Interobserver and Intraobserver Agreement are Unsatisfactory When Determining Abstract Study Design and Level of Evidence.

BACKGROUND: Understanding differences between types of study design (SD) and level of evidence (LOE) are important when selecting research for presentation or publication and determining its potential clinical impact. The purpose of this study was to evaluate interobserver and intraobserver reliability when assigning LOE and SD as well as quantify the impact of a commonly used reference aid on these assessments. METHODS: Thirty-six accepted abstracts from the Pediatric Orthopaedic Society of North America (POSNA) 2021 annual meeting were selected for this study. Thirteen reviewers from the POSNA Evidence-Based Practice Committee were asked to determine LOE and SD for each abstract, first without any assistance or resources. Four weeks later, abstracts were reviewed again with the guidance of the Journal of Bone and Joint Surgery (JBJS) LOE chart, which is adapted from the Oxford Centre for Evidence-Based Medicine. Interobserver and intraobserver reliability were calculated using Fleiss' kappa statistic (k). χ2 analysis was used to compare the rate of SD-LOE mismatch between the first and second round of reviews. RESULTS: Interobserver reliability for LOE improved slightly from fair (k=0.28) to moderate (k=0.43) with use of the JBJS chart. There was better agreement with increasing LOE, with the most frequent disagreement between levels 3 and 4. Interobserver reliability for SD was fair for both rounds 1 (k=0.29) and 2 (k=0.37). Similar to LOE, there was better agreement with stronger SD. Intraobserver reliability was widely variable for both LOE and SD (k=0.10 to 0.92 for both). When matching a selected SD to its associated LOE, the overall rate of correct concordance was 82% in round 1 and 92% in round 2 (P<0.001). CONCLUSION: Interobserver reliability for LOE and SD was fair to moderate at best, even among experienced reviewers. Use of the JBJS/Oxford chart mildly improved agreement on LOE and resulted in less SD-LOE mismatch, but did not affect agreement on SD. LEVEL OF EVIDENCE: Level II.

Validation of Pediatric Self-Report Patient-Reported Outcomes Measurement Information System (PROMIS) Measures in Different Stages of Legg-Calvé-Perthes Disease.

OBJECTIVES: Patient-reported outcomes (PRO) assessing health-related quality of life (HRQoL) are important outcome measures, especially in Legg-Calvé-Perthes disease (LCPD) where symptoms (pain and limping), activity restrictions, and treatments vary depending on the stage of the disease. The purpose of this study was to investigate the validity of the Patient-reported Outcomes Measurement Information System (PROMIS) for measuring HRQoL of patients with LCPD in various stages of the disease. METHODS: This is a multicenter validity study. Patients with LCPD between 4 and 18 years old were included and classified into modified Waldenström stages of disease: Early (1 or 2A), Late (2B or 3), or Healed (4). Seven PROMIS domains were collected, including Pain Interference, Fatigue, Mobility, Depression, Anger, Anxiety, and Peer Relationships. Convergent, discriminant, and known group validity was determined. RESULTS: A total of 190 patients were included (mean age: 10.4±3.1 y). All 7 domains showed the worst scores in patients in the Early stage (known group validity). Within each domain, all domains positively correlated to each other (convergent validity). Patients who reported more anxiety, depression, and anger were associated with decreased mobility and increased fatigue and pain. Peer relationships had no to weak associations with other domains (discriminant validity). CONCLUSIONS: PROMIS has construct validity in measuring the HRQoL of patients in different stages of LCPD, suggesting that PROMIS has potential to serve as a patient-reported outcome tool for this population. LEVEL OF EVIDENCE: Diagnostic level III study.

Timing of Pavlik Harness Initiation: Can We Wait?

BACKGROUND: Developmental dysplasia of the hip is effectively treated with a Pavlik harness (PH) within the first 6 months of life. Over 80% of unstable hips in the newborn period will naturally stabilize by 2 months of age. If there is no difference in the effectiveness of initiating PH treatment at 1 week compared with 4 weeks of age, waiting may allow the hips to naturally stabilize and avoid treatment. The purpose of this study is to evaluate whether the timing of PH implementation influences its effectiveness in the treatment of developmental dysplasia of the hip. METHODS: A retrospective review was conducted between 2004 and 2010. Patients were included if PH therapy was prescribed for hip instability or dislocation at or before 6 months of age. PH failure was defined as requiring any operative procedure for definitive management. Groups were divided based on the age at which the PH was initiated-group1=<30 days, group 2=30 to 60 days, group 3=>60 days. RESULTS: A total of 176 children were included with 38 (21.6%) failing PH treatment. The mean age at PH initiation was 1.3 months (SD=1.3) in the successfully treated children and 1.4 months (SD=1.2) in the failures (P=0.77). There was no difference in the failure rates by age with group 1=19.1% (18/94), group 2=22.5% (9/40), and group 3=26.2% (11/42) (P=0.87). There was no statistical difference with respect to sex or breech positioning in the success or failure groups; however, there was a higher percentage of bilateral involvement in the failure group (P=0.04). CONCLUSIONS: Patients who had PH initiation before 30 days of age were no more or less likely to fail than when PH was initiated after 30 days of age. Parents can be counseled that waiting until after 30 days of age is appropriate before PH implementation. By avoiding swaddling during this period, the hips may stabilize without treatment and allow for more parental-infant bonding before implementation of PH. LEVEL OF EVIDENCE: Level III-therapeutic, case control study.

