerized tomography related to every 10% increment of migration percentage was regarded as clinically significant in hip disorders. Results: The acetabular index measured on the reconstructive computerized tomography showed an increasing trend with the increment of migration percentage. The most significant acetabular index measured on the reconstructive computerized tomography change occurred between the 20%-29% and 30%-39% migration percentage groups (p < 0.001), suggesting that a migration percentage of 30% is the starting point of hip disorder. A significant increase in the posterolateral acetabular index measured on the reconstructive computerized tomography occurred in migration percentages >50%, indicating posterolateral acetabular dysplasia. Hips with migration percentages from 80% to 100% had consistent acetabular indexes measured on the reconstructive computerized tomography values, suggesting complete dislocation and no more contact and interaction between the femoral head and acetabular fossa. Conclusion: Structural characteristics in the acetabulum reflect hip dysfunction and potentially classify hip disorders. Results suggest the migration percentage 30% as a starting point of hip disorder and 80% as a turning point of hip dislocation in children with cerebral palsy. Level of evidence: level IV, diagnostic study.

Guided Growth Improves Coxa Valga and Hip Subluxation in Children With Hereditary Multiple Exostoses.

BACKGROUND: In children with severe hereditary multiple exostoses (HME), coxa valga, and hip subluxation are common deformities. The literatures related to surgical management and prevention of hip joint subluxation in HME are scarce. In this study, we aimed to investigate the efficacy of guided growth procedure to correct coxa valga and hip subluxation in HME patients. METHODS: We retrospectively retrieved 12 patients who received guided growth procedures for coxa valga and hip subluxation in HME patients with proximal femur exostoses with a minimum follow-up time of 2 years between 2012 and 2019. Radiographic parameters include head-shaft angle, Hilgenreiner-epiphyseal angle, acetabular index, Reimer migration percentage, center-edged angle, articulo-trochanteric distance, and femoral neck length for comparison between preoperative and latest follow-up results. It was conducted statistically by paired t test and Wilcoxon signed rank test. RESULTS: In this study, the mean difference between preoperative and latest follow-up was significant in head-shaft angle (12±5 degrees; CI, 10-14; P<0.001), Hilgenreiner-epiphyseal angle (12±5 degrees; CI, 10-15; P<0.001), and MP (7%±8%; CI, 3-11; P=0.001). There was a low revision rate (4 of 21, 19%) and no complication in our study. Compared with previous studies on guided growth in children with cerebral palsy and developmental dysplasia of the hip, our study showed good comparable outcomes. CONCLUSION: The results indicated that guided growth improves the hip radiographic parameters of children with HME and may prevent coxa valga and hip subluxations. It is a safe procedure and provides predictable results. LEVEL OF EVIDENCE: Level IV; therapeutic, case series.

Tibial Lengthening along Submuscular Plate with Simultaneous Acute Tibial Deformity Correction by High-Energy Osteotomy: A Comparative Study.

Submuscular plating and osteotomy using power saw have shown the benefits in certain situations of limb lengthening. However, no previous studies combining both procedures have been conducted for acute tibial deformity correction and limb lengthening. Nineteen cases were enrolled in this study. Ten patients received tibial lengthening with acute knee angular deformity correction using high-energy osteotomy (Group 1), and nine patients received tibial lengthening only with osteotomy using multiple drills and osteotome (Group 2). Radiographic parameters retrieved before and after the operation included leg-length discrepancy, tibial length, length gained, mechanical lateral distal femoral angle (mLDFA), medial proximal tibial angle (MPTA), and mechanical axis deviation (MAD). There were significant differences between groups in terms of external fixator index (EFI) (p = 0.013) and healing index (HI) (p = 0.014), but no significance in the length gained (p = 0.356). The latest postoperative mLDFA (p = 0.315), MPTA (p = 0.497), and MAD (p = 0.211) of Group 1 were not distinguishable from Group 2. The functional outcomes were excellent, and there were no permanent complications. Despite showing a longer healing time, this alternative lengthening procedure which combines fixator-assisted plate lengthening in the tibia with simultaneous surgical intervention of acute tibial deformity correction using an oscillating saw is appropriate for patients with leg-length discrepancy and angular deformity of the tibia.

