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.

Exploring the Influencing Factors of Health Literacy among Older Adults: A Cross-Sectional Survey.

Background and Objectives: To investigate the health literacy (HL) among older adults in Taiwan, we referenced an existing integrated model of HL to confirm the influencing factors of HL in older adults. We propose this study to examine the personal, situational, and socioenvironmental factors influencing HL among older adults. Materials and Methods: A cross-sectional survey was conducted at a district hospital and affiliated community center in northern Taiwan from August 2016 to May 2017. This study used the Mandarin Chinese version of the European Health Literacy Survey Questionnaire (EU-Q47). We designed three models based on the three domains of HL. Model 1 assesses personal factors. Model 2 incorporates situational factors. Model 3 adds the socioenvironmental factor. Results: We recruited 161 participants aged over 65 years. Most adults in this study had limited overall HL. The final regression model revealed that age >85 years, unknown insurance status, and dominant spoken dialect of Hakka or Taiwanese were significantly associated with higher scores of HL. Conclusions: Our study results may help clinicians with early identification of older adults at high risk for poor HL and help health administrators establish geriatric policies and health education plans.

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.

Guided Growth Improves Coxa Valga and Hip Subluxation in Children with Cerebral Palsy.

BACKGROUND: Spastic hip subluxation or dislocation that is associated with an excessive coxa valga deformity is a common pathologic condition in children with cerebral palsy (CP) that is often treated with large bone reconstructive procedures. Guided growth techniques (such as stapling, plate, or transphyseal screw) have been widely used to alter the growth axis in patients with a lower-limb deformity but only a few reports have described their use in patients with coxa valga deformities. QUESTIONS/PURPOSES: (1) Does guided growth surgery using a transphyseal screw combined with adductor tenotomy prevent progressive coxa valga deformity and lateral hip subluxation in children with CP? (2) What factors influence the correction of coxa valga deformity and the success of hip stabilization? (3) What complications were associated with this operation and how often did children treated with it undergo reoperation? METHODS: From 2012 to 2016, at our institution, three authors (H-CH, KNK, K-WW) retrospectively studied data on children with CP who underwent guided growth of the hip for progressive bilateral hip subluxation associated with coxa valga deformities. A single percutaneous screw was inserted across the inferomedial portion of proximal femoral physis in an AP view and centered along femoral neck in lateral view under fluoroscopy guidance. During the period, we treated 25 consecutive children with CP who had progressive hip subluxation with coxa valga deformities. The indications for surgery were migration percentage > 30% and head-shaft angle > 155° with at least 2 years growth remaining. Of those, 13 patients underwent guided growth alone, and 48% (12) underwent a combination of guided growth and adductor tenotomy. Of the 25 patients treated with this approach, 96% (24) were available for follow-up with complete data at a minimum of 2 years follow-up (mean 50 months; range 25 to 72). All children (17 boys and seven girls; 48 hips) underwent surgery at a mean age of 8 years (range 5 to 12). With regard to the gross motor function classification system, three patients were Level 1, four patients were Level II, seven patients were Level III, seven were Level IV, and three were Level V. Radiographic parameters including the head-shaft angle, Hilgenreiner's epiphyseal angle, acetabular index, and Reimer's migration percentage were assessed before surgery and at the latest follow-up examination by one author (H-CH). Complications and reoperations were assessed by chart review. During the period in question, we generally offered secondary reconstructive surgery to patients who underwent a guided growth procedure once their subluxation progressed. RESULTS: With the data available, the coxa valga and lateral hip subluxation improved in terms of the reduction of head-shaft angle by a mean of 13° ± 7° (95% CI 11 to 15; p < 0.001) and the reduction of the migration percentage by 10% ± 11% (95% CI 7 to 13; p < 0.001). After controlling for potentially confounding variables like gender, gross motor function classification system, Hilgenreiner's epiphyseal angle and acetabular index, we found that longer follow-up duration (r = 0.234; p < 0.001) and a smaller preoperative migration percentage (r = -0.258; p = 0.004) were associated with larger changes in the head-shaft angle. In terms of complications, we found that the proximal femoral physis grew off the screw tip in 44% (21 of 48 hips) at a mean of 28 months. Among these, 31% of hips (15 of 48) in 33% of patients (eight of 24) underwent replacement with a longer screw. Among the 17% of hips (eight of 48) in 21% of patients (five of 24) who had progressive lateral subluxation and underwent secondary reconstructive surgery, we found that their preoperative acetabular index was higher (mean 29° versus 21°; p < 0.001), as was their head-shaft angle (mean 166° versus 162°; p = 0.045), and migration percentage (mean 54% versus 36 %; p < 0.001). CONCLUSIONS: Although guided growth with single transphyseal screw did not create as large a degree of varus as proximal femoral osteotomy, it did stabilize the hip in children with cerebral palsy with migration percentage less than 50% in our series. It is a simple procedure that can be of benefit to children with cerebral palsy with unstable hip. Reoperation in patients where the physis has grown off the screw tip can be a problem; fortunately, it is a rather minor procedure to replace with a longer screw. LEVEL OF EVIDENCE: Level III, therapeutic study.

