Does Combining Drilling and Curettage to Percutaneous Trans-epiphyseal Screws Improve Correction of Limb Length Discrepancy? A Comparative Study.

Objectives: Physeal drilling and curettage (PDC) and percutaneous epiphysiodesis using transphyseal screws (PETS) are among the most widely used techniques to treat leg-length discrepancy (LLD). This study compared the efficacy and outcomes between PETS alone and PETS combined with PDC (PETS + PDC). Methods: Retrospective study of children who underwent epiphysiodesis of the proximal tibia or distal femur with either PETS or PETS + PDC between 2008 and 2018 at a single institution. Radiographic parameters and complications were reviewed at completion of treatment and most recent follow-up. Results: A total of 23 epiphysiodeses in 15 patients, average age 13.1 years, with either PETS (13 femur/tibias) or PETS + PDC (10 femur/tibias) were included. PETS patients were treated for a longer time (median: 24 months vs 11 months, p = 0.004), however, follow-up time was similar between groups (p = 0.577), on average 2.7 years. In the PETS group, LLD decreased from 2.55 to 0.84 cm at most recent follow-up (p = 0.010), and in the PETS + PDC group from 3.01 to 1.2 cm (p = 0.005), achieving a correction of 1.71 cm for PETS and 1.83 cm for PETS + PDC (p = 0.871). A correction of LLD to ≤ 2 cm was achieved in 8 PETS (89%) and 4 PETS + PDC cases (67%) (p = 0.525). Two PETS patients (22%) and 1 PETS + PDC (17%) patient returned to the OR for further correction due to persistent LLD (p = 1.000). No differences existed in total number of complications, angular deformity or return to physical activity between groups (p ≥ 0.05 for each comparison). Conclusions: This study showed equal efficiency in resolving LLD between the PETS and PETS + PDC procedures with minimal operative complications.Level of Evidence III.

The Effect of Guided Growth Surgery on Langenskiold Stage and Mechanical Axis in Early-Onset Blount Disease: A Retrospective Case Series.

INTRODUCTION: Our understanding of the efficacy of guided growth surgery with tension-band plating (TBP) in early-onset Blount disease is evolving. Preliminary work has demonstrated that TBP can normalize the mechanical axis, yet its effect on Langenskiöld stage (LS) has not previously been reported. The primary outcome of this study was improvement in LS after TBP. Secondary outcomes were improvement in LS at most recent follow-up and improvement in mechanical axis deviation (MAD), mechanical medial proximal tibial angle, and mechanical lateral distal femoral angle at treatment completion and most recent follow-up. METHODS: A retrospective review was done of patients with early-onset Blount disease treated with TBP between January 1, 2010, and December 31, 2019, across two institutions. Inclusion criteria were a radiographic diagnosis of early-onset Blount disease (LS changes present), surgery with TBP, and follow-up beyond implant removal. Radiographs before surgery, at removal of hardware (ROH), and at most recent follow-up were evaluated. RESULTS: Twenty-five limbs in 16 children who underwent TBP at a mean age of 5.8 ± 2.3 years were included. Implants were in situ a mean of 1.9 ± 0.7 years. The mean follow-up after ROH was 3.6 ± 1.4 years. LS ranged from 1 to 5 preoperatively with 14 of 25 limbs (56%) staged ≥3. LS improved in 15 of 25 limbs (60%) at ROH and in 21 of 25 limbs (84%) at most recent follow-up. Langenskiöld changes resolved in 7 of 25 limbs (28%) at most recent follow-up. Preoperatively, the MAD was varus in all limbs, but at ROH, the MAD had improved in 22 of 23 limbs with neutral or valgus alignment in 20 of 23 limbs (87%). At most recent follow-up, 16 of 23 limbs (70%) maintained improved alignment. DISCUSSION: There was improvement/resolution of LS and varus deformity in early-onset Blount disease in most patients who underwent TBP. Based on these results, TBP for early-onset Blount disease should be the first-line surgical treatment. LEVEL OF EVIDENCE: IV.

The Impact of Standardized Recovery Pathways on Language Barriers and Inpatient Pain Management.