Guided growth versus varus osteotomy for type II avascular necrosis following surgery for developmental dysplasia of the hip.

AIMS: The aim of this study was to compare outcomes of guided growth and varus osteotomy in treating Kalamchi type II avascular necrosis (AVN) after open reduction and Pemberton acetabuloplasty for developmental dysplasia of the hip (DDH). METHODS: This retrospective study reviewed patients undergoing guided growth or varus osteotomy for Kalamchi type II AVN between September 2009 and January 2019. All children who had undergone open reduction and Pemberton acetabuloplasty for DDH with a minimum two-year follow-up were enrolled in the study. Demographic and radiological data, which included the head-shaft angle (HSA), neck-shaft angle (NSA), articulotrochanteric distance (ATD), Sharp angle (SA), and lateral centre-edge angle (LCEA) at baseline, two years, and at the extended follow-up, were compared. Revision rates were evaluated. Clinical outcomes using the Harris Hip Score were assessed two years postoperatively. RESULTS: A total of 24 patients underwent guided growth and 19 underwent varus osteotomy, over a mean period of 3.3 years (95% confidence interval (CI) 2.8 to 3.8) and 5.2 years (95% CI 4.5 to 6.0), respectively. There were no differences in demographic and preoperative radiological data, except for a younger age at time of acetabuloplasty and larger ATD for the osteotomy group. The HSA did not differ at two years and the extended follow-up because of postoperative rebound in the osteotomy group. The NSA of the osteotomy group remained smaller postoperatively. There were no significant differences in the follow-up ATD, SA, and LCEA, except for a smaller two-year ATD of the osteotomy group. Seven patients (29.2%) in the guided growth group underwent revision surgery and none in the osteotomy group. The Harris Hip Score was similar between groups. CONCLUSION: Guided growth and varus osteotomy had comparable results in improving caput valgum deformity, given the rebound of lateral tilting of the physis after osteotomy correction. There were no differences in clinical outcomes at two years postoperatively. Cite this article: Bone Joint J 2022;104-B(7):902-908.

A Long-Term Study of Alignment Correction Following Proximal Femoral Varus Osteotomy and Pemberton Osteotomy in Children With Legg-Calvé-Perthes Disease and Developmental Dysplasia of the Hip.

Proximal femoral varus osteotomy (PFVO) is a common procedure performed in children with developmental dysplasia of the hip (DDH) and Legg-Calvé-Perthes disease (LCPD). However, the long-term effect on angular deformities of the knees and ankles following PFVO remains controversial. This study investigated the relationship between PFVO and alignment changes in the knee and ankle after the procedure. Twenty-five patients undergoing PFVO procedure with a minimum 4-year evaluation period were enrolled in the study, including 14 unilateral LCPD and 11 unilateral DDH. The standing scanogram examinations were collected before the operation, immediately following surgery, after a 1-year follow-up, after a 3-year follow-up, and at the final visit to the clinic. The radiographic parameters included leg length, femoral neck-shaft angle (FNSA), femorotibial angle (FTA), mechanical axis deviation (MAD), tibiotalar angle (TTA), and mechanical lateral distal femoral angle (mLDFA). At the final examination, FNSA demonstrated insignificant change between the operative and non-operative limbs in the DDH group. Compared with the postoperative result, FNSA significantly improved in the LCPD group (p = 0.039). Both groups did not develop statistical significance in TTA, mLDFA, MAD, and leg length discrepancy after more than a 5-year follow-up. From a biomechanical perspective that the foot passes more medial to the knee under the center of leg mass, varus knee was prone to develop. In order to correct the mechanical axis, the knee reverted to a valgus position gradually. Our study indicates that patients with LCPD or DDH receiving PFVO and Pemberton osteotomy narrow the gap of angular growth in knees and ankles between the operative and non-operative limbs after a long-term follow-up.