Management of Juvenile Hallux Valgus Deformity: the role of combined Hemiepiphysiodesis.

BACKGROUND: This study aimed to investigate the efficacy of percutaneous hemiepiphysiodesis for gradual correction of symptomatic juvenile hallux valgus (HV) deformity. METHODS: Between 2012 to 2014, 24 patients with symptomatic juvenile HV were treated by combined percutaneous medial drilling hemiepiphysiodesis of the first proximal phalanx and lateral transphyseal screw hemiepiphysiodesis of the first metatarsal at our institution. Twenty-one of 24 patients fulfilled inclusion criteria had a complete radiological and clinical follow-up of at least 2 years. Preoperative and postoperative radiographs of the feet were reviewed for measurements of hallux valgus angle (HVA), intermetatarsal angle (IMA), proximal metatarsal articular angle (PMAA), proximal phalangeal articular angle (PPAA), and metatarsal length ratio (MTLR). Clinical outcomes were assessed using the AOFAS hallux metatarsophalangeal-interphalangeal score. RESULTS: The study included 21 consecutive patients (37 ft) for analysis. The mean age at surgery was 12.0 years (SD = 1.3) and mean follow-up after surgery was 35.1 months (SD = 6.0). With the data available, the HV deformity improved in terms of the reduction of HVA by a mean of 4.7 degrees (P < .001) and the reduction of IMA by 2.2 degrees (P < .001). The PMAA and PPAA also improved significantly in the anteroposterior plane; however, the PMAA difference was insignificant in lateral plane as expected. The mean difference in the MTLR was 0.00 (P = .216) which was indicative of no length discrepancy between first and second metatarsals. The AOFAS score increased from 68.7 to 85.2 (P < .001). In correlation analysis, time to physeal closure was significantly correlated with the final HVA change (r = -.611, P = .003). CONCLUSION: Although combined hemiepiphysiodesis does not create a large degree of correction as osteotomy, yet it did improve HV deformity with adequate growth remaining in our series. It is a procedure that can be of benefit to patients with symptomatic juvenile HV from this minimal operative approach before skeletal maturity. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Comparison of two methods for idiopathic clubfoot treatment: A case-controlled study in Taiwan.

BACKGROUND/PURPOSE: In last century, two distinctive methods of manipulation and casting were developed, Kite method and Ponseti method. The purpose of this study is to compare the outcomes of parallel series between two methods in one institution. METHODS: From 2003 to 2008, two pediatric orthopedic services in one institution treated 57 patients with 88 idiopathic clubfeet. One service continued using Kite casting method consisted of 58 feet, and other service employed Ponseti casting method consisted of 30 feet. There was a minimum of 4 years follow-up. RESULTS: Both groups had similar Dimeglio severity scores before treatment. Initial correction was achieved in 40 feet (69%) in the Kite group compared with 27 feet (90%) in the Ponseti group, while 19 feet (63.3%) had percutaneous Achilles tenotomy. The Ponseti method was found to have a significantly higher correction rate (p = 0.028). After a mean follow-up of 72 months, there were 29 relapses (50%) in the Kite group and 8 relapses (26.7%) in the Ponseti group with significant difference (p = 0.036). At the latest follow-up, the outcome measures were 24 feet (41.4%) good, 18 feet (31%) fair and 16 (27.6%) poor in the Kite group and 25 feet (83.3%) good, 3 feet (10%) fair and 2 feet (6.7%) poor in the Ponseti group with significant difference between two groups (p < 0.001). CONCLUSION: In this simultaneous series of two casting methods in a single institution with more than 4 years follow up, we concluded that Ponseti method significantly achieved better midterm outcome in clubfoot management.