BACKGROUND AND OBJECTIVES: Inpatient postoperative care is reliant upon clear, open communication between providers and patient-families, and thus is particularly vulnerable to disparities when discordant languages exist. It is not yet understood how standardized postoperative protocols may mitigate disparities related to language discordance. METHODS: This is a retrospective cohort study among adolescent idiopathic scoliosis patients who underwent posterior spinal fusion at a tertiary care children's hospital in Bronx, New York after implementation of a postoperative pathway in 2017. Outcomes reliant upon communication between patient-families and providers were measured, including measures of pain management (number and type of pain medications requested, daily pain assessments, total opioids consumed), as well as outpatient pain scores. RESULTS: A total of 160 patients were included (39 language other than English [LOE]). Between patient cohorts, there were no significant differences in demographic or operative characteristics. On univariate analyses, LOE patients were more likely to be given a basal dosing of patient-controlled analgesia or additional boluses (26% vs 12%, P = .03), consumed 0.53 fewer benzodiazepine medications per day (P = .01), and were more likely to have pain at outpatient follow-up (67% vs 43%, P = .03). On multivariate analyses, LOE patients were more likely to be placed on basally dosed or receive additional boluses of patient-controlled analgesia (odds ratio 3.19, 95% confidence interval 1.15-8.85). CONCLUSIONS: As standardized pathways become more common in health care, it is critical to monitor for components of these protocols that may be vulnerable to language-related disparities, such as therapies reliant on symptom description and outpatient follow-up.

Percutaneous Ultrasound-Guided Tenotomy of the Iliotibial Band for Trochanteric Pain Syndrome: A Longitudinal Observational Study With One-Year Durability Results.

BACKGROUND: Upper lateral hip pain is a common complaint in adults and is referred to as greater trochanteric pain syndrome (GTPS) and is more prevalent among older women. This is a debilitating condition that could result in lower physical activity and quality of life, and higher unemployment rate. GTPS is a clinical diagnosis, and many cases improve with conservative medical management (CMM). However, there is still a gap between patients not responding to CMM and those who are not good surgical candidates. Thus, percutaneous ultrasound tenotomy (PUT) may be a valuable treatment option to limit this gap. OBJECTIVES: Demonstration of the one-year pain and functional outcomes, including sit to stand. SETTING: Academic tertiary care medical center. METHODS: Forty-eight consecutive patients with refractory trochanteric pain due to iliotibial band (ITB) tendinopathy. Fifty-six hips were treated; 8 patients underwent bilateral procedures. Electronic medical record review of consecutive patients who underwent ITB TENEX® was performed at Montefiore Medical Center from December 2019 to December 2021. Institutional guidelines recommended TENEX® for greater trochanteric pain refractory to conservative treatment and ultrasound (US) confirmed ITB tendinopathy (hypoechogenicity or thickened tendon > 6 mm). Pain level, as well as sit-to-stand, side-lying, and walking tolerance levels were evaluated at baseline preprocedure visit and one-year visit. Follow-up was performed by independent practitioners and corroborated by chart review. RESULTS: Numeric Rating Scale (NRS-11) improved by 4 points across all patients. Seventy percent of patients endorsed pain relief at one-year visit. Median preprocedure NRS-11 was 9. The reported median NRS-11at one year was 5 (Wilcoxon signed rank NRS-11 demonstrated a Z score of -6.042 with P < 0.001). One-year analysis among all patients revealed 57%, 78%, and 66% improvement in side-lying, sit-to-stand, and walking tolerance levels, respectively. LIMITATIONS: We believe that our results must be confirmed with a randomized control trial with a control arm and more patients included. CONCLUSIONS: PUT of the ITB using the TENEX® tissue remodeling device could be a safe and effective treatment for ITB tendinopathy-associated GTPS.

Pediatric Fractures: Does Vitamin D Play a Role?

