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.

The Association Between the Classification of Early-onset Scoliosis and Smith Complications After Initiation of Growth-friendly Spine Surgery: A Preliminary Study.

BACKGROUND: Early-onset scoliosis (EOS) is a complex, heterogeneous condition involving multiple etiologies, genetic associations, and treatment plans. In 2014, Williams and colleagues proposed a classification system of EOS (C-EOS) that categorizes patients by etiology, Cobb angle, and kyphosis. Shortly after, Smith and colleagues validated a classification system to report complications of growth-friendly spine instrumentation. Severity refers to the level of care and urgency required to treat the complication, and can be classified as device-related or disease-related complications. The purpose of this study was to investigate if C-EOS can be used as a reliable predictor of Smith complications to better risk stratify these young, surgical patients. METHODS: This study queried retrospective data from a large multicenter registry with regard to growth-friendly spine instrumentation in the EOS population. One-hundred sixteen patients were included in final data analysis to investigate the outcomes of their growth-friendly procedures according to the Smith complication classification system. RESULTS: There were 245 Smith complications distributed among 116 patients included in this study (2.1 complications per patient). The majority of the complications were device related requiring at least one unplanned trip to the operating room (Smith Device Complication IIA or IIB; 111 complications). There were no complications that caused abandonment of growth-friendly instrumentation (Smith Complication III) and no mortalities (Smith Complication IV). The most severely affected EOS group was the hyperkyphotic syndromic group with a major curve angle >50 degrees (S3+), with 3.4 complications per patient. The least affect EOS group was the hyperkyphotic congenital group with a major curve angle between 20 and 50 degrees, with 0.3 complications per patient. CONCLUSIONS: The C-EOS simplifies a complex pathology and the Smith complication classification scheme creates a language to discuss treatment of known complications of growth-friendly spine surgery. Although there is an association between more advanced C-EOS and Smith complications, there does not appear to be a correlation that can satisfy a risk stratification at this time. LEVEL OF EVIDENCE: Level II.

Ankle Fractures: The Current State of Online Patient Information.

Background. We assessed the quality, accuracy, and readability of websites for ankle fractures. Methods. Ankle Fracture, Broken Ankle, and Fibular Fracture were entered into 3 search engines. The first 25 results from each search were collected. Quality, accuracy, and readability were assessed by a custom rubric, 3 surgeons, and Fleisch-Kincaid grade level (FKGL), respectively. Results. A total of 57 websites were included: 24 were assigned to Ankle Fracture, 26 to Broken Ankle, and 7 to Fibular Fracture. The average quality score out of 36, accuracy score out of 12, and FKGL for all websites were 13.1 ± 6.8, 10.8 ± 1.2, and 9.6 ± 1.7, respectively. Websites assigned to the term Broken Ankle had a significantly lower New Dale-Chall score. Websites of lower FKGL and appearing earlier in results had significantly higher quality scores. Physician specialty societies (PSSs) had a significantly lower FKGL than websites of other types. Conclusion. The readability of patient materials is above the recommended level for ankle fractures. Encouragingly, a trade-off between readability and quality was not found. Patients should use search terms they are familiar with and prioritize websites that appear earlier in search results, are easier to read, and produced by PSSs.Level of Evidence: Level 3.

Kienböck Disease: Quality, Accuracy, and Readability of Online Information.

Background: Patients with limited health literacy require online educational materials to be written below a sixth grade level for optimal understanding. We assessed the quality, accuracy, and readability of online materials for Kienböck disease (KD). Methods: "Kienbock's Disease" and "Lunate Avacular Necrosis" were entered into 3 search engines. The first 25 Web sites from each search were collected. Quality was assessed via a custom grading rubric, accuracy by 2 residents and a fellow, and readability by Flesch-Kincaid grade level (FKGL) and New Dale-Chall test. Web sites were stratified according to the search term, FKGL, order of appearance, and authorship type. Results: A total of 38 unique Web sites were included, of which 22 were assigned to "KD" and 16 to "Lunate Avascular Necrosis." The average quality score out of 30, accuracy score out of 12, and FKGL for all Web sites were 13.3 ± 7.3, 10.4 ± 1.9, and 10.5 ± 1.4, respectively. Web sites assigned to the term "Kienbock's Disease" had a significantly higher FKGL. Web sites of higher FKGL had significantly worse accuracy scores. Order of appearance had no influence. Physician specialty societies (PSS) had a significantly lower FKGL than Web sites of other authorship types. Conclusions: Despite concerted efforts by national organizations, the readability of online patient materials is above the recommended level for KD. Patients with limited health literacy will be most affected by this reality. Until readability improves, patients should continue to consult their physicians when uncertain and prioritize Web sites that are easier to read and produced by PSS.

Treatment of Proximal Pole Scaphoid Fracture Nonunions With Intramedullary Cancellous Autograft and Cannulated Headless Compression Screw.

