National Trends in Inpatient Hospital Outcomes of Children with Osteogenesis Imperfecta and the Importance of Extraskeletal Manifestations: A Kids' Inpatient Database Study.

OBJECTIVE: To investigate the extent of extraskeletal manifestations along with inpatient outcomes and complications associated with osteogenesis imperfecta (OI). STUDY DESIGN: This cross-sectional study utilized the Kids' Inpatient Database as a part of the Healthcare Cost and Utilization Project to investigate inpatient hospital outcomes and management in patients with OI from 1997 through 2016. Data regarding hospital characteristics, cost of treatment, inpatient outcomes, and procedures were collected and analyzed. RESULTS: There were 7291 admissions that listed OI as a diagnosis in the Kids' Inpatient Database from 1997 through 2016. Unexpectedly, more than one-third of all admissions in these children with OI presented with an extraskeletal manifestation. The rate of major complications was 3.85%. The rate of minor complications was 19.4%, most commonly respiratory problems. The mortality rate was 18.2% in the neonatal period and 1.0% in all other admissions. Total charges of hospital stay increased over the years. CONCLUSIONS: We identified a striking prevalence of extraskeletal manifestations in OI along with inpatient outcomes and complications associated with OI, of which respiratory complications were predominant. We observed a significant financial burden for patients with OI and identified additional risks for financial crisis, in addition to disparities in care identified among socioeconomic groups. These data contribute to a more holistic understanding of OI from diagnosis to management.

Controversies in the Management of Pediatric Musculoskeletal Infections: An International Viewpoint.

Pediatric musculoskeletal infections (MSIs) are a major contributor to the global burden of musculoskeletal disease in children and young adults. If untreated, or treated inappropriately or inadequately, pediatric bone and joint infections can be fatal or result in morbidity that causes significant functional disabilities to the patient and economic burden to the family and the community at large. The past decade has witnessed many advances in this field with respect to early diagnosis, management, and prevention of complications. It is important to discuss the current controversies in the management of pediatric MSIs with an international perspective. This discussion should include the controversies associated with the early diagnosis and identification of pediatric MSI in diverse settings; the controversies involved in the nonsurgical and surgical management of acute pediatric MSIs; and the controversies associated with the management of sequelae of pediatric MSI.

Congenital Synostosis of the Knee: Long-term Outcomes of Limb Reconstruction Surgery.

BACKGROUND: Congenital synostosis of the knee is a rare condition with limited data on treatment options and outcomes. This study reports clinical findings, treatment approach, and surgical/clinical outcomes for congenital synostosis of the knee. METHODS: An institutional review board-approved retrospective review of patients with congenital synostosis of the knee presenting to 2 institutions between 1997 and 2021 was performed. RESULTS: Eight patients (13 knees) with a median follow-up of 11.3 years (3.3 to 17 y) were included. Seven patients had associated syndromes. Patients presented with an average knee flexion deformity of 100° (range 60 to 130°) and delayed walking ability. Seven patients had associated upper extremity hypoplasia/phocomelia. The average age at the index surgery was 4.3 years (range 1.2 to 9.2 y). Synostosis resection with gradual deformity correction was performed in most patients. An attempt was made at a mobile knee in some patients, but all went on to knee fusion. Mean flexion deformity at final follow-up was 11.6° (range: 0 to 40°) and 5 limbs were fused in full extension. Mean limb length discrepancy at final follow-up was 6.8 cm (range: 0 to 8 cm). All patients maintained their improved ambulation status at final follow-up. Twenty-two complications were identified. CONCLUSIONS: Reliable correction of the deformity associated with congenital knee synostosis was achieved at a median follow-up of 11 years. Importantly, all patients maintained their improved ambulation at final follow-up. This is the largest study on patients with congenital knee synostosis and outlines a reconstructive approach to improve ambulatory status. LEVEL OF EVIDENCE: Level IV.

Art and Pediatric Orthopaedics: Ribera, an Artist for the Downtrodden.

Jusepe de Ribera's most famous artistic works consisted of the bizarre such as mutilated bodies and social outcasts, with one being of a Neapolitan beggar boy with upper and lower limb joint contractures. Although the etiology of the boy's contractures in The Clubfoot has been debated, we present a case for arthrogryposis with a unilateral clubfoot as the most likely diagnosis.

