Blood Pressure Responses During Exercise: Physiological Correlates and Clinical Implications.

BACKGROUND: Abnormal blood pressure (BP) responses to exercise can predict adverse cardiovascular outcomes, but their optimal measurement and definitions are poorly understood. We combined frequently sampled BP during cardiopulmonary exercise testing with vascular stiffness assessment to parse cardiac and vascular components of exercise BP. METHODS: Cardiopulmonary exercise testing with BP measured every two minutes and resting vascular tonometry were performed in 2858 Framingham Heart Study participants. Linear regression was used to analyze sex-specific exercise BP patterns as a function of arterial stiffness (carotid-femoral pulse wave velocity) and cardiac-peripheral performance (defined by peak O2 pulse). RESULTS: Our sample was balanced by sex (52% women) with mean age 54±9 years and 47% with hypertension. We observed variability in carotid-femoral pulse wave velocity and peak O2 pulse across individuals with clinically defined exercise hypertension (peak systolic BP [SBP] in men ≥210 mm Hg; in women ≥190 mm Hg). Despite similar resting SBP and cardiometabolic profiles, individuals with higher peak O2 pulse displayed higher peak SBP (P≤0.017) alongside higher fitness levels (P<0.001), suggesting that high peak exercise SBP in the context of high peak O2 pulse may in fact be favorable. Although both higher (favorable) O2 pulse and higher (adverse) arterial stiffness were associated with greater peak SBP (P<0.0001 for both), the magnitude of association of carotid-femoral pulse wave velocity with peak SBP was higher in women (sex-carotid-femoral pulse wave velocity interaction P<0.0001). In sex-specific models, exercise SBP measures accounting for workload (eg, SBP during unloaded exercise, SBP at 75 watts, and SBP/workload slope) were directly associated with the adverse features of greater arterial stiffness and lower peak O2 pulse. CONCLUSIONS: Higher peak exercise SBP reflects a complex trade-off between arterial stiffness and cardiac-peripheral performance that differs by sex. Studies of BP responses to exercise accounting for vascular and cardiac physiology may illuminate mechanisms of hypertension and clarify clinical interpretation of exercise BP.

Protocol and validity testing of femoroacetabular posterior translation with dynamic hip ultrasonography.

OBJECTIVE: To describe femoroacetabular posterior translation (FAPT) using dynamic hip ultrasonography (DHUS), and to determine the inter- and intra-rater reliability of hip ultrasound measurements of FAPT. MATERIALS AND METHODS: The study design was a feasibility study of 13 healthy young adults (26 hips) using test-retest analysis. The data was collected prospectively over a 2-week time period. Three DHUS measurements (posterior neutral (PN), flexion, adduction, and internal rotation (PFADIR), and stand and load (PStand) were measured by four independent raters (2 senior who divided the cohort, 1 intermediate, 1 junior) at two time points for bilateral hips of each participant. Reliability was assessed by calculating the intraclass correlation coefficient (ICC) along with 95% confidence intervals (CIs) for each rater and across all raters. RESULTS: A total of 468 US scans were completed. The mean age of the cohort was 25.7 years (SD 5.1 years) and 54% were female. The inter-rater reliability was excellent for PFADIR (ICC 0.85 95% CI 0.76-0.91), good for PN (ICC 0.69 95% CI 0.5-0.81), and good for PStand (ICC 0.72 95% CI 0.55-0.83). The intra-rater reliability for all raters was good for PFADIR (ICC 0.60 95% CI 0.44-0.73), fair for PN (ICC 0.42 95% CI 0.21-0.59), and fair for PStand (ICC 0.42 95% CI 0.22-0.59). CONCLUSION: This is the first study to present a protocol using dynamic ultrasonography to measure FAPT. DHUS measure for FAPT was shown to be reliable across raters with varying levels of ultrasound experience.

Anterior Distal Femoral Hemiepiphysiodesis in Children With Fixed Knee Flexion Deformities: Does Screw Position Matter?