Radiographic Outcomes of Ganz versus Modified Triple Osteotomies in Femoral Head Medialization and Coverage in Acetabular Dysplasia.

Variable techniques in periacetabular osteotomy have been formulated for the treatment of acetabular dysplasia. However, few studies have compared the radiographic outcomes between different osteotomy types. This study compared modified triple innominate (MTI) osteotomy and Ganz osteotomy with respect to radiographic outcomes. Patients receiving MTI osteotomies and Ganz osteotomies at any time between 2006 and 2018 in a tertiary medical centre were recruited. Only patients with unilateral osteotomies were recruited to eliminate potential influence from the contralateral hip following periacetabular osteotomy. Patients having hip-joint dislocation, receiving simultaneous proximal femoral osteotomy, or having fewer than 2 years of follow-up were excluded. The radiographic parameters of preoperative and postoperative anteroposterior radiographs of the pelvis were measured, and Sharp's angle (SA), the lateral centre-edge angle (CE angle), the femoral head extrusion index (FHEI), and the centre-head distance discrepancy (CHDD) were included for comparison. Among 55 participants, 23 received MTI osteotomies and 32 received Ganz osteotomies. The mean age at which patients underwent surgery was 21.9 years in the Ganz osteotomy group and 21.1 years in the MTI group. The mean follow-up length was 2.5 years. The preoperative radiographic parameters between groups differed only slightly and nonsignificantly. Both groups exhibited significantly improved SA, LCEA, and FHEI after surgery. The Ganz osteotomy group exhibited more favourable postoperative FHEI (13.5 vs. 24.3, p < 0.0001), CHDD (3.7 vs. 11.5, p < 0.0001), Sharp angle (45.0 vs. 41.8, p = 0.0489) and CE angles (28.3 vs. 21.1, p = 0.029) compared with the MTI osteotomy group. Notably, CHDD became better and worse following Ganz and MTI osteotomies, respectively; this suggests that the femoral head is pushed laterally in modified triple osteotomy. With respect to femoral head coverage and the medialization of the femoral head, Ganz osteotomy exhibits more favourable corrections in postoperative radiographic parameters than does MTI osteotomy.

Relationship between metformin use and lactic acidosis in advanced chronic kidney disease: The REMIND-TMU study.

BACKGROUND: Evidence of metformin-associated lactic acidosis (MALA) in advanced chronic kidney disease (CKD) has been limited due to high mortality rate but rare incidence rate. The mechanism of increased MALA in advanced CKD is mainly based on the hypothesis of decreased drug elimination, which might also be confounded by increased comorbidities as CKD progresses. The goal of the study is to analyze the incidence and associated factors of lactic acidosis between metformin user and non-user with advanced CKD. METHODS: This study used a three million population-based, propensity score-matched cohort from 2008 to 2016. The primary outcome was laboratory-defined lactic acidosis. Relationships between the probability of lactic acidosis and various estimated glomerular filtration rate (eGFR) values in advanced CKD patients were also presented in regression analysis. RESULTS: Adults with type 2 diabetes whose eGFR was <30 mL/min/1.73 m2 were enrolled in this study. After the process of propensity score matching, 7707 patients were divided into metformin and non-metformin groups. In linear regression model, metformin significantly increased the risk of lactic acidosis (p=0.0204) as the eGFR declined in advanced CKD over a mean follow up of over 600 days even after confounder adjustment with age, sex and comorbidities. CONCLUSIONS: Metformin was associated with a significant increased risk of laboratory-defined lactic acidosis (p=0.0204) even after adjusting confounder such as age, sex and underlying comorbidities. This "REMIND" study reminds us that metformin-associated lactic acidosis is mainly caused by decreased drug renal elimination other than underlying comorbidities in advanced CKD patients.