A Long-term Follow-up of Young Adults With Idiopathic Clubfoot: Does Foot Morphology Relate to Pain?

BACKGROUND: Individuals with clubfoot, treated in infancy with either the Ponseti method or comprehensive clubfoot release, often encounter pain as adults. Multiple studies have characterized residual deformity after Ponseti or surgical correction using physical exam, radiographs and pedobarography; however, the relationship between residual foot deformity and pain is not well defined. The purpose of the current study was 2-fold: (1) to evaluate the relationship between foot morphology and pain for young adults treated as infants for idiopathic clubfoot and (2) to describe and compare pedobarographic measures and outcome measures of pain and morphology among surgically treated, Ponseti treated, and typically developing feet. METHODS: We performed a case-control study of individuals treated for clubfoot at 2 separate institutions with either the Ponseti method or comprehensive clubfoot release between 1983 and 1987. All subjects (24 treated with comprehensive clubfoot release, 18 with Ponseti method, and 48 controls) were evaluated using the International Clubfoot Study Group (ICFSG) morphology scoring, dynamic pedobarography, and foot function index surveys. During pedobarography, we collected the subarch angle and arch index as well as the center of pressure progression (COPP) on all subjects. RESULTS: Foot morphology (ICFSG) scores were highly correlated with foot function index pain scores (r=0.43; P<0.001), although the difference in pain scores between the surgical and Ponseti group did not reach significance. The surgical group exhibited greater subarch angle and arch indexes than the Ponseti group, demonstrating a significant difference in morphology, a flatter foot. Finally, we found more abnormalities in foot progression, decreased COPP in the forefoot and increased COPP in the midfoot and hindfoot, in the surgical group compared with controls. CONCLUSIONS: Measures of foot morphology were correlated with pain among all treated for clubfoot. Compared with Ponseti method, comprehensive surgical release lead to greater long-term foot deformity, flatter feet and greater hindfoot loading time. LEVEL OF EVIDENCE: Level III-Therapeutic.

The Times they Are a-Changin' - Healthcare 4.0 Is Coming!

The Industrial Revolution brought new economics and new epidemic patterns to the people, which formed the healthcare 1.0 that focused on public health solutions. The emergence of large production concept and technology brought healthcare to 2.0. Bigger hospitals and better medical education were established, and doctors were trained for specialty for better treatment quality. The size of computer shrunk. This allowed fast development of computer-based devices and information technology, leading the healthcare to 3.0. The initiation of smart medicine nowadays announces the arrival of healthcare 4.0 with new brain and new hands. It is an era of big revision of previous technologies, one of which is artificial intelligence which will lead humans to a new world that emphasizes more on advanced and continuous learnings.

Prognosticating Factors of Relapse in Clubfoot Management by Ponseti Method.

BACKGROUND: It is challenging that some Ponseti method corrected clubfeet have a tendency to relapse. Controversies remain as to the implication of initial severity, representing the deformity degree, as well as number of casts needed, representing the treatment process, in predicting relapse. However, no study has been reported to take these 2 parameters into comprehensive consideration for outcome measurement. The purpose of this study is to investigate the correlation between the initial Pirani score and the number of casts required to correct the deformity in our series; to evaluate noncompliance as a risk factor of the deformity recurrence in Ponseti treatment; to test the validity and predictive value of a new proposed parameter, ratio of correction improvement (RCI) which is indicated by the initial Pirani scores divided by the number of casts. METHODS: A total of 116 consecutive patients with 172 idiopathic clubfeet managed by Ponseti method were followed prospectively for a minimum of 2 years from the start of brace wearing. RCI value and the other clinical parameters were studied in relation to the risk of relapse by using multivariate logistic regression analysis modeling. RESULTS: A positive correlation between the initial Pirani score and the number of casts required to correct the deformity was found in our series (r=0.67, P<0.01). There were 45 patients (39%) with brace noncompliance. The relapse rate was 49% (22/45). The odds ratio of relapse in noncompliant patients was 10 times more that in compliant patients (odds ratio=10.30 and 95% confidence interval, 2.69-39.42; P<0.01). The multivariate logistic regression analysis showed that there was significant association between relapse and RCI value. There were 42 patients (36%) with RCI value <1, among them, the relapse rate was 57% in 24 patients. The odds ratio of relapse in patients with RCI value <1 was 27 times more likely to relapse than those >1 (odds ratio=26.77 and 95% confidence interval, 5.70-125.72; P<0.01). CONCLUSIONS: On the basis of the findings from our study, we propose the RCI to be a new parameter in predicting the risk of relapse in Ponseti method of clubfoot management. Early intervention is recommended to optimize the brace compliance particularly in case with lower RCI value. LEVEL OF EVIDENCE: Level II-prognostic.