BACKGROUND: Anterior distal femoral hemiepiphysiodesis (ADFH) using 2 percutaneous screws is an effective technique for the treatment of fixed knee flexion deformities in children with neuromuscular disorders. The role of sagittal screw position on the outcome of the procedure is unknown. METHODS: This is a retrospective case series of patients who underwent ADFH at a single pediatric hospital from 2013 to 2020. Radiographs were evaluated for sagittal screw position and the associated change in lateral distal femoral physeal angle over time. The position of the 2 screws was classified as either being both in the anterior third of the physis (AA), one screw in the anterior third and the other screw in the middle third (AM), or both screws in the middle third of the physis (MM). RESULTS: The study population included 68 knees in 36 patients. The mean physeal angle at the time of surgery was 93 degrees (SD 4.0 degrees), which increased to 102.4 degrees (SD 5.7 degrees) at 12 months, for a change of 9.4 degrees ( P <0.001). At 24 months, the mean physeal angle was 104.6 degrees (SD 6.3 degrees) for a further change of 2.9 degrees ( P <0.001). When stratified by screw position all screw configurations resulted in an increase in the physeal angle at 12 months. At the 24-month follow-up, the physeal angle in knees with AA screws continued to increase another 3.5 degrees ( P <0.05), there was a minimal change in knees with AM screws (1.47°, P >0.05) and knees with MM screws saw a reversal of physeal angle change (-7.1 degrees, P <0.05). CONCLUSIONS: ADFH using percutaneous screws results in an increase in the lateral distal femoral physeal angle. The rate of correction is largest in the first 12 months after the procedure. As such, this procedure should be considered in patients with less than 2 years of growth remaining. However, initial screw positioning influences the amount of change over time, and close postoperative surveillance until physeal closure is essential for all patients. LEVEL OF EVIDENCE: Level IV-retrospective case series.

Radiographic Measurements of Pes Planovalgus Do Not Predict Clinical Outcomes in Tarsal Coalition Excision.

OBJECTIVE: Many patients who undergo tarsal coalition excision have persistent postoperative pain. Most studies have utilized cat scan (CT) scan parameters of pes planovalgus and heel valgus but have found this to be an inconsistent predictor of outcomes. Plain radiographic parameters have been less utilized in trying to predict outcomes after coalition excision. Radiographic talonavicular coverage angle correlates with pain in patients with flexible pes planovalgus (PPV) but has not been studied in tarsal coalition population. Furthermore, foot alignment is not understood to change after simple coalition excision. The purpose of this study was to compare plain radiographic parameters, including talonavicular coverage angle, with pain after tarsal coalition excision, as well as compare preoperative and postoperative weight-bearing radiographs. METHODS: Seventy-seven feet that underwent excision of the tarsal coalition had clinical outcomes and radiographic data collected >1 year postoperatively. Measures of PPV on preoperative and postoperative weight-bearing radiographs and CT scans were evaluated. RESULTS: Patients were an average of 13 years old at excision. Of the total, 65% had calcaneonavicular (CN) coalitions, whereas the remainder had talocalcaneal coalitions. All patients had significant postoperative improvement in clinical outcomes but 34% (13/38) had continued pain at the most recent follow-up, more so in talocalcaneal than CN coalitions (55% vs 26%, P < 0.001). The subset with CN coalitions had more severe preoperative PPV but greater postoperative PPV improvement. Except for a weak correlation between radiographic weight-bearing (anterior-posterior) talus-first metatarsal angle and pain with activity (r = -0.54), there were no other correlations between preoperative radiographic parameters and clinical outcomes. Heel valgus on CT did not correlate with radiographic measurements of PPV or pain. CONCLUSIONS: We did not find a correlation of radiographic PPV with persistent pain after tarsal coalition excision. We did find improvement in radiographic PPV in CN coalitions after treatment with simple excision. Heel valgus on CT was not a useful metric for evaluating PPV in the setting of a tarsal coalition. LEVEL OF EVIDENCE: Level III-prognostic study.

The Predictability of Clinical Findings and Radiographs for Detecting Tarsal Coalition.