Pavlik Harness initiation on Barlow positive hips: Can we wait?

We investigated if infants with a Barlow positive hip(s) have natural hip stabilization and can thus avoid Pavlik Harness (PH) treatment. We conducted a chart review for infants who presented within two weeks of life, had a Barlow positive hip, and were deferred treatment. Of the thirty infants, eighteen were treated with PH at 4-6 weeks or 12 weeks due to persistent dysplasia. Twelve infants avoided PH entirely. There were zero cases of PH failure. Parents can be counseled that deferring treatment until at least 4-6 weeks of age might avoid treatment altogether without an increased risk of harness failure.

Late Presentation of Developmental Hip Dislocation: A Case Report.

CASE: We describe a patient who was diagnosed with developmental hip dislocation at 21 months of age despite having had normal ultrasonography findings at 5 weeks of age. CONCLUSION: This case report provides evidence that late developmental hip dislocation can occur despite normal clinical and sonographic findings early in life, and that it is difficult to know the cause of developmental hip dislocation when it presents late.

What's New in Pediatric Orthopaedic Quality, Safety, and Value? A Systematic Review With Results of the 2016 POSNA Quality, Safety, and Value Initiative (QSVI) Challenge.

BACKGROUND: Enhancing the safety, quality, and value of care provided is a point of emphasis for modern health care systems. We performed a review of recent literature to highlight those efforts relevant to pediatric musculoskeletal care. METHODS: We searched the PubMed database for all papers related to quality improvement, patient safety, and/or value in pediatric orthopaedics published from October 1, 2012 to October 31, 2017, yielding 193 papers. RESULTS: A total of 36 papers were selected for review based upon new findings. Papers were selected based on significant contributions in the following categories: casting safety, antibiotic stewardship/infection prevention, perioperative care pathways, blood conservation, venous thromboembolic disease prevention, and imaging safety/appropriateness. CONCLUSIONS: There have been numerous advances in safety, quality, and value in pediatric orthopaedic care. Quality improvement efforts emphasizing provider education and safety monitoring can lead to a decrease in cast-related complications. Perioperative care pathways and bundles are associated with a decrease risk of surgical site infection and decreased length of stay in pediatric spinal deformity surgery. Increased scrutiny has been placed on the value of routine follow-up radiographs in pediatric fracture and spinal deformity care. LEVEL OF EVIDENCE: Level 4-literature review.

Radiofrequency ablation in the treatment of osteoid osteoma: results and complications.

BACKGROUND: Percutaneous radiofrequency ablation (RFA) for treatment of osteoid osteoma is effective and avoids the potential complications of open surgical resection. This study evaluates the efficacy of RFA at a single tertiary-care pediatric hospital and highlights an important complication. MATERIALS AND METHODS: The medical records of 21 cases of RFA in 21 children between 2004 and 2010 were reviewed retrospectively for demographic data, lesion site, access point and technique for ablation, clinical outcome and complications. RESULTS: Clinical follow-up was available for 17/21 children (81%) at an average of 17.0 months (range 0.5-86.1 months). No persistence or recurrence of pre-procedural pain was noted. Two children (9.5%) had a complication, including a burn to the local skin and muscle requiring local wound care, and a late subtrochanteric femur fracture treated successfully with open reduction internal fixation. CONCLUSION: RFA is a safe and effective alternative to surgical resection of the osteoid osteoma nidus. When accessing the proximal femur, the risk of late post-procedural fracture must be considered and discussed with the family. An understanding of biomechanical principles in the proximal femur might provide an effective strategy for limiting this risk.

Cotransplantation with specific populations of spina bifida bone marrow stem/progenitor cells enhances urinary bladder regeneration.