Clinical Scores Predict Acute and Chronic Complications in Pediatric Osteomyelitis: An External Validation.

BACKGROUND: Pediatric acute hematogenous osteomyelitis (AHO) outcomes are highly dependent on the disease severity. Recently, the A-SCORE and C-SCORE, were proposed as predictors of an acute complicated course and chronic morbidity, respectively. The purpose of this study was to externally validate the A-SCORE and C-SCORE at a single institution. METHODS: This IRB-approved retrospective chart review included AHO patients admitted at a tertiary referral hospital between October 1, 2015 and December 31, 2019. The inclusion criteria were ages 0 to 18 and clinical response to treatment. The exclusion criteria were immunocompromised status or penetrating inoculation. RESULTS: The A-SCORE demonstrated an area under the receiver operator curve (ROC area) of >86% with regards to all acute complications. It also demonstrated sensitivities >85% and specificities >92% at the cut-off of 4 (Youden index) for all acute complications. The C-SCORE demonstrated an ROC area of 100% with regards to chronic osteomyelitis. It also demonstrated sensitivities >70% and specificities >93% for the chronic morbidity variables seen in our population at the cut-off of 3 (Youden index.). CONCLUSIONS: These novel composite clinical scores, in combination with clinical judgment, could help guide early care decisions. The A-SCORE and C-SCORE are useful risk stratification tools in the management of pediatric AHO and in predicting acute complicated courses or chronic sequelae of AHO, respectively. These scoring systems, if integrated into standardized pediatric AHO guidelines, can allow clinicians to stratify the AHO population and guide clinical decision making. LEVEL OF EVIDENCE: Level III (prognostic study, retrospective chart review).

Primary Bacterial Pyomyositis in Children: A Systematic Review.

BACKGROUND: Tropical pyomyositis has had a recent increase in the United States, Europe, and other nontropical areas. The purpose of this study was to provide an accurate description of the demographics, presenting features, sites of involvement, microbiology, imaging modalities, medical and surgical management, complications, and predictors of clinical course. METHODS: We searched PubMed, Cochrane, Web of Science Collection, Scopus, and Embase databases yielding 156 studies. Of these, 23 articles were selected for statistical analysis. RESULTS: The average age at presentation was 8.4±1.9 years with males more commonly affected. Fever, painful limp, and localized pain were the most common presenting symptoms. Pelvis, lower extremity, trunk and spine, in descending order, were the most commonly affected locations. Iliopsoas, obturator musculature, and gluteus musculature were the most commonly affected muscle groups. The mean time to diagnosis was 6.6±3.05 days. Staphylococcus aureus was the most common offending organism. The mean length of hospital stay was 12.0±4.6 days. Medical management alone was successful in 40% of cases (143/361) with an average duration of 9.5±4.0 and 22.7±7.2 days of intravenous and oral antibiotics, respectively. Surgical management consisted of open drainage in 91.3% (199/218) or percutaneous drainage in 8.7% (19/218) of cases. Painful limp, fever, and larger values of white cell count and erythrocyte sedimentation rate were associated with an increased need for surgery. Obturator and calf muscle involvement were strongly associated with multifocal involvement. There were 42 complications in 41 patients (11.3%). Methicillin-resistant S. aureus was associated with an increased risk of complications. The most common complications were osteomyelitis, septicemia, and septic arthritis. CONCLUSIONS: Primary pyomyositis should be considered in cases suggesting pediatric infection. Magnetic resonance imaging is the most commonly used imaging modality; however, ultrasound is useful given its accessibility and low cost. Medical management alone can be successful, but surgical treatment is often needed. The prognosis is favorable. Early diagnosis, appropriate medical management, and potential surgical drainage are required for effective treatment. LEVEL OF EVIDENCE: Level IV-systematic review.

Diversity and Inclusion in an Orthopaedic Surgical Society: A Longitudinal Study.