INTRODUCTION: Tarsal coalition is a disorder of the foot characterized by the abnormal union between 2 or more of the tarsal bones. A minority of patients will develop pain and limited motion when reaching adolescence, for whom surgical resection of the coalition may be necessary. The diagnostic value of clinical and radiologic signs remains unclear. The aim of this study is to assess the predictive value of clinical symptoms and plain x-rays to diagnose tarsal coalition in symptomatic patients. METHODS: We performed a retrospective chart review of patients with clinical suspicion of tarsal coalition between January 2011 and November 2019. Patient demographic data; clinical data on pain, limited motion, peroneal spasm, recurrent, or previous trauma; and radiologic data on the presence and type of coalition were collected. Multivariable general estimating equations analysis was used to assess associations between demographic and clinical characteristics and the likelihood of a positive coalition diagnosis. RESULTS: The study cohort was 336 patients (672 feet) with a mean age of 13 years and a 1:1 sex distribution. Thirt-eight percent of feet were diagnosed with a coalition of which 53% were talocalcaneal and 41% were calcaneonavicular. Coalitions were significantly more common in younger patients, males (OR 1.66, P=0.04), patients with lower BMI (OR 0.96, P=0.045), and patients who presented with painful feet (OR 1.59, P=0.04) or feet with limited motion (OR 7.49, P<0.001). Diagnostic utility of plain x-ray compared with CT diagnosis yielded a sensitivity of 76% and a specificity of 94%, with higher sensitivity (90%) in calcaneonavicular coalitions than in talocalcaneal (66%). DISCUSSION: Our study shows that limited subtalar movement, male sex, and low BMI have a high predictive value for tarsal coalition in symptomatic patients. Classic clinical findings that were not predictive of coalition in our cohort of symptomatic patients included peroneal spasm, recurrent ankle sprains, and recent trauma. Plain x-rays offer a reliable alternative to CT for diagnosis, especially for calcaneonavicular coalitions. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

MRI of the Spine in Patients who Toe Walk: Is There a Role?

BACKGROUND: Little is known about the prevalence of intraspinal pathology in children who toe walk, but magnetic resonance imaging (MRI) may be part of the diagnostic workup. The purpose of this study was to examine the role of MRI for children who toe walk with a focus on the rate of positive findings and associated neurosurgical interventions performed for children with said MRI findings. METHODS: A single-center tertiary hospital database was queried to identify a cohort of 118 subjects with a diagnosis of toe walking who underwent spinal MRI during a 5-year period. Patient and MRI characteristics were summarized and compared between subjects with a major abnormality, minor abnormality, or no abnormality on MRI using multivariable logistic regression. Major MRI abnormalities included those with a clear spinal etiology, such as fatty filum, tethered cord, syrinx, and Chiari malformation, while minor abnormalities had unclear associations with toe walking. RESULTS: The most common primary indications for MRI were failure to improve with conservative treatment, severe contracture, and abnormal reflexes. The prevalence of major MRI abnormalities was 25% (30/118), minor MRI abnormalities was 19% (22/118), and normal MRI was 56% (66/118). Patients with delayed onset of toe walking were significantly more likely to have a major abnormality on MRI ( P =0.009). The presence of abnormal reflexes, severe contracture, back pain, bladder incontinence, and failure to improve with conservative treatment were not significantly associated with an increased likelihood of major abnormality on MRI. Twenty-nine (25%) subjects underwent tendon lengthening, and 5 (4%) underwent neurosurgical intervention, the most frequent of which was detethering and sectioning of fatty filum. CONCLUSIONS: Spinal MRI in patients who toe walk has a high rate of major positive findings, some of which require neurosurgical intervention. The most significant predictor of intraspinal pathology was the late onset of toe walking after the child had initiated walking. MRI of the spine should be considered by pediatric orthopedic surgeons in patients with toe walking who present late with an abnormal clinical course. LEVEL OF EVIDENCE: Level III Retrospective Comparative Study.

Acute Pelvic and Hip Apophyseal Avulsion Fractures in Adolescents: A Summary of 719 Cases.

BACKGROUND: Apophyseal avulsion fractures of the pelvis and hip are common injuries in adolescent athletes. However, high volume comparative studies elucidating the spectrum of injuries are largely absent from the literature. The current study provides a comprehensive analysis of demographic, anatomic, pathophysiological, clinical, and athletic-related variables associated with such injuries in an extensive population of affected adolescents. METHODS: A retrospective review was performed of records of patients presenting to a single tertiary care pediatric hospital between January 1, 2005, and July 31, 2020, collecting variables including patient sex, age, body mass index, fracture location, injury mechanism, sport at the time of injury, and duration of prodromal symptoms. RESULTS: Seven hundred nineteen fractures were identified in 709 patients. The average patient age was 14.6, and 78% of the fractures occurred in male patients. The anterior inferior iliac spine (33.4%), anterior superior iliac spine (30.5%), and ischial tuberosity (19.4%) were the most common fracture sites. The most common injury mechanisms were running (27.8%), kicking (26.7%), and falls (8.8%). The most common sports at the time of injury were soccer (38.1%), football (11.2%), and baseball (10.5%). Fracture site was significantly associated with patient sex, age, body mass index, laterality, mechanism, sport, time from injury, and presence of prodromal symptoms. The annual volume of pelvic avulsion fractures treated at the institution increased significantly from n=17 in 2005 to n=75 in 2019. CONCLUSIONS: Adolescent pelvic and hip avulsion fractures occur during a narrow window of age and skeletal maturation and are frequently sustained during sporting activities. Each fracture location is associated with certain demographic, mechanistic, and patient-specific characteristics. The associations between fracture site and patient-specific or injury-specific variables offer insights into the pathophysiology and possible underlying biomechanical risk factors that contribute to these injuries. LEVEL OF EVIDENCE: This is a level III retrospective study.

