Improving Quality in the Treatment of Pediatric Forearm Fractures: Minimizing the Need for Repeat Intervention With Long-arm Extension Casting.

PURPOSE: Repeat intervention for pediatric forearm fractures after closed manipulation is as high as 46% with flexed elbow (FE) long-arm casts. Casting with the elbow extended (EE) has been advocated as an alternative technique. We documented outcomes of patients treated with closed manipulation and casting with EE long-arm casts for displaced, diaphyseal both-bone forearm fractures. METHODS: We retrospectively reviewed charts for patients who had sedated manipulations and casting for closed, diaphyseal forearm fractures. Open fractures, immediate surgical intervention, metabolic bone disease, recurrent fractures, and Monteggia injuries were excluded. Closed manipulations were performed by orthopaedic residents assisted by cast technicians, with sedation provided by emergency department physicians. Radiographic angulation and displacement of the radius and ulna on immediate postreduction radiographs and all follow-up radiographs were recorded. Patients requiring repeat intervention were compared with those who did not by using the Mann-Whitney U and Fisher exact tests. RESULTS: Of 86 patients (7.2±2.8 y) available for analysis, 82 (95.3%) completed treatment after a single-sedated manipulation and placement of an EE long-arm cast. There were no malunions or nonunions. The average follow-up was 50 days. Four (4.7%) patients required repeat interventions (2 had surgery, 1 had a repeat sedated manipulation, and 1 had a nonsedated manipulation). There were no statistically significant differences in age, sex, laterality, fracture position in the diaphysis, or immediate postreduction angulation of the radius or ulna. A literature review showed average repeat intervention rates of 14.9% (range, 0% to 45.9%) for FE casts and 3.3% (range, 0% to 15%) for EE casts. CONCLUSIONS: There was a low rate of repeat interventions (4.7%) in patients with EE casts compared with historical rates for FE casts. Improving the quality of health care involves identifying and implementing practices that provide the best outcomes at the lowest costs. The use of EE long-arm casts following closed manipulation of pediatric forearm fractures may decrease the rate of repeat manipulation or surgery compared with conventional FE casts. LEVEL OF EVIDENCE: Level IV-case series.

Management of Clubfoot Relapses With the Ponseti Method: Results of a Survey of the POSNA Members.

BACKGROUND: Despite the high rate of initial success using the Ponseti method to manage idiopathic clubfoot deformity, relapse continues to be a problem. We surveyed the Pediatric Orthopedic Society of North America (POSNA) members about their experience with relapsed deformity following the initial correction of clubfeet. METHODS: We created a survey to focus on the management of clubfeet after initial correction of deformity. The survey included questions on postcorrective bracing, clinical findings used to identify relapse, the observed frequency of relapsed deformity, and how relapses are managed. The questionnaire was approved by the POSNA Evidence Based Committee and was sent electronically to all POSNA members. RESULTS: We received responses from 321 members (26%). Of those, 94% were fellowship trained in pediatric orthopaedics. The Ponseti method was used by 98% of respondents. The Mitchell-Ponseti orthosis was most commonly used (51%), followed by the Denis-Browne brace (25%). The duration of bracing used varied among members with 23% recommending only 2 years, 33% recommending 3 years, and 34% recommending 4 years. A tight heel cord was felt to be the first sign of relapse by 59% of respondents, and dynamic supination by 30%. The rate of relapse was observed to be <10% by 22% of the respondents, 10% to 20% by 52%, and 20% to 40% by 25%. Manipulation and cast treatment alone (55%) and cast treatment with tenotomy (23%) were reported as the 2 most common initial treatment approaches for a relapsed deformity. Cast treatment to correct relapsed deformity before tibialis anterior tendon transfer was reported by 62% of respondents. Heel cord tenotomy (75%) and posterior capsular release (43%) were the 2 most common procedures used in addition to tibialis anterior tendon transfer for the treatment of clubfoot relapse. CONCLUSION: This study highlights the wide variation with which clubfoot relapses are evaluated and treated among the POSNA membership with differences in the recommended duration of bracing, identification of relapses, and their management. These wide differences highlight the need for future research and educational programs to inform and standardize the management of clubfoot using the Ponseti Method. LEVEL OF EVIDENCE: Not applicable.