The treatment of chronic radial head dislocation in Monteggia fracture without annular ligament reconstruction.

INTRODUCTION: The treatment of neglected radial head dislocation after missed Monteggia fracture dislocation in children is a controversial issue. The purpose of this study is to report our clinical experience in the treatment of the condition without annular ligament reconstruction. METHOD: This is a retrospective review of 20 patients between 2008 and 2014. Procedures included open reduction of the radial head and ulnar lengthening angulation osteotomy. In cases of unstable radial head reduction, a trans-capitellar K wire was applied. The pre- and post-operative radiographs were available for evaluation as well as the Mayo Elbow Performance Index (MEPI). RESULTS: The average pre-operative elbow extension-flexion arc was 99.5° and pronation-supination arc was 151°. At last follow-up, the flexion of elbow had significant improvement (from 110° to 124°), while the average pronation and supination arc decreased, most in pronation (from 75° to 65°). Post-operatively, MEPI scored higher, especially in elbow pain and stability. Patients underwent surgery within one year of injury had better functional outcome than those injured over one year. The patients required trans-capitellar K wire for unstable radial head reduction and were in the older age group. At final follow-up, the reduction of radial head was maintained in all cases except two with mild subluxations of the radial head in radiographs. Two cases required radial shaft shortening to facilitate the reduction because of proximal migration of the radius. CONCLUSION: For neglected radial head dislocation following Monteggia fracture dislocation, we presented our surgical strategy to reduce the radial head without annual ligament reconstruction. Our patients functionally benefited from the procedure with significant improvement in elbow pain and stability, as well as improved flexion of the elbow with stable radial head reduction. LEVEL OF EVIDENCE: IV.

Vocational rehabilitation for enhancing return-to-work in workers with traumatic upper limb injuries.

BACKGROUND: Traumatic upper limb injury is a leading cause of work-related disability. After return-to-work (RTW), many survivors of injuries are able to regain a quality of life (QoL) comparable with the normal population. Since RTW plays an important role in economic productivity and regaining health-related QoL, enhancing RTW in workers with traumatic limb injuries is the primary goal of rehabilitation. Vocational rehabilitation has been commonly employed in the field of occupational safety and health to increase the number of injured people returning to the labour market, prevent illness, increase well-being, and reduce disability. OBJECTIVES: To assess the effects of vocational rehabilitation programmes for enhancing RTW in workers with traumatic upper limb injuries. SEARCH METHODS: This is an update of a Cochrane review previously published in 2013. We updated our searches of the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 9), MEDLINE (to 30 August 2017), EMBASE (to 3 September 2017), CINAHL (to 6 September 2017), and PsycINFO (to 6 September 2017), and we handsearched the references lists of relevant review articles. SELECTION CRITERIA: We aimed to include all randomised controlled trials (RCTs) comparing vocational rehabilitation with an alternative (control) intervention such as standard rehabilitation, a limited form of the vocational rehabilitation intervention (such as advice on RTW, referral information, or liaison with employer), or waiting-list controls. DATA COLLECTION AND ANALYSIS: Two authors independently inspected abstracts, and we obtained full papers when necessary. When the two authors disagreed about the inclusion of a study, we resolved disagreements by discussion. A third author arbitrated when necessary. MAIN RESULTS: Our updated search identified 466 citations. Based on assessments of their titles and abstracts, we decided to evaluate the full texts of five records; however, none met our inclusion criteria. AUTHORS' CONCLUSIONS: There is currently no high-quality evidence to support or refute the efficacy of vocational rehabilitation for enhancing RTW in workers with traumatic upper limb injuries. Since injured people in occupational settings frequently receive vocational rehabilitation with the aim of decreasing work disability, enhancing RTW, increasing productivity, and containing the welfare cost, further high-quality RCTs assessing the efficacy of vocational rehabilitation for workers with traumatic upper limb injury are needed to fill this gap in knowledge.

