Risk Factors for Prolonged Symptoms of Mild Traumatic Brain Injury: A Pediatric Sports Concussion Clinic Cohort.

OBJECTIVE: To examine predictors of prolonged symptom duration from mild traumatic brain injury (mTBI) in a pediatric sports medicine specialty clinic cohort as these predictors may be distinct in this population. DESIGN: Retrospective chart review. SETTING: Outpatient specialty clinic. PATIENTS: Charts of 549 patients (age range: 10-18 years) with concussions were reviewed in an outpatient clinic that predominantly managed sports-related injuries (77.3%). Patients (n = 431) included in the final analysis met the criteria for mTBI and were symptomatic at their first visit. ASSESSMENT OF RISK FACTORS: Patient history, injury, and recovery variables were evaluated. MAIN OUTCOME MEASURES: Predictors of prolonged time to reach self-reported symptom recovery were evaluated using Cox proportional hazards. RESULTS: Median time to symptom recovery of the 431 patients who presented to clinic with symptoms was 40 days (full clinic sample median = 34 days). Analyses identified 3 unique predictors of symptom recovery: loss of consciousness (LOC) [hazard ratio (HR) = 0.56, P < 0.0001], female sex (HR = 0.57, P < 0.0001), and concussion symptom score at first clinic visit (HR = 0.76, P < 0.0001). CONCLUSIONS: Prolonged duration of mTBI symptoms in patients who present to a pediatric sports-based concussion clinic is related to initial symptom severity, female sex, and LOC.

Serial CAD/CAM Bracing: An Alternative to Serial Casting for Early Onset Scoliosis.

BACKGROUND: Years of casting for infantile scoliosis can lead to significantly detrimental quality of life for both the child and parents. Concerns have been raised about the long-term negative neurodevelopmental effects of repeated anesthesia on young children. We developed an elongation bending derotation brace (EBDB) that uses primarily a bending derotation force applied to the curve to achieve the same goals as the cast. The goal of the study is to describe the preliminary results of a technique for creation of EBDB for infantile idiopathic scoliosis using computer-aided design/computer-aided milling (CAD/CAM) technology with at least 24 months follow-up. METHODS: Nine patients with infantile idiopathic scoliosis had minimum 2-year follow-up (mean, 3.4 y; range, 2 to 6 y). Mean age at the treatment was 11 months (4 to 24 mo). There were 2 right thoracic, 7 left thoracic curves. CAD/CAM technology was used to create the EBDB after the child was placed in traction and a derotation strap applied. The same rotational forces that are used in the creation of the Mehta-type cast can also be utilized in creating the brace. A laser scanner was used to obtain the spinal geometry. Compliance can be monitored with a heat sensor. RESULTS: Four patients were full corrected with serial bracing alone (curve ≤10 degrees). Five patients with more rigid curves showed improvement from mean 57 degrees (48 to 62 degrees) to mean 21 degrees (10 to 44 degrees). CONCLUSIONS: This paper describes the preliminary results of a new methodology for creating a patient-specific brace for infantile scoliosis using CAD/CAM technology. This methods shows promising potential to treat the infantile curve without the drawbacks of casting. LEVEL OF EVIDENCE: Level IV.

The Relationship of Foot Strike Pattern, Shoe Type, and Performance in a 50-km Trail Race.

Recent "in-race" studies have observed the foot strike patterns of runners in traditional road marathon races. However, similar studies have not been conducted for trail runners, which have been estimated to account for 11% of all runners. The purpose of this study was to (a) determine the rear-foot strike (RFS) prevalence in a 50-km trail race and compare with traditional road marathon races; (b) determine if there is a relationship between foot strike and sex in a 50-km trail race; and (c) determine if there is a relationship between foot strike, shoe type, and performance in a 50-km trail race. One hundred sixty-five runners were videotaped at the 8.1-km mark of the 2012 Ice Age Trail 50-km race. Foot strike analysis revealed RFS prevalence of 85.1%, less than previously reported in traditional road marathon races. There was no relationship found between sex and foot strike (p = 0.60). A significant effect of shoe type on foot strike (RFS was less common among runners in minimalist shoes, p < 0.01) and performance (faster runners were more likely to be wearing minimalist shoes, p < 0.01) was observed; however, no association between foot strike and performance was observed (p = 0.83). This study suggests that most trail runners, albeit less than road runners, prefer an RFS pattern, which is accompanied by biomechanical consequences unique from a non-RFS pattern and, therefore, likely carries a unique injury profile. In addition, the findings in this study suggest that minimalist shoes may represent a reasonable training modification to improve performance.