Orthopaedic Care for Children: Who Provides It? How Has It Changed Over the Past Decade? Analysis of the Database of the American Board of Orthopaedic Surgery.

BACKGROUND: The field of orthopaedic surgery has subspecialized over the past decade with an increasing number of graduates of orthopaedic residency programs entering fellowship training. The number of graduates from pediatric orthopaedic fellowships has also increased over the past decade. We hypothesize as the number of pediatric orthopaedic fellowship graduates has increased, the proportion of orthopaedic cases completed by pediatric surgeons in comparison with adult surgeons has also increased. We have used the database of the American Board of Orthopaedic Surgery (ABOS) to analyze the trends in who is providing the orthopaedic care for children. METHODS: Procedure logs of applicants for ABOS part II certification from 2004 to 2014 were collected and pediatric cases were used for this study. Applicants were divided into pediatric orthopaedic surgeons and adult orthopaedic surgeons based on the self-declared subspecialty for part II examination. CPT codes were used to place the cases into different categories. Descriptive and statistical analysis were performed to evaluate the change in the practice of pediatric orthopaedics over the past decade. RESULTS: ABOS part II applicants performed 102,424 pediatric cases during this period. In total, 66,745 (65%) cases were performed by nonpediatric surgeons and 35,679 cases (35%) by pediatric surgeons. In total, 82% of the pediatric cases were done by adult surgeons in 2004 which decreased to 69% in 2009 and to 53% in 2014 (r=0.8232, P=0.0019). In pediatric sports medicine, pediatric orthopaedic surgeons performed 7% of the cases in 2004 which increased to 14% in 2009 and to 28% in 2014 (300% increase from 2004). Pediatric surgeons also increased their share of pediatric trauma cases. In total, 12% of lower extremity trauma cases were attended by pediatric surgeons in 2004 compared with 47% in 2014 (235% increase from 2004). In upper extremity trauma, pediatric surgeons increased their share of the cases from 12% in 2004 to 43% in 2014 (175% increase from 2004). CONCLUSIONS: Over the past decade, pediatric orthopaedic specialists are caring for an increasing share of pediatric cases. Pediatric trauma, pediatric spine, and pediatric sports medicine have seen the greatest increase in the percentage of cases performed by pediatric orthopaedic surgeons. LEVEL OF EVIDENCE: Level III.

Isokinetic concentric quadriceps and hamstring normative data for elite collegiate American football players participating in the NFL Scouting Combine.

Isokinetic concentric quadriceps and hamstring strength data using a Cybex dynamometer are collected for elite collegiate American football players invited to the annual National Football League Scouting Combine. We constructed a normative (reference) database of the Cybex strength data for the purpose of allowing comparison of an individual's values to his peers. Data reduction was performed to construct frequency distributions of hamstring/quadriceps (H/Q) ratios and side-to-side strength differences. For the cohort (n = 1,252 players), a statistically significant but very small (1.9%) mean quadriceps strength preference existed for dominant side vs. nondominant side. Peak torque (Newton meters, best repetition) for quadriceps and hamstrings was significantly correlated to player body mass (weight) (the same relationship was found for other variables using peak torque in the calculation). Peak torque varied by player position, being greatest for offensive linemen and lowest for kickers (p < 0.0001). Adjusting for body weight overcorrected these differences. The H/Q ratios and frequency distributions were similar across positions, with a mean of 0.6837 ± 0.137 for the cohort dominant side vs. 0.6940 ± 0.145 for the nondominant side (p = 0.021, n = 1,252). Considerable variation was seen for dominant-to-nondominant side difference for peak torque. For quadriceps, 47.2% of players had differences between -10% and +10%, 21.0% had a peak torque dominant-side deficit of 10% or greater compared to nondominant side, and for 31.8% of players, dominant-side peak torque was greater than 10% compared to nondominant side. For hamstrings, 57.0% of players had differences between -10% and +10%, 19.6% had a peak torque dominant-side deficit of 10% or greater compared to nondominant side, and 23.4% of players, dominant-side peak torque was greater than 10% compared to nondominant side. We observed that isokinetic absolute strength variables are dependent on body weight and vary across player position. The H/Q ratios vary only within a relatively narrow range. Side-to-side differences in strength variables >10% are common, not the exception.

Epiphyseal-entry cannulated screws for temporary guided growth of the knees: a retrospective review of 89 cases.