Nonsteroidal anti-inflammatory drugs are associated with reduced risk of early hepatocellular carcinoma recurrence after curative liver resection: a nationwide cohort study.

PURPOSE: The efficacy of nonsteroidal anti-inflammatory drugs (NSAIDs) in reducing the risk of various de novo cancers has been reported; however, its role in reducing hepatocellular carcinoma (HCC) recurrence after liver resection still remains unknown. METHODS: We have conducted a nationwide cohort study by recruiting all patients with a newly diagnosed HCC who had received curative liver resection as their initial treatment. The use of NSAIDs and the risk of early HCC recurrence have been examined by multivariate and stratified analyses. To avoid immortal time bias, the use of NSAIDs has been treated as a time-dependent variable in Cox proportional hazard ratio models. RESULTS: Between January 1997 and December 2010, a total of 15,574 HCC patients who had received liver resection were enrolled in this study. The 1-, 3-, and 5-year overall survival rates were 90.4%, 73.2%, and 59.8%, respectively. The 1-, 3-, and 5-year disease-free survival rates were 80.5%, 59.4%, and 50.2%, respectively. NSAID use (hazard ratio, 0.81; 95% confidence interval, 0.73-0.90) and minor liver resection (hazard ratio, 0.83; 95% confidence interval, 0.78-0.89) were independently associated with a reduced risk of early HCC recurrence after liver resection. In the stratified analyses, NSAID usage was universally associated with reduced risks in most subgroups, particularly for those aged younger than 65 years, male, with underlying diabetes mellitus and receiving major liver resection. CONCLUSIONS: The use of NSAIDs can be associated with a reduced risk of early HCC recurrence within 2 years after curative liver resection, regardless of patients' age, extent of liver resection, viral hepatitis status, underlying diabetes, and liver cirrhosis.

A tool to predict risk for gastric cancer in patients with peptic ulcer disease on the basis of a nationwide cohort.

BACKGROUND & AIMS: Patients with gastric ulcers have significantly higher risk of gastric cancer, especially within 2 years after diagnosis. We used data from a national database to develop a personalized risk prediction model for patients with peptic ulcer diseases. METHODS: We collected data from Taiwan's National Health Insurance Research Database on 278,898 patients admitted for the first time with a primary diagnosis of peptic ulcer disease. We used the data to develop a nomogram, which we validated by discrimination and calibration, and in a test cohort. Cumulative incidences of study subjects predicted by the nomogram were examined. RESULTS: In total, 1269 subjects developed gastric cancer. Age, sex, peptic ulcer sites, peptic ulcer complications, Helicobacter pylori eradication, nonsteroidal anti-inflammatory drug use, and surveillance endoscopy were independent factors associated with risk of gastric cancer (all P < .001). The concordance index for the nomogram developed on the basis of these factors was 0.78. Study subjects were divided into quartiles of predicted risk scores; from lowest score quartile to highest, cumulative incidences at 1 year were 7.4/10,000 people, 14.2/10,000 people, 25.5/10,000 people, and 86.6/10,000 people. The cumulative incidences at 2 years were 9.3/10,000 people, 20.9/10,000 people, 38.0/10,000 people, and 135.7/10,000 people for the same quartiles of risk scores. The nomogram was validated in an independent cohort, and similar incidence values were determined. CONCLUSIONS: We developed and validated a nomogram to predict risk for gastric cancer 1 and 2 years after diagnosis of peptic ulcer disease. The nomogram provides a prognostic tool that can be easily used for individuals and can help physicians explain risk levels to patients.

Delayed Slipped Capital Femoral Epiphysis After Treatment of Femoral Neck Fracture in Children.