An efficient three-component synthesis of highly functionalized tetrahydroacenaphtho[1,2-b]indolone derivatives catalyzed by L-proline.

An efficient and diastereoselective synthetic procedure for highly functionalized tetrahydroacenaphtho[1,2-b]indolone derivatives was successfully developed by the three-component reaction of acenaphthequinone, enaminones, and barbituric acid in the presence of a catalytic amount of L-proline. This method has the advantages of convenient operation, excellent yields, mild reaction conditions, and environmental friendliness.

Correlation of transverse rotation of the spine using surface topography and 3D reconstructive radiography in children with idiopathic scoliosis.

PURPOSE: The relationship between axial surface rotation (ASR) measured by surface topography (ST) and axial vertebral rotation (AVR) measured by radiography in the transverse plane is not well defined. This study aimed to: (1) quantify ASR and AVR patterns and their magnitudes from T1 to L5; (2) determine the correlation or agreement between the ASR and AVR; and (3) investigate the relationship between axial rotation differences (ASR-AVR) and major Cobb angle. METHODS: This is a retrospective study evaluating patients (age 8-18) with IS or spinal asymmetry with both radiographic and ST measurements. Demographics, descriptive analysis, and correlations and agreements between ASR and AVR were evaluated. A piecewise linear regression model was further created to relate rotational differences to Cobb angle. RESULTS: Fifty-two subjects met inclusion criteria. Mean age was 14.1 ± 1.7 and 39 (75%) were female. Looking at patterns, AVR had maximal rotation at T8, while ASR had maximal rotation at T11 (r = 0.35, P = .006). Cobb angle was 24.1° ± 13.3° with AVR of - 1° ± 4.6° and scoliotic angle was 20.9° ± 11.5° with ASR of - 2.3° ± 6.6°. (ASR-AVR) vs Cobb angle was found to be very weakly correlated with a curve of less than 38.8° (r = 0.15, P = .001). CONCLUSION: Our preliminary findings support that ASR measured by ST has a weak correlation with estimation of AVR by 3D radiographic reconstruction. This correlation may further help us to understand the application of transverse rotation in some clinical scenarios such as specific casting manipulation, padding mechanism in brace, and surgical correction of rib deformity.

3D Back Contour Metrics in Predicting Idiopathic Scoliosis Progression: Retrospective Cohort Analysis, Case Series Report and Proof of Concept.

Adolescent Idiopathic Scoliosis is a 3D spinal deformity commonly characterized by serial radiographs. Patients with AIS may have increased average radiation exposure compared to unaffected patients and thus may be implicated with a modest increase in cancer risk. To minimize lifetime radiation exposure, alternative imaging modalities such as surface topography are being explored. Surface topography (ST) uses a camera to map anatomic landmarks of the spine and contours of the back to create software-generated spine models. ST has previously shown good correlation to radiographic measures. In this study, we sought to use ST in the creation of a risk stratification model. A total of 38 patients met the inclusion criteria for curve progression prediction. Scoliotic curves were classified as progressing, stabilized, or improving, and a predictive model was created using the proportional odds logistic modeling. The results showed that surface topography was able to moderately appraise scoliosis curvatures when compared to radiographs. The predictive model, using demographic and surface topography measurements, was able to account for 86.9% of the variability in the future Cobb angle. Additionally, attempts at classification of curve progression, stabilization, or improvement were accurately predicted 27/38 times, 71%. These results provide a basis for the creation of a clinical tool in the tracking and prediction of scoliosis progression in order to reduce the number of X-rays required.

Does extracorporeal shock wave therapy enhance healing of osteochondritis dissecans of the rabbit knee?: a pilot study.

