The Prevalence of Hip Dysplasia on Radiographs for Adolescent Idiopathic Scoliosis.

BACKGROUND: During radiographic assessment of adolescent idiopathic scoliosis (AIS), upright images frequently capture the hip. The purpose of this study was to assess the prevalence of radiographic hip dysplasia on postero-anterior (PA) scoliosis radiographs, as defined as a lateral center edge angle (LCEA) ≤25 degrees. METHODS: All patients with upright PA scoliosis radiographs over a one-year study period at a single tertiary academic medical center (2020 to 2021) were included in the study. Radiographs containing the hip joints were annotated by 3 reviewers for left and right LCEA, and triradiate cartilage (TRC) status. Inter-rater reliability was determined among the 3 reviewers. RESULTS: Two hundred fifty patients {500 hips, 75.6% female, median age 14 [interquartile range (IQR)=3]} had PA scoliosis radiographs that captured the hip, which qualified for analysis. Seventy-four hips (14.8%) demonstrated evidence of dysplasia (LCEA ≤25 deg) in 55/250 patients (22%). The median LCEA was significantly lower in the dysplastic hip cohort (23.9 deg, IQR=4.8 deg), compared with those without dysplasia (33 deg IQR=7.3 deg; P=0.001). A higher percentage of dysplastic hip patients were female than male (72.7% vs. 27.3%). Patients with bilateral dysplasia had a similar LCEA ( 22.9 deg) [to those with unilateral dysplasia (22.9 deg left, 23.9 deg right, P=0.689)]. CONCLUSIONS: In a cohort of 250 AIS patients, 22% demonstrated evidence of hip dysplasia, as defined as an LCEA ≤2 degrees. The dysplastic patients were more likely to be female. Screening for hip symptomatology in AIS patients may be of benefit, considering the frequency of radiographic hip dysplasia in this population. LEVEL OF EVIDENCE: III. Type of Evidence: diagnostic.

Trends in the Utilization of Implants in Index Procedures for Early Onset Scoliosis From the Pediatric Spine Study Group.

INTRODUCTION: Because of the relative rarity of Early Onset Scoliosis (EOS) cases, patient registries were developed to combine clinical information from multiple institutions to maximize patient care and outcomes. This study examines the history and trends regarding the use of growth-friendly devices for index surgical procedures in EOS patients within the Pediatric Spine Study Group database. METHODS: All index growth-friendly implants were queried from registry inception until October 2020. EOS etiology, device/implant type, and geographic area/institution for each procedure were recorded. RESULTS: From 1994 to 2020, 2786 patients underwent index surgery at a mean age of 6.2±2.9 years. There were 908 traditional growing rods (TGR) (32.3%), 922 vertical expandable prosthetic titanium rib devices (VEPTR) (33.1%), 5 hybrid VEPTR/TGR (0.18%), and 951 magnetically controlled growing rods (MCGR) (34.2%) index implants. Fifty-six different institutions reported an index implant, and 5 accounted for 823 (30%) of the cases during the study period. Institutions in the Northeast accounted for more index implants than other regions of the United States. There was a 40% increase in index implant insertions annually when comparing 1994 (3 implants/1 center) to 2018 (234 implants/56 centers), ( P <0.001). Beginning in 2009, there was a 90.9% decrease in the number of TGR/VEPTR procedures (2009: 156 implants/32 centers; 2019: 22 implants/49 centers P =0.001), and a 479% increase in MCGR (2009: 1 implant/1 center; 2018: 197 implants/34 centers ( P =0.005). The overall number of growth-friendly index procedures performed in 2019 (150/49 centers) decreased 34.5% when compared to 2018 (234/48 centers). CONCLUSION: The number of growth-friendly implants reported in the Pediatric Spine Study Group registry as the initial surgical management of EOS increased markedly over the past 20 years. MCGR is currently the predominant type of device utilized for index surgical procedures by group members, surpassing the use of VEPTR and TGR in 2014. There was a significant decrease in index growth-friendly procedures in 2019 compared to 2018. LEVEL OF EVIDENCE: Level IV.

