How Is Variability in Femoral and Acetabular Version Associated With Presentation Among Young Adults With Hip Pain?

BACKGROUND: Acetabular and femoral version contribute to hip pain in patients with femoroacetabular impingement (FAI) or dysplasia. However, definitions and measurement methods of femoral version have varied in different studies, resulting in different "normal" values being used by clinicians for what should be the same anatomic measurement. This could result in discrepant or even inappropriate treatment recommendations. QUESTIONS/PURPOSES: In patients undergoing hip preservation surgery, (1) what is the range of acetabular and femoral version at presentation, and how much do two commonly used measurement techniques (those of Murphy and Reikerås) differ? (2) How are differences in acetabular and femoral version associated with clinical factors and outcomes scores at the time of presentation? METHODS: This was a retrospective analysis of data gathered in a longitudinally maintained database of patients undergoing hip preservation at a tertiary care referral center. Between June 2020 and December 2021, 282 hips in 258 patients were treated for an isolated labral tear (9% [26 hips]), hip dysplasia (21% [59 hips]), FAI (52% [147 hips]), mixed FAI and dysplasia (17% [47 hips]), or pediatric deformity (slipped capital femoral head epiphysis or Perthes disease; 1% [3 hips]) with hip arthroscopy (71% [200 hips]), periacetabular osteotomy (26% [74 hips]), surgical hip dislocation (2.5% [7 hips]), or femoral derotation osteotomy (0.5% [1 hip]). We considered those with complete radiographic data (CT including the pelvis and distal femur) and patient-reported outcome scores as potentially eligible. Exclusion criteria were age younger than 18 or older than 55 years (5 hips, 3 patients), signs of hip osteoarthritis (Tönnis grade ≥ 2; 0), pediatric deformity (slipped capital femoral head epiphysis or Perthes disease; 3 hips, 3 patients), previous femoral or acetabular osteotomy (2 hips, 2 patients), avascular necrosis of the femoral head (0), history of neuromuscular disorder (Ehlers-Danlos syndrome; 3 hips, 3 patients) or rheumatoid disease (ankylosing spondylitis; 1 hip, 1 patient), and when CT did not include the knees (19 hips, 19 patients). Based on these criteria, 249 hips in 227 patients were included. Of patients with bilateral symptomatic hips, one side was randomly selected for inclusion, leaving 227 hips in 227 patients for further analysis. The patients' median age (range) was 34 years (19 to 55 years), the median BMI (range) was 27 kg/m2 (16 to 55 kg/m2), and 63% (144) were female; they were treated with hip arthroscopy (in 74% [168]) or periacetabular osteotomy (in 23% [52]). Patients underwent a CT scan to measure acetabular version and femoral version using the Murphy (low < 10°; normal: 10° to 25°; high > 25°) or Reikerås (low < 5°; normal: 5° to 20°; high > 20°) technique. The McKibbin index was calculated (low: < 20°; normal: 20° to 50°; high > 50°). Based on the central acetabular version and femoral version as measured by Murphy, hips were grouped according to their rotational profile into four groups: unstable rotational profile: high (high acetabular version with high femoral version) or moderate (high acetabular version with normal femoral version or normal acetabular version with high femoral version); normal rotational profile (normal acetabular version with femoral version); compensatory rotational profile (low acetabular version with high femoral version or high acetabular version with low femoral version); and impingement rotational profile (low acetabular version with low femoral version): high (low acetabular version with low femoral version) or moderate (low acetabular version with normal femoral version or normal acetabular version with low femoral version). Radiographic assessments were manually performed on digitized images by two orthopaedic residents, and 25% of randomly selected measurements were repeated by the senior author, a fellowship-trained hip preservation and arthroplasty surgeon. Interobserver and intraobserver reliabilities were calculated using the correlation coefficient with a two-way mixed model, showing excellent agreement for Murphy technique measurements (intraclass correlation coefficient 0.908 [95% confidence interval 0.80 to 0.97]) and Reikerås technique measurements (ICC 0.938 [95% CI 0.81 to 0.97]). Patient-reported measures were recorded using the International Hip Outcome Tool (iHOT-33) (0 to 100; worse to best). RESULTS: The mean acetabular version was 18° ± 6°, and mean femoral version was 24° ± 12° using the Murphy technique and 12° ± 11° with the Reikerås method. Eighty percent (181 of 227) of hips had normal acetabular version, 42% (96 of 227) to 63% (142 to 227) had normal femoral version per Murphy and Reikerås, respectively, and 67% (152 to 227) had a normal McKibbin index. Patients with an impingement profile (low acetabular version or femoral version) were older (39 ± 9 years) than patients with an unstable (high acetabular version or femoral version; 33 ± 9 years; p = 0.004), normal (33 ± 9 years; p = 0.02), or compensatory (high acetabular version with low femoral version or vice versa; 33 ± 7 years; p = 0.08) rotational profile. Using the Murphy technique, femoral version was 12° greater than with the Reikerås method (R2 0.85; p < 0.001). There were no differences in iHOT-33 score between different groups (impingement: 32 ± 17 versus normal 35 ± 21 versus compensated: 34 ± 20 versus unstable: 31 ± 17; p = 0.40). CONCLUSION: Variability in femoral version is twice as large as acetabular version. Patients with an impingement rotational profile were older than patients with a normal, compensatory, or unstable profile, indicating there are other variables not yet fully accounted for that lead to earlier pain and presentation in these groups. Important differences exist between measurement methods. This study shows that different measurement methods for femoral anteversion result in different numbers; if other authors compare their results to those of other studies, they should use equations such as the one suggested in this study. LEVEL OF EVIDENCE: Level III, prognostic study.