BACKGROUND: Severe osteochondritis dissecans (OCD) in children and adolescents often necessitates surgical interventions (ie, drilling, excision, or débridement). Since extracorporeal shock wave therapy (ESWT) enhances healing of long-bone nonunion fractures, we speculated ESWT would reactivate the healing process in OCD lesions. QUESTIONS/PURPOSES: We asked whether ESWT would enhance articular cartilage quality, bone and cartilage density, and histopathology of osteochondral lesions compared to nontreated controls in an OCD rabbit model. METHODS: We harvested a 4-mm-diameter plug of the weightbearing osteochondral surface on the medial femoral condyle of each knee in 20 skeletally immature (8-week-old) female rabbits. We placed a piece of acellular collagen-glycosaminoglycan matrix into the cavity and then replaced the plug. Two weeks after surgery, we sedated each rabbit and treated the right knee in a single setting with shock waves: 4000 impulses at 4 Hz and 18 kV. The left knee was a sham control. Ten weeks after surgery, we assessed cartilage morphology of the lesion using a modified Outerbridge Grading System, bone and cartilage density using histologic imaging, bone and cartilage morphology using the histopathology assessment system, and radiographic bone density and union and compared these parameters between ESWT-treated and control knees. RESULTS: Histologically, we observed more mature bone formation and better healing (1.1 versus 3.4) and density of the cartilage (60 versus 49) on the treated side. Radiographically, we noted an increase in bony density (154 versus 138) after ESWT. CONCLUSIONS: ESWT accelerated the healing rate and improved cartilage and subchondral bone quality in the OCD rabbit model. CLINICAL RELEVANCE: This therapeutic modality may be applicable in OCD treatment in the pediatric population. Future research will be necessary to determine whether it may play a role in healing of human osteochondral defects.

Can fresh osteochondral allografts restore function in juveniles with osteochondritis dissecans of the knee?

BACKGROUND: Failure of initial treatment for juvenile osteochondritis dissecans (OCD) may require further surgical intervention, including microfracture, autograft chondrocyte implantation, osteochondral autografting, and fresh osteochondral allografting. Although allografts and autografts will restore function in most adults, it is unclear whether fresh osteochondral allograft transplantations similarly restore function in skeletally immature patients who failed conventional treatment. QUESTIONS/PURPOSES: Therefore, we determined function in (1) daily activity; (2) sports participation; and (3) healing (by imaging) in children with juvenile OCD who failed conventional therapy and underwent fresh osteochondral allograft transplantation. METHODS: We retrospectively reviewed 11 children with OCD of the knee treated with a fresh stored osteochondral allograft between 2004 and 2009 (six males and five females). The average age of the children at the time of their allograft surgery was 15.2 years (range, 13-20 years). The clinical assessments included physical examination, radiography, MRI, and a modified Merle D'Aubigné-Postel score. The size of the allograft was an average of 5.11 cm(2). The minimum followup was 12 months (average, 24 months; range, 12-41 months). RESULTS: All patients had returned to activities of daily living without difficulties at 6 months and returned to full sports activities between 9 and 12 months after surgery. The modified Merle D'Aubigné-Postel score improved from an average of 12.7 preoperatively to 16.3 at 24 months postoperatively. Followup radiographs at 2 years showed full graft incorporation and no demarcation between the host and graft bone. CONCLUSIONS: Our observations suggested fresh osteochondral allografts restored short-term function in patients with juvenile OCD who failed standard treatments. LEVEL OF EVIDENCE: Level IV, case series. See Guidelines for Authors for a complete description of levels of evidence.

The in-vivo effect of torque on growth in caudal vertebrae.

Numerous studies involving axial distraction and compression of the spine indicate that longitudinal loading affects the vertebral growth plate as well as modulation of spinal growth. Furthermore, asymmetric loading is involved in curve progression as a result of vertebral bone changes and disc wedging. As with longitudinal loading, direct or indirect application of torque to the growth plate may have an influence as well. A study was undertaken to develop a fixture that may be applied in-vivo to generate controlled torsional loads and to examine the effect of such torsional loads on the growth plate in caudal vertebrae. It is shown that application of torque leads to curvature in the morphology of the growth plate, a reduced width (medial to lateral distance of the growth plate) and remarkably increased thickness (height of 3 physeal zones in the growth plate) and dramatically widened disc space.

Idiopathic Congenital Talipes Equinovarus in Wisconsin Newborns: Incidence and Associated Risk Factors.