BACKGROUND: Diversity and inclusion are critical to providing the best possible health care. Previous studies have shown that diversity among physicians increases cultural competency, which in turn enhances the quality of care provided and increases minoritized patients' participation in decisions regarding their health care. However, physician diversity in both race and sex is lacking in orthopaedic surgery. This study seeks to determine the sex and racial diversity in the membership and leadership of the Pediatric Orthopaedic Society of North America (POSNA). METHODS: POSNA membership and leadership were reviewed for the years 2010, 2015, and 2020. This data was gathered from membership directories and committee reference books. All North American Active Members' race/ethnicity and sex were recorded for each year. The categories for race/ethnicity are Caucasian, East/South/Middle Eastern Asian American (Asian), Hispanic/Latin/South American (HLSA), and African American. RESULTS: From 2010 to 2020, Active Members of POSNA increased from 608 to 818, and the percentage of female (14.6% to 23.7%), Asian (7.4% to 11.2%), HLSA (2.5% to 2.9%), and African American membership (1.6% to 1.8%) increased. Male (85.4% to 76.3%) and Caucasian (88.5% to 84.0%) membership decreased. From 2010 to 2020, male leadership decreased on both the Board of Directors and Committee Chairs (89.5% to 81.8% and 86.4% to 64.7%, respectively), as did Caucasians (94.7% to 81.8% and 90.9% to 88.2%, respectively). The number of Asian members holding positions on both the Board of Directors and Committee Chairs increased (0% to 18.2% and 4.5% to 11.8%, respectively) as did the number of females (10.5% to 18.2% and 13.6% to 35.3%, respectively). HLSA and African American members were proportionally represented in leadership for the years 2010 and 2015. CONCLUSIONS: Membership in POSNA has increased between 2010 to 2020 for every diversity category examined and POSNA membership exhibits significantly more diversity than the orthopaedic specialty as a whole. Leadership as a whole is more diverse in 2020 than it was in 2010. LEVEL OF EVIDENCE: Level II-retrospective.

Correction of Cubitus Varus After Pediatric Supracondylar Elbow Fracture: Alternative Method Using the Taylor Spatial Frame.

BACKGROUND: Cubitus varus is a well-reported complication of supracondylar fracture of the humerus potentially resulting in cosmetic problems, impaired function, and malpractice claims. Traditional methods of correcting malunited distal humeral fractures involve complex osteotomies that have a high complication rate, require a large exposure, and challenging fixation. We present a technique of gradual correction using a percutaneous transverse osteotomy and 3 dimensional correction with a Taylor Spatial Frame. METHODS: This was a retrospective, IRB-approved study of 12 patients between 2006 and 2010, with cubitus varus after a malunited pediatric supracondylar fracture. The average age at initial injury was 5+8 years. The average age of the patients at surgery was 8+8 years. We measured technical (radiographic parameters and complications), functional (clinical carrying angle, range of motion, QuickDash), and satisfaction domain (questionnaire) outcomes at a minimum follow-up of 6 months. RESULTS: The osteotomy healed in all patients by 10 weeks after the index surgery. The mean external fixator time was 10 weeks. The average preoperative and postoperative humeroulnar angles for the affected elbow were 23 degrees varus and 5.8 degrees valgus, respectively. This was statistically significant (P<0.001). The mean preoperative and postoperative carrying angles were 22 degrees of varus and 5.8 degrees of valgus. This was statistically significant (P<0.001). The results of the QuickDash assessment showed that patients were doing very well with regard to the use of their upper extremity. The mean symptom/disability score was 0.80. No major complications or neurovascular complications were encountered. Overall satisfaction with the procedure was high. CONCLUSIONS: The Taylor Spatial Frame as used in this case series provides the experienced surgeon another safe, accurate, and reliable method to correct cubitus varus after pediatric supracondylar fracture. We used in 7 of our 12 cases, a previously unreported pattern of distal humeral pin fixation that allows for a very distal metaphyseal osteotomy, close to the deformity apex. This is a biplanar delta configuration that straddles the olecranon fossa and is appropriate for both children and adults. LEVEL OF EVIDENCE: Level IV.

Cervicothoracic myelopathy in children with Morquio syndrome A: a report of 4 cases.