The Otto Aufranc Award: Does Hip Arthroscopy at the Time of Periacetabular Osteotomy Improve the Clinical Outcome for the Treatment of Hip Dysplasia? A Multicenter Randomized Clinical Trial.

BACKGROUND: A periacetabular osteotomy (PAO) is often sufficient to treat the symptoms and improve quality of life for symptomatic hip dysplasia. However, acetabular cartilage and labral pathologies are very commonly present, and there is a lack of evidence examining the benefits of adjunct arthroscopy to treat these. The goal of this study was to compare the clinical outcome of patients undergoing PAO with and without arthroscopy, with the primary end point being the International Hip Outcome Tool-33 at 1 year. METHODS: In a multicenter study, 203 patients who had symptomatic hip dysplasia were randomized: 97 patients undergoing an isolated PAO (mean age 27 years [range, 16 to 44]; mean body mass index of 25.1 [range, 18.3 to 37.2]; 86% women) and 91 patients undergoing PAO who had an arthroscopy (mean age 27 years [range, 16 to 49]; mean body mass index of 25.1 [17.5 to 25.1]; 90% women). RESULTS: At a mean follow-up of 2.3 years (range, 1 to 5), all patients exhibited improvements in their functional score, with no significant differences between PAO plus arthroscopy versus PAO alone at 12 months postsurgery on all scores: preoperative International Hip Outcome Tool-33 score of 31.2 (standard deviation [SD] 16.0) versus 36.4 (SD 15.9), and 12 months postoperative score of 72.4 (SD 23.4) versus 73.7 (SD 22.6). The preoperative Hip disability and Osteoarthritis Outcome pain score was 60.3 (SD 19.6) versus 66.1 (SD 20.0) and 12 months postoperative 88.2 (SD 15.8) versus 88.4 (SD 18.3). The mean preoperative physical health Patient-Reported Outcomes Measurement Information System score was 42.5 (SD 8.0) versus 44.2 (SD 8.8) and 12 months postoperative 48.7 (SD 8.5) versus 52.0 (SD 10.6). There were 4 patients with PAO without arthroscopy who required an arthroscopy later to resolve persistent symptoms, and 1 patient from the PAO plus arthroscopy group required an additional arthroscopy. CONCLUSIONS: This randomized controlled trial has failed to show any significant clinical benefit in performing hip arthroscopy at the time of the PAO at 1-year follow-up. Longer follow-up will be required to determine if hip arthroscopy provides added value to a PAO for symptomatic hip dysplasia.

Mitigating the Denosumab-Induced Rebound Phenomenon with Alternating Short- and Long-Acting Anti-resorptive Therapy in a Young Boy with Severe OI Type VI.

Osteogenesis imperfecta (OI) type VI, a recessively inherited form of OI caused by mutations in SERPINF1, is a severe form distinguished by osteomalacia on bone histomorphometry. We describe a boy with severe OI type VI who was initially treated with intravenous (IV) zoledronic acid (ZA) at 1.4 years of age; however, a year later he transitioned to denosumab 1 mg/kg sub-cutaneously every three months in an effort to decrease fracture rates. After two years on denosumab, he presented with symptomatic hypercalcemia due to the denosumab-induced, hyper-resorptive rebound phenomenon. Laboratory parameters at the time of the rebound were as follows: elevated serum ionized calcium (1.62 mmol/L, N 1.16-1.36), elevated serum creatinine due to hypercalcemia-induced muscle catabolism (83 µmol/L, N 9-55), and suppressed parathyroid hormone (PTH) (< 0.7 pmol/L, N 1.3-5.8). The hypercalcemia was responsive to low-dose IV pamidronate, with a rapid decline in serum ionized calcium, and otherwise normalization of the aforementioned parameters within 10 days. To benefit from the powerful, albeit short-term, anti-resorptive effect of denosumab without further rebound episodes, he was treated thereafter with denosumab 1 mg/kg alternating every three months with IV ZA 0.025 mg/kg. Five years later, he remained on dual alternating anti-resorptive therapy without further rebound episodes, and an overall improvement in his clinical status. This novel pharmacological approach of alternating short- and long-term anti-resorptive therapy every three months has not previously been described. Our report suggests this strategy may be an effective method for prevention of the rebound phenomenon in select children for whom denosumab may be beneficial.

Contralateral hamstring autografts do not provide benefit compared to ipsilateral hamstring autografts in primary or revision anterior cruciate ligament reconstruction: a systematic review.