Analysis of Author Gender in the Pediatric Orthopaedic Literature from 2011 to 2020.

INTRODUCTION: Orthopaedic surgery remains a male-dominated specialty. To date there has not been a focused analysis of gender in authorship within the pediatric orthopaedic literature. METHODS: The electronic table of contents from 2011 to 2020 of 3 major pediatric orthopaedic journals [Journal of Children's Orthopaedics (JCO), Journal of Pediatric Orthopaedics (JPO), and Journal of Pediatric Orthopaedics Part B (JPO-B)] were reviewed. Publications were reviewed for the number of articles with at least 1 female author and the number of articles with women listed as first authors. These were compared over the 10-year study period, and by individual year of publication. Statistical analysis included a general linear model with factorial one-way anslysis of variance and Bonferroni post hoc testing. RESULTS: A total of 4097 articles were reviewed. In 2020, there was a significantly higher percentage of articles with a female author when compared with 2011 (64% to 42%, P=0.010). A female was listed as first author in significantly more publications in 2020 as compared with 2011 (23% to 10%, P=0.031). During the 10-year study period, the highest mean proportion of articles with at least 1 female author was seen in JPO (60%), with similar findings in JCO (55%). Significantly fewer articles in JPO-B contained a female author (37%, P=0.001). The highest percentage of publications with a female first author across 10 years was in JCO (22%), followed by JPO (20%). Significantly fewer articles with a female first author were found in JPO-B (9%, P=0.001). CONCLUSION: There is an increasing proportion of publications in the pediatric orthopaedic literature with female authors and female first authors from 2011 to 2020. In addition, there was a statistical difference in female authorship when comparing specific publications, which should be investigated further. LEVEL OF EVIDENCE: Level IV.

Evaluation and Management of Common Accessory Ossicles of the Foot and Ankle in Children and Adolescents.

Accessory ossicles are a common radiographic finding about the foot and ankle in children and adolescents. They are often noted incidentally during evaluation of foot and ankle injuries, and most can be managed nonsurgically. Although over 20 accessory ossicles have been described around the foot and ankle, five specific structures generate the most concern in pediatric patients. An accessory navicular presents commonly with medial midfoot pain and may require surgical intervention after failure of nonsurgical treatment. Although an accessory navicular can be treated surgically with simple excision, there is some recent evidence that supports concomitant reconstruction of associated flatfoot deformities. Os trigonum, an ossicle posterior to the talus, is also commonly asymptomatic. However, os trigonum may be associated with persistent posterior ankle pain, and open and endoscopic resection techniques are successful. Os subfibulare is an uncommon ossicle that may be associated with recurrent ankle sprains. Recent literature reports successful return to activities after ossicle excision and ligament reconstruction. Os subtibiale may be confused with a medial malleolar fracture in skeletally immature patients. Os peroneum may contribute to lateral midfoot pain.

A Single Sugar-Tong Splint Can Maintain Pediatric Forearm Fractures.

Displaced pediatric forearm fractures often are treated with closed reduction and immobilization. Recent literature demonstrates no difference in maintaining alignment or needing repeat intervention in patients immobilized with either a single sugar-tong splint or a long-arm cast, but most series include patients with distal fractures. This study included patients 3 to 15 years old who underwent closed reduction and immobilization for displaced midshaft or proximal forearm fractures. Radiographs from the time of injury, after reduction, and at 4-week follow-up were reviewed for coronal and sagittal plane angular alignment. Secondary interventions also were recorded. A total of 121 patients (70 long-arm cast, 51 simple sugar-tong splint) met inclusion criteria. Groups were matched in terms of age (P=.95), sex (P=.41), body mass index (P=.12), and angular deformity prior to reduction in the sagittal (P=.78) and coronal (P=.83) planes. Following closed reduction, sagittal (P=.003) and coronal (P=.002) alignment improved significantly in all patients. At 4-week follow-up, there were no significant differences in sagittal (P=.15) or coronal (P=.68) alignment between the 2 groups. Nine patients underwent a secondary intervention after the index reduction (long-arm cast, n=7; simple sugar-tong splint, n=2), with no statistically significant difference between groups (P=.30). There were no statistically significant differences between patients managed with long-arm cast or simple sugar-tong splint regarding residual sagittal or coronal plane deformity at 4-week follow-up or incidence of secondary intervention. These findings indicate simple sugar-tong splint and long-arm cast appear to be acceptable and equivalent methods of immobilization for these injuries. [Orthopedics. 2021;44(2):e178-e182.].