Do Adolescent Idiopathic Scoliosis Patients With Vitamin D Deficiency Have Worse Spine Fusion Outcomes?

BACKGROUND: Prior research has shown that patients with adolescent idiopathic scoliosis (AIS) have a higher prevalence of vitamin D deficiency compared with healthy peers. In adult orthopaedic populations, vitamin D deficiency has been shown to be a risk factor for higher reported pain and lower function. We investigated whether there was an association between vitamin D levels and AIS patient-reported outcomes, as measured by the Scoliosis Research Society (SRS-30) questionnaire. METHODS: This was a single-center, cross-sectional study. Postoperative AIS patients were prospectively recruited during routine follow-up visits, 2 to 10 years after spine fusion. Vitamin D levels were measured by serum 25-hydroxyvitamin D (ng/mL). Patients were categorized based on vitamin D level: deficient (<20 ng/mL), insufficient (20 to 29 ng/mL), or sufficient (≥30 ng/mL). The correlation between vitamin D levels and SRS-30 scores was analyzed using multivariable analysis and pair-wise comparisons using Tukey method. RESULTS: Eighty-seven AIS patients (83% female) were enrolled who presented at median 3 years (interquartile range: 2 to 5 y; range: 2 to 10 y) after spine fusion. Age at time of surgery was mean 15 (SD±2) years. Major coronal curves were a mean of 57 (SD±8) degrees preoperatively and 18 (SD±7) degrees postoperatively. It was found that 30 (34%) of patients were vitamin D sufficient, 33 (38%) were insufficient, and 24 (28%) were deficient. Although there was no correlation between vitamin D level and Pain, Mental Health, or Satisfaction domains ( P >0.05), vitamin D-deficient patients were found to be younger ( P <0.001) and had lower SRS-30 function ( P =0.002), Self-image ( P <0.001), and total scores ( P =0.003). CONCLUSIONS: AIS patients with vitamin D deficiency (<20 ng/mL) are more likely to be younger age at time of surgery, and report lower Function, Self-image, and Total SRS-30 scores postoperatively. Further work is needed to determine whether vitamin D supplementation alters curve progression and patient outcomes. LEVEL OF EVIDENCE: Level II-prognostic study.

Outcomes of Adolescent T-condylar Fractures: Kids Do Not Always Make You Look Good.

BACKGROUND: Optimal treatment for pediatric and adolescent T-condylar fractures remains poorly understood. We sought to assess how functional outcomes and range of motion (ROM) after surgical fixation of T-condylar fractures are affected by patient and surgical factors. METHODS: This is a retrospective cohort study of 52 patients with operatively treated T-condylar fractures at a single tertiary pediatric referral center between 2003 and 2021. All patients younger than 18 at the time of injury with a radiographically confirmed diagnosis were included. RESULTS: Fifty-two T-condylar fractures were included, with a mean patient age of 12.9 years (SD, 2.8). The cohort was 65% male. Nine (19%) fractures were open, 46% (24/52) were AO type C2, and 33% (17/52) occurred in skeletally mature individuals. The surgical approach was through olecranon osteotomy in 29% (15/52) of patients, and fixation included anatomically specific plates and screws in 42% (22/52) of patients. In our cohort, 46% (24/52) achieved good outcomes based on Jarvis ROM criteria and 42% (22/52) achieved good to excellent results based on Roberts functional criteria. The median loss of ROM was 58 degrees at 6 weeks, 20 degrees at 3 and 6 months, and 8 degrees at 1 year postoperatively. We observed a complication rate of 54% (28/52). Patients undergoing adult-type plate fixation had better postoperative range of motion at 6 weeks (ROM loss 52 vs. 80 degrees, P =0.03) and 3 months (10 vs. 35 degrees P =0.004) compared with pediatric-type fixation and trended towards better functional outcomes. We did not identify significant differences in functional outcome scores or complication rates with respect to surgical approach or skeletal maturity. CONCLUSIONS: Surgical fixation of pediatric and adolescent T-condylar fractures achieved a good to excellent functional outcome in only a minority of patients (46% Jarvis / 42% Roberts) with a high rate of postoperative complications (54%). Future work is needed to elucidate optimal treatment to minimize complications and achieve the best functional outcomes in these challenging fractures. LEVEL OF EVIDENCE: Level-IV.