BACKGROUND: Craniovertebral junction anomalies and C1-C2 instability resulting in myelopathy have been well described in the literature on mucopolysaccharidosis IV (MPS-IV). Spinal involvement in MPS-IV patients, with neurological impairment, other than atlanto-axial instability and thoracolumbar kyphosis, has been scarcely mentioned in the literature. METHODS: Retrospective clinical and radiologic review of the medical records and imaging studies of 4 individuals with Morquio A syndrome, who had undergone decompression and fusion of the cervicothoracic spine for myelopathy secondary to cervicothoracic stenosis between 1990 and 2009. Data regarding the presence of kyphosis at the cervicothoracic and upper thoracic spine, and neurological symptoms and signs were obtained. RESULTS: There were 3 girls and 1 boy with an average age of 5 years and 11 months at presentation with neurological symptoms. Half of the patients had previously undergone occipitocervical fusion for atlanto-axial instability, whereas the other half were noted to have spinal cord compression at both the upper cervical and cervicothoracic regions, and underwent decompression and fusion at both levels concomitantly. All patients showed postoperative neurological improvement. All patients presented with the classical Morquio syndrome vertebral morphology. Cervicothoracic kyphosis was found in all of our patients in a varying severity (10 to 35 degrees). Levels of stenosis were similar in 3 patients, C7-T2; and occurred at a lower spinal level, T1-T4, in the remaining patient. Posterior disk bulging and thecal sac indentation were found in all 4 patients. CONCLUSIONS: Neurological problems secondary to progressive kyphosis and stenosis at the cervicothoracic and upper thoracic spine are seen in children with Morquio syndrome. Early detection with a careful neurological assessment, whole spine MR imaging, and appropriate surgical treatment can prevent permanent neurological sequelae.

Oblique Dorsiflexion Osteotomy of the Distal Tibia for Fixed Ankle Equinus: Surgical Technique.

Aim: There are significant challenges in the treatment of a severe rigid ankle equinus caused by a flat-topped talus, arthrogryposis, burn sequelae, or extensive scarring. Conventional approaches, such as soft tissue releases, often fail due to joint incongruence or compromised soft tissues, thereby necessitating supramalleolar osteotomies. The classic transverse supramalleolar osteotomy (TSO) of the distal tibia can lead to secondary anterior translation of the centre of rotation of the ankle and alters mechanical and anatomical axes. An alternative technique involves an oblique closing wedge osteotomy of the distal tibia, with a fulcrum near the ankle joint. This technical note delineates the planning parameters and procedural steps for the oblique dorsiflexion osteotomy of the distal tibia (ODODT). Method: Using an anterior approach to the distal tibia, the "alpha angle," which determines the size of the closing wedge required for the foot to be plantigrade, is resected with a fulcrum at the most posterior part of the ankle joint, ensuring that the posterior cortex remains intact. The inclination of this resected wedge is planned preoperatively and is referred to as the "beta angle." This aims to equalise the lengths on both sides of the osteotomy. For osteotomy fixation, 2 or 3 cannulated screws in lag mode are employed. Postoperatively, a short cast boot is used for 6 weeks. Results: The ODODT is a salvage solution for severe rigid ankle equinus when first-line foot and ankle procedures are impractical due to tibiotalar incongruence or poor soft tissues. Advantages include minimal translation of the centre of rotation of the ankle, excellent stability when the posterior cortex remains intact, avoidance of large internal fixation devices, and cost-effectiveness, making it suitable for low-resource settings. How to cite this article: Olleac R, Farfan F, Acosta L, et al. Oblique Dorsiflexion Osteotomy of the Distal Tibia for Fixed Ankle Equinus: Surgical Technique. Strategies Trauma Limb Reconstr 2024;19(2):104-110.

Pigmented villonodular synovitis of the flexor hallucis longus tendon: A rare cause of leg pain in a 12-year-old girl.

Pigmented villonodular synovitis is an uncommon benign neoplastic proliferation associated with the synovium, bursa, or tendon sheaths; most commonly occurring in the third to fourth decade of life. It is rare in children and may be painful or painless. Magnetic resonance imaging is the diagnostic study of choice. In this report, the radiologic, ultrasound, and magnetic resonance imaging findings of pigmented villonodular synovitis of the flexor hallucis longus in a 12-year-old girl are discussed. We briefly review the surgical findings as well. To our knowledge, this is the first case report that simultaneously synthesizes the imaging findings of 3 diagnostic imaging modalities for optimal visualization and is the youngest reported case of pigmented villonodular synovitis of the flexor hallucis longus tendon.

Perioperative Health Interventions in Children With Chronic Neuromuscular Conditions Undergoing Major Musculoskeletal Surgery: A Scoping Review.

