Return to Play After Hook of Hamate Fracture: A Systematic Review and Meta-Analysis.

In athletes, a hook of hamate fracture is concerning in terms of time to return to sport and effect on performance upon return. This study aims to analyze the treatment of hook of hamate fractures in athletes to determine their rates of return to play, timelines of recovery, and performance level upon return to play. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to perform this analysis. The PubMed database was queried to perform the literature search. Data were pooled and analyzed. P values <.05 were considered significant. Data were analyzed using the Comprehensive Meta-Analysis software to determine heterogeneity. Twenty studies with 823 patients sustaining hook of hamate fractures that reported any competitive level of play were included in the analysis. Of the 823 patients, 778 (94.5%) were able to return to play with 91.2% (506/555) of patients demonstrating similar or improved performance. The mean time to return to play was 45 days (range: 21-168 days). Treatment included surgical excision for 787 patients (95.6%), open reduction and internal fixation for 18 patients (2.2%), stress reduction/casting for 13 patients (1.6%), and loss to follow-up or surgery refusal for 5 patients (0.6%). A very high number of athletes return to play following a hook of hamate fracture at the same or improved level of performance. In our study, the majority of injuries were treated with surgical excision of the fractured hook of hamate fragment. Most athletes returned to their sport at an average of 45 days.

The 50 most influential publications in clavicle fractures.

PURPOSE: Clavicle fractures are among the most common orthopedic fractures, and treatment methods, operative versus nonoperative, have been a point of contention. The purpose of this study was to evaluate the 50 most influential articles regarding clavicle fractures to better understand past focuses of research and to identify any gaps in knowledge. METHODS: A review of the most cited articles related to clavicle fractures was conducted using Web of Science database. A search was conducted in April 2022 by one trained researcher. Two independent researchers evaluated each article based on relevance to clavicle fracture. RESULTS: The mean number of citations was 179.1, ranging from 576 to 81 citations, and collectively cited 8954 times. The decade from 2000 to 2009 contributed the greatest portion of articles, with only a small portion coming from before 1980. The Journal of Bone and Joint Surgery-American Volume contributed the greatest number of articles (20%). The majority of the articles were therapeutic (n = 37) and focused on treatment and outcome (n = 32). Most of the clinically focused articles had a level of evidence of IV (n = 26). CONCLUSION: There is an increased influence of recent articles focused on clavicle fracture and management, due to the idea that conventional nonoperative treatment has a high rate of nonunion. Many of the most influential studies evaluate the outcomes of various treatments. Many of these studies, however, are lower levels of evidence, leaving a paucity of high level of evidence articles to support these conclusions. LEVEL OF EVIDENCE: V.

Blade plate versus locking plate fixation of proximal femoral varus osteotomy in children with cerebral palsy.

The hip is commonly affected in children with cerebral palsy (CP), requiring proximal femoral varus derotational osteotomies. Novel locking plates afford a popular alternative to traditional blade plates. The purpose of this study was to compare the effectiveness of blade plate versus locking plate fixation in children with CP undergoing proximal femoral osteotomy. We conducted a retrospective review of patients who underwent proximal femoral osteotomy over an 8-year period. Incidence of healing, failure of the procedure, and loss of varus correction were compared between the two groups (blade plate vs. locking plate). Independent samples t -tests and Chi-square analysis were employed to compare differences between continuous and categorical variables, respectively. A total of 268 hips [137 right (51.1%)] met inclusion criteria. Ninety-eight hips (36.6%) were fixed with blade plates [170 (63.4%) locking plates]. Although those in the blade plate cohort were more likely to achieve complete radiographic healing by 6 weeks postoperatively (41.09% vs. 18.84%; P < 0.050), there was no significant difference ( P > 0.050) between the two groups for healing at 3, 6, and 12 months ( P > 0.050). There was no significant difference between the two cohorts regarding the number of patients experiencing migration percentage at least 50% at 6 (3.06% vs. 3.53%) and 12 (3.06% vs. 5.88%) months ( P > 0.050) or in those undergoing revision surgery at 12 (5.33% vs. 1.18%) and 24 (2.04% vs. 1.76%) months ( P > 0.050). The findings of this retrospective study show similar outcomes between blade plate and proximal femoral locking plates in proximal femoral varus osteotomy in children with CP.