MRI diagnosis of rubber band constriction syndrome.

Rubber band syndrome is caused by constriction of the wrist from elastic bracelets worn for decorative purposes. Overtime, the fixed or elastic band burrows into the skin and becomes invisible. We present the case of a 2.5-year-old female child presenting to our institution with signs of circumferential swelling and inflammatory changes about the right wrist. MRI of the wrist demonstrated a subcutaneous circular foreign body, which was confirmed at surgery to be a rubber band. Although this disease entity is rare, radiologists can be instrumental in suggesting this diagnosis based on the location involved, ie, wrist, and the imaging findings.

Diagnosis and Management of Common Conditions of the Pediatric Spine.

Back pain and spinal deformity in the pediatric and adolescent patient population are common reasons for presentation to the orthopaedic surgeon, and although most conditions are benign and self-limiting, a standardized approach to the history and physical examination can identify concerning signs and symptoms as well as aid in determining the final diagnosis and a recommended treatment plan. The most common and concerning etiologies of back pain and spinal deformity will be reviewed, along with nonsurgical and surgical management of these conditions.

Hemiepiphyseodesis for Juvenile and Adolescent Tibia Vara Utilizing Percutaneous Transphyseal Screws.

BACKGROUND: In juvenile and adolescent tibia vara patients with sufficient growth remaining, implant-controlled hemiepiphyseodesis, or guided growth, can be used to correct deformity. Recent reports have described hardware failure of certain hemiepiphyseodesis implants in overweight patients with tibia vara. We describe our experience using transphyseal screws to correct deformity in this patient population. METHODS: A retrospective chart and radiograph review was conducted on all juvenile and adolescent tibia vara patients who underwent lateral proximal tibial hemiepiphyseodesis using a single transphyseal screw. Charts were queried for preoperative and postoperative mechanical axis deviation, medial proximal tibial angle, lateral distal femoral angle, and postoperative complications or need for further surgery. RESULTS: In total, 14 affected limbs in 9 patients (6 males) who underwent lateral proximal tibial transphyseal screw hemiepiphyseodesis were considered. Average chronologic age at implantation was 10.4 years and average body mass index was 31.7 kg/m. At average 23-month follow-up, the average mechanical axis deviation improved from 46 to 0 mm (P<0.001), and the average medial proximal tibial angle improved from 81 to 92 degrees (P<0.001). No limbs underwent further surgery to correct residual deformity. There were no complications or instances of implant failure associated with the transphyseal screws. CONCLUSIONS: Hemiepiphyseodesis using transphyseal screws is an effective technique to correct deformity in juvenile and adolescent tibia vara patients with sufficient growth remaining. This method can be used safely with few complications and with minimal risk of mechanical failure, even in overweight patients. LEVEL OF EVIDENCE: Level IV-therapeutic.

Current concepts in neuromuscular scoliosis.

PURPOSE OF REVIEW: Spinal deformity is a common issue in pediatric patients with an underlying neurological diagnosis or syndrome. Management of neuromuscular scoliosis (NMS) is a major part of the orthopedic care of such patients, as the deformity is often progressive, and may affect gait, seating and positioning. In addition, untreated large spinal deformities may be associated with pain and/or cardiopulmonary issues over time. RECENT FINDINGS: Recent changes in medical management of the underlying disease process appears to alter the natural history of certain neuromuscular conditions, and in the case of patients with Duchenne's muscular dystrophy significantly diminish the incidence of spinal deformity. In the most common diagnosis associated with NMS, cerebral palsy, there is evidence that despite a high complication rate, surgical management of spinal deformity is associated with measurable improvements in validated health-related quality-of-life measures. Spinal deformity is a common finding in patients with neurological diagnoses. It is important for those involved in the care of these patients to understand the natural history of NMS, as well as the potential risks and benefits to the patient and caregivers, of surgical and non-surgical interventions.