BACKGROUND AND OBJECTIVES: Children with chronic neuromuscular conditions (CCNMC) have many coexisting conditions and often require musculoskeletal surgery for progressive neuromuscular scoliosis or hip dysplasia. Adequate perioperative optimization may decrease adverse perioperative outcomes. The purpose of this scoping review was to allow us to assess associations of perioperative health interventions (POHI) with perioperative outcomes in CCNMC. METHODS: Eligible articles included those published from January 1, 2000 through March 1, 2022 in which the authors evaluated the impact of POHI on perioperative outcomes in CCNMC undergoing major musculoskeletal surgery. Multiple databases, including PubMed, Embase, Cumulative Index of Nursing and Allied Health Literature, Web of Science, the Cochrane Library, Google Scholar, and ClinicalTrials.gov, were searched by using controlled vocabulary terms and relevant natural language keywords. Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines were used to perform the review. A risk of bias assessment for included studies was performed by using the Risk of Bias in Non-randomized Studies of Interventions tool. RESULTS: A total of 7013 unique articles were initially identified, of which 6286 (89.6%) were excluded after abstract review. The remaining 727 articles' full texts were then reviewed for eligibility, resulting in the exclusion of 709 (97.5%) articles. Ultimately, 18 articles were retained for final analysis. The authors of these studies reported various impacts of POHI on perioperative outcomes, including postoperative complications, hospital length of stay, and hospitalization costs. Because of the heterogeneity of interventions and outcome measures, meta-analyses with pooled data were not feasible. CONCLUSIONS: The findings reveal various impacts of POHI in CCNMC undergoing major musculoskeletal surgery. Multicenter prospective studies are needed to better address the overall impact of specific interventions on perioperative outcomes in CCNMC.

Common Errors in the Management of Idiopathic Clubfeet Using the Ponseti Method: A Review of the Literature.

Congenital talipes equinovarus is one of the most prevalent birth defects, affecting approximately 0.6 to 1.5 children per 1000 live births. Currently, the Ponseti method is the gold-standard treatment for idiopathic clubfeet, with good results reported globally. This literature review focuses on common errors encountered during different stages of the management of idiopathic clubfeet, namely diagnosis, manipulation, serial casting, Achilles tenotomy, and bracing. The purpose is to update clinicians and provide broad guidelines that can be followed to avoid and manage these errors to optimize short- and long-term outcomes of treatment of idiopathic clubfeet using the Ponseti method. A literature search was performed using the following keywords: "Idiopathic Clubfoot" (All Fields) AND "Management" OR "Outcomes" (All Fields). Databases searched included PubMed, EMBASE, Cochrane Library, Google Scholar, and SCOPUS (age range: 0-12 months). A full-text review of these articles was then performed looking for "complications" or "errors" reported during the treatment process. A total of 61 articles were included in the final review: 28 from PubMed, 8 from EMBASE, 17 from Google Scholar, 2 from Cochrane Library, and 6 from SCOPUS. We then grouped the errors encountered during the treatment process under the different stages of the treatment protocol (diagnosis, manipulation and casting, tenotomy, and bracing) to facilitate discussion and highlight solutions. While the Ponseti method is currently the gold standard in clubfoot treatment, its precise and intensive nature can present clinicians, health care providers, and patients with potential problems if proper diligence and attention to detail is lacking. The purpose of this paper is to highlight common mistakes made throughout the Ponseti treatment protocol from diagnosis to bracing to optimize care for these patients.

Accuracy of Multimodality Fetal Imaging (US, MRI, and CT) for Congenital Musculoskeletal Anomalies.

