The Healthcare Experience of Autistic Patients in Orthopaedic Surgery and Closely Related Fields: A Scoping Review.

Orthopaedic and related care has the potential to present unique obstacles for patients with a range of autism manifestations. In this review, we aim to describe and analyze the literature on autistic patients' experience within orthopaedics and closely related fields. This literature search utilized the PubMed, Embase, and Cumulative Index to Nursing and Allied Health Literature databases. Three major concepts were built into the search terms: (1) patients on the autism spectrum; (2) patient experience; and (3) movement sciences, including orthopaedics, physical medicine and rehabilitation (PM&R), occupational therapy (OT), and physical therapy (PT). Our search yielded 35 topical publications, with the major topic areas addressed as follows: (1) clinical and perioperative management, (2) therapy interventions, (3) participation in exercise and social play, (4) sensory management and accommodations, (5) caregiver/parent training and involvement in care, (6) healthcare needs and barriers to care, and (7) utilization of technology. In the current literature, there are no studies that attempt to directly assess autistic patient experience with care practices and clinical environments in orthopaedics. Rigorous, direct examination of the experience of autistic patients within clinical orthopaedic settings is urgently needed to address this gap.

Pediatric Venous Thromboembolism: Different Rates of Incidence, Anatomic Locations, and Risk Factors Between Orthopaedic and Nonorthopaedic Related Patients.

BACKGROUND: The prevalence of venous thromboembolism (VTE) may be increasing in children; however, scarce literature exists comparing incidence rates between pediatric orthopaedic patients and other pediatric patients. The purpose of this study was to compare the incidence, anatomic locations, and risk factors of VTEs between orthopaedic and nonorthopaedic pediatric related patients to determine if important differences exist. METHODS: Computed tomography and ultrasound data were reviewed for children (below 19 y old) with a diagnosed VTE between January 1, 2009 and December 31, 2016. Demographic and clinical data, including VTE anatomic location and risk factors, were recorded. Two major cohorts were identified: orthopaedic-related (ORTH) and nonorthopaedic-related (NORTH) VTEs. Incidence rates were estimated and risk factors were compared using χ2 testing. RESULTS: There were 373 children diagnosed with a VTE (average age 10.3 y) of a total of 810,097 treated as in-patients for an incidence rate of 4.60 per 10,000 cases (95% confidence interval=4.15 to 5.10 per 10,000 cases). The rate of ORTH VTEs (28 of 188,669 orthopaedic patients, 1.48 per 10,000 cases) was significantly lower than that of NORTH VTEs (345 of 621,428 nonorthopaedic patients, 5.55 per 10,000 cases; P<0.001). For the ORTH cohort, there was a significant difference in the proportion of deep vein thrombosis in the lower extremity (91%) compared with the upper extremity (9%) (P<0.001), while a more even distribution of NORTH deep vein thrombosis in the upper (50%) and lower (41%) extremities was appreciated. The primary risk factors for ORTH VTEs included surgery (93%; P<0.001), change in ambulatory status (61%; P<0.001), and trauma (18%; P<0.001), while the primary risk factors for NORTH VTEs included intravenous peripheral inserted central catheter/central line (61%; P<0.001) and cancer (27%; P=0.001). CONCLUSIONS: Pediatric ORTH VTEs have a significantly lower incidence rate and different primary risk factors than those of NORTH VTEs. This information is useful for health care providers when making decisions regarding risk and prophylaxis in pediatric patients with orthopaedic and nonorthopaedic conditions. LEVEL OF EVIDENCE: Level III.

Are Some Randomized Clinical Trials Impossible?

Congenital tibial pseudarthrosis is a rare condition seen in neurofibromatosis type 1 (NF1), and treatment is complex. A randomized, placebo-controlled trial of bone morphogenetic protein (rhBMP-2; INFUSE bone graft) at time of tibial surgery was developed by the Neurofibromatosis Clinical Trials Consortium. Patients were randomized to receive rhBMP-2 that would, or would not, be added to the standard surgical procedure consisting of resection of pseudarthrosis tissue, insertion of a rigid intramedullary rod, and placement of autogenous iliac crest bone graft. Despite involvement of 16 centers with wide experience with NF1 orthopaedic management, only 5 patients (of 54 required) were able to be enrolled in the study during a 3-year time period. Because of the inability to recruit sufficient patients, this study was closed in June 2019, with plans to terminate. The obstacles that were encountered during the study are summarized. The authors question whether a randomized, placebo-controlled trial of a rare pediatric orthopaedic condition is possible to accomplish. Recommendations are provided to guide future studies of orthopaedic manifestations of NF1.Level of Evidence: Level V.