PURPOSE: To evaluate the clinical outcomes of primary or revision ACL reconstruction (ACLR) after contralateral hamstring autografts versus ipsilateral hamstring autograft harvest. METHODS: Three databases (MEDLINE, PubMed and EMBASE) were searched from inception to April 27th, 2023 for studies investigating contralateral hamstring autografts in primary or revision ACLR. The authors adhered to the PRISMA and R-AMSTAR guidelines as well as the Cochrane Handbook for Systematic Reviews of Interventions. Data on demographics, strength measures, patient-reported outcome measures (PROMs), and rates of positive Lachman test, positive pivot-shift test and graft rupture were extracted. PROMs included Lysholm, International Knee Documentation Committee (IKDC) and Tegner scores. RESULTS: Nine studies comprising 371 patients were included in this review. In primary ACLR, there were no significant differences between contralateral and ipsilateral groups in isokinetic hamstring torque in the non-ACLR limb or isokinetic quadriceps torque in both limbs when tested at 60, 90, 120 or 180 degrees/second. Isokinetic hamstring torque in the non-ACLR limb was significantly weaker in the contralateral group at six months for primary ACLR; however, these deficits did not persist. There were no significant differences in postoperative median Tegner scores and Lysholm scores between contralateral and ipsilateral groups in primary ACLR. There were no significant differences in postoperative median Tegner, mean Lysholm and IKDC scores between groups in revision ACLR. There were no significant differences in positive Lachman, positive pivot-shift and rupture rates in primary ACLR between groups. Rates of positive Lachman and pivot-shift were slightly higher in the contralateral than ipsilateral group for revision ACLR. CONCLUSION: Contralateral hamstring autografts results in comparable muscle strength to ipsilateral hamstring autografts, with the exception of weaker hamstring strengths in the early postoperative period. Patient-reported outcome measures were similar between the two groups across both primary and revision ACLR, with rates of instability and failure being similar between groups for primary ACLR. Contralateral hamstring grafts do not provide additional benefit when compared to ipsilateral options for either primary or revision ACLR, and should be used only in select circumstances including insufficient ipsilateral hamstring grafts or situations where quadriceps or patella autografts are not optimal. LEVEL OF EVIDENCE: Level IV.

Variability in Pain Management Practices for Pediatric Anterior Cruciate Ligament Reconstruction.

BACKGROUND: The opioid epidemic in the United States is a public health crisis. Pediatric orthopaedic surgeons must balance adequate pain management with minimizing the risk of opioid misuse or dependence. There is limited data available to guide pain management for anterior cruciate ligament reconstruction (ACLR) in the pediatric population. The purpose of this study was to survey current pain management practices for ACLR among pediatric orthopaedic surgeons. METHODS: A cross-sectional survey study was conducted, in which orthopaedic surgeons were asked about their pain management practices for pediatric ACLR. The voluntary survey was sent to members of the Pediatric Orthopaedic Society of North America. Inclusion criteria required that the surgeon perform anterior cruciate ligament repair or reconstruction on patients under age 18. Responses were anonymous and consisted of surgeon demographics, training, practice, and pain management strategies. Survey data were assessed using descriptive statistics. RESULTS: Of 64 included responses, the average age of the survey respondent was 48.9 years, 84.4% were males, and 31.3% practiced in the southern region of the United States. Preoperative analgesia was utilized by 39.1%, 90.6% utilized perioperative blocks, and 89.1% prescribed opioid medication postoperatively. For scheduled non-narcotic medications postoperatively 82.8% routinely advocated and 93.8% recommended cryotherapy postoperatively.Acetaminophen was the most used preoperative medication (31.3%), the most common perioperative block was an adductor canal block (81.0%), and the most common postoperative analgesic medication was ibuprofen (60.9%). Prior training or experience was more frequently reported than published research as a primary factor influencing pain management protocols. CONCLUSIONS: Substantial variability exists in pain management practices in pediatric ACLR. There is a need for more evidence-based practice guidelines regarding pain management. LEVEL OF EVIDENCE: Level V.

Clinical Practice Guideline Recommendations in Pediatric Orthopaedic Injury: A Systematic Review.

BACKGROUND: Lack of adherence to recommendations on pediatric orthopaedic injury care may be driven by lack of knowledge of clinical practice guidelines (CPGs), heterogeneity in recommendations or concerns about their quality. We aimed to identify CPGs for pediatric orthopaedic injury care, appraise their quality, and synthesize the quality of evidence and the strength of associated recommendations. METHODS: We searched Medline, Embase, Cochrane CENTRAL, Web of Science and websites of clinical organizations. CPGs including at least one recommendation targeting pediatric orthopaedic injury populations on any diagnostic or therapeutic intervention developed in the last 15 years were eligible. Pairs of reviewers independently extracted data and evaluated CPG quality using the Appraisal of Guidelines Research and Evaluation (AGREE) II tool. We synthesized recommendations from high-quality CPGs using a recommendations matrix based on the GRADE Evidence-to-Decision framework. RESULTS: We included 13 eligible CPGs, of which 7 were rated high quality. Lack of stakeholder involvement and applicability (i.e., implementation strategies) were identified as weaknesses. We extracted 53 recommendations of which 19 were based on moderate or high-quality evidence. CONCLUSIONS: We provide a synthesis of recommendations from high-quality CPGs that can be used by clinicians to guide treatment decisions. Future CPGs should aim to use a partnership approach with all key stakeholders and provide strategies to facilitate implementation. This study also highlights the need for more rigorous research on pediatric orthopaedic trauma. LEVEL OF EVIDENCE: Level II-therapeutic study.