BACKGROUND: Ultrasonography (US) is the first-line diagnostic tool used to assess fetal musculoskeletal (MSK) anomalies. Associated anomalies in other organ systems may benefit from evaluation via Magnetic Resonance Imaging (MRI). In this study, we compared the diagnostic accuracy of US and MRI to diagnose fetal MSK (primary objective) and non-MSK anomalies (secondary objective). We describe additional findings by low-dose computerized tomography (CT) in two cases incompletely characterized via US and MRI. MATERIALS AND METHODS: This was an IRB-approved retrospective study of consecutive patients with suspected fetal MSK anomalies examined between December 2015 and June 2020. We compared individual MSK and non-MSK anomalies identified via US, MRI, and CT with postnatal outcomes. Sensitivity and specificity for US and MRI were calculated and compared. RESULTS: A total of 31 patients with 112 MSK and 43 non-MSK anomalies were included. The sensitivity of MRI and US for MSK anomalies was not significantly different (76.6% vs. 61.3%, p = 0.3). Low-dose CT identified eight additional skeletal anomalies. MRI diagnosed a higher number of non-MSK anomalies compared to US (81.4% vs. 37.2%, p < 0.05). CONCLUSIONS: Fetal MRI and US have comparable sensitivity for MSK anomalies. In selected cases, low-dose CT may provide additional information. Fetal MRI detected a larger number of non-MSK anomalies in other organ systems compared to US. Multimodality imaging combining all the information provided by MRI, US, and CT, if necessary, ultimately achieved a sensitivity of 89.2% (95% CI: 83.4% to 95.0%) for the diagnosis of musculoskeletal anomalies and 81.4% for additional anomalies in other organs and systems.

Prenatal radiographic evaluation of congenital transverse limb deficiencies: A scoping review.

BACKGROUND: Congenital transverse deficiencies are horizontal deficiencies of the long bones that occur with a reported incidence as high 0.38%. They can occur alone or represent a manifestation of a various clinical syndromes. Diagnosis has traditionally comprised of conventional radiography and prenatal imaging studies. There has been much advancement regarding prenatal imaging modalities to allow for early diagnosis and appropriate treatment. AIM: To summarize the current state of knowledge on congenital transverse limb deficiencies and to provide an update regarding the radiographic evaluation of congenital transverse limb deficiencies. METHODS: This IRB-exempt scoping review followed the PRISMA-ScR checklist for scoping reviews strictly. Five search engines were searched for a total of 265 publications. Four authors reviewed these during the screening process. Of these, 51 studies were included in our article. Prenatal magnetic resonance imaging (MRI), 3D Ultrasound, and multidetector Computed tomography (CT) exist are emerging modalities that have the potential to improve diagnosis. RESULTS: Use of the appropriate classification system, three-dimensional ultrasonography with a maximum intensity projection, and appropriate use of prenatal MRI and prenatal CT can improve diagnosis and inter-provider communication. CONCLUSION: Further scholarly efforts are required to develop improve standardized guidelines regarding the pre-natal radiographic evaluation of congenital limb deficiencies.

The lower extremity in Morquio syndrome.

BACKGROUND: The modalities and results of surgical intervention in the lower extremity in children with Morquio syndrome type A [mucopolysaccharidosis-IV (MPS-IVA)] have not been well described. The aims of this study are to define the lower extremity deformities, and describe the results of intervention in MPS-IVA patients. METHODS: Retrospective chart and radiograph review of 23 MPS-IVA patients with a minimum follow-up of >2 years. Patients were divided into no intervention and surgical groups. Demographic data, surgical details, clinical results, and complications were recorded. Standard lower extremity radiographic measurements made on standing radiographs at initial presentation, preoperatively (in surgical group), and at the final follow-up were used to study the deformities and effects of hip, knee, and ankle surgery. Descriptive statistics were performed. RESULTS: There were 11 boys and 12 girls. The average age at presentation was 6.8±3.4 years and at the last visit was 13.5±5 years with a mean follow-up of 6.7±3.7 years. Progressive hip subluxation, genu valgum, and ankle valgus were observed in all patients without intervention. Twenty patients had a total of 159 lower extremity surgical procedures (average, 8 procedures per patient). There were 61 hip, 78 knee, and 20 ankle procedures. Surgery resulted in improvement of the center edge angle, femoral head coverage, lateral distal femoral angle, medial proximal tibial angle, tibiofemoral angle, and lateral distal tibial angle. Mechanical axis of the lower extremities improved after intervention. Six patients (12 hips) had recurrence of hip subluxation after acetabular osteotomies and/or femoral varus derotation osteotomy, and 8 patients (16 knees) had postoperative genu valgum recurrence requiring subsequent intervention. There was no recurrent hip subluxation after shelf acetabuloplasty. CONCLUSIONS: Progressive hip subluxation, genu valgum, and ankle valgus were seen and often needed surgery. After shelf acetabuloplasty and varus derotation osteotomy, there was no recurrent hip subluxation. Recurrence after genu valgum correction was common. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Progressive Ankle Subluxation Following Panfibular Osteomyelitis Requiring Fibular Resection.