Blood loss in hip reconstructive surgery in children with cerebral palsy: when do I need to be prepared for blood transfusion?

The hip is the second most common joint involved in pediatric patients with cerebral palsy (CP). Hip reconstructive procedures are performed to improve function and comfort level. Blood loss can occur leading to blood transfusion in close to 1/3 of children with CP undergoing hip reconstruction. The purpose of this study was to report the rate and risk factors for blood transfusion after hip reconstruction in a large cohort of children with CP. We conducted a retrospective chart review of pediatric patients at our tertiary referral children's hospital who underwent reconstructive hip osteotomy over an 8-year period. Binary logistic regression was employed to compare and model differences in transfusion between age greater than 4 or 6 years and the number of osteotomies. A total of 180 patients met our inclusion criteria. Thirty-seven patients (20.6%) received blood transfusion. Incidence of transfusion increased as number of osteotomies increased from 1 to 4 (3.7%, 7.3%, 34.0%, 58.3%, respectively). We did not find a significant effect of age greater than 4 or 6 years on the rate of blood transfusion (P = 0.676 and P = 0.323, respectively). The number of osteotomies was a significant factor in the rate of blood transfusion in both models (P < 0.001). Number of osteotomies and not age was a significant risk factor in the rate of blood transfusion. This data can help the orthopedic surgeons in preoperative planning for the possibility of blood transfusion in these patients.

Failure of Hip Reconstruction in Children With Cerebral Palsy: What Are the Risk Factors?

BACKGROUND: The rates and risk factors contributing to failure after hip reconstruction among patients with cerebral palsy (CP) are not well established. In analyzing a large cohort of children with CP who underwent hip reconstruction, the objectives of this study are to establish (1) the failure rates and (2) associated risk factors. METHODS: This retrospective study included chart and radiographic review of patients between the ages of 1 to 18, with a diagnosis of CP, who underwent a hip reconstructive procedure at a single children's hospital over a 9-year period (2010 to 2018). Patients without at least 2 years of follow-up were excluded. Age at time of surgery, sex, Gross Motor Function Classification System (GMFCS), procedure(s) performed, preoperative migration percentage (MP), neck-shaft angle, and acetabular index (AI) were recorded. Failure was defined as need for revision surgery or a MP >50% on follow-up radiographs. Logistic regression and multiple-variable regression-type models were used to test for significance of risk factors. RESULTS: Of the 291 hips in 179 patients (102 males, 77 females) that met inclusion criteria, 38 hips (13%) failed. Significant differences in the failure group were seen in age at time of surgery (6.2±3.2 vs. 8.1±3.2; P<0.001), preoperative MP (62.3±28.7 vs. 39.9±24.1%; P<0.001) and preoperative neck-shaft angle (164.9±8.2 vs. 157.3±15.6 degrees; P<0.001). Age below 6 at time of surgery significantly increased failure rate (26% vs. 6.3%, P<0.001) as did preoperative MP >70% (28.9% vs. 9.9%, P<0.001). Receiving an acetabular osteotomy was protective against failure (9.1% vs. 16.9%, P=0.048), particularly in patients with a preoperative AI >25° (odds ratio=0.236; confidence interval: 0.090-0.549). CONCLUSIONS: In this case series, failure after hip reconstruction for children with CP was determined to be 13.1%. There was a higher risk associated with age under 6 at time of surgery or a preoperative MP >70%. Correction of acetabular dysplasia when AI is more than 25 degrees with acetabular osteotomy at time of hip reconstruction, exerted a protective effect against subsequent failure. LEVEL OF EVIDENCE: Level III-retrospective case series.