Orthopaedic Surgery Pediatric Sports Medicine: Characterizing Practice Patterns and Subspecialization.

BACKGROUND: Pediatric sports medicine is a new and rapidly growing subspecialty within orthopaedic surgery. However, there is very limited literature on the practice of pediatric sports medicine in North America. Therefore, the purpose of this study was to evaluate and describe the current practice patterns of orthopaedic surgeons specializing in pediatric sports medicine. METHODS: An online survey was distributed to orthopaedic surgeons specializing in pediatric sports medicine through the Pediatric Research in Sports Medicine Society. The purpose of the survey was to characterize (1) surgeon demographics, (2) the breakdown of different joint specialization, and (3) the specific procedures for joints that the surgeons specialize in. RESULTS: Responses from 55 orthopaedic surgeons were collected and analyzed. Most respondents considered pediatric sports medicine as the primary focus of their practice (89.1%, n=49/55). The number of fellowships completed was almost evenly split between either a single fellowship (52.7%, n=29/55) or 2 or more (47.3%, n=26/55). The most common combination of fellowships was pediatric orthopaedics and adult sports medicine (32.7%, n=18/55). Most survey respondents had been in practice for <10 years (69.0%, n=38/55) and were affiliated with an academic center (61.8%, n=34/55). On average, 77.5% of the patients treated were <18 years old. The knee joint was the most specialized joint, with 98.2% (n=54/55) respondents reporting that the knee joint constituted ≥25% of their practice. The knee joint constituted a mean of 52.1% of the respondents' overall practice, followed by the shoulder (15.2%), hip (13.9%), ankle (7.5%), elbow (7.1%), and wrist (4.2%). CONCLUSIONS: Pediatric sports medicine practices are variable and have distinct practice patterns in pediatric, orthopaedic, and adult sports practices. In the current study, most surgeons are less than 10 years into practice, affiliated with academic centers, and have typically completed either 1 or 2 fellowships after residency. Surgeons were most commonly specialized in the knee joint and cared for patients <18 years old. LEVEL OF EVIDENCE: Level of evidence IV.

The Toddler's Fracture.

OBJECTIVE: The tibial toddler's fracture is an important diagnosis in both emergency and urgent care, presenting as acute onset lower extremity pain or limping in a young child. Diagnosis and management may be challenging because of an extensive differential diagnosis. The objectives of this study were to provide an overview of the toddler's fracture and to guide clinicians by summarizing up to date literature for both diagnosis and management this common condition. METHODS: This study analyzed literature from the PubMed database from the years of 1964 to 2018. The main focus was on the diagnosis and management of the toddler's fracture. RESULTS: This review demonstrates that diagnosis is primarily made through history and physical examination, as radiographs are often negative at initial presentation. Treatment involves a short period of immobilization, which can be facilitated through the use of a cast, a splint, or no external support. Successful healing and a full return to normal activities and development are near universal. CONCLUSIONS: Although a stable fracture with an excellent prognosis, opportunities exist to improve toddler's fractures diagnosis and treatment protocols, to optimize clinical management.

Hip Joint Preservation Surgery: What Every Orthopaedic Provider Needs to Know.

The understanding of the native hip's mechanics, physiology, and pathology has dramatically improved over the recent 2 decades. This was facilitated by the introduction of open and arthroscopic procedures to the native hip aimed at improving the joint's function and longevity. Associations between abnormal hip mechanics and further development of osteoarthritis are now clear. As the knowledge of hip joint mechanics has improved, other conditions around the hip have become evident, which may lead to pain but not necessarily osteoarthritis. It is important for the orthopaedic surgeon to be up to date on how the hip preservation field has evolved and the steps to consider when a painful hip presents in clinic.

Management and Complications in Nonoperative Fractures of the Tibial Spine: A Systematic Review.

Effective options exist for acute nonoperative management of anterior tibial spine fractures, yet there exists a paucity of literature describing long-term outcomes for these patients. This systematic review thus aims to consolidate management strategies and complications for patients with nonoperative anterior tibial spine fractures. In accordance with PRISMA guidelines, 5 databases (CINAHL, MEDLINE, EMBASE, Cochrane, and Pubmed) were searched and screened in duplicate. Quality assessment was performed using the Methodological Index for Non-Randomized Studies (MINORS) criteria. Of 485 studies identified in the initial search, a total of 18 studies involving 369 patients were eligible for this review. These were stratified into 173 type I, 124 type II, and 72 type III injuries as described by Meyers and McKeever. All patients were treated with knee immobilization in either full extension or slight flexion, with possible closed reduction and/or aspiration of hemarthrosis. Complications at final follow-up comprised 33.9% of patients with persistent stiffness, 19.4% persistent instability, 11.1% mechanical symptoms, 6.37 delayed anterior cruciate ligament reconstruction, 4.9% delayed operative intervention for other complications, and 1.9% extension impingement. Given the lack of comparative studies in this review, definitive conclusions for nonoperative management are difficult to establish on the basis of the current body of literature alone. A modestly higher rate of arthrofibrosis and persistent laxity are seen in higher-grade injuries, however, only a minority of studies stratified complications by Meyers and McKeever classification in this review. A better understanding of variables in treatment decision making require further prospective study focused on the collection of functional and patient-reported outcome measures, whereas also further delineating complications by injury severity.