Cold Weather as a Risk Factor for Late Diagnosis and Surgery for Developmental Dysplasia of the Hip.

BACKGROUND: Newborn hip screening aims to prevent the late diagnosis of and subsequent surgical procedures for developmental dysplasia of the hip (DDH). Weather may affect how parents swaddle their babies in early life, but weather has never been formally regarded as a risk factor in hip screening. This study investigates the association between the incidence of surgically treated DDH and the outdoor temperature. METHODS: Surgical procedures for late-diagnosed DDH were investigated in 12 birth-year cohorts (1999 to 2010) using the Taiwan National Health Insurance Research Database. The number of children who underwent a DDH-related surgical procedure between 6 months and 5 years of age per total live births was evaluated as an outcome of hip screening. Trend and regression analyses were used to determine the association between the incidence of surgically treated DDH and birth year, birth month, and the temperature during the birth month and first 3 months of life. RESULTS: The mean incidence of surgically treated DDH was 0.48 per 1,000 live births (1,296 surgically treated patients per 2,712,002 live births). The incidence of surgically treated DDH among babies born in winter months (0.70 per 1,000) was significantly higher than that among babies born in summer months (0.32 per 1,000), and it was significantly correlated with mean temperature in the first 3 months of life (r2 = 0.91; p < 0.0001) and birth month (r2 = 0.68; p < 0.001). Multivariable regression revealed that external temperature in the first 3 months of life was the most significant factor (ß = -0.034 [95% confidence interval, -0.042 to -0.022]; p < 0.001) for the incidence of surgically treated DDH (adjusted r2 = 0.485). The trend of seasonal differences remained the same throughout the study years following implementation of the hip-screening policy. CONCLUSIONS: As the incidence of surgically treated DDH is the ultimate outcome of newborn hip screening, cold weather should be regarded as a risk factor and should be incorporated into future screening programs. Weather patterns of different geographical areas should be studied to determine if children born in the winter are at an increased risk for requiring a surgical procedure for DDH, and newborn hip-screening programs should be revised accordingly. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Relationships among Antecedents, Processes, and Outcomes for Shared Decision Making: A Cross-Sectional Survey of Patients with Lumbar Degenerative Disease.

BACKGROUND: Among musculoskeletal disorders, lumbar degenerative disease (LDD) is the leading cause of total disability-adjusted life years globally. Clinical guidelines for LDD describe multiple treatment options in which shared decision making becomes appropriate. OBJECTIVES: To explore the relationships among measures of decision antecedents, process, and outcomes in patients with LDD. METHODS: Patients with LDD were recruited from outpatient clinics in a teaching hospital in Taiwan and administered surveys to collect measures of decision antecedents, processes, and outcomes. Multiple linear regression was conducted to assess the association between decision antecedents and the decision making process. Hierarchical linear regression was conducted to assess the relationships among decision antecedents, the decision making process, and decision outcomes. RESULTS: A total of 132 patients (mean age, 61 years) completed the survey. After adjustment for personal factors, 2 decision antecedents (namely, decision making self-efficacy and readiness) significantly predicted patients' experiences of engaging in shared decision making (SDM). Decision making readiness and process were associated with fewer decisional conflicts and greater decision satisfaction. LIMITATIONS: Models derived from cross-sectional surveys cannot establish causal relationships among decision antecedents, decision making processes, and decision outcomes. CONCLUSIONS: Our results support the SDM framework, which proposes relationships among decision antecedents, the decision making process, and decision outcomes.

Simple scoring algorithm to identify community-dwelling older adults with limited health literacy: a cross-sectional study in Taiwan.