A 10-month-old boy presented with fever, a swollen left leg, and septicemic shock. He was diagnosed with panfibular osteomyelitis. Failure of combined medical and surgical treatment to achieve source control necessitated fibular resection. He subsequently developed a progressive superolateral subluxation of his left ankle, valgus deformity, and brace intolerance. Tibiotalar arthrodesis resulted in a stable plantigrade ankle, excellent weight-bearing ability, and a minor leg-length discrepancy at the 14-month postoperative follow-up.

Spondyloepiphyseal dysplasia congenita: Use of complementary 3D reconstruction imaging for preoperative planning.

We present a case of spondyloepiphyseal dysplasia congenita (SEDC), a rare autosomal dominant genetic disorder that results in short stature and skeletal anomalies. Children with SEDC have disproportionate short-trunked short stature, platyspondyly, coxa vara, and epiphyseal involvement. Those with coxa vara can develop osteoarthritis of the hip early and a valgus hip osteotomy is recommended to preserve hip function and delay progression to osteoarthritis. Surgery is difficult due to the three-dimensional deformity, unossified femoral head, and small patient size. In this case, a patient-specific surgical plan and implant sizing was developed using a composite 3D reconstruction from computed tomography (CT) and magnetic resonance imaging (MRI). The complementary use of both modalities allowed for a complete visualization of the patient's dysplastic femoral head & neck anatomy.

Motion laboratory gait analysis and orthopedic resident education: preliminary results.

Gait analysis in the pediatric and adult orthopedic patient populations can adjunct the diagnosis and treatment of a multitude of musculoskeletal conditions. Understanding of normal and abnormal gait biomechanics is an important aspect of orthopedic residency; yet, there is great variability in the time residency programs dedicate to gait analysis education. The purpose of this study was to investigate if formal gait analysis education during residency improves an orthopedic resident's understanding of normal and pathologic gait. Five residency programs consisting of 81 resident subjects were surveyed at the beginning of the 2016-2017 academic year. The residents were divided into those with formal gait analysis education (group A) and those without (group B). Each resident was sent an online survey with 11 questions from former orthopedic in-training exams (OITE) regarding gait pattern analysis. The average number of correct questions was compared between the two groups with Student's t-test. Fifty-three of the 81 surveys sent out were completed. There were 23 subjects in group A and 30 in group B. All five programs and all postgraduate years (PGYs) were represented (PGY1: 10, PGY2: 12, PGY3: 12, PGY4: 6, PGY5 12). The average score for all residents was 5.6 out of 11 correct (51%). The residents from group A averaged a significantly higher score (6.3) than group B (5.0) (P = 0.017). Understanding gait biomechanics is a critical skill for orthopedic surgeons, and residency training often lacks sufficient training in their curriculum. A good understanding of gait analysis allows orthopedic surgeons to analyze gait disturbances and develop patient-specific treatment plans in adult and pediatric populations. This study found improved knowledge of gait patterns amongst orthopedic residents with formal education. Even though the residents with formal education fared better than their counterparts, the overall percent correct was still low (51%). Evidence: Level 3: Prospective Cohort Study.

Perceived Physician Empathy in Pediatric Orthopedics: A Cross-Sectional Study.

Empathy is the cornerstone of the patient-physician relationship and is consistently ranked by patients as one of the most important factors in the quality of their care. In this paper we examine the degree to which perceived physician empathy is associated with the characteristics of the caregiver (parent or legal guardian) and physician in pediatric orthopedic surgery. This was a cross-sectional survey study of 200 English-speaking caregivers of pediatric patients at a large children's hospital. The Consultation and Relational Empathy (CARE) Measure was used to measure perceived physician empathy. Only if the caregiver felt carefully listened to by the physician (p-value < 0.001), and if the physician showed respect for what the caregiver had to say (p-value = 0.007) were statistically significant and positively associated with perceived physician empathy. The most significant determinant of perceived physician empathy is whether the caregiver felt listened to during the encounter. Other factors such as caregiver demographics, health literacy, self-rated mental health, wait time, and time spent with the physician do not significantly affect perceived physician empathy.