Electronic Consultation Systems: Impact on Pediatric Orthopaedic Care.

BACKGROUND: The demand for pediatric orthopaedic surgery consultation has grown rapidly, leading to longer wait times for elective consultation in some regions. Some specialties are addressing this increased demand through electronic consultation services. We wanted to examine the impact of pediatric orthopaedic e-consultations in Canada's Eastern Ontario region. METHODS: We developed a cross-sectional study of all the cases directed to a pediatric orthopaedic surgery specialist using the Champlain Building Access to Specialists through eConsultation (BASE) eConsult service over a 2-year period and examined their impact on in-person referrals, time of e-consultation and primary care satisfaction as well as types of clinical questions that were asked. RESULTS: Electronic consultations avoided in-person appointments in 68% of the submitted cases. The median response by specialists received by the primary care providers (PCPs) was <20 hours. A total of 69% of consultations involve >1 type of clinical questions, most commonly about basic trauma/fracture care and management recommendations. Ninety-seven percent of the PCPs found the overall value for the care of the patients to be good or excellent. CONCLUSIONS: This cross-sectional study demonstrates the effective and timely use of eConsult in pediatric orthopaedic surgery. It also shows a significant reduction in the number of in-person consultations required and demonstrates a high satisfaction rate by PCPs using the service. CLINICAL RELEVANCE: In addition to the efficacy and time-sensitive care provided to the patients, the study shows that, professionally, 89% of PCPs found this service to be excellent or good. The broader implications of electronic consultation on overall quality of care, population health, and patient satisfaction requires further investigation.

Acetabular Version Increases During Adolescence Secondary to Reduced Anterior Femoral Head Coverage.

BACKGROUND: Acetabular version influences joint mechanics and the risk of impingement. Cross-sectional studies have reported an increase in acetabular version during adolescence; however, to our knowledge no longitudinal study has assessed version or how the change in version occurs. Knowing this would be important because characterizing the normal developmental process of the acetabulum would allow for easier recognition of a morphologic abnormality. QUESTIONS/PURPOSES: To determine (1) how acetabular version changes during adolescence, (2) calculate how acetabular coverage of the femoral head changed during this period, and (3) to identify whether demographic factors or hip ROM are associated with acetabular development. METHODS: This retrospective analysis of data from a longitudinal study included 17 volunteers (34 hips) with a mean (± SD) age of 11 ± 2 years; seven were male and 10 were female. The participants underwent a clinical examination of BMI and ROM and MRIs of both hips at recruitment and at follow-up (6 ± 2 years). MR images were assessed to determine maturation of the triradiate cartilage complex, acetabular version, and degree of the anterior, posterior, and superior acetabular sector angles (reflecting degree of femoral head coverage provided by the acetabulum anteriorly, posteriorly and superiorly respectively). An orthopaedic fellow (GG) and a senior orthopaedic resident (PJ) performed all readings in consensus; 20 scans were re-analyzed for intraobserver reliability. Thereafter, a musculoskeletal radiologist (KR) repeated measurements in 10 scans to test interobserver reliability. The intra- and interobserver interclass correlation coefficients for absolute agreement were 0.85 (95% CI 0.76 to 0.91; p < 0.001) and 0.77 (95% CI 0.70 to 0.84), respectively. All volunteers underwent a clinical examination by a senior orthopaedic resident (PJ) to assess their range of internal rotation (in 90° of flexion) in the supine and prone positions using a goniometer. We tested investigated whether the change in anteversion and sector angles differed between genders and whether the changes were correlated with BMI or ROM using Pearson's coefficient. The triradiate cartilage complex was open (Grade I) at baseline and closed (Grade III) at follow-up in all hips. RESULTS: The acetabular anteversion increased, moving caudally further away from the roof at both timepoints. The mean (range) anteversion angle increased from 7° ± 4° (0 to 18) at baseline to 12° ± 4° (5 to 22) at the follow-up examination (p < 0.001). The mean (range) anterior sector angle decreased from 72° ± 8° (57 to 87) at baseline to 65° ± 8° (50 to 81) at the final follow-up (p = 0.002). The mean (range) posterior (98° ± 5° [86 to 111] versus 97° ± 5° [89 to 109]; p = 0.8) and superior (121° ± 4° [114 to 129] to 124° ± 5° [111 to 134]; p = 0.07) sector angles remained unchanged. The change in the anterior sector angle correlated with the change in version (rho = 0.5; p = 0.02). The change in version was not associated with any of the tested patient factors (BMI, ROM). CONCLUSIONS: With skeletal maturity, acetabular version increases, especially rostrally. This increase is associated with, and is likely a result of, a reduced anterior acetabular sector angle (that is, less coverage anteriorly, while the degree of coverage posteriorly remained the same). Thus, in patients were the normal developmental process is disturbed, a rim-trim might be an appropriate surgical solution, since the degree of posterior coverage is sufficient and no reorientation osteotomy would be necessary. However, further study on patients with retroversion (of various degrees) is necessary to characterize these observations further. The changes in version were not associated with any of the tested patient factors; however, further study with greater power is needed. LEVEL OF EVIDENCE: Level II, prognostic study.