BACKGROUND: Vitamin D (25-OHD) deficiency and insufficiency are reported in about half of all children. The literature on low 25-OHD and pediatric fracture risk presents inconsistent results. This study evaluates the association between pediatric fractures and 25-OHD, parathyroid hormone (PTH), and calcium. METHODS: This is a prospective case-control study in 2 urban pediatric emergency departments (2014-2017). Patients aged 1 to 17 requiring intravenous access were enrolled. Demographics, nutrition, and activity information were recorded and levels of 25-OHD, calcium, and PTH were measured. RESULTS: Two hundred forty-five subjects were enrolled: 123 fractures and 122 controls. Overall, the mean 25-OHD level was 23 ng/mL±8.5: 52 (21%) of patients were 25-OHD sufficient; 193 (79%) were not. Ninety-six percent of patients with lower extremity fractures had low 25-OHD versus 77% of patients with upper extremity fractures ( P =0.024). The fracture cohort was younger ( P =0.002), included more males ( P =0.020), and spent more time playing outdoor sports ( P =0.011) than the control cohort. The 25-OHD level (fracture 22.8 ng/mL±7.6 vs. nonfracture 23.5 ng/mL±9.3, P =0.494) and median calcium level (fracture 9.8 mg/dL vs. nonfracture 10.0 mg/dL, P =0.054) were similar between cohorts. The median PTH level was higher in the fracture than the control cohort (33 vs. 24.5 pg/mL; P <0.0005); PTH was elevated to hyperparathyroidism (>65 pg/mL) in 13% of fractures and 2% of controls ( P =0.006). Matched subgroup analysis of 81 fracture patients and 81 controls by age, gender, and race showed that PTH was the only variable independently associated with increased odds of fracture (odds ratio=1.10, 95% CI, 1.01-1.19, P =0.021) in a model adjusted for vitamin D sufficiency and time spent playing outdoor sports. CONCLUSIONS: Low 25-OHD is common in children with fractures but we found no difference in 25-OHD levels between fracture and nonfracture cohorts. This research can impact evidence-based guidelines on vitamin D level screening and/or supplementation after fracture. LEVEL OF EVIDENCE: Diagnostic level IV-case-control study.

Back pain in adolescent idiopathic scoliosis: A comprehensive review.

Purpose: Adolescent idiopathic scoliosis (AIS) is a common spinal deformity that affects millions of children worldwide. A variety of treatment algorithms exist for patients based on radiographic parameters such as the Cobb angle and the Risser stage. However, there has been a growing focus on nonradiographic outcomes such as back pain, which can cause functional disability and reduced quality of life for patients. In spite of this, back pain in AIS is poorly characterized in the literature. We aimed to summarize various factors that may influence back pain in AIS and the impact of different treatment methods on pain reduction. Methods: A comprehensive systematic review was undertaken using the PubMed and Cochrane database. Keywords that were utilized and combined with "Adolescent Idiopathic Scoliosis" included, "back pain," "treatment," "biomechanics," "biochemistry," "epidemiology," and "biopsychosocial." The literature was subsequently evaluated and deemed relevant or not relevant for inclusion. Results: A total of 93 articles were ultimately included in this review. A variety of contradictory literature was present for all sections related to epidemiology, underlying biomechanics and biochemistry, biopsychosocial factors, and treatment methodologies. Conclusion: Back pain in AIS is common but remains difficult to predict and treat. The literature pertaining to causative factors and treatment options is heterogeneous and inconclusive. Longer-term prospective studies combining biopsychosocial intervention in conjunction with existing curve correction techniques would be meaningful.

Percutaneous epiphysiodesis using transphyseal screws (PETS) versus tension-band plating (TBP): comparative study of outcomes for correcting limb length discrepancy.