Congenital Pseudarthrosis of the Fibula: Controlling Ankle Valgus in a Heterogenous Condition.

BACKGROUND: Congenital pseudarthrosis of the fibula (CPF) is a rare disorder characterized by a deficiency in the continuity of the fibula and can lead to progressive ankle valgus malalignment. An existing classification system for CPF is imperfect and may contribute to heterogeneity in reporting and discrepancy of outcomes in the literature. METHODS: Fifteen patients with CPF treated at our institution between 1995 and 2017 were retrospectively identified. Only patients with dysplasia leading to spontaneous fracture or pseudarthrosis were included in this series. The median age at presentation was 2.5 years (range: 3 mo to 13.4 y). The median duration of follow-up from the initial presentation was 11.8 years (range: 2.0 to 24 y). Chart review and serial radiographs were analyzed to assess natural history and outcomes following surgery. RESULTS: The coexistence of tibial dysplasia in CPF is very common. Patients were classified into 3 groups based on the degree of tibial involvement-group 1: no evidence of tibial dysplasia, group 2: mild tibial dysplasia, and group 3: significant tibial dysplasia. Age at presentation and age at which fibular fracture occurred were progressively younger with a greater degree of tibial involvement (P<0.05). In the absence of surgical intervention, group 1 patients did not undergo progressive ankle valgus (defined as the valgus change in tibiotalar angle by ≥4 degrees), whereas all patients in groups 2 and 3 did (P<0.001). Fibular osteosynthesis was performed in 6 patients, with union seen only in group 1 patients. Ten patients underwent distal tibiofibular fusion, with no cases of nonunion seen. Distal tibiofibular fusion with or without medial distal tibial hemiepiphysiodesis halted the progression of ankle valgus in 8 of the 10 patients. Further progression of ankle valgus occurred only in patients who did not undergo concurrent medial distal tibial hemiepiphysiodesis and with considerable wedging of the distal tibial epiphysis at the time of fusion. CONCLUSIONS: Tibial dysplasia and CPF are intimately related. Grouping patients on this basis may help guide natural history and treatment and may explain discrepancies in findings in the literature. Fibular osteosynthesis, distal tibiofibular fusion, and medial distal tibial hemiepiphysiodesis may all have an important role in the treatment of CPF. LEVEL OF EVIDENCE: Level IV-case series.

Osteoid Osteoma About the Hip in Children and Adolescents.

BACKGROUND: The etiology of hip pain in pediatric and adolescent patients can be unclear. Osteoid osteoma (OO) about the hip in children has only been described in case reports or small studies. The present study assessed the clinical presentation and diagnostic course, imaging, and treatment approaches in a large cohort of pediatric cases of OO about the hip. METHODS: Medical record and imaging results were reviewed for all cases of OO identified within or around the hip joint in patients <20 years old between January 1, 2003, and December 31, 2015, at a tertiary-care pediatric center. Demographic, clinical, and radiographic data were analyzed. RESULTS: Fifty children and adolescents (52% female; mean age, 12.4 years; age range, 3 to 19 years) were identified. Night pain (90%) and symptom relief with nonsteroidal anti-inflammatory drugs (NSAIDs) (88%) were common clinical findings. Sclerosis/cortical thickening was visible in 58% of radiographs, although a radiolucent nidus was visible in only 42%. Diagnostic imaging findings included perilesional edema and a radiolucent nidus on 100% of available magnetic resonance imaging (MRI) and computed tomography (CT) scans, respectively. Initial alternative diagnoses were given in 23 cases (46%), the most common of which was femoroacetabular impingement (FAI). Delay in diagnosis of >6 months occurred in 43% of patients. Three patients underwent operative procedures for other hip diagnoses, but all had persistent postoperative pain until the OO was treated. Of the 41 patients (82%) who ultimately underwent radiofrequency ablation (RFA), 38 (93%) achieved complete post-RFA symptom resolution. CONCLUSIONS: Initial misdiagnosis, the most common of which was FAI, and delayed correct diagnosis are common in pediatric OO about the hip. Presenting complaints were variable and nonspecific MRI findings were frequent. Night pain and relief with NSAIDs were present in the vast majority of cases. CT scans provided definitive diagnosis in all patients who received them. As increasing numbers of young, active patients are being evaluated for various causes of hip pain, such as FAI, OO should not be overlooked in the differential diagnosis. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.