Use of Patient-reported Outcome Measures in Pediatric Orthopaedic Literature.

BACKGROUND: Patient-reported outcomes are increasingly used as primary measures of success and impact of health care services. There is no current consensus on the efficacy of functional health status (FHS) or health-related quality of life (HRQoL) evaluation in pediatric orthopaedic surgery. The purpose of this study was to quantify and characterize the use of such patient-reported outcomes in the pediatric orthopaedic literature over the last several years. METHODS: A cross-sectional review of 6 orthopaedic journals-Journal of Bone and Joint Surgery, Bone and Joint Journal, Spine, Journal of Pediatric Orthopaedics A, Journal of Pediatric Orthopaedics B, and Journal of Children's Orthopaedics, was conducted by 2 independent reviewers. Articles were analyzed for patient-reported outcome usage over the time periods of 2000 to 2001, 2007 to 2008, and 2012 to 2013. RESULTS: A total of 189 articles (2.7%) were identified that used patient-reported outcomes in pediatric populations. A total of 71 (37.5%) of these articles used FHS tools, 95 (50.3%) used HRQoL tools and 23 (12.2%) used a combination of both. The use of FHS and HRQoL tools has increased over time, with 8 FHS and 2 HRQoL publications in the year 2000 expanding to 19 and 28, respectively, in 2013. Journal of Bone and Joint Surgery American Volume published both the highest total number of articles containing patient-reported outcome measures (57/189) and the highest number of articles specifically using FHS measures (28/71). Spine published the highest number of articles using HRQoL measures (43/95). The most frequently used FHS and HRQoL tools were the Lysholm knee score and the Scoliosis Research Society tools, respectively. Only 33/73 identified patient-based outcome instruments had been validated in a pediatric population. CONCLUSIONS: Patient-reported outcome measures are underutilized in the pediatric orthopaedic literature. Instruments are frequently used that are neither designed nor validated for a pediatric population. Consequently, further work is necessary to develop, validate, and implement pediatric-specific FHS and HRQoL tools to fully understand the impact of a clinical intervention on all aspects of patient quality of life.

Treatment With the SIGN Nail in Closed Diaphyseal Femur Fractures Results in Acceptable Radiographic Alignment.

BACKGROUND: The burden of orthopaedic trauma in the developing world is substantial and disproportionate. SIGN Fracture Care International is a nonprofit organization that has developed and made available to surgeons in resource-limited settings an intramedullary interlocking nail for use in the treatment of femoral and tibial fractures. Instrumentation also is donated with the nail. A prospectively populated database collects information on all procedures performed using this nail. Given the challenging settings and numerous surgeons with varied experience, it is important to document adequate alignment and union using the device. QUESTIONS/PURPOSES: The primary aim of this research was to assess the adequacy of operative reduction of closed diaphyseal femur fractures using the SIGN interlocking intramedullary nail based on radiographic images available in the SIGN database. The secondary aims were to assess correlations between postoperative alignment and several associated variables, including fracture location in the diaphysis, degree of fracture site comminution, and time to surgery. The tertiary aim was to assess the functionality of the SIGN database for radiographic analyses. METHODS: A review of the prospectively populated SIGN database was performed for patients with a diaphyseal femur fracture treated with the SIGN nail, which at the time of the study totaled 32,362 patients. After study size calculations, a random number generator was used to select 500 femur fractures for analysis. Exclusion criteria included open fractures and those without radiographs during the early postoperative period. The following information was recorded: location of the fracture in the diaphysis; fracture classification (AO/Orthopaedic Trauma Association [OTA] classification); degree of comminution (Winquist and Hansen classification); time from injury to surgery; and patient demographics. Measurements of alignment were obtained from the AP and lateral radiographs with malalignment defined as deformity in either the sagittal or coronal plane greater than 5°. Measurements were made manually by the four study authors using on-screen protractor software and interobserver reliability was assessed. RESULTS: The frequency of malalignment greater than 5° observed on postoperative radiographs was 51 of 501 (10%; 95% CI, 6.5-11.5), and malalignment greater than 10° occurred in eight of 501 (1.6%) of the femurs treated with this nail. Fracture location in the proximal or distal diaphysis was strongly correlated with risk of malalignment, with an odds ratio (OR) of 3.7 (95% CI, 1.5-9.3) for distal versus middle diaphyseal fractures and an OR of 4.7 (95% CI, 1.9-11.5) for proximal versus middle fractures (p < 0.001). Time from injury to surgery greater than 4 weeks also was strongly correlated with risk of malalignment (p < 0.001). Inherent fracture stability, based on fracture site comminution as per the Winquist and Hansen classification (Class 0-1 stable versus 2-4 unstable) showed an OR of 2.3 (95% CI, 1.2-4.3) for malalignment in unstable fractures. Interobserver reliability showed agreement of 88% (95% CI, 83-93) and mean kappa of 0.81 (95% CI, 0.65-0.87). The SIGN database of radiographic images was found to be an excellent source for research purposes with 92% of reviewed radiographs of acceptable quality. CONCLUSIONS: The frequency of malalignment in closed diaphyseal femoral fractures treated with the SIGN nail closely approximated the incidence reported in the literature for North American trauma centers. Increased time from injury to surgery was correlated with increased frequency of malalignment; as humanitarian distribution of the SIGN nail increases, local barriers to timely care should be assessed and improved as possible. Prospective clinical study with followup, despite its inherent challenges in the developing world, would be of great benefit in the future. LEVEL OF EVIDENCE: Level III, therapeutic study.

