Child Opportunity Index and Diagnosis of Developmental Dysplasia of the Hip: Insights From a Children's Hospital Serving Disadvantaged Communities.

INTRODUCTION: Initiation of Pavlik harness treatment for developmental dysplasia of the hip (DDH) by 6 to 7 weeks of age predicts a higher rate of success. Child Opportunity Index (COI) 2.0 is a single metric designed to measure resources and conditions affecting children's healthy development. This study investigates COI in relation to the timing of DDH diagnosis. METHODS: This is a retrospective cohort study on patients younger than 4 years diagnosed with DDH between 2016 and 2023, treated with a Pavlik harness, rigid hip abduction orthosis, and/or surgery. Demographic and clinical data were recorded, including date of first diagnostic imaging. Patients with syndromes, congenital anomalies, or neuromuscular disorders and those referred with an unknown date of first diagnostic imaging were excluded. A subgroup analysis of patients diagnosed at ≤6 weeks ("early") and >6 weeks ("late") was conducted. Statewide COI scores (total, three domains) and categorical quintile scores (very low, low, moderate, high, and very high) were recorded. RESULTS: A total of 115 patients were included: 90 female infants (78%), with a median age of 32 days at diagnostic imaging. No notable difference was observed between median age at diagnosis for study patients in low or very low quintiles and those in moderate, high, or very high quintiles for COI total or domains. "Early" and "late" diagnosis subgroups did not differ markedly by COI total or domains, nor insurance type, race, or ethnicity. Subgroups differed markedly by race and insurance status. DISCUSSION: In an urban children's hospital, COI did not differ markedly between patients diagnosed with DDH by ≤6 weeks and >6 weeks. This is the first study to pose this question on DDH in a population with predominantly low/very low COI scores and public insurance, which may lead to unexpected results. Replicating the study in a different setting could yield different results. LEVEL OF EVIDENCE: III.

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.

Artificial Intelligence in Modern Orthopaedics: Current and Future Applications.

➢: With increasing computing power, artificial intelligence (AI) has gained traction in all aspects of health care delivery. Orthopaedics is no exception because the influence of AI technology has become intricately linked with its advancement as evidenced by increasing interest and research. ➢: This review is written for the orthopaedic surgeon to develop a better understanding of the main clinical applications and potential benefits of AI within their day-to-day practice. ➢: A brief and easy-to-understand foundation for what AI is and the different terminology used within the literature is first provided, followed by a summary of the newest research on AI applications demonstrating increased accuracy and convenience in risk stratification, clinical decision-making support, and robotically assisted surgery.

Characterization of Hematopoiesis in Sickle Cell Disease by Prospective Isolation of Stem and Progenitor Cells.

The consequences of sickle cell disease (SCD) include ongoing hematopoietic stress, hemolysis, vascular damage, and effect of chronic therapies, such as blood transfusions and hydroxyurea, on hematopoietic stem and progenitor cell (HSPC) have been poorly characterized. We have quantified the frequencies of nine HSPC populations by flow cytometry in the peripheral blood of pediatric and adult patients, stratified by treatment and control cohorts. We observed broad differences between SCD patients and healthy controls. SCD is associated with 10 to 20-fold increase in CD34dim cells, a two to five-fold increase in CD34bright cells, a depletion in Megakaryocyte-Erythroid Progenitors, and an increase in hematopoietic stem cells, when compared to controls. SCD is also associated with abnormal expression of CD235a as well as high levels CD49f antigen expression. These findings were present to varying degrees in all patients with SCD, including those on chronic therapy and those who were therapy naive. HU treatment appeared to normalize many of these parameters. Chronic stress erythropoiesis and inflammation incited by SCD and HU therapy have long been suspected of causing premature aging of the hematopoietic system, and potentially increasing the risk of hematological malignancies. An important finding of this study was that the observed concentration of CD34bright cells and of all the HSPCs decreased logarithmically with time of treatment with HU. This correlation was independent of age and specific to HU treatment. Although the number of circulating HSPCs is influenced by many parameters, our findings suggest that HU treatment may decrease premature aging and hematologic malignancy risk compared to the other therapeutic modalities in SCD.

