Pediatric hallux valgus: An overview of history, examination, conservative, and surgical management.

Pediatric hallux valgus (PHV), while relatively rare, is still often encountered by general pediatricians. Herein, we concisely summarize the existing literature regarding the pathogenesis, associated conditions, clinical diagnosis, radiographic characteristics, conservative management, and surgical management of PVH. Though PHV is generally considered benign, the progression of hallux valgus can result in complications. The presence of an open physis in the pediatric age group delineates first line treatment choices, whenever possible, as nonoperative. The general exception to this recommendation is for children with neuromuscular and connective tissues disease who may benefit from earlier surgical management. If conservative approaches fail prior to skeletal maturity, the risk of recurrence and need for revision surgery should be discussed with patients and their families before surgical referral is made. The current review was conducted to aid primary care providers in better understanding the pathogenesis, associated conditions, and intervention options available to manage PHV.

Which surgical approach is optimal for joint preparation in talonavicular fusion - A cadaver study.

BACKGROUND: Fusion of the talonavicular joint has proven challenging in literature. The optimal surgical approach for talonavicular arthrodesis is still uncertain. This study compares the amount of physical joint preparation between dorsal and medial approaches to the talonavicular joint. METHODS: Twenty fresh frozen cadaver specimens were randomly assigned to receive either a dorsal or medial operative approach to the talonavicular joint. The joint surface was prepared, and the joint was disarticulated. Image analysis, using ImageJ, was performed by two blinded reviewers to assess the joint surface preparation and this was compared by surgical approach. RESULTS: The dorsal approach had a higher median percentage of talar and total talonavicular joint surface area prepared (75% vs. 59% (p = .007) and 82% vs. 70% (p = .005)). Irrespective of approach, the talus was significantly more difficult to prepare than the navicular (62% vs 88% (p = .001)). CONCLUSION: The dorsal approach provides superior talonavicular joint preparation. The lateral »th of the talar head was the most difficult surface to prepare, and surgeons performing double or triple arthrodesis may prepare the lateral talar head from the lateral approach. LEVEL OF EVIDENCE: Level V.

Institutional performance and validation of severity of illness score for children with acute hematogenous osteomyelitis.

A scoring system has recently been published that uses parameters within the first 4-5 days of hospitalization to determine the severity of illness (SOI) in children with acute hematogenous osteomyelitis (AHO). To our knowledge, no additional studies to date have examined the validity of the SOI score outside of the institution of origin. This study evaluates the performance of the SOI score in a retrospective cohort of cases at our institution. Patients admitted to our institution over the past 5 years with AHO who met inclusion and exclusion criteria were analyzed. Parameters including C reactive protein over the first 96 h of hospitalization, febrile days on antibiotics, ICU admission, and presence of disseminated disease were used to calculate the SOI score for each patient. Pearson and Spearman correlations were used when appropriate. SOI score comparison between groups was achieved with the Kruskal-Wallis and Wilcoxon two-sample tests. Seventy-four patients were analyzed. Significantly higher SOI scores were noted for patients with bacteremia, ICU admission, fever for two or more days on presentation, multiple surgeries, and any complication. Markers of disease severity that significantly correlated with SOI score were total length of stay, LOS, duration of antibiotic course, number of surgical procedures, and case mix index. The SOI score functioned well as higher scores were associated with sicker patients. The SOI score is helpful for determining which patients will require longer hospitalizations and more intense treatment in a setting other than the institution of origin.

Comparison of nonoperative versus operative management in pediatric gustilo-anderson type I open tibia fractures.