The Otto Aufranc Award. On the etiology of the cam deformity: a cross-sectional pediatric MRI study.

BACKGROUND: Femoroacetabular impingement (FAI) has been recognized as a common cause of hip pain as well as a cause of hip arthritis, yet despite this, little is known about the etiology of the cam morphology or possible risk factors associated with its development. QUESTIONS/PURPOSES: The purposes of our study were to determine when the cam morphology associated with FAI developed in a cross-sectional cohort study of pediatric patients pre- and postphyseal closure using MRI and whether increased activity level during the period of physeal closure is associated with an increased likelihood that the cam deformity will develop. METHODS: Alpha angles were measured at the 3 o'clock (anterior head-neck junction) and 1:30 (anterosuperior head-neck junction) positions in both hips with a cam deformity defined as an alpha angle ≥ 50.5° at the 3 o'clock position. Forty-four volunteers (88 hips) were studied: 23 with open physes (12 females, mean age 9.7 years; 11 males, age 11.7 years) and 21 with closed physes (five females, age 15.2 years; 16 males, age 16.2 years). Daily activity level using the validated Habitual Activity Estimation Scale was compared for patients in whom cam morphology did and did not develop. RESULTS: None of the 23 (0%) patients prephyseal closure had cam morphology, whereas three of 21 (14%, p = 0.02; all males) postclosure had at least one hip with cam morphology. Daily activity level was higher (p = 0.02) for patients with the cam morphology (7.1 hours versus 2.9 hours). Mean alpha angles at the 3 o'clock head-neck position were 38° (95% confidence interval [CI], 37.2°-39.1°) in the open physes group and 42° (95% CI, 40.16°-43.90°) in the closed physes group; at the 1:30 head-neck position, they were 45° (95% CI, 44.0°-46.4°) in the open physes group and 50° (47.9°-52.3°) in the closed physes group. CONCLUSIONS: The fact that cam morphology was present exclusively in the closed physeal group strongly supports its development during the period of physeal closure with increased activity level as a possible risk factor.

Arthroscopic suture fixation of tibial spine fractures.

A tibial spine fracture refers to an intraarticular fracture of the osseous insertion of the anterior cruciate ligament at the proximal tibia, commonly seen in pediatric and adolescent patients. This fracture is classified based on the degree of displacement and the presence or absence of an intact posterior hinge point. For significantly displaced fractures, surgical reduction and fixation are often recommended. Both open and arthroscopic approaches have been described. This technical note describes our technique for arthroscopic-assisted reduction and fixation of tibial spine fractures using trans-osseous tunnels and suture fixation over a bone bridge. This technique restores native anatomy, provides fracture compression, and has favorable biomechanical properties, allowing for early range of motion.

Predictors of True Scaphoid Fractures in Children.

BACKGROUND: The scaphoid is the most commonly fractured carpal bone in children. True scaphoid fractures have proven to be difficult to diagnose, as they may not be apparent on initial imaging. Children with clinical suspicion of a scaphoid fracture may be treated with continued immobilization, even in the absence of radiographic evidence of a fracture. The purpose of this study is to identify predictors of true scaphoid fractures in children to help guide management. METHODS: This study is a retrospective cohort study of children presenting to a tertiary pediatric hospital with hand or wrist injuries. Patients were grouped based on the presence of a true scaphoid fractures (confirmed on imaging) or those with clinical suspicion of a scaphoid fracture alone (no radiographic evidence of fracture). Demographic and clinical characteristics were compared with univariate and multivariate statistics to identify fracture predictors. RESULTS: One hundred and thirty patients were included in the study: 57 in the true scaphoid fracture group and 73 in the clinical scaphoid fracture group. Patients with a true scaphoid fracture were older than those with a clinical scaphoid fracture (median age [interquartile range], 14.2 [13.0-15.4] vs 12.9 [11.9-14.4], P = .01). Men were more likely to sustain a true scaphoid fracture (65.0% vs 35.0%, P = .01). Older age and male sex were shown to be independent predictors of true scaphoid fractures (odds ratio [95% confidence interval], 1.25 [1.03-1.50] and 2.93 [1.39-6.17], respectively). CONCLUSIONS: In the pediatric population, older age and male children may be at increased risk of true scaphoid fractures. This may help guide decisions surrounding further imaging and treatment.

Inter-Rater and Intrarater Reliability of Radiographs in the Diagnosis of Pediatric Scaphoid Fractures.