INTRODUCTION: Clubfoot, also known as idiopathic congenital talipes equinovarus, is one of the most common pediatric deformities affecting 1 to 2 in every 1,000 live births. We sought to provide the first known analysis of incidence of clubfoot diagnoses in the most populous region of Wisconsin as well as risk factors associated with the deformity. METHODS: We conducted a retrospective study on children treated for clubfoot at Children's Wisconsin from January 1, 2004, through December 31, 2018. To examine trends, we performed a linear trend of annual clubfoot births for each county covered as well as the southeastern region of Wisconsin. We also analyzed common risk factors associated with clubfoot. RESULTS: The study population included 760 clubfoot patients: 497 males and 263 females. Most patients were non-Hispanic/Latino (76.8%) and White (72.2%). A total of 414 patients (54.4%) had no family history of clubfoot, 130 patients (17.1%) had a positive family history of clubfoot, and family history was unknown for 216 patient (28.4%). The southeastern region of Wisconsin contained the largest patient population (n = 523) and, among counties studied, Milwaukee County had the largest patient population (n = 269). Linear trends for Milwaukee County and the southeastern region of Wisconsin showed a statistically significant increase in clubfoot births from 2004 through 2017 (P < 0.001). CONCLUSIONS: In this study of children diagnosed with clubfoot, high population areas showed a statistically significant increase in the number of children affected over time, with a low evidence of family history. This study provides further insight into the possible etiology of clubfoot being influenced by an exogenous, environmental factor.

Long-term follow-up of children with a surgically treated clubfoot: Assessing the multi-segment-foot motions, dynamic plantar pressures, and functional outcomes.

OBJECTIVE: The purpose of this study was to compare surgically treated clubfoot with typically developing (TD) children using plantar pressure, multi-segment-foot kinematic analysis, and multiple functional outcomes in comprehensive and long-term study. Methods: 26 patients with 45 clubfeet and 23 TD children with 45 normal feet were evaluated. Most clubfoot patients had a complete subtalar release and a few patients had a posterior medial-lateral release at the mean age of 5 years and 6 months. The mean age at follow-up for clubfoot was 12 years and 5 months. Subjects underwent physical and radiographic examination, plantar pressure analysis, multi-segment-foot motion analysis, AAOS Foot & Ankle Questionnaire (AAOS-FAQ), the Pediatric Outcomes Data Collection Instrument (PODCI), and the Child Behavior Checklist (CBCL). RESULTS: Clubfoot patients scored significantly worse than TD on the AAOS-FAQ (90.9 vs.99.9 for pain and comfort), the CBCL Problems scale (23.1 vs.6.3), and several subscales of the PODCI (86.5 vs.96.7 for Sports and Physical Functioning) (P<0.05). Peak pressure at the lateral heel (25.6 vs.29.6 N/cm2), contact area at the 1 st metatarsal head (1 st MT) (6.0 vs. 7.2 cm2) and the pressure time integral at the 1 st MT (5.2 vs. 11.0 N/cm2 ∗ s) were significantly lower for the clubfoot group compared to the TD foot group (P<0.05). Maximum dorsiflexion of the 1 st metatarsal-hallux (1 st MT-Hal) (17.5° vs. 34.8°) during stance phase (ST), supination of the 1 st MT-Hal during swing phase (SW) (4° vs. 7°), maximum plantarflexion of the ankle during ST (-6.8° vs.-11.2°), and maximum varus of the ankle during SW (4.4° vs. 6.9°) were also lower for clubfoot except for maximum dorsiflexion of the navicular-1 st MT (P<0.05). CONCLUSION: This study supports evidence that surgically treated clubfoot continues to have residual deformity of forefoot, overcorrection of hindfoot, stiffness, and a decrease in physical functioning. This comprehensive study accurately portrays postsurgical clubfoot function with objective means through appropriate technologies. A plantar pressure redistributed and finite element analysis designed orthosis may be of importance in the improvement of the foot and ankle joint function for ambulatory children with a relapse of clubfoot deformity.

A Retrospective Comparison of Above- vs Below-the-Knee Cast Treatment for Salter Harris-II Distal Tibia Fractures.