Reconstructive hip surgery in children with cerebral palsy: factors influencing risk of femoral head avascular necrosis.

Femoral head avascular necrosis (AVN) is a complication of hip reconstruction in children with cerebral palsy (CP) with uncertain incidence. The purpose of this study was to establish the rate of AVN in children undergoing hip reconstruction and to identify the factors associated with AVN. Medical records and radiographs of patients aged 1-18 with a diagnosis of CP who have undergone hip reconstruction over a 9-year period (2010-2018) with at least 1-year follow-up were reviewed. Age at time of surgery, sex, Gross Motor Function Classification System (GMFCS), procedure(s), preoperative migration percentage (MP), and signs of AVN on anterioposterior pelvis radiographs at routine follow-up visits (3 months, 6 months, and years 1-9, annually) according to the Bucholz-Ogden (BO) and Kalamchi-MacEwen (KM) classification systems were recorded. Univariate analysis was used to test for significance. Three hundred forty-nine hips in 209 patients met our inclusion criteria. Eleven hips (rate; 3%), in 11 patients, developed AVN. Classification of AVN was found to consist of: class I-4 (36%), class II-1 (9%), class III-[BO: 4 (36%)] [KM: 3 (27%)], and Class IV-[BO: 2 (18%)] [KM: 3 (27%)]. Average follow-up was of 3.5 years. The AVN cohort displayed older age (11.0 ± 2.8 vs. 8.1 ± 3.4; P = 0.005). Open reduction was associated with increased AVN, occurring in 9% of the hips (P = 0.004). No significant association was found between preoperative MP, GMFCS, or acetabular osteotomy. The method of open reduction (anterior vs. medial) was not significantly associated with AVN (P = 0.4471). In this large series, the observed rate of AVN was 3%, associated with open reductions at time of hip reconstruction. If possible, closed reduction would be preferred at time of hip reconstruction in children with CP to lower the risk of AVN. Level of evidence: III.

Insurance Coverage Criteria for Femoroacetabular Impingement Surgery: Are They Responding to Improving Evidence?

BACKGROUND: With the rapidly growing body of FAI literature in the last decade, improved evidence exists to support FAI surgery. However, it remains unclear how well third-party insurance company's FAI policies have adapted over time to improved evidence. The purpose of this study was (1) to compare the 2020 FAI surgery criteria of four major insurance companies utilizing a multi-center cohort of FAI patients undergoing surgery to identify rates and causes of ineligibility, and (2) to compare the rates of approval based on changes in policy from 2012 to 2020. METHODS: Four major insurance companies' coverage policies with specific criteria for the surgical treatment of FAI were applied to this population at two time points (2012 and 2020). The policies listed various combinations of age, symptom duration, radiographic signs of FAI, radiographic signs of osteoarthritis, and physical exam findings. A prospective, multi-center cohort of 712 patients (including 45.5% males and 54.5% females with a mean age of 28.7 years) undergoing surgical treatment of FAI was utilized for analysis of insurance policies. RESULTS: Based on 2020 FAI policies across 4 insurers, 22.5% (range 18.4-28.4%) of FAI patients would be deemed ineligible. In 2012, the average percent exclusion of the four companies was 23.7%. The most likely reason to be excluded was either failure to meet imaging criteria (alpha angle >50° or positive cross-over sign) [13%, n=94]) or the absence of an impingement sign (9%, n=65). Other causes of exclusion were <6-month symptom duration (6%, n=44), age <15 years (4%, n=28), or skeletally immaturity (3%, n=23). CONCLUSION: Our study shows that despite a six-year span of growing literature and updated policies, nearly 1 in 5 patients diagnosed with FAI would still potentially be denied coverage. This highlights a continued divide between surgeons and insurance companies. There is a major need for improved consensus regarding the diagnosis of FAI and appropriate indications for surgical intervention.Level of Evidence: IV.