BACKGROUND: Slipped capital femoral epiphysis (SCFE) after the treatment of femoral neck fracture is a rare entity in children that poses important treatment challenges. CASE DESCRIPTION: We describe the presentation and management of two patients, a 12-year-old girl and a 6-year-old girl, each of whom developed SCFE at 5 months and 9 months, respectively, after operative treatment of femoral neck fracture. LITERATURE REVIEW: Five similar cases have been reported in the literature. Along with our two case studies, the average age of all seven patients was 8.9 years (range, 3.6-12 years; boys, 8.9 years; girls, 9 years). None of the children was in a high weight percentile or had any known endocrinologic disorder. Two had asymptomatic mild SCFE, whereas the others felt unexplained pain with ambulation when the slippage was brought to their attention. Although it is not possible to prove a causal relationship between the initial fracture and the subsequent SCFE, clinical factors such as implant irritation, early return to weightbearing, delayed union or nonunion, coxa vara, and avascular necrosis warrant consideration as potentially related to the subsequent slip. CLINICAL RELEVANCE: The onset of SCFE after surgical treatment of a femoral neck fracture may reflect inadequate treatment of the fracture. For best practice, we should perform a gentle anatomic reduction, appropriate internal fixation for femoral neck fracture in skeletally immature patients. Postoperative cast immobilization and delayed weightbearing are also important to avoid complication. It is essential for pediatric orthopaedic surgeons to be aware of this clinical scenario to allow prompt recognition and patient treatment.

Determinants of Hip Displacement in Children With Cerebral Palsy.

BACKGROUND: Coxa valga and femoral anteversion often are seen in patients with spastic hip displacement and osteotomy is recommended. However, the relationship between femoral deformities and hip displacement has not been clearly defined and other factors, such as joint motion and posture, should be considered before recommending treatment. QUESTIONS: For children with cerebral palsy with Gross Motor Function Classification System Level IV or V, we questioned (1) whether hip abduction range correlates with hip displacement, (2) what the relationships are between proximal femoral deformities and hip displacement, and (3) whether the patient with a windblown posture has greater degrees of femoral anteversion? METHODS: We retrospectively studied 31 consecutive children with cerebral palsy with Level IV or V gross motor function who underwent three-dimensional CT for preoperative assessment of hip displacement between January 2010 and December 2013. Among the children, 23 had a windblown posture and eight had symmetric hip motion. Femoral anteversion and true neck-shaft angle were measured from the three-dimensional CT images. Migration percentage was the dependent variable we chose to study in relation to femoral anteversion, neck-shaft angle, maximal hip abduction, and hip flexion contracture, using correlations and multiple linear regressions. Using ANOVA and Scheffé's post hoc tests, we analyzed and compared the data of 23 abducted hips and 23 adducted hips in the 23 children with windblown posture and in 16 displaced hips in the eight children with symmetric hip abduction. RESULTS: Greater migration percentage was associated with less hip abduction range (r = -0.86; p < 0.001). Femoral anteversion had a weak correlation (r = 0.28; p < 0.05) to migration percentage, and the association became insignificant after considering hip abduction motion. Adducted windblown hips had greater femoral anteversion than the symmetric displaced hips and abducted windblown hips (46° vs 36° and 38°, respectively; p < 0.05). CONCLUSIONS: Our study results did not support a relationship between femoral deformities and hip displacement after considering gross motor function and hip abduction motion. Greater femoral anteversion was noted in the adducted hips of patients with windblown posture, and derotation osteotomy is especially recommended. LEVEL OF EVIDENCE: Level III, diagnostic study.

Pronator teres transfer for forearm and wrist deformity in cerebral palsy children.