BACKGROUND: Pediatric scaphoid fractures can be challenging to diagnose on plain radiograph. Rates of missed scaphoid fractures can be as high as 30% to 37% on initial imaging and overall sensitivity ranging from 21% to 97%. Few studies, however, have examined the reliability of radiographs in the diagnosis of scaphoid fractures, and none are specific to the pediatric population. Reliability, both between different specialists and for individual raters, may elucidate some of the diagnostic challenges. METHODS: We conducted a 2-iteration survey of pediatric orthopedic surgeons, plastic surgeons, radiologists, and emergency physicians at a tertiary children's hospital. Participants were asked to assess 10 series of pediatric wrist radiographs for evidence of scaphoid fracture. Inter-rater and intrarater reliability was calculated using the intraclass correlation coefficient of 2.1. RESULTS: Forty-two respondents were included in the first iteration analysis. Inter-rater reliability between surgeons (0.66; 95% confidence interval, 0.43-0.87), radiologists (0.76; 0.55-0.92), and emergency physicians (0.65; 0.46-0.86) was "good" to "excellent." Twenty-six respondents participated in the second iteration for intrarater reliability (0.73; 0.67-0.78). Sensitivity (0.75; 0.69-0.81) and specificity (0.78; 0.71-0.83) of wrist radiographs for diagnosing scaphoid fractures were consistent with results in other studies. CONCLUSIONS: Both inter-rater and intrarater reliability for diagnosing pediatric scaphoid fractures on radiographs was good to excellent. No significant difference was found between specialists. Plain radiographs, while useful for obvious scaphoid fractures, are unable to reliably rule out subtle fractures routinely. Our study demonstrates that poor sensitivity stems from the test itself, and not rater variability.

The relationship of pain catastrophizing with postoperative patient-reported outcome measures in adults with pre-arthritic hip disease.

The association between preoperative pain catastrophizing and postoperative patient-reported outcome measures of patients with pre-arthritic hip disease was evaluated. All patients scheduled for joint-preserving surgeries of the hip (JPSH) at our institution were approached. Patient demographics (age, sex, body mass index (BMI)), pain intensity (Numeric Pain Scale (NPS)) and pain catastrophizing (Pain Catastrophizing Scale (PCS)) were collected preoperatively. Patient function (12-Item International Hip Outcome Tool (iHot-12)) and physical and mental health (Patient-Reported Outcomes Measurement Information System (PROMIS-10) mental/physical) were collected preoperatively, three-month and one-year postoperatively. The analysis consisted of multivariate linear regression models fitted for continuous scores of outcome measures at three-month and one-year. Correlation between preoperative PCS and iHot-12 was assessed using the Pearson correlation coefficient. A total of 274 patients completed the PCS and were included in the multivariate linear regression models. Most patients were females (66.8%), mean age was 33 (SD 9), mean BMI was 26.5 (SD 5.8) and most were diagnosed with femoro-acetabular impingement (46.0%) and underwent arthroscopy (77.0%). There were statistically significant correlations between PCS and iHot-12 (preoperatively -0.615, P < 0.001; three-month -0.242, P = 0.002). Statistically significant associations were found for function (three-month PCS P = 0.046, age P = 0.014, NPS P = 0.043; one-year BMI P = 0.005, NPS P = 0.014), physical health (three-month BMI, P = 0.002, NPS P = 0.008; one-year BMI P = 0.002, NPS P = 0.013) and mental health (three-month BMI P = 0.047; one-year BMI P = 0.030). There is an association between function and preoperative pain catastrophizing in patients with pre-arthritic hip disease undergoing JPSH. When considering confounding variables, preoperative pain catastrophizing is associated with short-term recovery.

Social determinants of health and disparities in pediatric trauma care: protocol for a systematic review and meta-analysis.

BACKGROUND: Social determinants of health (SDH), including "the conditions in which individuals are born, grow, work, live and age" affect child health and well-being. Several studies have synthesized evidence about the influence of SDH on childhood injury risks and outcomes. However, there is no systematic evidence about the impact of SDH on accessing care and quality of care once a child has suffered an injury. We aim to evaluate the extent to which access to care and quality of care after injury are affected by children and adolescents' SDH. METHODS: Using Cochrane methodology, we will conduct a systematic review including observational and experimental studies evaluating the association between social/material elements contributing to health disparities, using the PROGRESS-Plus framework: place of residence, race/ethnicity/culture/language, occupation, gender/sex, religion, education, socioeconomic status, and social capital and care received by children and adolescents (≤ 19 years of age) after injury. We will consult published literature using PubMed, EMBASE, CINAHL, PsycINFO, Web of Science, and Academic Search Premier and grey literature using Google Scholar from their inception to a maximum of 6 months prior to submission for publication. Two reviewers will independently perform study selection, data extraction, and risk of bias assessment for included studies. The risk of bias will be assessed using the ROBINS-E and ROB-2 tools respectively for observational and experimental study designs. We will analyze data to perform narrative syntheses, and if enough studies are identified, we will conduct a meta-analysis using random effects models. DISCUSSION: This systematic review will provide a synthesis of evidence on the association between SDH and pediatric trauma care (access to care and quality of care) that clinicians and policymakers can use to better tailor care systems and promote equitable access and quality of care for all children. We will share our findings through clinical rounds, conferences, and publication in a peer-reviewed journal. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42023408467.