Guided growth affects the physis in children to produce a desired effect. Several devices achieve alteration of growth, including staples, plates, and screws. Complications can include device failures, failure to modulate growth as expected, and unintended physeal arrest. We present the results of a unique technique designed to minimize these complications. This was a retrospective review of guided growth at the knee at a single institution utilizing cannulated screws with epiphyseal-entry points. Each case was reviewed to determine the presence of complications related to guided growth, including implant breakage, implant pull-out or pull-through, iatrogenic physeal arrest, failure to modulate growth, and the incidence of revision surgeries. There were 89 patients who had 146 epiphyseal-entry guided growth procedures with a total of 221 4.5 mm cannulated screws. There were no iatrogenic physeal arrests. Five (2.26%) screws in 4 (4.49%) patients had either a broken screw or screw pull-out/pull-through requiring revision procedures. Three patients had osteotomies after skeletal maturity. Four had revision-guided growth for other reasons: 2 due to a lack of timely follow-up, 1 for iatrogenic genu varum without implant failure, and 1 due to recurrent deformity after implant removal. Revision procedures were unanticipated in 6 (6.74%) patients. This study describes a technique for placing cannulated screws at the knee with epiphyseal starting points. Our rate of complications and number of revision surgeries compare favorably with those noted for other techniques. Guided growth using epiphyseal-entry cannulated screws is a safe, effective option for most patients.

Conservative Management of Transitional Ankle Fractures in Adolescents: A Pilot Study to Determine Whether Type of Immobilization Affects Outcome.

Intra-articular Tillaux and triplane ankle fractures are treated surgically when displaced. Minimally displaced fractures are treated with immobilization alone. Long leg casts (LLCs) are the most traditional method of immobilization because they can prevent weight bearing by flexing the knee and control ankle rotation. However, they also are heavy, decrease mobility, increase the area for contact dermatitis, and increase knee stiffness. Short leg casts (SLCs) may be adequate for these injuries. This study compared outcomes of adolescents with transitional ankle fractures treated in LLCs vs SLCs. All transitional ankle fractures treated with immobilization during 11 years at a multicenter children's health system were reviewed. Patients were grouped based on initial treatment with LLC vs SLC. Cases were analyzed for differences in demographics, length of treatment, weight-bearing status, outcomes, and complications. A total of 159 patients met inclusion criteria. Sixty-five were treated initially with LLCs and 94 were treated initially with SLCs, with no significant age difference between the groups. Computed tomography scans had been obtained for 55.4% of the patients with LLCs vs 29.8% of the patients with SLCs. Mean time in the initial cast was 24 days for both groups. Mean total time in any cast was 40 days for the LLC group vs 29 days for the SLC group. Mean time to weight bearing was 7 days shorter and return to full activity was 12 days shorter in the SLC group. There were no cases of fracture displacement, malunion, nonunion, or functional limitations. [Orthopedics. 2023;46(4):230-233.].

Which to use to evaluate change in BMD at follow-up: RMS-SD or RMS-%CV?

There is bias toward the use of root-mean-square standard deviation (RMS-SD) over root-mean-square coefficient of variation (RMS-%CV) to calculate a least significant change (LSC) value that is used to determine if change in bone mineral density (BMD) at follow-up is statistically significant. In part, this bias is based on the assumption that SD is relatively constant over a wide range of BMD as opposed to %CV, which is assumed to increase as BMD decreases. However, evidence to support these assumptions is scant. The purpose of this project was to determine the frequency of discrepancies in interpretation of follow-up data using an LSC based on RMS-SD (LSC-SD) vs RMS-%CV (LSC-%CV). A convenience sample of 100 patients returning for follow-up dual-energy X-ray absorptiometry scans was used to compare the frequency of change in BMD exceeding LSC-SD vs LSC-%CV. Results showed that agreement in exceeding (or not) both LSC-SD and LSC-%CV was 94% for L1-L4 (lumbar spine), femoral neck, and total hip. Disagreements were characterized by BMD changes that usually marginally exceeded either LSC-SD or LSC-%CV but not the other, and they occurred at both high and low absolute BMD. We conclude that significant change in BMD typically exceeds both LSC-SD and LSC-%CV. Thus, there seems to be no basis for the bias in favor of using LSC-SD as long as RMS-SD and RMS-%CV are calculated in the same manner. Furthermore, a criterion that both LSC-SD and LSC-%CV must be exceeded may help avoid overcalling marginal change as being significant, especially at high and low BMD.