BACKGROUND: Recent studies suggest pediatric Gustilo-Anderson type I fractures, especially of the upper extremity, may be adequately treated without formal operative debridement, though few tibial fractures have been included in these studies. The purpose of this study is to provide initial data suggesting whether Gustilo-Anderson type I tibia fractures may be safely treated nonoperatively. METHODS: Institutional retrospective review was performed for children with type I tibial fractures managed with and without operative debridement from 1999 through 2020. Incomplete follow-up, polytrauma, and delayed diagnosis of greater than 12 h since the time of injury were criteria for exclusion. Data including age, sex, mechanism of injury, management, time-to-antibiotic administration, and complications were recorded. RESULTS: Thirty-three patients met inclusion criteria and were followed to union. Average age was 9.9 ± 3.7 years. All patients were evaluated in the emergency department and received intravenous antibiotics within 8 h of presentation. Median time-to-antibiotics was 2 h. All patients received cefazolin except one who received clindamycin at an outside hospital and subsequent cephalexin. Three patients (8.8%) received augmentation with gentamicin. Twenty-one patients (63.6%) underwent operative irrigation and debridement (I&D), and of those, sixteen underwent surgical fixation of their fracture. Twelve (36.4%) patients had bedside I&D with saline under conscious sedation, with one requiring subsequent operative I&D and intramedullary nailing. Three infections (14.3%) occurred in the operative group and none in the nonoperative group. Complications among the nonoperative patients include delayed union (8.3%), angulation (8.3%), and refracture (8.3%). Complications among the operative patients include delayed union (9.5%), angulation (14.3%), and one patient experienced both (4.8%). Other operative group complications include leg-length discrepancy (4.8%), heterotopic ossification (4.8%), and symptomatic hardware (4.8%). CONCLUSION: No infections were observed in a small group of children with type I tibia fractures treated with bedside debridement and antibiotics, and similar non-infectious complication rates were observed relative to operative debridement. This study provides initial data that suggests nonoperative management of type I tibial fractures may be safe and supports the development of larger studies.

Delayed Presentation of Popliteal Artery Injury after Salter-Harris III Proximal Tibia Fracture.

Introduction: Proximal tibia physeal fractures in children are not very common but can be dangerous because they can harm popliteal fossa structures, especially the popliteal artery. Popliteal artery injuries (PAI) are most commonly the result of trauma to the lower extremity, including blunt force, hyperextension injuries, complex fractures, and knee dislocations that can compromise popliteal neurovascular structures. Case Presentation. A 14-year-old boy presents to the emergency department after being transferred from an outside hospital 24 hours after a left lower extremity hyperextension injury. Radiographs demonstrated a Salter-Harris III proximal tibia fracture with posterior displacement. ABIs were deferred due to palpable distal pulses and no evidence of compartment syndrome. Closed reduction and percutaneous pinning were planned to correct the fracture. Intraoperatively, it was discovered that knee extension decreased lower extremity perfusion while knee flexion returned perfusion. An angiography revealed a popliteal artery occlusion with no distal flow. Based on this, an above-knee to below-knee popliteal bypass using the contralateral great saphenous vein was performed followed by closed reduction and percutaneous pinning of the proximal tibia. Conclusion: Proximal tibia physeal injuries, especially the Salter-Harris III and IV injuries, warrant a high index of suspicion of popliteal artery injuries. Palpable pulses and delayed presentation in the distal lower extremity do not rule out a PAI because collateral flow to the anterior and posterior tibial arteries may mask signs of an avascular limb, highlighting the need for a thorough history and physical exam. The authors present this case to reaffirm the importance of an ankle-brachial index when evaluating hyperextension injuries with proximal tibial epiphyseal fractures.

Analysis of risk factors for nonunion in pediatric lateral column lengthening.

The lateral column lengthening procedure is a commonly used osteotomy for correction of pes planus performed by inserting a graft in the anterior aspect of the calcaneus through a transverse osteotomy. Though nonunion and calcaneo-cuboid subluxation have been previously reported, these complications have not been extensively studied in pediatric patients. After IRB approval, 111 patients (151 feet) who underwent lateral column lengthening at a single institution were identified. Fifty-three females (70 feet) and 58 males (81 feet) with an average age of 11.4 years (2.6 SD; range 5-17) were analyzed. The primary outcome was nonunion defined as a lack of radiographic evidence of osteotomy healing by 9 months. Underlying diagnosis, pre and postoperative radiographic measurements, age, operative technique, fixation, calcaneo-cuboid subluxation, graft material and concomitant procedures were analyzed for their relationship to nonunion. Nonunion occurred in 7 of 151 feet (4.6%). Patient age at the time of surgery and calcaneo-cuboid subluxation trended toward a significant association with nonunion ( P = 0.053, 0.054, respectively). The degree of surgical correction, as determined by radiographic analysis, and the use of calcaneo-cuboid fixation were not significantly associated with nonunion. None of the other factors evaluated were significantly associated with nonunion. There were three cases of postoperative infections (2.0%), two were superficial and 1 (0.7%) was deep. Thirty-five of 151 feet disclosed radiographic evidence of subluxation. Excluding subluxation, the overall complication rate was 8.6%. Nonunion occurred in 4.6% of pediatric feet undergoing lateral column lengthening. Fixation type was not significantly associated with nonunion. Older age at the time of surgery and calcaneocuboid subluxation trended towards significance. The placement of a calcaneo-cuboid pin was not found to be a significant factor in preventing calcaneo-cuboid subluxation or nonunion.