Experience with definitive instrumented final fusion after posterior-based distraction lengthening in patients with early-onset spinal deformity: single center results.

Limited reports exist with regard to clinical and radiographic details of patients with early-onset spinal deformity (EOSD) undergoing definitive instrumented final fusion (FF) following implantation of a growing construct. Charts and radiographs were queried for all patients who underwent FF after management of EOSD with a distraction-based posterior construct at a single institution from 2006 to 2017. Patients managed during the growth modulation period with either proximal rib or spinal fixation were included. Thirteen patients qualified for inclusion. Spinal deformity etiologies were varied (neuromuscular: 5, idiopathic: 4, congenital: 4). Average age at implantation was 6.5 years, and patients underwent an average of 8.15 lengthening procedures over an average of 69 months. After the growing program, modest correction in main coronal Cobb was obtained at FF (average 52.4° before FF, 37.6° following FF, P<0.001; average percent improvement of 27%). Five patients required posterior column osteotomies. Using criteria proposed by Flynn and colleagues, 'minimal' coronal correction was achieved in 23% of patients and 'moderate' in 77%. No patient achieved 'substantial' (>50%) correction. Subjective poor bone quality was appreciated in 67% of patients, and 85% were noted to have areas of autofusion over previously spanned levels. Two (15%) patients sustained a total of four complications. After growth modulation procedures, EOSD deformities are generally stiff, bone quality is often subjectively poor, and autofusion is common, even after use of proximally rib-based systems. Modestly improved coronal Cobb correction can be obtained at FF but may require single or multiple posterior osteotomies. Intraoperative difficulties can be expected, and clinicians should be alert for intraoperative and postoperative complications.

Septic arthritis of the pediatric hip: update on diagnosis and treatment.

PURPOSE OF REVIEW: To review the clinical diagnosis, management and natural history of septic arthritis of the hip (SAH) in the pediatric patient, and to highlight new information that may improve the management of these patients. RECENT FINDINGS: The basics of management of possible pediatric SAH have remained largely unchanged for generations. New questions have been raised regarding the role and timing of advanced imaging (MRI) in the evaluation of patients with possible SAH. Published criteria have been derived to guide the need for MRI studies in these patients. Validation of these guidelines continues. Recent reviews have highlighted the possibility of Lyme disease as a potential cause of monoarticular pediatric hip pain. The role of PCR technology in the diagnosis and management of SAH remains unclear at this time. SUMMARY: The child with a limp remains a common and urgent clinical concern. There may be expanded roles for MRI and PCR to better diagnose and treat the involved joint itself, as well as any associated nonarticular area of infection. Lyme disease should remain on the list of possible differential diagnoses in this population, particularly in geographic areas where the disease vector is known to be endemic.

Clinical and radiographic comparison of single-sugar-tong splint to long-arm cast immobilization for pediatric forearm fractures.

The purpose of this study was to compare the efficacy of a single-sugar-tong splint (SSTS) to a long-arm cast (LAC) in maintaining reduction of pediatric forearm fractures, while avoiding secondary intervention. One hundred patients age 3-15 with a forearm fracture requiring a reduction and immobilization were evaluated (50 LAC and 50 SSTS). Medical records and radiographs were reviewed at injury, postreduction, and at 1, 2, and 4 weeks postinjury. Sagittal and coronal angular deformities were recorded. Any secondary intervention due to loss of reduction was documented. The groups were matched by age (P = 0.19), sex (P = 0.26), mechanism of injury (P = 0.66), average injury sagittal deformity (LAC 27.4°, SSTS 25.4°; P = 0.50), and average injury coronal deformity (LAC 15.5°, SSTS 16°; P = 0.80) At 4 weeks postinjury follow-up, there were no statistically significant differences between use of an SSTS or LAC when comparing postimmobilization sagittal alignment (LAC 10.3 ± 7.2, SSTS 8.4 ± 5.1°; P = 0.46), coronal alignment (LAC 6.9 ± 4.6, SSTS 7.6 ± 9.3°; P = 0.46), or need for repeat manipulation or surgery (LAC 4/50, SSTS 3/50; P = 0.70).