Double-plate compound osteosynthesis for pathological fractures of the proximal femur: high survivorship and low complication rate.

INTRODUCTION: Management of pathological fractures of the proximal femur is often challenging. Compound double-plate osteosynthesis has been specifically developed for surgical treatment of these pathological fractures. To our knowledge, this study represents the largest series to date of double-plate compound osteosynthesis with the longest follow-up. MATERIALS AND METHODS: Using our institutional digital database, we identified 61 procedures in 53 patients at the proximal femur. Patients were divided into two groups. A 'primary' group with all cases in which a double-plate compound osteosynthesis was performed as initial procedure (n = 46) and a 'revision' group with all cases in which a double-plate compound osteosynthesis was performed as revision procedure after failed previous attempts of internal fixation (n = 15). (1) The survivorship of the hip was calculated using the Kaplan-Meier survivorship analysis. (2) Complications were graded using Sink's classification. (3) The functional outcome was quantified with the Merle d'Aubigné and Postel score. (4) Risk factors were identified based on a multivariate Cox-regression analysis. RESULTS: The cumulative Kaplan-Meier survivorship of the primary group was 96% at 6 months, 90% at 1 year, 5 years and thereafter and 83% at 6 months, 74% at 1 year, 53% at 2 years for the 'revision' group (p = 0.0008). According to the classification of Sink et al., the rate of grade III and IV complications was significantly lower in the primary group (p < 0.0001). The mean Merle d'Aubigné score was 14 ± 7 at 0-3 months, 13 ± 3 at 3-6 months, 15 ± 3 at 6-12 months and 15 ± 4 thereafter (p = 0.54). The only multivariate negative predictor was previous surgery with a hazard ratio of 9.2 (p < 0.006). CONCLUSION: Double-plate compound osteosynthesis is a valuable treatment option for pathological fractures in proximal femur with good functional results.

Complications associated with surgical repair of syndromic scoliosis.

BACKGROUND: There are a number of syndromes that have historically been associated with scoliosis e.g.: Marfan, Down, and Neurofibromatosis. These syndromes have been grouped together as one etiology of scoliosis, known as syndromic scoliosis. While multiple studies indicate that these patients are at high risk for perioperative complications, there is a paucity of literature regarding the collective complication rates and surgical needs of this population. METHODS: PubMed and Embase databases were searched for literature encompassing the surgical complications associated with the surgical management of patients undergoing correction of scoliosis in the syndromic scoliosis population. Following exclusion criteria, 24 articles were analyzed for data regarding these complications. RESULTS: The collective complication rates and findings of these articles were categorized based on specific syndrome. The rates and types of complications for each syndrome and the special needs of patients with each syndrome are discussed. Several complication trends of note were observed, including but not limited to the universally nearly high rate of wound infections (>5% in each group), high rate of pulmonary complications in patients with Rett syndrome (29.2%), high rate (>10%) of dural tears in Marfan and Ehlers-Danlos syndrome patients, high rate (>20%) of implant failure in Down and Prader-Willi syndrome patients, and high rate (>25%) of pseudarthrosis in Down and Ehlers-Danlos patients. CONCLUSIONS: Though these syndromes have been classically grouped together under the umbrella term "syndromic," there may be specific needs for patients with each of these ailments. Given the high rate of complications, further research is necessary to understand the unique needs for each of these patient groups in the preoperative, intraoperative, and postoperative settings.

Results of Displaced Pediatric Tibial Spine Fractures: A Comparison Between Open, Arthroscopic, and Closed Management.