OBJECTIVES: The best effective treatment strategy for limb length discrepancy (LLD) is still being debated. The goal of this study was to compare the efficacy and results of tension-band plating (TBP) and percutaneous epiphysiodesis using transphyseal screws (PETS) for LLD correction. METHODS: From June 2008 to January 2019, children who had lower extremity epiphysiodesis with either TBP or PETS were reviewed retrospectively. At the conclusion of treatment, LLD, angular deformity, and complications were reviewed. The t-test or Wilcoxon rank sum test was used to compare continuous variables. Categorical variables were evaluated using Fisher's exact test or χ2 test. RESULTS: A total of 32 epiphysiodeses with TBP (14 patients, 24 femur/tibias) or PETS (13 patients, 23 femur/tibias) were compared. TBPs were conducted while the patients were younger (11.0 vs. 13.1 years, p = 0.005). The treatment durations were similar in both groups (TBP: 23.5 months vs. PETS: 24 months, p = 0.132). PETS had significantly shorter operative time (p = 0.047), length of hospital stay (p = 0.014), and time to return to full activity (p = 0.043). LLD in the TBP group reduced from 2.64 to 1.38 cm (p = 0.005), while in the PETS group it decreased from 2.76 to 1.08 cm (p = 0.001). During treatment, the rate of LLD correction was 0.49 ± 0.9 cm/year for limbs treated with TBP and 1.0 ± 1.1 cm/year for limbs treated with PETS (p = 0.185). At the end of treatment, 8 TBP cases (47%) and 9 PETS cases (60%) had achieved LLD ≤ 2 cm (p = 0.502), and at the most recent follow-up, this had grown to 11 (65%) in the TBP group and 12 (80%) in the PETS group. There were no significant differences in the total number of complications between groups (p > 0.05). Revision surgery was required in 11 TBP and 3 PETS limbs due to persistent LLD or angular deformity (AD) (p = 0.016). Logistic regression did not reveal any significant association between TBP and the rate of complication or revision surgery. CONCLUSION: PETS and TBP are both effective methods for limb length equalization. PETS, on the other hand, was linked to a shorter operative time, a shorter hospital stay, a faster recovery to pre-operative function, and a lower complication rate. The rate of revision surgery due to persistent LLD or AD was higher in TBP. We advise surgeons against utilizing TBP to correct LLD. LEVEL OF EVIDENCE: III.

Pre-operative prone radiographs can reliably determine spinal curve flexibility in adolescent idiopathic scoliosis (AIS).

PURPOSE: The purpose of this study was to evaluate the correlation between non-effort prone and bending radiographs in determining curve flexibility in adolescent idiopathic scoliosis (AIS). METHODS: A retrospective review of AIS patients who underwent pre-operative full spine radiographic imaging from 2006 to 2019 was performed. The Cobb angle (CA) of proximal thoracic (PT), main thoracic (MT) and thoracolumbar/lumbar (TL/L) curves were measured and correlated on standing, prone and bending radiographs. Standing, bending, and prone measurements were correlated using Spearman's analysis, and intra-rater reliability was evaluated using intraclass correlation analysis. RESULTS: A total of 381 patients (74% female) with a mean age of 15.1 ± 2.5 years were identified. A strong correlation existed between the prone and bending CA for the PT (rs = 0.797, p < 0.01) and MT (rs = 0.779, p < 0.01) curve and a moderate correlation existed between the prone and bending TL/L curve (rs = 0.641, p < 0.01). For a non-structural PT curve, a prone CA < 25° correctly identified a bending CA < 25° 96.7% of the time (p < 0.005). For a non-structural MT curve, a prone CA < 35° correctly identified a bending CA < 25° 90.2% of the time (p < 0.005). For a non-structural TL/L curve, a prone CA < 35° correctly identified a bending CA < 25° 95% of the time (p < 0.005). CONCLUSION: Prone radiographs demonstrated a moderate to strong correlation with bending radiographs and may be used as a proxy for determining spinal flexibility, especially when bending films are deemed unreliable. LEVEL OF EVIDENCE: III.

Sagittal spinopelvic changes after posterior spinal fusion in adolescent idiopathic scoliosis.