Long-term versus short-term precision of dual-energy X-ray absorptiometry scans and the impact on interpreting change in bone mineral density at follow-up.

We hypothesized that increased time between repeat scans would be a critical factor resulting in long-term precision (LTP) being greater than short-term precision (STP) because time erases the short-term mind's eye memory of positioning that makes STP easy to perform. In 2 prospective studies, STP, in which repeat scans were performed within minutes, was compared with LTP in the same patients in whom repeat scans were separated by 3-10 d (n=35) or 2-12 mo (n=30). The first baseline scan and the follow-up scan were used to calculate LTP. Rigorous exclusion criteria were applied to patients returning 2-12 mo after baseline to avoid the effects of biological change that could affect bone mineral density (e.g., bisphosphonate treatment). Results showed that LTP was significantly greater than STP irrespective of whether the interval between baseline was short (3-10d) or averaged 188 d. For example, LTP for left femoral neck (LFN) was 0.017 g/cm(2) with 3-10d separating follow-up from baseline, with STP being 0.007 g/cm(2) (duplicate scans at baseline, Day 1). For the second prospective cohort, LTP for LFN when the mean follow-up interval was 188 d was 0.024 g/cm(2); STP in the same patients was 0.009 g/cm(2) (p<0.05 by F test). A sampling of patients returning for follow-up to an osteoporosis clinic was used to evaluate the impact of using LTP vs STP to interpret change. The use of a least significant change value based on LTP (rather than STP) resulted in significantly fewer patients having "significant" change at follow-up and eliminated discrepancies in which BMD apparently increased at 1 skeletal site but decreased at another. We conclude that (1) time is the primary variable accounting for the difference between STP and LTP, and (2) STP underestimates true dual-energy X-ray absorptiometry variability, resulting in overdiagnosis of change at follow-up.

Anterior vertebral body tethering shows mixed results at 2-year follow-up.

STUDY DESIGN: Retrospective chart review. OBJECTIVE: To report 2-4-year outcomes of anterior vertebral body tethering (AVBT) for adolescent idiopathic scoliosis (AIS). AVBT is a relatively new procedure to correct AIS spine curvature and few outcomes studies have been published. METHODS: Patients from 2015 to 2017 with 2-year follow-up were included. Successful outcomes were defined as curves 35° or less without revision surgery. We also compared outcomes between thoracic and lumbar ABVT. RESULTS: There were 19 AVBTs in 17 patients, 13 thoracic and 6 lumbar. Nine curves (47%) in nine patients (53%) were successful. Preoperative kyphosis averaged 26° in the successful group and 14° in the unsuccessful group (P = 0.0337). Immediate correction for lumbar ABVTs (76%) was greater than thoracic ABVTs (43%) (P = 0.0140). Correction per level per month was greater in lumbar ABVTs (2.9° vs. 0.1°) (0.0440). Preoperative Sanders Maturity Scale (SMS) was 3.7 for successful cases and 2.5 for unsuccessful cases (P = 0.0232). Final SMS was 7.7 for successful cases and 5.7 for unsuccessful cases (P = 0.0518). All successful cases and 50% of unsuccessful cases were mature at final follow-up (P = 0.0294). There were four (24%) revision procedures, and three involving lumbar AVBTs. There were nine (47%) broken tethers. CONCLUSIONS: Despite several final curves > 35°, four revisions, and nine broken tethers, the majority of patients (53%) were considered successful. Lumbar ABVTs correct more intraoperatively and faster postoperatively. Patients who are tethered during or slightly after the curve acceleration phase of growth may have more successful outcomes than patients tethered prior to the curve acceleration phase. AVBT requires further study with longer outcomes to define best practices for indications, level selections, and surgical techniques. LEVEL OF EVIDENCE: IV.

Treatment Decisions in Pediatric Sports Medicine: Do Personal and Professional Bias Affect Decision-Making?