Management of Hip Disorders in Patients with Cerebral Palsy.

Hip disorders are the second most common musculoskeletal abnormality seen in children with cerebral palsy, affecting nearly 1 in 3. The goal of surgical intervention is to provide a mobile, located, and painless hip. Reconstructive procedures are indicated for children with migration percentages of >40%. Reconstructive procedures typically result in a long-term satisfactory outcome, although recurrence is seen particularly in nonambulatory children and when the reconstruction is performed earlier than 6 years of age. Salvage procedures are performed when reconstructive procedures are no longer an option and degenerative changes have occurred. They include proximal femoral valgus osteotomy, proximal femoral resection, and hip arthroplasty.

Outcome Metrics in Pediatric Sports Medicine: Do PROMIS Computer-adaptive Testing Metrics Correlate With Pedi-IKDC?

BACKGROUND: A modified version of the International Knee Documentation Committee (IKDC), the Pedi-IKDC, is a validated patient-reported outcome measure in pediatric patients with knee pain. However, this questionnaire is lengthy and can fatigue patients, leading to inconsistent outcome collection. Thus, we sought to compare more easily attainable Patient-Reported Outcomes Measurement Information System (PROMIS) computer adaptive testing patient reported outcomes to the gold standard Pedi-IKDC. METHODS: We prospectively collected PROMIS scores and Pedi-IKDC scores in 100 new, consecutive patients presenting with knee pain to a pediatric sports medicine practice. Patients were excluded if they provided an incomplete Pedi-IKDC, had prior ipsilateral lower extremity surgery, or significant associated medical comorbidities. PROMIS domains including Mobility, Pain Interference, and Upper Extremity (control) were compared with the Pedi-IKDC with Pearson correlations. The number of questions in each metric was analyzed. Floor and ceiling effects of each test were also assessed. RESULTS: The average age of the study cohort was 14 years (range, 7 to 18 y) with 53% female and 47% male. 70% of patients completed the Pedi-IKDC questionnaire, compared with 100% with PROMIS tests. The average Pedi-IKDC score was 48.8±22.3 (range, 5.4 to 100). Mean scores for Mobility, Pain Interference, and Upper Extremity domains were 38.4±10.1, 53.5±10.3, and 49.7±8.7, respectively. All tests demonstrated similar and acceptable floor and ceiling effects (<15%). The length of the Pedi-IKDC (22 questions) was roughly double that of combined PROMIS Pain Interference and Mobility tests (11.9±2.3 questions). Pedi-IKDC scores correlated with tested PROMIS measures (Mobility/Pain Interference, r=0.42/-0.49). When 7 highly functional patients with significant pain symptoms were removed for a secondary analysis, Mobility and Pain correlations improved to 0.69 and -0.67, respectively. CONCLUSIONS: PROMIS Mobility and Pain scores demonstrate moderate correlations with the Pedi-IKDC, highlighting these tests are not capturing the same patient experiences. These correlations are weakened by a small group of painful yet highly functioning patients. The Pedi-IKDC was significantly longer and had a much lower completion rate than PROMIS tests, highlighting a need for a validated computer adaptive testing in evaluating pediatric patients with knee pain. LEVELS OF EVIDENCE: Level II.

Pediatric Orthopedic Workforce: A Review of Recent Trends.

Pediatric orthopedic surgery has changed in many ways over the past 2 decades. Member surveys and recent literature confirm that there has been a sustained balance of interest and opportunity in growth of applicant numbers and fellowship spots. Pediatric orthopedics is leading the way in gender diversity in orthopedics. Concerns of competition are valid and appear to be rising; however, case load data suggest that with increased training of pediatric orthopedists, there seems to be an adequate increase in cases. Periodic workforce analysis should continue to gauge any changes in attitudes or monitor concerns of competition.