Spina bifida (SB) patients afflicted with myelomeningocele typically possess a neurogenic urinary bladder and exhibit varying degrees of bladder dysfunction. Although surgical intervention in the form of enterocystoplasty is the current standard of care in which to remedy the neurogenic bladder, it is still a stop-gap measure and is associated with many complications due to the use of bowel as a source of replacement tissue. Contemporary bladder tissue engineering strategies lack the ability to reform bladder smooth muscle, vasculature, and promote peripheral nerve tissue growth when using autologous populations of cells. Within the context of this study, we demonstrate the role of two specific populations of bone marrow (BM) stem/progenitor cells used in combination with a synthetic elastomeric scaffold that provides a unique and alternative means to current bladder regeneration approaches. In vitro differentiation, gene expression, and proliferation are similar among donor mesenchymal stem cells (MSCs), whereas poly(1,8-octanediol-cocitrate) scaffolds seeded with SB BM MSCs perform analogously to control counterparts with regard to bladder smooth muscle wall formation in vivo. SB CD34(+) hematopoietic stem/progenitor cells cotransplanted with donor-matched MSCs cause a dramatic increase in tissue vascularization as well as an induction of peripheral nerve growth in grafted areas compared with samples not seeded with hematopoietic stem/progenitor cells. Finally, MSC/CD34(+) grafts provided the impetus for rapid urothelium regeneration. Data suggest that autologous BM stem/progenitor cells may be used as alternate, nonpathogenic cell sources for SB patient-specific bladder tissue regeneration in lieu of current enterocystoplasty procedures and have implications for other bladder regenerative therapies.

Femoral fractures in adolescents: a comparison of four methods of fixation.

BACKGROUND: The optimal management of femoral fractures in adolescents is controversial. This study was performed to compare the results and complications of four methods of fixation and to determine the factors related to those complications. METHODS: We conducted a retrospective cohort study of 194 diaphyseal femoral fractures in 189 children and adolescents treated with elastic stable intramedullary nail fixation, external fixation, rigid intramedullary nail fixation, or plate fixation. After adjustment for age, weight, energy of the injury, polytrauma, fracture level and pattern, and extent of comminution, treatment outcomes were compared in terms of the length of the hospital stay, time to union, and complication rates, including loss of reduction requiring a reoperation, malunion, nonunion, refracture, infection, and the need for a reoperation other than routine hardware removal. RESULTS: The mean age of the patients was 13.2 years, and their mean weight was 49.5 kg. There was a loss of reduction of two of 105 fractures treated with elastic nail fixation and ten of thirty-three treated with external fixation (p < 0.001). At the time of final follow-up, five patients (two treated with external fixation and one in each of the other groups) had >or=2.0 cm of shortening. Eight of the 104 patients (105 fractures) treated with elastic nail fixation underwent a reoperation (two each because of loss of reduction, refracture, the need for trimming or advancement of the nail, and delayed union or nonunion). Sixteen patients treated with external fixation required a reoperation (ten because of loss of reduction, one for replacement of a pin complicated by infection, one for débridement of the site of a deep infection, three because of refracture, and one for lengthening). One patient treated with a rigid intramedullary nail required débridement at the site of a deep infection, and one underwent removal of a prominent distal interlocking screw. One fracture treated with plate fixation required refixation following refractures. A multivariate analysis with adjustment for baseline differences showed external fixation to be associated with a 12.41-times (95% confidence interval = 2.26 to 68.31) greater risk of loss of reduction and/or malunion than elastic stable intramedullary nail fixation. CONCLUSIONS: External fixation was associated with the highest rate of complications in our series of adolescents treated for a femoral fracture. Although the other three methods yielded comparable outcomes, we cannot currently recommend one method of fixation for all adolescents with a femoral fracture. The choice of fixation will remain influenced by surgeon preference based on expertise and experience, patient and fracture characteristics, and patient and family preferences.

Comparison of surgeon and physiotherapist-directed Ponseti treatment of idiopathic clubfoot.

BACKGROUND: Increasingly, the Ponseti method has been adopted worldwide as the preferred method of managing idiopathic clubfoot deformity. Following the successful implementation of the Ponseti method by orthopaedic surgeons in our institution, a clubfoot clinic was established in 2003. This clinic is directed by a physiotherapist who, using the Ponseti protocol, performs the serial cast treatment and supervises the brace management of all children with idiopathic clubfoot deformity. The purpose of this study was to compare the outcomes of physiotherapist-directed with surgeon-directed Ponseti cast treatment of idiopathic clubfeet. METHODS: We performed a retrospective cohort study of all patients with idiopathic clubfoot deformity treated from 2002 to 2006 and followed for a minimum of two years. Twenty-five children (thirty-four clubfeet) treated by surgeons were compared with ninety-five children (137 clubfeet) treated by a physiotherapist. The outcomes that were evaluated included the number of casts required, the rate of percutaneous Achilles tenotomy, the rate of recurrence, the failure rate, and the need for additional surgical procedures. RESULTS: At the time of presentation, the patients in the two groups were similar in terms of age, sex distribution, laterality of the clubfoot, and history of treatment. The mean duration of follow-up was thirty-four months in the physiotherapist-directed group and forty-eight months in the surgeon-directed group. No significant difference was found between the two groups with regard to the mean number of initial casts, the Achilles tenotomy rate, or the failure rate. Recurrence requiring additional treatment occurred in 14% of the feet in the physiotherapist-directed group and in 26% of the feet in the surgeon-directed group (p = 0.075). Additional procedures, including repeat Achilles tenotomy or a limited posterior or posteromedial release, were required in 6% of the feet in the physiotherapist-directed group and in 18% of those in the surgeon-directed group (p = 0.025). CONCLUSIONS: In our institution, the Ponseti method of cast treatment of idiopathic clubfeet was as effective when it was directed by a physiotherapist as it was when it was directed by a surgeon, with fewer recurrences and a less frequent need for additional procedures in the physiotherapist-directed group. The introduction of the physiotherapist-supervised clubfoot clinic at our institution has been effective without compromising the quality of care of children with clubfoot deformity.