BACKGROUND: Distal tibia fractures are common in the pediatric patient population. Recent reports suggest that patients with closed low-energy distal tibial fractures treated with short leg casts (SLCs) have similar radiographic outcomes with improved functional outcomes compared to those treated with long leg casts (LLCs). However, to date there has not been a study comparing these treatment modalities for Salter-Harris (SH) II distal tibia fractures. The purpose of this study was to compare the radiographic and time to weightbearing outcomes between patients with SH-II tibial ankle fractures treated with an SLC vs an LLC. METHODS: A retrospective review on SH-II distal tibia fractures was performed at a Level I pediatric trauma center from 2013 to 2020. Primary outcomes included final coronal angulation, sagittal angulation, and time to weightbearing. RESULTS: A total of 59 patients with SH-II distal tibia fractures were treated with an SLC (22 patients, median age 11.79 years) or an LLC (37 patients, median age 12.17 years). There was no statistically significant difference between the 2 treatment groups for coronal angulation at final follow-up, sagittal angulation at final follow-up, or percentage of patients fully weightbearing at 6 weeks (P > .05). No patients required subsequent remanipulation or operative treatment in either treatment group. CONCLUSION: In this retrospective review with relatively short-term follow-up, SLCs were found to be noninferior to LLCs for treatment of reduced SH-II distal tibia fractures. This casting option may still be considered by surgeons who are nonoperatively managing pediatric distal tibia fractures. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Biomechanical Effects of Thoracolumbosacral Orthosis Design Features on 3D Correction in Adolescent Idiopathic Scoliosis: A Comprehensive Multicenter Study.

STUDY DESIGN: Multicenter numerical study. OBJECTIVE: To biomechanically analyze and compare various passive correction features of braces, designed by several centers with diverse practices, for three-dimensional (3D) correction of adolescent idiopathic scoliosis. SUMMARY OF BACKGROUND DATA: A wide variety of brace designs exist, but their biomechanical effectiveness is not clearly understood. Many studies have reported brace treatment correction potential with various degrees of control, making the objective comparison of correction mechanisms difficult. A Finite Element Model simulating the immediate in-brace corrective effects has been developed and allows to comprehensively assess the biomechanics of different brace designs. METHODS: Expert clinical teams (one orthotist and one orthopedist) from six centers in five countries participated in the study. For six scoliosis cases with different curve types respecting SRS criteria, the teams designed two braces according to their treatment protocol. Finite Element Model simulations were performed to compute immediate in-brace 3D correction and skin-to-brace pressures. All braces were randomized and labeled according to 21 design features derived from Society on Scoliosis Orthopaedic and Rehabilitation Treatment proposed descriptors, including positioning of pressure points, orientation of push vectors, and sagittal design. Simulated in brace 3D corrections were compared for each design feature class using ANOVAs and linear regressions (significance P ≤ 0.05). RESULTS: Seventy-two braces were tested, with significant variety in the design approaches. Pressure points at the apical vertebra level corrected the main thoracic curve better than more caudal locations. Braces with ventral support flattened the lumbar lordosis. Lateral and ventral skin-to-brace pressures were correlated with changes in thoracolumbar/lumbar Cobb and lumbar lordosis (r =- 0.53, r = - 0.54). Upper straps positioned above T10 corrected the main thoracic Cobb better than those placed lower. CONCLUSIONS: The corrective features of various scoliosis braces were objectively compared in a systematic approach with minimal biases and variability in test parameters, providing a better biomechanical understanding of individual passive mechanisms' contribution to 3D correction.

Insole-pressure distribution for normal children in different age groups.

BACKGROUND: In measuring plantar pressures during gait, earlier methods have used a platform system that does not take into account the interactions feet have with orthotics and shoe wearing. The purpose of the study was to provide normal insole plantar pressure parameter data during stance phase using the Pedar pressure insole system. METHODS: Twenty-nine normal children, age 6 to 16 years, were recruited and walked along the 25 m walkway at self-selected speeds. Patients were divided into 2 separate groups for statistical analysis--juniors (< 12 y old) and teenagers (> 13 y old). The pressure map was divided into 8 regions (masks) determined by anatomic landmarks and a total of 7 pressure parameters were analyzed of each mask. RESULTS: We did not detect significant differences in foot pressures between juniors and teenagers when regarding sex, or left and right feet for 7 parameters measured. CONCLUSIONS: This normative data will provide a basis with which to more accurately assess pediatric pathologic foot deformities and to distinguish dynamic foot deformities from anatomic foot deformities. THE LEVEL OF EVIDENCE: Level II.

MRI pathoanatomy study of congenital vertical talus.