OBJECTIVE: Health literacy (HL) is the degree of individuals' capacity to access, understand, appraise and apply health information and services required to make appropriate health decisions. This study aimed to establish a predictive algorithm for identifying community-dwelling older adults with a high risk of limited HL. DESIGN: A cross-sectional study. SETTING: Four communities in northern, central and southern Taiwan. PARTICIPANTS: A total of 648 older adults were included. Moreover, 85% of the core data set was used to generate the prediction model for the scoring algorithm, and 15% was used to test the fitness of the model. PRIMARY AND SECONDARY OUTCOME MEASURES: Pearson's χ2 test and multiple logistic regression were used to identify the significant factors associated with the HL level. An optimal cut-off point for the scoring algorithm was identified on the basis of the maximum sensitivity and specificity. RESULTS: A total of 350 (54.6%) patients were classified as having limited HL. We identified 24 variables that could significantly differentiate between sufficient and limited HL. Eight factors that could significantly predict limited HL were identified as follows: a socioenvironmental determinant (ie, dominant spoken dialect), a health service use factor (ie, having family doctors), a health cost factor (ie, self-paid vaccination), a heath behaviour factor (ie, searching online health information), two health outcomes (ie, difficulty in performing activities of daily living and requiring assistance while visiting doctors), a participation factor (ie, attending health classes) and an empowerment factor (ie, self-management during illness). The scoring algorithm yielded an area under the curve of 0.71, and an optimal cut-off value of 5 represented moderate sensitivity (62.0%) and satisfactory specificity (76.2%). CONCLUSION: This simple scoring algorithm can efficiently and effectively identify community-dwelling older adults with a high risk of limited HL.

Increasing retractions of meta-analyses publications for methodological flaw.

Purpose of this letter was to explore the trends regarding methodological flaws of systematic review and meta-analyses (SRMAs) based on retraction notes in the past decades, and the categories of reasons for the retractions. Content analysis with descriptive statistics, Cochran Q test, and multinomial logistic regression were used. Based on 187 records of retracted SRMAs, retraction announcements can be categorized into academic ethical violation, methodological flaw, and writing or reporting problem. The numbers of academic ethical violation were significantly higher than those with methodological flaw (z = 3.51; p < 0.01) or writing problem (z = 8.58; p < 0.001). The numbers of methodological flaw were also higher than that with writing problem (z = 6.47; p < 0.001). Moreover, an increased proportion of methodological flaw was observed since 2006, and the retraction year was significantly associated with increased proportion of methodological flaw when academic ethical violation as the reference group.

Balance control and lower limb joint work in children with bilateral genu valgum during level walking.

BACKGROUND: Genu valgum results in lower limb malalignment and altered joint mechanics. The study aimed to identify the effects of genu valgum on balance control and muscular work at the joints during gait in children. RESEARCH QUESTION: Would bilateral genu valgum affect balance control and muscular work at the joints during gait in children? METHODS: Thirteen children with genu valgum and thirteen healthy peers walked at their preferred speed while the body's motions and ground reaction forces were measured to calculate the inclination angles (IA) and the rates of change of IA (RCIA) of the body's center of mass (COM) relative to the center of pressure (COP), as well as the muscular work done at the joints. An independent t-test was used to compare the variables between groups (α = 0.05). RESULTS: Compared to the controls, the patients showed significantly increased step width with altered frontal IA and RCIA variables (p < 0.05), including increased average IA over single-limb support and increased peak RCIA during double-limb support (p < 0.05). The patients significantly increased posterior RCIA at heel-strike but decreased anterior RCIA at toe-off (p < 0.05). The patients showed increased muscular work at both the hip and knee during single-limb support (p < 0.05). SIGNIFICANCE: The children with genu valgum showed a specific balance control strategy during gait. In the frontal plane, greater hip and knee muscular work was needed to maintain balance under an increased IA, likely owing to increased step width associated with the valgus alignment. In the sagittal plane, less smooth and less stable COM-COP control with increased RCIA at the key gait events indicates faster weight transfer between double-limb and single-limb support. It is suggested that patients with genu valgum, especially in more severe cases, should be monitored for signs of decreased ability and/or muscular strength in maintaining balance during gait.

Effectiveness of shared decision-making intervention in patients with lumbar degenerative diseases: A randomized controlled trial.