Minimizing Surgeon Radiation Exposure During Operative Treatment of Pediatric Supracondylar Humerus Fractures.

BACKGROUND: Orthopaedic surgeons are exposed to high levels of radiation, which may lead to higher rates of cancer among orthopaedic surgeons. There are a series of techniques currently practiced to pin supracondylar humerus fractures including pinning the arm on the C-arm itself, using a plexiglass rectangle or a graphite floating arm board; however, the variation in radiation exposure to the surgeon is unknown. We aimed to determine how the position of the C-arm affects radiation exposure to the surgeon during the treatment of a pediatric supracondylar humerus fracture. MATERIAL AND METHODS: A simulated operating room was created to simulate a closed reduction and percutaneous pinning of a supracondylar humerus fracture. A phantom model was used to simulate the patient's arm. We assessed performing the procedure with the arm on plexiglass, graphite, or on top of the C-arm image receptor. The C-arm was positioned either with the source down and image receptor up (standard position) or with the source up and image receptor down (inverted position). Radiation exposure was recorded from levels corresponding to the surgeon's head, midline, and groin. The estimated effective dose equivalent was calculated to account for the varying radiation sensitivity of different organs. RESULTS: We found the effective dose equivalent, or the overall body damage from radiation, was 5.4 to 7.8% higher than the surgeon when the C-arm was in the inverted position (source up, image receptor down). We did not find any differences in radiation exposure to the surgeon when the arm was supported on plexiglass versus graphite. CONCLUSION: The C-arm positioned in the standard fashion exposes the surgeon to less damaging radiation. Therefore, when the surgeon is standing, we recommend using the C-arm in the standard position. CLINICAL RELEVANCE: Orthopaedic surgeons who stand should use the C-arm in the standard position to pin supracondylar humerus fractures to lower the risk of ionizing radiation exposure.

Reliability of the Masada Classification for Forearm Involvement in Patients With Hereditary Multiple Osteochondromas (HMO).

BACKGROUND: Classifications describing forearm lesions in patients with Hereditary Multiple Osteochondromatosis (HMO) have been used to recommend surgical intervention and stratify outcomes; however, there is no consensus on which classification offers greater reliability. The purpose of this study was to determine the reliability of the Masada classification and newer classifications among pediatric hand surgeons. METHODS: One hundred one patients with HMO between June 2014 and October 2019 were enrolled in the Congenital Upper Limb Differences (CoULD) Registry. Of those, 67 patients with 101 forearms were included. Four pediatric hand surgeons from the CoULD study group undertook an online evaluation. Each rater classified radiographs according to the Masada classification. Six weeks later, raters were asked to reclassify images according to the Masada, Gottschalk, and Jo classifications. Rater agreement for these classifications was assessed by estimating Fleiss kappa along with a 95% CI. RESULTS: Interrater agreement for Masada classification after the first reading was poor (κ=0.35; 95% CI=0.30-0.41) across all raters. Interrater agreement across the 4 raters decreased for the Masada classification from the first to the second reading (κ=0.35 vs 0.21; P <0.001). Intrarater agreement for the Masada classification ranged from 0.32 to 0.63 from the first to the second study reading. Gottschalk and Jo classifications yielded significantly better interrater agreement compared with Masada (κ=0.43 vs 0.21; P <0.001). Unclassifiable cases were highest in the Masada classification (34% to 44%) and lower in the Jo (17%) and Gottschalk (14%) classifications. CONCLUSION: Despite wide use, the Masada classification was found to have low reliability when classifying forearm deformities in HMO. Gottschalk offered more options for location, yet lacked deformity description including radial head dislocation. Jo classification offered more locations than Masada and incorporated radial head dislocation in some patterns. Based on the shortcomings in all 3 classification systems, the development of a more inclusive and reliable classification is warranted. LEVEL OF EVIDENCE: Level II; Diagnostic.