BACKGROUND: Forearm pronation and wrist flexion contracture can be a disability for daily living care and 2-hand function in cerebral palsy (CP) children. It may be beneficial to improve their posture and hand-grip power for better functional outcome. The purpose of our study was to investigate the outcome of pronator transfer in CP children. METHODS: Seventeen spastic CP patients (14 hemiplegic, 3 diplegic; 14 male, 3 female; mean age, 12 y 5 mo) underwent pronator teres transfer for forearm pronation and wrist flexion contractures. The mean follow-up period was 46 months. We recorded Gross Motor Function Classification System level, modified Ashworth scale, forearm and wrist range of motion, forearm resting position, grip power, and 3 basic daily living skills preoperatively and postoperatively. Paired t test was used for statistical analysis. RESULTS: The average forearm active supination gained 80.9 degrees (P<0.05) and the active forearm pronation lost 22 degrees (P<0.05), with average postoperative total active forearm range of motion 130.9 degrees (P<0.05). The average active wrist extension gained 76.9 degrees (P<0.05) and the active wrist flexion lost 31.8 degrees (P<0.05). The average grip power gained 4.5 kg (P<0.05). The average forearm resting position improved to 10 degrees pronation (P<0.05). The basic daily living skills showed great improvement. CONCLUSIONS: Our procedure improved the functional outcome in wrist extension and decreased the forearm pronation. Therefore, significant grip-strength enhancement and better forearm posture was noted. It is an additional armamentarium in the management of upper extremity disability in CP children. LEVEL OF EVIDENCE: Level IV-case series.

Implementation of evidence-based practice in relation to a clinical nursing ladder system: a national survey in Taiwan.

BACKGROUND: Although evidence-based practice (EBP) has been widely investigated, few studies have investigated its correlation with a clinical nursing ladder system. The current national study evaluates whether EBP implementation has been incorporated into the clinical ladder system. METHODS: A cross-sectional questionnaire survey was conducted nationwide of registered nurses among regional hospitals of Taiwan in January to April 2011. Subjects were categorized into beginning nurses (N1 and N2) and advanced nurses (N3 and N4) by the clinical ladder system. Multivariate logistic regression model was used to adjust for possible confounding demographic factors. RESULTS: Valid postal questionnaires were collected from 4,206 nurses, including 2,028 N1, 1,595 N2, 412 N3, and 171 N4 nurses. Advanced nurses were more aware of EBP than beginning nurses (p < 0.001; 90.7% vs. 78.0%). In addition, advanced nurses were more likely to hold positive beliefs about and attitudes toward EBP (p < 0.001) and possessed more sufficient knowledge of and skills in EBP (p < 0.001). Furthermore, they more often implemented EBP principles (p < 0.001) and accessed online evidence-based retrieval databases (p < 0.001). The most common motivation for using online databases was self-learning for advanced nurses and positional promotion for beginning nurses. Multivariate logistic regression analyses showed advanced nurses were more aware of EBP, had higher knowledge and skills of EBP, and more often implemented EBP than beginning nurses. LINKING EVIDENCE TO ACTION: The awareness of, beliefs in, attitudes toward, knowledge of, skills in, and behaviors of EBP among advanced nurses were better than those among beginning nurses. The data indicate that a clinical ladder system can serve as a useful means to enhance EBP implementation.

Comparison of acetabular anterior coverage after Salter osteotomy and Pemberton acetabuloplasty: a long-term followup.

BACKGROUND: The Salter osteotomy and Pemberton acetabuloplasty are common procedures for a deficient acetabulum in patients with developmental dysplasia of the hip. However, the degree of increasing retroversion and anterior acetabular coverage of these two procedures remains unanswered. QUESTIONS/PURPOSES: The purpose of this study is to show the change in anterior coverage and relevant parameters in measuring pain and function among patients who have undergone either a Salter osteotomy or Pemberton acetabuloplasty. METHODS: Forty-two patients who underwent either a Salter or Pemberton procedure at one institution between January 1981 and December 2000 and were available for followup at least 10 years later (mean, 18 years; range, 12-28 years) were evaluated retrospectively. This represented 12% of the Salter and Pemberton procedures performed in patients between 12 and 36 months old at our institution during the study period. We measured vertical-center-anterior margin angle, anterior acetabular head index, and weightbearing zone acetabular index, and we made comparisons using the radiographic parameter ratio (the division of each radiographic measurement of the operative side by that of the nonoperated side). All patients completed SF-36 and Harris hip score questionnaires at followup. RESULTS: In the Salter group, there were no differences in vertical-center-anterior margin angle, anterior acetabular head index, or weightbearing zone acetabular index. In the Pemberton group, there was no difference in vertical-center-anterior margin angle or anterior acetabular head index, but the weightbearing zone acetabular index decreased, suggesting increased anterior acetabular coverage (surgically treated side, 6 [95% CI, 4.84, 7.16]; nonoperated side, 12 [95% CI, 10.07, 13.39]; p < 0.001). Compared with that in the Salter group, the weightbearing zone acetabular index ratio was smaller in the Pemberton group, which means more acquired anterior coverage after a Pemberton acetabuloplasty (Salter procedure, 0.94 [95% CI, 0.70, 1.17], Pemberton procedure, 0.53 [95% CI, 0.40, 0.65]; p < 0.001). Three patients in the Pemberton group had an anterior impingement sign at followup, whereas none in the Salter group did. The SF-36 and Harris hip scores were good and showed no differences between the two groups. CONCLUSIONS: Our study suggests the weightbearing zone acetabular index on false profile radiographs of the hip, a parameter focusing on morphologic features of the anterior acetabulum, decreased after Pemberton acetabuloplasty compared with the nonoperated side and after the Salter acetabuloplasty. This suggests that by modifying the shape of the acetabulum with a hinge in the triradiate cartilage, a Pemberton acetabuloplasty may result in increasing acetabular anterior coverage and the risk of hip impingement. However, the functional results with at least 10 years followup were good and similar for both procedures. LEVEL OF EVIDENCE: Level III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Long-term results of comprehensive clubfoot release versus the Ponseti method: which is better?