Management of proximal pole scaphoid nonunion remains a challenging problem. Multiple surgical techniques have been described, although no treatment has proven superior. Recent studies have questioned the need for vascularized bone grafting, even in in the setting of avascular proximal poles. We present a relatively simple technique of intramedullary autogeneous cancellous bone grafting that does not disturb the intact cortical shell of the nonunion, which has so far provided gratifying clinical results.

Treatment of Idiopathic Scoliosis With Vertebral Body Stapling.

STUDY DESIGN: Retrospective cohort. OBJECTIVES: Identify the effectiveness of vertebral body stapling (VBS) in children with idiopathic scoliosis. SUMMARY OF BACKGROUND DATA: VBS has been proposed as an alternative to bracing moderate curves in patients with adolescent idiopathic scoliosis (AIS) although a clear picture of comparative efficacy and safety remains to be established. METHODS: Ten skeletally immature patients with AIS and curves between 25° and 35° underwent anterior VBS by a single surgeon from 2008 to 2018. Indications included strong family history, high ScoliScore, curve progression despite bracing, or as an alternative for patients/families refusing bracing. Patients with thoracic kyphosis greater than 40°, curvature with a level above T4 or below L4, and double major curves were contraindicated. Patients with hybrid surgical plans or those who failed to reach skeletal maturity were excluded. Age, gender, levels stapled, pre- and postoperative radiographs, and incidence of secondary surgical intervention were evaluated. Outcomes were also compared with untreated and braced subjects from the BrAIST study. RESULTS: Ten patients met the inclusion criteria. Average age at VBS was 11.8 (9.7-13.5) with an average major Cobb angle of 30.9° (26°-35°). Average duration of follow-up was 6.4 years. All patients demonstrated curve correction at their first postoperative visit. At final follow-up, 50% of patients experienced curve progression greater than 5°, whereas the remaining 50% either remained stable or corrected over time. The five patients whose curves progressed underwent VBS at a significantly younger age (10.8 vs. 12.8; p value .003). Four of these patients required additional surgical intervention for worsening scoliosis. CONCLUSIONS: Although early outcomes after VBS appear to parallel the results of bracing, stapling does not affect the percentage of patients ultimately requiring PSIF. Initial curve correction degraded over time in younger patients with significant growth remaining, and high rates of progression in this group, even with bracing, merits investigation into more efficacious treatment strategies. LEVEL OF EVIDENCE: Level III.

Patellar Instability in the Skeletally Immature.

PURPOSE OF REVIEW: This review will focus on the evaluation and management of patellar instability in the developing patient. RECENT FINDINGS: A large number of surgical techniques have been described to prevent recurrent patellofemoral instability in the pediatric population, including both proximal and distal realignment procedures. The wide variety of treatment options highlights the lack of agreement as to the best surgical approach. However, when a comprehensive exam and workup are paired with a surgical plan to address each of the identified abnormalities, outcomes are predictably good. Patellar instability is a common knee disorder in the skeletally immature patient that presents a unique set of challenges. Rates of re-dislocation in pediatric and adolescent patients are higher than in their adult counterparts. Careful consideration of the physeal and apophyseal anatomy is essential in these patients. While the majority of primary patellar instability events can be treated conservatively, multiple events often require surgical intervention.

Brachioradialis Tendon Coverage in Volar Distal Radius Plating.

Volar plate fixation of unstable distal radius fractures has become the preferred technique by most surgeons for the operative treatment of displaced distal radius fractures. Flexor tendon rupture is a rare but serious complication associated with this operation that is thought to be due to irritation of the flexor tendons over the prominent distal edge of the plate. We describe a novel technique of using the brachioradialis tendon to cover the distal edge of the plate to help prevent tendon irritation and rupture.

Interobserver and intraobserver reliability of the modified Waldenström classification system for staging of Legg-Calvé-Perthes disease.

BACKGROUND: The absence of a reliable classification system for Legg-Calvé-Perthes disease has contributed to difficulty in establishing consistent management strategies and in interpreting outcome studies. The purpose of this study was to assess interobserver and intraobserver reliability of the modified Waldenström classification system among a large and diverse group of pediatric orthopaedic surgeons. METHODS: Twenty surgeons independently completed the first two rounds of staging: two assessments of forty deidentified radiographs of patients with Legg-Calvé-Perthes disease in various stages. Ten of the twenty surgeons completed another two rounds of staging after the addition of a second pair of radiographs in sequence. Kappa values were calculated within and between each of the rounds. RESULTS: Interobserver kappa values for the classification for surveys 1, 2, 3, and 4 were 0.81, 0.82, 0.76, and 0.80, respectively (with 0.61 to 0.80 considered substantial agreement and 0.81 to 1.0, nearly perfect agreement). Intraobserver agreement for the classification was an average of 0.88 (range, 0.77 to 0.96) between surveys 1 and 2 and an average of 0.87 (range, 0.81 to 0.94) between surveys 3 and 4. CONCLUSIONS: The modified Waldenström classification system for staging of Legg-Calvé-Perthes disease demonstrated substantial to almost perfect agreement between and within observers across multiple rounds of study. In doing so, the results of this study provide a foundation for future validation studies, in which the classification stage will be associated with clinical outcomes.