Septic Arthritis of the Hip-Risk Factors Associated With Secondary Surgery.

INTRODUCTION: Septic arthritis of the hip (SAH) is a common condition encountered by pediatric orthopaedic surgeons and is treated with arthrotomy and irrigation. Depending on the response to initial treatment, some patients require surgical treatment beyond the index procedure. The purpose of this study was to investigate risk factors for repeat surgical intervention after initial arthrotomy for presumed SAH. METHODS: A multicenter retrospective review of all children who underwent surgical arthrotomy for presumed SAH over a ten-year period was conducted. Variables queried included demographics, clinical presentation, laboratory parameters, imaging, infecting organism, presence of osteomyelitis, and surgical interventions performed. Logistic regression was used to predict the risk of a second procedure. Chi-square was used to compare patients who required further surgery and those who did not. RESULTS: One hundred and thirty-eight patients (139 hips) qualified for inclusion. The average age at initial surgery was 6.1 years (range, zero to 17 years), and 57% of the patients were male. Concomitant osteomyelitis was diagnosed in 55 cases (40%). An infecting organism was identified from 70 (50%) index intraoperative cultures, with Staphylococcus aureus infections (methicillin-resistant Staphylococcus aureus [MRSA], 27; methicillin-sensitive Staphylococcus aureus, 25) being the most frequent. Fifty-six patients (41%) underwent subsequent surgical intervention, at an average of 5.5 days (range, 2 to 95) from the index procedure. Independent risk factors for repeat surgical procedures included presenting C-reactive protein >10 mg/dL (P = 0.002) and presenting erythrocyte sedimentation rate >40 (P = 0.011). The odds of repeat surgical intervention were significantly increased by the presence of concomitant osteomyelitis (odds ratio, 3.4; P = 0.001) and positive index intraoperative cultures for MRSA (odds ratio, 1.19; P = 0.001). Preoperative MRI before the index procedure was not universal (73/138; 53%), and acquisition of preoperative MRI was not associated with secondary surgical intervention (P = 0.389). DISCUSSION: Forty-one percent of children in this multicenter cohort underwent at least one repeat surgical procedure after the index arthrotomy for management of presumed SAH. Risk factors for return to the operating room include elevated initial erythrocyte sedimentation rate and C-reactive protein, infection with MRSA, and presence of osteomyelitis. LEVEL OF EVIDENCE: Level 3, case-cohort series. Type of evidence, therapeutic.

The Crankshaft Phenomenon.

The crankshaft phenomenon, a progressive rotational and angular spinal deformity that can occur after posterior spinal surgery, has been reported in pediatric patients with idiopathic, congenital, and neuromuscular scoliosis. In the skeletally immature patient, the crankshaft phenomenon is thought to occur secondary to continued growth of the anterior elements of the spine after solid posterior spinal fusion. The condition has also been reported in the setting of newer, so-called growth-friendly posterior distraction-based spinal instrumentation. The clinical evidence of crankshaft phenomenon is often subtle, whereas radiographic findings are usually more apparent. However, objective measurement of radiographic signs may be complicated by instrumentation and postoperative changes. Treatment options for patients with the crankshaft phenomenon are limited; in those with problematic deformity and/or risk of progression, additional surgery may be indicated.

Orthobiologics in Pediatric Orthopedics.

Orthobiologics are biologic devices or products used in orthopedic surgery to augment or enhance bone formation. The use of orthobiologics in pediatric orthopedics is less frequent than in other orthopedic subspecialties, mainly due to the naturally abundant healing potential and bone formation in children compared with adults. However, orthobiologics are used in certain situations in pediatric orthopedics, particularly in spine and foot surgery. Other uses have been reported in conjunction with specific procedures involving the tibia and pelvis. The use of bioabsorable implants to stabilize children's fractures is an emerging concept but has limited supporting data.

Evaluation of Pediatric Questions on the Orthopaedic In-Training Examination-An Update.