BACKGROUND: Personal and professional biases can affect decision-making regarding important issues in pediatric sports medicine. Gaining insight into the opinions of health care professionals who specialize in pediatric sports medicine will provide information that may be useful for directing ongoing research in this field. HYPOTHESIS: It was hypothesized that surgeons would demonstrate bias toward early surgical intervention versus nonsurgeons. In addition, it was hypothesized that youth sports medicine professionals who were parents of a child with a previous major sports injury or concussion would be less likely to allow their child to play American tackle football or return to football after a concussion. STUDY DESIGN: Cross-sectional study. METHODS: An online survey was provided to the active members of the Pediatric Research in Sports Medicine Society. We used both professional background information and responses to questions related to personal experiences with youth sports injuries to determine potential factors associated with underlying biases. Survey responses among subgroups were compared using the Fisher exact test. The Pearson correlation coefficient was used to evaluate years in practice versus opioid use. RESULTS: Of the survey participants, 62.5% were pediatric surgeons, and 37.5% represented different nonsurgical youth sports medicine professions. Surgeons were less likely than nonsurgeons to agree to allow their child to return to football after sustaining a concussion and completing a concussion protocol (48% vs 76%, P = .013). Surgeons were more likely than nonsurgeons to agree to both elective shoulder stabilization after a first-time dislocation and elective drilling of a stable knee osteochondritis dissecans (OCD) before nonoperative treatment (41% vs 10%, P = .003 and 52% vs 23%, P = .013, respectively). Those who reported having a child with a concussion history were more likely to support him or her returning to football after a concussion (65% vs 33%, P = .026). CONCLUSION: Surgeons were more likely to favor elective shoulder-stabilization surgery after a first-time dislocation and drilling of a stable knee OCD instead of nonoperative management. Personal experience of having a child who sustained a major sports injury or concussion did not demonstrate a bias against participation in football or return to football after a concussion.

Value in Scoliosis Surgery: Coordinated Surgical and Anesthetic Techniques Avoid Blood Transfusion without Fibrinolytic Medications or Red Blood Cell Salvage.

STUDY DESIGN: Retrospective chart review. OBJECTIVE: The aim of this study was to document the impact of coordinated surgical and anesthetic techniques on estimated blood loss (EBL) and subsequent need for transfusion. SUMMARY OF BACKGROUND DATA: Scoliosis surgery is typically associated with large quantities of blood loss, and consequently blood transfusion may be necessary. Many strategies have been employed to minimize blood loss, including blood collection with reinfusion ("cell-saver") and the use of antifibrinolytic drugs. We reviewed our experience with methods to minimize blood loss to show that transfusion should be a rare event. METHODS: One hundred and thirty consecutive cases of spine fusion for adolescent idiopathic scoliosis utilizing pedicle screw fixation were reviewed from March 2013 to October 2019. The senior author was the primary surgeon for all cases. Data were collected from the electronic medical record, including age, sex, weight, number of instrumented levels, EBL, total fluids administered during surgery, pre- and postoperative hemoglobin, and procedure duration. RESULTS: The average EBL was 232 ±â€Š152 mL (range 37-740 mL). The average preoperative hemoglobin was 13.4 ±â€Š1.2 g/dL and the average postoperative hemoglobin (last measured before discharge) was 9.0 ±â€Š1.2 g/dL. One patient received a transfusion of 270 mL homologous blood. Blood salvage and reinfusion ("cell-saver") was not used. No patient was managed with antifibrinolytic drugs. CONCLUSION: Minimizing blood loss using a combination of surgical and anesthesia techniques can effectively eliminate the need for blood transfusion. The elimination of costly adjuncts increases the value of a complex orthopedic procedure.Level of Evidence: 5.

Vitamin D Status in Children With Forearm Fractures: Incidence and Risk Factors.