BACKGROUND: Clubfoot can be treated nonoperatively, most commonly using a Ponseti approach, or surgically, most often with a comprehensive clubfoot release. Little is known about how these approaches compare with one another at longer term, or how patients treated with these approaches differ in terms of foot function, foot biomechanics, or quality-of-life from individuals who did not have clubfoot as a child. QUESTIONS/PURPOSES: We compared (1) focused physical and radiographic examinations, (2) gait analysis, and (3) quality-of-life measures at long-term followup between groups of adult patients with clubfoot treated either with the Ponseti method of nonsurgical management or a comprehensive surgical release through a Cincinnati incision, and compared these two groups with a control group without clubfoot. METHODS: This was a case control study of individuals treated for clubfoot at two separate institutions with different methods of treatment between 1983 to 1987. One hospital used only the Ponseti method and the other mainly used a comprehensive clubfoot release. There were 42 adults (24 treated surgically, 18 treated with Ponseti method) with isolated clubfoot along with 48 healthy control subjects who agreed to participate in a detailed analysis of physical function, foot biomechanics, and quality-of-life metrics. RESULTS: Both treatment groups had diminished strength and motion compared with the control subjects on physical examination measures; however, the Ponseti group had significantly greater ankle plantar flexion ROM (p < 0.001), greater ankle plantar flexor (p = 0.031) and evertor (p = 0.012) strength, and a decreased incidence of osteoarthritis in the ankle and foot compared with the surgical group. During gait the surgical group had reduced peak ankle plantar flexion (p = 0.002), and reduced sagittal plane hindfoot (p = 0.009) and forefoot (p = 0.008) ROM during the preswing phase compared with the Ponseti group. The surgical group had the lowest overall ankle power generation during push off compared with the control subjects (p = 0.002). Outcome tools revealed elevated pain levels in the surgical group compared with the Ponseti group (p = 0.008) and lower scores for physical function and quality-of-life for both clubfoot groups compared with age-range matched control subjects (p = 0.01). CONCLUSIONS: Although individuals in each treatment group experienced pain, weakness, and reduced ROM, they were highly functional into early adulthood. As adults the Ponseti group fared better than the surgically treated group because of advantages including increased ROM observed at the physical examination and during gait, greater strength, and less arthritis. This study supports efforts to correct clubfoot with Ponseti casting and minimizing surgery to the joints, and highlights the need to improve methods that promote ROM and strength which are important for adult function. LEVEL OF EVIDENCE: Level III, prognostic study.

Pulmonary Embolism in Klippel-Trenaunay-Weber Syndrome With Slipped Capital Femoral Epiphysis.

CASE: A 12-year-old boy with Klippel-Trenaunay-Weber syndrome underwent surgery for unstable slipped capital femoral epiphysis who developed pulmonary embolism postoperatively. CONCLUSION: It is important to be vigilant about pulmonary embolism in children because it is rare but potentially fatal, especially in the presence of risk factors. Early diagnosis and treatment of unstable slipped capital femoral epiphysis are crucial to minimize immobility. Close monitoring of femoral head osteonecrosis is also necessary.