BACKGROUND: Pediatric orthopaedics is tested frequently on the Orthopaedic In-Training Examination (OITE). The most recent data on the pediatrics section of the OITE were generated from content 10 years old. The purpose of this study is to assess the pediatric orthopaedic questions on the 2011 to 2014 OITE, and to compare question categories and cognitive taxonomy with previous data. METHODS: Four years (2011 to 2014) of OITE questions, answers, and references were reviewed. The number of pediatric questions per year was recorded, as well as presence of a clinical photo or imaging modality. Each question was categorized and assigned a cognitive taxonomy level. Categories included: knowledge; knowledge-treatment modalities; diagnosis; diagnosis/recognition of associated conditions; diagnosis/further studies; and diagnosis/treatment. Cognitive taxonomy levels included: simple recall, interpretation of data, and advanced problem-solving. RESULTS: The 3 most commonly covered topics were upper extremity trauma (17.4%), scoliosis (10.1%), and developmental dysplasia of the hip (5.7%). Compared with previous data, the percentage of pediatric questions was constant (13% vs. 14%). Categorically, the more recent OITE examinations contained significantly fewer questions testing simple knowledge (19% vs. 39%, P=0.0047), and significantly more questions testing knowledge of treatment modalities (17% vs. 9%, P=0.016) and diagnosis with associated conditions (19% vs. 9%, P=0.0034). Regarding cognitive taxonomy, there was a significant increase in the average number of questions that required advanced problem-solving (57% vs. 46%, P=0.048). Significantly more questions utilized clinical photographs and imaging studies (62% vs. 48%, P=0.012). The most common reference materials provided to support correct responses included Lovell and Winter's Pediatric Orthopaedics (25.7%) and the Journal of Pediatric Orthopaedics (23.4%). CONCLUSIONS: Although the percentage of pediatric questions on the OITE has remained essentially constant, the percentage of questions requiring advanced problem-solving or interpretation of images has increased significantly in the past 10 years. Knowledge of question type and content may be helpful for those involved in resident education and in the development of didactic pediatric orthopaedic curricula. LEVEL OF EVIDENCE: Level IV.

Complications following spine fusion for adolescent idiopathic scoliosis.

Complications following spine fusion for adolescent idiopathic scoliosis can be characterized as either intra-operative or post-operative. The most serious and feared complication is neurologic injury, both in the intra- and post-operative period. Other intra-operative complications include dural tears and ophthalmologic or peripheral nerve deficits, which may be related to positioning. Among the most common post-operative complications are surgical site infection, venous thromboembolism, gastrointestinal complications, and implant-related complications. Significant blood loss requiring transfusion, traditionally considered a known sequelae of spine fusion, is now being recognized as a "complication" in large national databases. Pediatric spine surgeons who care for patients with AIS must be thoroughly familiar with all potential complications and their management.

Comparison of Intraoperative C-Arm Fluoroscopy to Postoperative Radiographs in Operative Fracture Fixation.

The purpose of this study is to evaluate the differences between intraoperative C-arm images and postoperative plain film radiographs and the utility of each in assessing fracture fixation and determining postoperative management. Intraoperative and postoperative images with varying fracture types and locations were analyzed. C-arm images were compared to postoperative plain film radiographs for each treated fracture and reviewed by two orthopaedic surgeons. Image adequacy and quality for each radiograph were analyzed. The quality of reduction and fixation was also analyzed. Information was apparent on the postoperative radiographs, such that a reviewer felt that the postoperative treatment plan should change in 8.2% of cases. In the cases where treatment change was recommended, fracture gap, rotation, and angulation were found to be the strongest predictors. The ability of intraoperative and postoperative images to reflect fracture gap, rotation, and angulation may vary between images.

Lower extremity rotational and angular issues in children.

Familial concern regarding perceived rotational and angular deformities is a common part of any primary care practice. It is essential for the medical practitioner to understand the wide normal range in children and the natural history of lower extremity development over time. Most lower extremity rotational and angular issues in young children resolve spontaneously over time, and require little or no intervention. In the current atmosphere of medical cost containment, coupled with the shortage of pediatric orthopedic surgeons, many of these patients should be managed by the primary care provider and do not require referral for more specialized care.