BACKGROUND: Prior reports regarding the pathologic anatomy for congenital vertical talus have noted some disagreement as to which elements of the pathologic anatomy are consistently present. The purpose of his study is to evaluate the 3-dimensional morphologic changes and pathoanatomy of the congenital vertical talus using magnetic resonance imaging. METHODS: Nine patients with congenital vertical talus (ranging from 5 mo-11 y) underwent magnetic resonance imaging of both feet. A foot and ankle coil was used for the 1.5 T system. The protocol consisted of T1-weighted spin echo sequence image and T2-weighted fast spin echo sequence image in the sagittal, coronal, and axial planes. Slice thickness ranged from 3 to 4 mm with 0 to 1.0 mm interspace thickness. A descriptive analysis was performed based upon the T1-weighted image by physicians. RESULTS: At the level of the talonavicular joint, the navicular was seen significantly subluxed dorsally with associated wedging of the navicular. At the level of the calcaneocuboid joint, often there was a significant dorsal subluxation of the cuboid in relation to the calcaneus. Lateral obliquity of the calcaneocuboid joint could be present to varying degrees. The anterior calcaneus was significantly laterally displaced in relation to the talar head with an element of lateral translation and eversion of the calcaneus at the subtalar joint. Distal cavus at the cuneiform-first metatarsal joint was observed in 5 patients. CONCLUSIONS: This study suggests that there is significant pathology at the level of subtalar joint in congenital vertical talus. In addition to satisfactory reduction of the talonavicular joint, methods to ensure realignment of the calcaneus under the talus may be a crucial component of deformity correction and to prevent recurrence of deformity. LEVEL OF EVIDENCE: A Level III diagnostic study using normal pediatric foot anatomy in magnetic resonance imaging as a reference.

Modified constraint-induced movement therapy for a 12-month-old child with hemiplegia: a case report.

OBJECTIVE: This case report describes the use of modified constraint-induced movement therapy (CIMT) to improve upper-limb function in a 12-month-old child with right hemiplegia. It also describes parent concerns about CIMT and documents the short- and long-term effects of modified CIMT. METHOD: The participant was assessed 5 times over a 7.5-month period using the Peabody Developmental Motor Scales-2, Pediatric Motor Activity Log, Toddler Amount of Use Test, and Knox Parent Questionnaire. CIMT included a nonremovable cast worn on the unaffected arm and approximately 8 hr per week of occupational and physical therapy for 2 weeks. RESULTS: Benefits of improved upper-limb function measured immediately after CIMT were sustained at 6 months' follow-up. No adverse events related to cast use were reported. DISCUSSION: The findings from this case report suggest that CIMT was a safe intervention associated with improving upper-limb function for this young child with hemiplegia.

Reliability of Three-Dimensional Spinal Modeling of Patients With Idiopathic Scoliosis Using EOS System.

STUDY DESIGN: Three-dimensional (3D) spinal models of children with idiopathic scoliosis (IS) were created using the EOS imaging system (EOS) and sterEOS software. OBJECTIVE: To determine the inter- or intraobserver reproducibility of the 3D spinal models in children with IS of different apex locations. SUMMARY OF BACKGROUND DATA: 3D spinal model measurements include the Cobb angle, kyphosis, lordosis, and axial vertebral rotation (AVR). Variation of these measurements between two investigators and two different trials by the same investigator were analyzed by inter- and intraclass correlation coefficients (ICCs). METHODS: Biplanar radiographic images of 15 patients (age: 6-15 years) with IS were uploaded into the sterEOS software. Spinal and pelvic markers were manually identified to construct a 3D spinal model and measure spinal parameters. Two trained examiners independently performed modeling and performed modeling in spaced out trials. The ICC between inter- and intraobservers were calculated. RESULTS: ICCs between inter- and intraobservers were significant for all parameters (p < .05). Both the inter- and intraobservers showed excellent agreement for the Cobb angles in the thoracic segment, kyphosis and lordosis. Substantial interobserver agreement and excellent intraobserver agreement were determined for the Cobb angle in the thoracolumbar or lumbar (TL/L) segment, with less than 6° difference between two raters and less than 2° difference between two trials. Substantial interobserver agreement for the AVR in the TL/L region and substantial interobserver agreement for the AVR in the thoracic region were found, with less than 4° difference between raters. One rater had substantial intraobserver agreement for the AVR in the TL/L region whereas another rater reported moderate to substantial intraobserver agreement in both the thoracic and TL/L regions, with less than 3° difference between trials. CONCLUSION: The EOS system shows reliable and repeatable results in 3D spinal modeling of children with IS. LEVEL OF EVIDENCE: Level III.

Current Strategies and Future Directions to Optimize ACL Reconstruction in Adolescent Patients.