OBJECTIVE: To evaluate the efficacy of shared decision-making (SDM) intervention among patients with lumbar degenerative diseases (LDDs) in terms of decision self-efficacy, control preferences, SDM process, decision satisfaction, and conflict. METHODS: A total of 130 outpatients with LDDs recruited from orthopedic or rehabilitation clinics were randomly assigned to the SDM intervention (n = 67) or comparison (n = 63) groups. Patients in the intervention group received decision aids (DAs) with decision coaching and those in controlled group received standard educational materials from a health educator. The primary outcome was decision self-efficacy, and secondary outcomes were control preference, SDM process, conflict, and satisfaction. RESULTS: The SDM intervention significantly improved decision self-efficacy (mean difference [MD] = 7.1, 95% confidence interval [CI]: 1.7-12.5, partial η2 = 0.05) and reduced conflict (MD = -7.0, 95% CI: -12.2 to -1.9, partial η2 = 0.06), especially in patients without family involvement, compared with the health education group. However, no significant between-group differences were observed in other outcomes. CONCLUSION: SDM intervention improved SDM self-efficacy and reduced conflict in patients with LDDs. PRACTICE IMPLICATIONS: Clinicians can integrate DAs and decision coaching in SDM conversations. SDM intervention seems to engage patients in decision-making, especially those without family involvement.

Tendon release reduced joint stiffness with unaltered leg stiffness during gait in spastic diplegic cerebral palsy.

Biomechanical deviations at individual joints are often identified by gait analysis of patients with cerebral palsy (CP). Analysis of the control of joint and leg stiffness of the locomotor system during gait in children with spastic diplegic CP has been used to reveal their control strategy, but the differences between before and after surgery remain unknown. The current study aimed to bridge the gap by comparing the leg stiffness-both skeletal and muscular components-and associated joint stiffness during gait in 12 healthy controls and 12 children with spastic diplegic CP before and after tendon release surgery (TRS). Each subject walked at a self-selected pace on a 10-meter walkway while their kinematic and forceplate data were measured to calculate the stiffness-related variables during loading response, mid-stance, terminal stance, and pre-swing. The CP group altered the stiffness of the lower limb joints and decreased the demand on the muscular components while maintaining an unaltered leg stiffness during stance phase after the TRS. The TRS surgery improved the joint and leg stiffness control during gait, although residual deficits and associated deviations still remained. It is suggested that the stiffness-related variables be included in future clinical gait analysis for a more complete assessment of gait in children with CP.

Association of age in motor function outcomes after multilevel myofascial release in children with cerebral palsy.

BACKGROUND: Many recommend deferring orthopedic surgery for cerebral palsy-related disorders in young children. However, age is correlated with musculoskeletal deterioration, and deferral may affect surgical outcomes. We aimed to clarify the relationships among age, degree of musculoskeletal disorder, and postoperative motor function change in children with cerebral palsy. METHODS: We prospectively evaluated children with cerebral palsy and a knee flexion gait disorder who underwent multilevel myofascial release between June 2010 and July 2014. The children were divided into younger (<10 years of age) and older (>10 years of age) groups. Outcome measures included the Gross Motor Function Measure (GMFM), range of motion, spasticity, and physical capacity. Preoperative factors and postoperative changes were compared between the groups using the chi-squared, independent t-, and Mann-Whitney tests. Significant factors were plotted by participant age to identify the relationships between age and other variables. RESULTS: We analyzed 20 patients who underwent multilevel myofascial release (12 and 8 in the younger and older groups, respectively). Whereas most preoperative factors were comparable between the two groups, the older group had a higher range of motion limitation score (44.4 vs. 36.1, p < 0.05). The older group also showed less improvement in the GMFM (-0.3 vs. +3.0, p < 0.05) and physical capacity (+0 vs. +1, p < 0.05) scores after 6 months of postoperative rehabilitation. CONCLUSIONS: Age was positively correlated with the range of motion limitation and negatively correlated with postoperative GMFM improvement. The less favored postoperative rehabilitation course in older children needs to be considered for parents whose children are amenable to surgeries.