Treatment of neuromuscular and syndrome-associated (nonidiopathic) clubfeet using the Ponseti method.

BACKGROUND: Clubfeet are associated with many neuromuscular and congenital conditions. Nonidiopathic clubfeet are typically thought to be resistant to nonoperative management. The Ponseti method has revolutionized the treatment of patients with idiopathic clubfeet. The purpose of this study was to describe the use of the Ponseti method in the treatment of patients whose clubfeet are associated with a neuromuscular diagnosis or a syndrome. METHODS: All patients with clubfeet who were treated at the Hospital for Sick Children, Toronto, from 2001 to 2005 were reviewed. Patients were included only if a neuromuscular condition or a syndrome associated with clubfeet could be identified and if the primary treatment was at our institution. Twenty-three patients with 40 nonidiopathic clubfeet and 171 patients with 249 idiopathic clubfeet have been treated with a minimum follow-up time of 1 year. The outcomes evaluated included the number of casts, the percentage of patients requiring percutaneous Achilles tendon lengthening (tenotomy of the Achilles tendon [TAT]), rate of recurrences, rate of failures, and the need for additional secondary procedures. RESULTS: The mean age at presentation for nonidiopathic clubfeet was 11 weeks. The mean follow-up time was 33 months, and the mean number of casts was 6.4; a percutaneous TAT was necessary in 27 (68%) of 40 feet. Failure of the Ponseti casting occurred in 4 (10%) of the 40 feet. Recurrence requiring additional treatment occurred in 16 (44%) of 36 feet. Additional procedures included second percutaneous TAT, limited posterior/plantar release, or complete posteromedial release totaling 11 (28%) of 40. When compared with idiopathic clubfeet, nonidiopathic clubfeet required more casts and had a higher rate of failures, recurrences, and additional procedures than idiopathic clubfeet. CONCLUSIONS: Although not as successful as for idiopathic clubfeet, when the Ponseti technique is applied to nonidiopathic clubfeet, correction can be achieved and maintained in most patients. LEVEL OF EVIDENCE: Prognostic level 2.

A comparison of the thoracolumbosacral orthoses and providence orthosis in the treatment of adolescent idiopathic scoliosis: results using the new SRS inclusion and assessment criteria for bracing studies.

UNLABELLED: This is a retrospective cohort study comparing the effectiveness of the thoracolumbosacral orthosis (TLSO) and the Providence orthosis in the treatment of adolescent idiopathic scoliosis (AIS) using the new Scoliosis Research Society (SRS) Committee on Bracing and Nonoperative Management inclusion and assessment criteria for bracing studies. These new criteria will make future studies comparable and more valid and accurate. METHODS: We have used a custom TLSO (duration, 22 hours/day) and the Providence orthosis (duration, 8-10 hours/night) to control progressive AIS curves. Only 83 of 160 patients met the new SRS inclusion criteria: age of 10 years and older at initiation of bracing; initial curve of 25 to 40 degrees; Risser sign 0 to 2; female; premenarcheal or less than 1 year past menarche; and no previous treatment. There were 48 patients in the TLSO group and 35 in the Providence group. The new SRS assessment criteria of effectiveness included the percentage of patients who had 5 degrees or less and 6 degrees or more of curve progression at maturity, the percentage of patients whose curve progressed beyond 45 degrees, the percentage of patients who had surgery recommended or undertaken, and a minimum of 2 years of follow-up beyond maturity in those patients who were thought to have been successfully treated. All patients are evaluated regardless of compliance (intent to treat). RESULTS: There were no significant differences in age at brace initiation, initial primary curve magnitude, sex, or initial Risser sign between the 2 groups. In the TLSO group, only 7 patients (15%) did not progress (