Comparing complications of outpatient management of slipped capital femoral epiphysis and Blount's disease: A database study.

BACKGROUND: Currents trends in pediatric orthopaedics has seen an increase in surgeries being successfully completed in an outpatient setting. Two recent examples include slipped capital femoral epiphysis (SCFE) and Blount's disease. Surgical indications are well-studied for each pathology, but to our knowledge, there is an absence in literature analyzing safety and efficacy of inpatient vs outpatient management of either condition. We believed there would be no increase in adverse outcomes associated with outpatient treatment of either conditions. AIM: To investigate whether outpatient surgery for SCFE and Blount's disease is associated with increased risk of adverse outcomes. METHODS: The 2015-2017 American College of Surgeons National Surgical Quality Improvement Program Pediatric Registries were used to compare patient characteristics, rates of complications, and readmissions between outpatient and inpatient surgery for SCFE and Blount's disease. RESULTS: Total 1788 SCFE database entries were included, 30% were performed in an outpatient setting. In situ pinning was used in 98.5% of outpatient surgeries and 87.8% of inpatient surgeries (P < 0.0001). Inpatients had a greater percent of total complications than outpatients 2.57% and 1.65% respectively. Regarding Blount's disease, outpatient surgeries constituted 41.2% of the 189 procedures included in our study. The majority of inpatients were treated with a tibial osteotomy, while the majority of outpatients had a physeal arrest (P < 0.0001). Complications were encountered in 7.4% of patients, with superficial surgical site infections and wound dehiscence being the most common. 1.6% of patients had a readmission. No differences in complication and readmission risks were found between inpatients and outpatients. CONCLUSION: The current trend is shifting towards earlier discharges and performing procedures in an outpatient setting. This can be safely performed for a large portion of children with SCFE and Blount's disease without increasing the risk of complications or readmissions. Osteotomies are more commonly performed in an inpatient setting where monitoring is available.

Arthroscopic Treatment of Symptomatic Discoid Lateral Meniscus and Nondiscoid Meniscus in Adolescent Patients.

BACKGROUND: Discoid lateral meniscus (DLM) is a rare condition. Patient-reported outcomes using validated instruments are underreported in the literature. DLM outcomes have not been directly compared with nondiscoid meniscus (non-DLM) in adolescent patients. PURPOSE/HYPOTHESIS: This study sought to analyze the difference in patient characteristics, surgical treatment, and patient-reported outcomes for adolescent patients arthroscopically treated for symptomatic DLM and non-DLM pathology. We hypothesized that DLM and non-DLM patient-reported outcomes would be similar. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A retrospective review of patients aged <18 years with symptomatic DLM and non-DLM pathology was completed between 2015 and 2021 at a single academic institution. Chart reviews for patient characteristics and surgical operative indications and technique were completed. Patient-reported outcome scores were prospectively collected preoperatively and at 6 months, 1 year, and 2 years after surgery. RESULTS: Patients in the DLM group (n = 48), when compared with the non-DLM group (n = 45), were younger (12.71 vs 15.78 years, respectively; P < .001) and had lower body mass index (24.53 vs 28.91, respectively; P < .02). Both groups were majority Hispanic and more commonly male (DLM 65% vs non-DLM 60%). All of the DLM patients had surgery on the lateral discoid meniscus (n = 48), whereas the non-DLM group had surgery on the lateral meniscus (n = 37), medial meniscus (n = 7), or both (n = 1). A majority of patients in both groups underwent meniscal repair (DLM 73% and non-DLM 62%), and there was no difference in surgical treatment between groups (P > .05). A statistically significant improvement was seen in International Knee Documentation Committee (IKDC) and Physical Activity Questionnaire (PAQ) scores from the preoperative assessment to 6 months, 1 year, and 2 years after surgery for both DLM and non-DLM groups (P < .05). No difference was found in scores between DLM and non-DLM groups, between sexes, or between age groups (<13 years or ≥13 years) (P > .05). CONCLUSION: Although patients with DLM were younger and had lower body mass index, the IKDC and PAQ scores were not significantly different between the DLM and non-DLM groups. Both groups showed a significant improvement in scores relative to their preoperative scores. Sex and age did not affect IKDC or PAQ scores.

Increased open fracture complications following pediatric all-terrain vehicle accidents.