The incidence of anterior cruciate ligament (ACL) injuries in the pediatric population has risen in recent years. These injuries have historically presented a management dilemma in skeletally immature patients with open physes and significant growth remaining at time of injury. While those nearing skeletal maturity may be treated with traditional, transphyseal adult techniques, these same procedures risk iatrogenic damage to the growth plates and resultant growth disturbances in younger patients with open physes. Moreover, conservative management is non-optimal as significant instabilities of the knee remain. Despite the development of physeal-sparing reconstructive techniques for younger patients, there remains debate over which procedure may be most suitable on a patient to patient basis. Meanwhile, the drivers behind clinical and functional outcomes following ACL reconstruction remain poorly understood. Therefore, current strategies are not yet capable of optimizing surgical ACL reconstruction on an individualized basis with absolute confidence. Instead, aims to improve surgical treatment of ACL tears in skeletally immature patients will rely on additional approaches in the near future. Namely, finite element models have emerged as a tool to model complex knee joint biomechanics. The inclusion of several individualized variables such as bone age, three dimensional geometries around the knee joint, tunnel positioning, and graft tension collectively present a possible means of better understanding and even predicting how to enhance surgical decision-making. Such a tool would serve surgeons in optimizing ACL reconstruction in the skeletally immature individuals, in order to improve clinical outcomes as well as reduce the rate of post-operative complications.

Long-Term Effects of Orthoses Use on the Changes of Foot and Ankle Joint Motions of Children With Spastic Cerebral Palsy.

BACKGROUND: Orthoses commonly are prescribed to children with cerebral palsy (CP) to provide foot correction and to improve ambulatory function. Immediate effects of ankle foot orthosis (AFOs) have been investigated, but long-term kinematic effects are lacking clinical evidence. OBJECTIVE: To determine changes in 3-dimensional ankle and foot segment motion in pediatric patients with CP between initial and follow-up visits (18-month average time differences) in both barefoot gait and gait with their AFO. We also investigated intravisit changes between barefoot and AFO gait. DESIGN: A prospective cohort study. SETTING: Children's Hospital of Wisconsin, Department of Orthopaedic Surgery, Medical College of Wisconsin. PATIENTS: A total of 23 children with CP, mean age 10.5 years (6.2-18.1 years) were clinically prescribed either a solid ankle foot orthotic (SAFO), hinged ankle foot orthotic (HAFO), or supramalleolar orthotic. METHODS: Holes were cut in the study orthoses so that electromagnetic markers could be directly placed on the skin. A 6-foot segment model was used. OUTCOME MEASUREMENTS: Kinematic and kinetic data were recorded for each patient's initial and follow-up visit (18-month follow-up average, 15-20 months range). RESULTS: For the SAFO group (gait with AFO), a significant decrease in dorsiflexion was found between the initial and third visit (P = .008). Furthermore, the SAFO group (barefoot gait) had an increased eversion at the midfoot for most of the gait cycle (P < .008). Sagittal forefoot range of motion was reduced for all 3 groups between the barefoot and AFO groups. CONCLUSION: The use of AFOs long term either maintained or improved foot deformities or dysfunction. LEVEL OF EVIDENCE: Level II.

A Pilot Study of Iyengar Yoga for Pediatric Obesity: Effects on Gait and Emotional Functioning.

Obesity negatively impacts the kinematics and kinetics of the lower extremities in children and adolescents. Although yoga has the potential to provide several distinct benefits for children with obesity, this is the first study to examine the benefits of yoga for gait (primary outcome) in youths with obesity. Secondary outcomes included health-related quality of life (HRQoL), physical activity, and pain. Feasibility and acceptability were also assessed. Nine youths (11⁻17 years) participated in an eight-week Iyengar yoga intervention (bi-weekly 1-h classes). Gait, HRQOL (self and parent-proxy reports), and physical activity were assessed at baseline and post-yoga. Pain was self-reported at the beginning of each class. Significant improvements were found in multiple gait parameters, including hip, knee, and ankle motion and moments. Self-reported and parent-proxy reports of emotional functioning significantly improved. Time spent in physical activity and weight did not change. This study demonstrates that a relatively brief, non-invasive Iyengar yoga intervention can result in improved malalignment of the lower extremities during ambulation, as well as in clinically meaningful improvements in emotional functioning. This study extends current evidence that supports a role for yoga in pediatric obesity.