Does screw position matter for guided growth in cerebral palsy hips?

AIMS: Guided growth has been used to treat coxa valga for cerebral palsy (CP) children. However, there has been no study on the optimal position of screw application. In this paper we have investigated the influence of screw position on the outcomes of guided growth. METHODS: We retrospectively analyzed 61 hips in 32 CP children who underwent proximal femoral hemi epiphysiodesis between July 2012 and September 2017. The hips were divided into two groups according to the transphyseal position of the screw in the coronal plane: across medial quarter (Group 1) or middle quarter (Group 2) of the medial half of the physis. We compared pre- and postoperative radiographs in head-shaft angle (HSA), Reimer's migration percentage (MP), acetabular index (AI), and femoral anteversion angle (FAVA), as well as incidences of the physis growing-off the screw within two years. Linear and Cox regression analysis were conducted to identify factors related to HSA correction and risk of the physis growing-off the screw. RESULTS: A total of 37 hips in Group 1 and 24 hips in Group 2 were compared. Group 1 showed a more substantial decrease in the HSA (p = 0.003) and the MP (p = 0.032). Both groups had significant and similar improvements in the AI (p = 0.809) and the FAVA (p = 0.304). Group 1 presented a higher incidence of the physis growing-off the screw (p = 0.038). Results of the regression analysis indicated that the eccentricity of screw position correlated with HSA correction and increases the risk of the physis growing-off the screw. CONCLUSION: Guided growth is effective in improving coxa valga and excessive femoral anteversion in CP children. For younger children, despite compromised efficacy of varus correction, we recommend a more centered screw position, at least across the middle quarter of the medial physis, to avoid early revision. Cite this article: Bone Joint J 2020;102-B(9):1242-1247.

Diagnostic Performance of Delirium Assessment Tools in Critically Ill Patients: A Systematic Review and Meta-Analysis.

BACKGROUND: Critical care nurses are in the best position to detect and monitor delirium in critically ill patients. Therefore, an optimum delirium assessment tool with strong evidence should be identified with critical care nurses to perform in the daily assessment. AIM: To evaluate and compare the diagnostic performance of delirium assessment tools in diagnosing delirium in critically ill patients. METHODS: We searched five electronic databases including the Cochrane Library, PubMed, Embase, CINAHL, and a Chinese database for eligible diagnostic studies published in English or Mandarin up to December 2018. This diagnostic test accuracy meta-analysis was limited to studies in intensive care unit (ICU) settings, using the Diagnostic and Statistical Manual of Mental Disorders (DSM) as a standard reference to test the accuracy of delirium assessment tools. Eligible studies were critically appraised by two investigators independently. The summary of evidence was conducted for pooling and comparing diagnostic accuracy by a bivariate random effects meta-analysis model. The pooled sensitivities and specificities, summary receiver operating characteristic curve (sROC), the area under the curve (AUC), and diagnostic odds ratio (DOR) were calculated and plotted. The possibility of publication bias was assessed by Deeks' funnel plot. DATA SYNTHESIS: We identified and evaluated 23 and 8 articles focused on CAM-ICU and ICDSC, respectively. The summary sensitivities of 0.85 and 0.87, and summary specificities of 0.95 and 0.91 were found for CAM-ICU and ICDSC, respectively. The AUC of the CAM-ICU was 0.96 (95% CI, 0.94-0.98), with DOR at 99 (95% CI, 55-177). The AUC of the ICDSC was 0.95 (95% CI, 0.92-0.96), and the DOR was 65 (95% CI, 27-153). LINKING EVIDENCE TO ACTION: CAM-ICU demonstrated higher diagnostic test accuracy and is recommended as the optimal delirium assessment tool. However, the results should be interpreted with caution due to the between-study heterogeneity of this diagnostic test accuracy meta-analysis.