PURPOSE: This article examines if longer posterior spinal fusions with instrumentation (PSFI) into the lumbar spine (L3/4) alter spinopelvic parameters compared with selective fusions to T12/L1/L2 in adolescent idiopathic scoliosis (AIS) patients. METHODS: We analysed radiographs of 84 AIS patients, 58 (69%) females and 26 (31%) males, who underwent PSFI at an mean age of 15 years ± 2.5 years, range 10 years to 21 years, between 1st January 2007 and 31st December 2014. Radiographic parameters were measured pre- and post-operatively at most recent follow-up (range 2 years to 8.2 years): pelvic incidence (PI), lumbar lordosis (LL, L1-S1 and L4-S1), sagittal vertical alignment (SVA), scoliosis angle and proximal junctional kyphosis (PJK). PI-LL was calculated. Data was analysed using t-tests or Wilcoxon rank-sum tests. RESULTS: In total, 32 patients underwent a selective fusion with lowest instrumented vertebra (LIV) T12-L2, and 52 patients underwent a fusion with LIV L3-L4. In both groups, scoliosis angle was significantly corrected at follow-up (p < 0.005).Pre-operatively, both groups had similar LL (L1-S1) and PI-LL. Post-operatively, LL increased in the L3-4 fusion group (p < 0.005) but did not change in the selective fusion group (p = 0.116). This change in LL in the L3-4 fusion group affected the post-operative PI-LL (T12-L2 fusion -4.9° versus L3-4 fusion -13.6°, p = 0.002). No differences were seen in PI, SVA or LL L4-S1 between groups. Radiographic PJK occurred in seven of the L3-4 patients with and without PJK (noPJK -8.8° versus PJK -25.8°, p = 0.026). CONCLUSIONS: In patients who underwent a fusion ending at L3 or L4, LL was increased. This altered the PI-LL relationship, and appeared to increase the risk of PJK. LEVEL OF EVIDENCE: III.

Development of a Global Pediatric Orthopedic Outreach Program in Ecuador Through Project Perfect World: Past, Present, and Future Directions.

Global health delivery is a complex initiative requiring dedicated personnel to achieve a successful program. To be most beneficial, global health delivery should focus on cultural competence, bidirectional education, and capacity building through direct and purposeful means. The authors present the expansion of their global health delivery program in Ecuador focusing on the evolution of the program from a medical mission trip to a multilayered program that helps foster engagement, education, and learning while helping children who might not otherwise have access to care, along with future directions and potential methods to decrease the need for such initiatives in Ecuador.

Treatment of Isolated Serosanguinous Incision Drainage after Thoracolumbar Surgery: Is Surgical Management Always Necessary?

Background: There is no consensus regarding how to care for a patient presenting with early isolated incision drainage after thoracolumbar spine surgery. Although drainage is the most common presenting symptom of surgical site infection (SSI), it has low specificity for SSI in the absence of other symptoms. Given that invasive treatment for SSI is costly and high risk, it would be beneficial to determine whether antibiotic treatment alone is sufficient for isolated drainage and what factors predispose to failure of this conservative strategy. Methods: The authors retrospectively reviewed a clinical database of patients who underwent thoracolumbar spine surgery at a single center between 2012-2017. Patients were included if serosanguinous drainage was present within six weeks of surgery without other signs and symptoms of infection such as fever, chills, purulent discharge, fluctuance, wound dehiscence, or erythema. Results: Fifty-eight patients met the study inclusion criteria. After initial conservative management with antibiotics, drainage resolved in 51 patients. The seven patients with drainage that did not resolve were treated with operative surgical washout. Although the groups were similar in most respects, there was a significant difference in the American Society of Anesthesiologists (ASA) score, which is a marker of overall health (surgical group score 2.89 ± 0.33 versus 2.06 ± 0.61; p < 0.0001). In addition, patients with greater estimated blood loss, length of hospital stay, operative time, and spinal levels treated were more likely to require surgical washout, although these differences were not statistically significant. Groups were similar with respect to age, Body Mass Index, smoking status, diabetes mellitus status, revision versus primary surgery, and drainage latency. Conclusion: Most patients who present with isolated serosanguinous incision drainage within six weeks of surgery may be managed successfully using antibiotics only. Patients who fail to respond to conservative therapy have significantly worse general health, as indicated by the ASA score.

What's New in Pediatric Limb Lengthening and Deformity Correction?

Over the past 5 years, published literature regarding treatment of pediatric limb deformity and limb length discrepancy demonstrates much interest in better understanding, categorizing and treating these challenging problems. Many studies explore expanding and refining indications for traditional treatment methods like guided growth techniques. Other studies have evaluated the results of new techniques such as lengthening via mechanized intramedullary nails. Additionally, series comparing older and newer techniques such as lengthening with external devices versus mechanized nails are becoming increasingly available.