BACKGROUND: ATV (All-Terrain Vehicle) related open fractures are often high energy and may be highly contaminated. We asked whether they were more complicated than other open fractures in pediatric patients. METHODS: A retrospective chart review was performed comparing ATV associated open fractures to open fractures sustained in non-ATV related accidents. 97 pediatric open fractures from 2015 to 2021 were identified based on ICD-10 codes. Of these fractures, 62 were non-ATV related and 35 were ATV related. Charts were reviewed to collect basic demographics, fracture pattern, Gustilo-Anderson classification, procedures performed, operative findings, and complications. RESULTS: Our cohort was predominantly male (71% in the ATV group and 76% in the non-ATV group). White race was more common in both the ATV (28 (80%)) and non-ATV (50(78%)) groups. The distribution of AO/OTA fractures was significantly different (p = 0.046), with humerus fractures being more common in the ATV group (8 (22%)) vs. non-ATV group (6 (9.3%)). The ATV group had a higher proportion of more severe type II and III open fractures with 77.1% (n = 27), versus 56% (n = 35) in the non-ATV group (p = 0.020).. Revision and reoperation were more likely in the ATV group (16 (23%)) vs. the non-ATV group (12 (15%)), as was malunion (ATV group 3 (4.3%) Vs. non-ATV 0 (0%)). CONCLUSION: Open fractures resulting from ATV injuries tend to be more complex and have higher rates of revision and malunion. This information supports the large body of evidence on the dangers of ATVs to children and can help guide expectations of both clinicians and family members of patients presenting with these injuries.

Delayed Diagnosis of Pediatric Sternoclavicular Joint Infections and Clavicular Osteomyelitis During the COVID-19 Pandemic: A Report of 3 Cases.

Sternoclavicular joint infections and osteomyelitis of the clavicle are extremely rare infections, especially in the pediatric population. Early signs of these infections are nonspecific and can be mistaken for common upper respiratory infections such as COVID-19 and influenza. Rapid diagnosis and treatment are critical for preventing potentially fatal complications such as mediastinitis. We present three cases of sternoclavicular joint infections in the past year during the COVID-19 pandemic. All three patients had delayed diagnoses likely secondary to COVID-19 workup. Each patient underwent surgical irrigation and débridement. Two of three patients required multiple surgeries and prolonged antibiotic courses. Placement of antibiotic-impregnated calcium sulfate beads into the surgical site cleared the infection in all cases where they were used. All three patients made a full recovery; however, the severity of their situations should not be overlooked. Children presenting to the hospital with chest pain, fever, and shortness of breath should not simply be discharged based on a negative COVID-19 test or other viral assays. A higher index of suspicion for bacterial infections such as clavicular osteomyelitis is important. Close attention must be placed on the physical examination to locate potential areas of concentrated pain, erythema, or swelling to prompt advanced imaging if necessary.

A Case Report of Trevor's Disease in a Pediatric Patient with Hereditary Multiple Exostoses Disease.

Introduction: Hereditary multiple exostoses (HME) disease is hallmarked by cartilaginous osteochondromas secondary to an autosomal dominant mutation within the exostosin gene family. These outgrowths predominantly occur around the long bone physis. An associated disease is dysplasia epiphysealis hemimelica also known as Trevor's disease. Trevor's disease is hallmarked by intra-articular osteochondromas. While the two diseases are similar, they are not genetically related and often have differing patient presentations. Case Report: We report on a case of a 7-year-old female with a familial history significant for HME that presented with an isolated chief complaint of elbow extension block secondary to osteochondromas found both intra-articular and at the olecranon fossa. We present what could be one of the first cases of coexisting HME and Trevor's disease of the upper extremity. Conclusion: Our patient's unique presentation of an intra-articular osteochondroma speculated to be a result of Trevor's disease, in the presence of an established HME diagnosis. Management for this patient did not deviate heavily from the established approach for HME which entails conservative observation until symptomatic. Due to the substantial loss of range of motion (ROM), surgical intervention took place in the form of exostoses removal and necessary reconstruction of the fossa. The patient's ROM subsequently was restored to near normal.

Impact of Patient Resilience on Outcomes of Open Brostrom-Gould Lateral Ligament Repair.