INTRODUCTION: The association between vitamin D status and fracture characteristics in children remains ambiguous. We hypothesized that vitamin D deficient or insufficient children would have an increased risk of forearm fractures severe enough to require surgical management. METHODS: One hundred children with low-energy forearm fractures were prospectively enrolled from a single hospital. Each participant answered a questionnaire focusing on the risk factors for vitamin D deficiency. Fractures were categorized as requiring nonsurgical or surgical management. Vitamin D status was based on the measurement of 25-hydroxyvitamin D (25(OH)D) concentration obtained during the clinic visit and compared between the two fracture groups. RESULTS: The cohort exhibited a mean age of 9.8 ± 3.2 years (range: 3-15 years), comprising 65 (65%) men and 35 (35%) women. Overall, mean 25(OH)D was 27.5 ± 8.3 ng/mL. Using the Endocrine Society guidelines, 21% of patients were categorized as "vitamin D deficient" (25(OH)D ≤ 20 ng/mL) and 49% as "vitamin D insufficient" (25(OH)D: 21 to 29 ng/mL). Stratification by intervention revealed a mean 25(OH)D of 23.3 ± 8.8 ng/mL in the surgical group (n = 12) and 28.1 ± 8.1 in the nonsurgical group (n = 88) (P = 0.057). Fifty percent of the surgical group were "vitamin D deficient" compared with 17% of the nonsurgical group (P = 0.017). The relative risk of requiring surgical treatment in children with forearm fracture and vitamin D deficiency (25(OH)D < 20 ng/mL) was 3.8. 25(OH)D level, negatively correlated with body mass index (r = -0.21, P = 0.044); 9 surgical patients were overweight or obese (as defined by the criteria of the Centers for Disease Control and Prevention). 25(OH)D level was significantly lower in non-Caucasians compared with Caucasians (26.0 ± 7.2 versus 32.5 ± 9.9 ng/mL; P = 0.0008). DISCUSSION: Vitamin D deficiency is common in children with forearm fractures and may be a contributing risk factor for forearm fractures requiring surgical management in children. CONCLUSION: Vitamin D deficiency and inefficiency are common in children with low energy forearm fractures, especially in obese children and in fractures requiring surgical treatment.

Blood pressure measurements during intraoperative pediatric scoliosis surgery.

BACKGROUND: Intraoperative hypotension is frequently encountered during surgery and it can be associated with adverse outcomes. Blood pressure monitoring is critical during surgery, but there are no universally agreed upon standards for interpreting values of hypotension and no consensus regarding interventions. MATERIAL AND METHODS: We performed a retrospective chart review of pediatric patients who underwent idiopathic scoliosis surgery by a single surgeon. We used the arterial line for all measures. Intraoperative hypotension was defined as 20% decrease of the baseline systolic blood pressure (SBP), 30% decrease of baseline SBP, or mean arterial pressure less than 60 mmHg. Use of vasopressor agents was also recorded and correlated with blood pressure definitions. RESULTS: Seventy idiopathic scoliosis patients were retrospectively evaluated. There was a significant correlation between the three measures of hypotension. Sixty percent of the patients received vasopressors. There was a significant correlation between a drop of mean arterial pressure to less than 60 mmHg and the use of the ephedrine. We did not find any changes on neuromonitoring measures during the case and there were no intraoperative or one-month postoperative complications. CONCLUSIONS: Blood pressure is only one of the measures anesthesiologists look to for good perfusion during surgery. Pediatric anesthesiologists and orthopedics agree in trying tight blood pressure control during surgery to decrease blood loss, but what the exact definition of that blood pressure number is, is still unclear. We propose that using mean arterial pressure less than 60 mmHg is perhaps a better definition. We provide recommendations for future studies.

Clavicles continue to grow beyond skeletal maturity: radiographic analysis of clavicle length in adolescents and young adults.

There has been minimal research regarding the clavicle's growth and its clinical implications in the late adolescent and early adult population. Previous studies have evaluated postnatal clavicle growth to age 18 without analysing growth through the age of secondary ossification center closure. The purpose of this study was (1) to determine clavicle length and age-related growth in males and females from age 12 to 25 years and (2) to specifically analyse clavicle growth in late adolescence. This was a retrospective analysis of chest radiographs in patients aged 12-25 years. The ruler tool was used to measure clavicle length. Mean values were tabulated for each year of age in males (n = 697) and females (n = 672). Mean right clavicle growth significantly increased from age 12 to 25 in both males and females (P < 0.0001). In males, the increase from age 16 to 25 was 17.5 mm, representing 10.6% of total clavicle length (P < 0.0001). In females, the increase from age 14 to 25 was 7.7 mm, representing 5.2% of total clavicle length (P < 0.0001). We found that from skeletal maturity to the closure of the secondary ossification center, growth was 17.5 mm (10.6% of total clavicle length) in males and 7.7 mm (5.2% of total clavicle length) in females. During their growth spurts, the adolescent male and female clavicle have growth potentials very similar to previous studies of radius growth. Understanding these clavicular growth potentials can influence operative vs. nonoperative management decisions by orthopaedic surgeons. Level of evidence: Level III.