Parental understanding of intoeing gait - A preliminary study.

OBJECTIVE: Evaluation of a child's intoeing gait is one of the most common referrals made to a pediatric orthopedist. Families may have difficulty understanding the often transient and usually benign nature of intoeing. The purpose of this study was to investigate parental perceptions of an intoeing gait both before and after consultation with an orthopedic practitioner. METHODS: 48 parents of children referred to pediatric orthopedic surgeons for evaluation of intoeing gait completed a 22-item questionnaire that assessed demographics, anxiety, and parental perceptions of intoeing. Questionnaires were administered before and after visits. Statistical analysis was performed using Wilcoxon signed-rank tests and Fisher exact tests. RESULTS: Before their visits, parents reported similar levels of anxiety and understanding regarding intoeing, independent of their age or education. After the visits, anxiety decreased (P < 0.001), and understanding increased (P < 0.001) although younger parents (18-25 years) reported higher post-visit anxiety compared to parents older than 25 (P = 0.014). Similarly, parents with a high school degree or less reported higher post-visit anxiety compared to parents who attended college (P = 0.009). Post-visit understanding was inversely correlated with post-visit anxiety (r = -0.717; P < 0.001). Additionally, parents who reported high anxiety post-visit stated they were more likely to seek additional care (P < 0.001). CONCLUSIONS: Younger parents with lower education levels were more likely to leave visits with high anxiety and poor understanding. These parents were more likely to consider seeking further treatment for their child's intoeing, placing additional stress on their child, themselves and an overburdened healthcare system.

ACR Appropriateness Criteria® Scoliosis-Child.

Scoliosis is frequently encountered in childhood, with prevalence of 2%. The majority is idiopathic, without vertebral segmentation anomaly, dysraphism, neuromuscular abnormality, skeletal dysplasia, tumor, or infection. As a complement to clinical assessment, radiography is the primary imaging modality used to classify scoliosis and subsequently monitor its progression and response to treatment. MRI is utilized selectively to assess for neural axis abnormalities in those at higher risk, including those with congenital scoliosis, early onset idiopathic scoliosis, and adolescent idiopathic scoliosis with certain risk factors. CT, although not routinely employed in the initial evaluation of scoliosis, may have a select role in characterizing the bone anomalies of congenital scoliosis and in perioperative planning. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR Appropriateness Criteria® Suspected Spine Trauma-Child.

Choosing the appropriate imaging in children with accidental traumatic spine injuries can be challenging because the recommendations based on scientific evidence at this time differ from those applied in adults. This differentiation is due in part to differences in anatomy and physiology of the developing spine. This publication uses scientific evidence and a panel of pediatric experts to summarize best current imaging practices for children with accidental spine trauma. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

A National Analysis on Predictors of Discharge to Rehabilitation After Corrective Surgery for Adolescent Idiopathic Scoliosis.

STUDY DESIGN: Retrospective study of a national database. OBJECTIVE: To identify the incidence and risk factors for discharge to a rehabilitation facility after corrective surgery for adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: The vast majority of patients who undergo surgery for AIS are discharged home, with limited data on rates and causes for discharge to a rehabilitation facility. METHODS: The United States National Inpatient Sample (NIS) database was queried for the years 2012 to 2014. Inclusion criteria were children aged 10 to 18 who underwent surgery for idiopathic scoliosis. Studied data included patient demographics, operative parameters, length of stay, and hospital charges. Perioperative complications were also examined, along with their association with discharge to an inpatient rehabilitation facility. Statistical analysis was performed via chi-squared testing and multivariate analysis, with significance defined as a P-value <0.05. RESULTS: A total of 17,275 patients were included (76.3% female, mean age 14 yr). Out of the entire cohort, 4.8% of patients developed a complication and 0.6% were discharged to a rehabilitation facility. The most common complications included respiratory failure (2.3%), reintubation (0.8%), and postoperative hematoma (0.8%). Following multivariate analysis, male sex (Odds ratio (OR) 4.7; 95% Confidence Interval (CI), 1.8-12.2; P = 0.002), revision surgery (OR 29.6; 95% CI, 5.7-153.5; P < 0.001), and development of a perioperative complication (OR 12.3; 95% CI, 4.7-32.4; P < 0.001) were found to be significant predictors of discharge to rehabilitation. Average length of stay was 8 ±â€Š6 versus 5 ±â€Š3 days and hospital charges were $254,425 versus $186,273 in the complication and control groups, respectively (both P < 0.001). CONCLUSION: Discharge to rehabilitation after AIS surgery is uncommon. However, patients who are male, undergo revision procedures, or develop a complication may have a higher risk of a non-routine discharge. Complication occurrence also resulted in significantly longer lengths of stay and healthcare costs. LEVEL OF EVIDENCE: 3.