INTRODUCTION: Little is known about the factors affecting the intermediate outcomes of the Brostrom-Gould repair as measured by new patient-reported outcome instruments and the impact of patient resilience on postoperative outcomes. This is the first study to investigate the impact of resilience on the outcomes of lateral ligament repair. METHODS: Retrospectively, 173 patients undergoing Brostrom-Gould at single institution from January 2013 to June 2020 were identified. Patient characteristics, participation in athletic activities, surgical variables, and complications were recorded. Patient-Reported Outcome Measurement Information System (PROMIS) Pain Interference v1.1 (PI), Physical Function v1.2 (PF), and the Foot Ankle Ability Measure (FAAM) were collected. The Brief Resilience Scale was used to quantify resilience. A linear regression model was constructed to evaluate the independent effect of resilience on each PROMIS and FAAM outcome instrument. Variables were included in the regression model based on an a priori significance threshold of P <0.05 in bivariate analysis. RESULTS: Resilience's independent effect on outcome measures was as follows: PROMIS PF (unstandardized ß 8.2, 95% confidence interval [CI] 3.9 to 12.6), PROMIS PI (unstandardized ß -4.8, 95% CI -7.9 to -1.7), FAAM Activities of Daily Living (unstandardized ß 16.6, 95% CI 8.7 to 24.6), and FAAM Sports (unstandardized ß 28.4, 95% CI 15.9 to 40.9). Preoperative participation in athletic activities also had a positive independent effect on multiple outcome metrics including PROMIS PF (unstandardized ß 9.4, 95% CI 2.8 to 16.0), PROMIS PI (unstandardized ß -5.3, 95% CI -10.0 to -0.582), and FAAM Sport scores (unstandardized ß 34.4, 95% CI 15.4 to 53.4). CONCLUSIONS: Resilience and patient participation in athletic activities are independent predictors of improved postoperative functional outcomes as measured by PROMIS and FAAM instruments at intermediate term follow-up. Resilient patients and athletes reported markedly higher PF and less pain burden postoperatively. Preoperative quantification of resilience could enable improved prognostication of patients undergoing lateral ligament repair of the ankle.

The Role of Dendritic Cell Maturation in the Induction of Insulin-Dependent Diabetes Mellitus.

Dendritic cells (DCs) are the dominant class of antigen-presenting cells in humans and are largely responsible for the initiation and guidance of innate and adaptive immune responses involved in maintenance of immunological homeostasis. Immature dendritic cells (iDCs) phagocytize pathogens and toxic proteins and in endosomal vesicles degrade them into small fragments for presentation on major histocompatibility complex (MHC) II receptor molecules to naïve cognate T cells (Th0). In addition to their role in stimulation of immunity, DCs are involved in the induction and maintenance of immune tolerance toward self-antigens. During activation, the iDCs become mature. Maturation begins when the DCs cease taking up antigens and begin to migrate from their location in peripheral tissues to adjacent lymph nodes or the spleen where during their continued maturation the DCs present stored antigens on surface MHCII receptor molecules to naive Th0 cells. During antigen presentation, the DCs upregulate the biosynthesis of costimulatory receptor molecules CD86, CD80, CD83, and CD40 on their plasma membrane. These activated DC receptor molecules bind cognate CD28 receptors presented on the Th0 cell membrane, which triggers DC secretion of IL-12 or IL-10 cytokines resulting in T cell differentiation into pro- or anti-inflammatory T cell subsets. Although basic concepts involved in the process of iDC activation and guidance of Th0 cell differentiation have been previously documented, they are poorly defined. In this review, we detail what is known about the process of DC maturation and its role in the induction of insulin-dependent diabetes mellitus autoimmunity.

The Role of Indoleamine 2, 3-Dioxygenase in Immune Suppression and Autoimmunity.

Indoleamine 2, 3-dioxygenase (IDO) is the first and rate limiting catabolic enzyme in the degradation pathway of the essential amino acid tryptophan. By cleaving the aromatic indole ring of tryptophan, IDO initiates the production of a variety of tryptophan degradation products called "kynurenines" that are known to exert important immuno-regulatory functions. Because tryptophan must be supplied in the diet, regulation of tryptophan catabolism may exert profound effects by activating or inhibiting metabolism and immune responses. Important for survival, the regulation of IDO biosynthesis and its activity in cells of the immune system can critically alter their responses to immunological insults, such as infection, autoimmunity and cancer. In this review, we assess how IDO-mediated catabolism of tryptophan can modulate the immune system to arrest inflammation, suppress immunity to cancer and inhibit allergy, autoimmunity and the rejection of transplanted tissues. Finally, we examine how vaccines may enhance immune suppression of autoimmunity through the upregulation of IDO biosynthesis in human dendritic cells.