Age influences anthropometric and fitness-related predictors of bone mineral in men.

OBJECTIVE: This study assessed the influence of age on the predictors of bone mineral in men. METHODS: Middle-age (n = 41, 54 +/- 4 yrs) and older (n = 40, 69 +/- 5 yrs) men underwent grip and knee extensor strength tests, total body dual-energy X-ray absorptiometry with regional analyses and a graded exercise treadmill test. RESULTS: Bone-free lean mass (BFLM) and, to a lesser extent, fat mass (FM) were correlated with bone mineral variables in middle-age men. In older men, BFLM and, to a lesser extent, FM were related to bone mineral content (BMC) at most sites, but inconsistently to bone mineral density (BMD). Knee extensor strength related to bone mineral (BMC and BMD) at most sites in middle-age men, but none in older men. Grip strength inconsistently related to bone mineral in both groups. Aerobic capacity related to bone mineral in middle-age men, but none in older men. In multiple regression, body weight or BFLM predicted bone mineral in middle-age men (R2 = 0.33-0.68) and BMC in older men (R2 = 0.33-0.50). Predictors of BMD were inconsistent in older men. CONCLUSIONS: Relationships of body composition, muscular strength and aerobic capacity to bone mineral are stronger in middle-age versus older men.

Variance in 10-year fracture risk calculated with and without T-scores in select subgroups of normal and osteoporotic patients.

The World Health Organization fracture risk assessment tool (FRAX) uses clinical risk factors to predict the patient's 10-yr probability of sustaining a hip or other major osteoporosis-related fracture. Inclusion of the femoral neck T-score is optional in the calculation. We evaluated the impact of including the T-score in the calculation of fracture risk and resultant treatment recommendation. We retrospectively reviewed charts of 180 white women scanned on a Hologic dual-energy X-ray absorptiometry (DXA). FRAX scores were calculated with T-scores (FRAX+) and without T-scores (FRAX-). We compared the National Osteoporosis Foundation (NOF) treatment recommendations (>or=20% risk of a major osteoporotic fracture or >or=3% risk of hip fracture for osteopenic patients) between FRAX+ and FRAX- scores. Agreement between FRAX+ and FRAX- was 89.4%. Disagreement occurred in 2 distinct subgroups of patients (10.6% of cases), that is, FRAX+ scores exceeded the NOF recommended treatment thresholds and FRAX- scores did not, or vice versa. One subgroup comprised older patients with normal T-scores for whom FRAX- scores exceeded the treatment threshold. The second subgroup comprised younger patients with high body mass index (BMI) and low T-scores for whom FRAX- scores did not exceed the treatment threshold. FRAX scores generated without T-scores may lead to treatment recommendations for patients who have normal bone mineral density and no treatment recommendations for patients who have osteoporosis. T-scores should be used for optimal application of FRAX.

Impact of Race Subgroups on the Assessment of Vitamin D Status in Adolescent Idiopathic Scoliosis.

The authors' main objective was to demonstrate the confounding effect of combining subgroup data, specifically race, on the prevalence of vitamin D deficiency in adolescent idiopathic scoliosis (AIS). This was a retrospective chart review. Vitamin D deficiency was defined as 25-hydroxyvitamin D (25[OH]D) less than 20 ng/mL. Data were compared between white patients and black and Hispanic patients. Vitamin D status in girls with AIS was also compared with that in girls without AIS who had a history of fracture and with the medical literature to determine if deficiency in AIS was equal to or greater than other cohorts. Mean age was 13.9±2.3 years for the white girls with AIS (n=221) and 13.6±2.2 years for pooled non-whites (n=134). Significant racial differences were found that biased interpretation of the total pooled cohort. Mean 25(OH)D was 27.9±8.5 ng/mL for white girls with AIS vs 21.9±10.3 ng/mL for non-whites (P<.0001). Deficiency was present in 13.1% of white girls vs 47.8% of non-white girls (P<.0001). Compared with girls with fractures and with the published literature, the race-matched deficiency rates were not abnormally high in girls with AIS. Prevalence of deficiency was greater in non-whites with AIS than in whites. However, percent deficiency was not greater in girls with AIS than in race-matched cohorts without AIS. Without separating data by race, interpretation of vitamin D status can be confounded. [Orthopedics. 2019; 42(3):158-162.].