BACKGROUND: Displaced tibial spine fractures are frequently treated with surgical reduction and fixation, but no comparison studies have been performed. This study was undertaken to compare fragment reduction and adverse outcomes between open arthrotomy [open reduction and internal fixation (ORIF)], arthroscopy [arthroscopic-assisted internal fixation (AAIF)], and closed management [closed management and casting (CMC)] of pediatric tibial spine fractures. METHODS: A retrospective review of children treated for displaced tibial spine fractures from 2003 to 2011 was performed after categorizing into the 3 treatment groups. Demographics, mechanism of injury, radiographic measures (plain film and computed tomography), treatment, duration of immobilization and follow-up, final range of motion, and complications were recorded. Families were contacted to obtain long-term Lysholm scores, return to activity, pain, and satisfaction with treatment. RESULTS: Seventy-six children (mean age, 12.4 y) met criteria with 29 ORIF, 28 AAIF, and 19 CMC. Radiographic measurements between x-ray and computed tomography scans found a mean error of 1 mm (SD=1.33 mm; inter-class coefficient = 0.977, P < 0.001). Initial fracture displacement was similar between AAIF and ORIF, 10.3 ± 4.4 mm and 10.8 ± 3.9 mm; but, less in CMC group (5.3 ± 2.6 mm). The mean reduction amount was 8.6 ± 4.7, 9.1 ± 4.0, and 2.3 ± 2.6 mm, respectively. A Bonferroni post hoc analysis revealed a difference between surgical and nonoperative reduction (P < 0.001), but not between AAIF and ORIF (P=0.9). Arthrofibrosis occurred with equal frequency in surgical cohorts (AAIF 12.5%, ORIF 11.1%), compared with none in the CMC group. Yet, the CMC group had a 16.7% risk for reoperation secondary to instability, loose bodies, or impingement. Twenty-four percent of each cohort was available (at mean 6.0 y) for interview with mean (median) Lysholm score: ORIF 97.4 (99), AAIF 95 (100), and CMC 86 (97.5), P = 0.35. CONCLUSIONS: Open or arthroscopic treatment of displaced tibial spine fractures affords a better reduction than closed management, but with higher risk for arthrofibrosis. Closed management may be successful when displacement is < 5 mm, and advanced imaging may not be necessary to delineate the amount of displacement.

Childhood obesity as a risk factor for lateral condyle fractures over supracondylar humerus fractures.

BACKGROUND: Obese children reportedly have an increased risk of sustaining musculoskeletal injuries compared with their normal-weight peers. Obese children are at greater risk for sustaining fractures of the forearm, particularly from low-energy mechanisms. Furthermore, obesity is a risk factor for sustaining an extremity fracture requiring surgery. However, it is unclear what role obesity plays in fractures about the distal humerus. QUESTIONS/PURPOSES: We therefore asked whether (1) children who sustain lateral condyle (LC) fractures have a higher body mass index (BMI) as compared with those with supracondylar (SC) humerus fractures; and (2) children with a higher BMI sustain more severe fractures regardless of fracture pattern. METHODS: We retrospectively reviewed 992 patients: 230 with LC injuries and 762 with SC fractures. We determined BMI and BMI-for-age percentiles. Fracture types were classified by the systems proposed by Weiss et al. (LC fractures) and Wilkins (SC fractures). RESULTS: The LC group had both a higher mean BMI and BMI-for-age percentile than the SC group as well as had more obese patients (37% versus 19%). Within the LC group, children with Type 3 fractures had a higher BMI that those with Type 1 fractures (19 versus 17). There was a higher percentage of obese patients with Type 3 LC fractures compared with Type 1 and 2 fractures (44% versus 27% and 26%). Among patients with SC fractures, there was no difference among the BMI, BMI-for-age percentiles, or percentage of obese children when analyzed by fracture subtype. CONCLUSIONS: Obesity places a child at greater risk for sustaining a LC fracture and when these fractures occur, they are often more severe injuries compared with those in nonobese children. LEVEL OF EVIDENCE: Level II, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.