Ultrasound elastography of the patellar tendon in young, asymptomatic sedentary and moderately active individuals.

BACKGROUND: The recent use of ultrasound elastography to study patellar tendon softness has demonstrated increased tendon softness in high-level athletes. We hypothesized that measurable alterations in patellar tendon softness may be present in young asymptomatic subjects engaging in moderate levels of physical activity. METHODS: This was a cross-sectional study. Gray-scale ultrasound and ultrasound elastography of the right and left patellar tendons were performed in young asymptomatic sedentary subjects and moderately active subjects who engaged in at least 30 min of physical activity 4-5 times weekly. The distribution of soft, intermediate and stiff tissue within each tendon was analyzed. Tendon softness was correlated with subject age, gender and level of athletic activity. RESULTS: Sixty patellar tendons in 30 subjects were evaluated (18 males, 12 females, mean age 22.5 years). Seventeen subjects were defined as "active" and 13 as "sedentary." All tendons had a normal gray-scale sonographic appearance. Tendon softness was significantly higher in active subjects (P = 0.01) and decreased with age (P = 0.04). In sedentary individuals there was no significant correlation between age and tendon softness (P = 0.404). Similarly, gender showed no correlation with tendon softness (P > 0.05). CONCLUSIONS: Patellar tendon softness is higher in young subjects and in those engaging in moderate physical activity. This may reflect an adaptation to increased tendon load. Tendon softness in active subjects decreases with age, while it remains at a constant value in sedentary individuals. LEVEL OF EVIDENCE: Level 3.

Narrowing of ischiofemoral and quadratus femoris spaces in pediatric ischiofemoral impingement.

OBJECTIVE: To correlate MRI findings of quadratus femoris muscle edema (QFME) with narrowing of the ischiofemoral space (IFS) and quadratus femoris space (QFS) in children, and to identify threshold values reflecting an anatomic architecture that may predispose to ischiofemoral impingement. MATERIALS AND METHODS: A case-control retrospective MRI review of 49 hips in 27 children (mean, 13 years) with QFME was compared to 49 hips in 27 gender and age-matched controls. Two radiologists independently measured IFS and QFS. Generalized linear mixed-effects models were fit to compare IFS and QFS values between cases and controls, and adjust for correlation in repeated measures from the same subject. Receiver operating characteristic (ROC) analysis determined optimal threshold values. RESULTS: Compared to controls, cases had significantly smaller IFS (p < 0.001, both readers) and QFS (reader 1: p < 0.001; reader 2: p = 0.003). When stratified as preteen (< 13) or teenage (≥ 13), lower mean IFS and QFS were observed in cases versus controls in both age groups. Area under ROC curve for IFS and QFS was high in preteens (0.77 and 0.71) and teens (0.94 and 0.88). Threshold values were 14.9 mm (preteens) and 19 mm (teens) for IFS and 11.2 mm (preteens) and 11.1 mm (teens) for QFS. IFS and QFS were modestly correlated with age among controls only. CONCLUSIONS: Pediatric patients with QFME had significantly narrower QFS and IFS compared with controls. IFS and QFS were found to normally increase in size with age. Optimal cutoff threshold values were identified for QFS and IFS in preteens and teenagers.