Pitfalls with Vitamin D Research in Musculoskeletal Disorders and Recommendations on How to Avoid Them

Reports suggesting that vitamin D may have extraskeletal roles have renewed interest in vitamin D research and stimulated publication of an increasing number of new studies each year. These studies typically assess vitamin D status by measuring the blood concentration of 25-hydroxyvitamin D [25(OH)D], the principal circulating metabolite of vitamin D. Unfortunately, variations in assay format, inconsistency in interpreting 25(OH)D concentrations, cohort bias (age, body mass index, race, season of measurements etc.) and failure to measure critical variables needed to interpret study results, makes interpreting results and comparing studies difficult. Further, variation in reporting results (reporting mean values vs. percent of the cohort that is deficient, no clear statement as to clinical relevance of effect size, etc.) further limits interstudy analyses. In this paper, we discuss many common pitfalls in vitamin D research. We also provide recommendations on avoiding these pitfalls and suggest guidelines to enhance consistency in reporting results.

The Potential Value of Dual-Energy X-Ray Absorptiometry in Orthopedics.

Dual-energy X-ray absorptiometry (DXA) is a well-established technology with an important and well-known role in measuring bone mineral density (BMD) for the purpose of determining fracture risk, diagnosing osteoporosis, and monitoring treatment efficacy. However, aside from the assessment of bone status, DXA is likely underutilized in the field of orthopedics, and most orthopedists may not be aware of the full capabilities of DXA, particularly with regard to total body scans and body composition assessment. For example, DXA would be a valuable tool for monitoring body composition after surgery where compensatory changes in the affected limb may lead to right-left asymmetry (eg, tracking lean mass change after knee surgery), rehabilitation regimens for athletes, congenital and metabolic disorders that affect the musculoskeletal system, or monitoring sarcopenia and frailty in the elderly. Furthermore, preoperative and postoperative regional scans can track BMD changes during healing or alert surgeons to impending problems such as loss of periprosthetic bone, which could lead to implant failure. This article discusses the capabilities of DXA and how this technology could be better used to the advantage of the attending orthopedist.

Maturity Indicators and Adolescent Idiopathic Scoliosis: Evaluation of the Sanders Maturity Scale.

STUDY DESIGN: Retrospective review. OBJECTIVE: To determine the correlation between the Sanders Maturity Scale (SMS) and Risser stages, between both systems and menarche, and whether Risser can be used to predict SMS. SUMMARY OF BACKGROUND DATA: Predicting curve progression is critical to understanding adolescent idiopathic scoliosis and making treatment recommendations. The SMS is a better predictor of the curve acceleration phase of growth than the Risser stage. However, Scoliosis Research Society bracing criteria utilize the Risser stage and menarche. METHODS: Consecutive female patients, 8 to 16 years old, evaluated for idiopathic scoliosis or spinal asymmetry over a 31-month period were included. Main curve size, Risser stage, menarchal status, and SMS stage were recorded for each encounter, and analyzed using Spearman rank correlation and regression models. RESULTS: Six hundred fifty-six encounters (452 patients) were included with SMS staging, including 402 encounters that included menarchal data. The correlation between the Risser stage and the SMS stage was 0.9031 (P < 0.0001). However, ranges for the SMS at each Risser stage were large. Correlation between Risser stage and menarche was 0.7327 (P < 0.0001), and between SMS and menarche was 0.8355 (P < 0.0001). Eighty-five percent of SMS 3 patients were Risser 0, with or without open triradiate cartilages. Eighty-one percent of Risser 1 patients were SMS 4 or greater. CONCLUSION: When assessing maturity in idiopathic scoliosis, SMS correlates strongly with Risser stages, and both SMS and Risser correlate with menarche. However, Risser stage is a poor predictor of the exact SMS stage for individual patients due to the large ranges. The majority of patients who are ≥Risser 1 have passed the curve acceleration phase of growth. Developing brace criteria based upon the SMS stage may allow more accurate predictions regarding which patients will benefit from bracing. LEVEL OF EVIDENCE: 2.