The Reliability of the AO Spine Upper Cervical Classification System in Children: Results of a Multi-Center Study.

BACKGROUND: There is no uniform classification system for traumatic upper cervical spine injuries in children. This study assesses the reliability and reproducibility of the AO Upper Cervical Spine Classification System (UCCS), which was developed and validated in adults, to children. METHODS: Twenty-six patients under 18 years old with operative and nonoperative upper cervical injuries, defined as from the occipital condyle to the C2-C3 joint, were identified from 2000 to 2018. Inclusion criteria included the availability of computed tomography and magnetic resonance imaging at the time of injury. Patients with significant comorbidities were excluded. Each case was reviewed by a single senior surgeon to determine eligibility. Educational videos, schematics describing the UCCS, and imaging from 26 cases were sent to 9 pediatric orthopaedic surgeons. The surgeons classified each case into 3 categories: A, B, and C. Inter-rater reliability was assessed for the initial reading across all 9 raters by Fleiss's kappa coefficient (kF) along with 95% confidence intervals. One month later, the surgeons repeated the classification, and intra-rater reliability was calculated. All images were de-identified and randomized for each read independently. Intra-rater reproducibility across both reads was assessed using Fleiss's kappa. Interpretations for reliability estimates were based on Landis and Koch (1977): 0 to 0.2, slight; 0.2 to 0.4, fair; 0.4 to 0.6, moderate; 0.6 to 0.8, substantial; and >0.8, almost perfect agreement. RESULTS: Twenty-six cases were read by 9 raters twice. Sub-classification agreement was moderate to substantial with α κ estimates from 0.55 for the first read and 0.70 for the second read. Inter-rater agreement was moderate (kF 0.56 to 0.58) with respect to fracture location and fair (kF 0.24 to 0.3) with respect to primary classification (A, B, and C). Krippendorff's alpha for intra-rater reliability overall sub-classifications ranged from 0.41 to 0.88, with 0.75 overall raters. CONCLUSION: Traumatic upper cervical injuries are rare in the pediatric population. A uniform classification system can be vital to guide diagnosis and treatment. This study is the first to evaluate the use of the UCCS in the pediatric population. While moderate to substantial agreement was found, limitations to applying the UCCS to the pediatric population exist, and thus the UCCS can be considered a starting point for developing a pediatric classification. LEVEL OF EVIDENCE: Level III.

Intrarater and Interrater Reliability of Radiographic Characteristics in Skeletally Immature Patients With Anterior Cruciate Ligament Tears: A PLUTO Study Group Reliability Study.

BACKGROUND: Radiographic measurements of limb alignment in skeletally immature patients with anterior cruciate ligament (ACL) tears are frequently used for surgical decision-making, preoperative planning, and postoperative monitoring of skeletal growth. However, the interrater and intrarater reliability of these radiographic characteristics in this patient population is not well documented. HYPOTHESIS: Excellent reliability across 4 raters will be demonstrated for all digital measures of length, coronal plane joint orientation angles, mechanical axis, and tibial slope in skeletally immature patients with ACL tears. STUDY DESIGN: Cohort study (diagnosis). METHODS: Three fellowship-trained orthopaedic surgeons and 1 medical student performed 2 rounds of radiographic measurements on digital imaging (lateral knee radiographs and long-leg radiographs) of skeletally immature patients with ACL tears. Intrarater and interrater reliability for continuous radiographic measurements was assessed with intraclass correlation coefficients (ICCs) across 4 raters with 95% CIs for affected and unaffected side measurements. Interrater reliability analysis used an ICC (2, 4) structure and intrarater reliability analysis used an ICC (2, 1) structure. A weighted kappa coefficient was calculated for ordinal variables along with 95% CIs for both interrater and intrarater reliability. Agreement statistic interpretations are based on scales described by Fleiss, and Cicchetti and Sparrow: <0.40, poor; 0.40 to 0.59, fair; 0.60 to 0.74, good; and >0.74, excellent. RESULTS: Radiographs from a convenience sample of 43 patients were included. Intrarater reliability was excellent for nearly all measurements and raters. Interrater reliability was also excellent for nearly all reads for all measurements. CONCLUSION: Radiographic reliability of long-leg radiographs and lateral knee x-rays in skeletally immature children with ACL tears is excellent across nearly all measures and raters and can be obtained and interpreted as reliable and reproducible means to measure limb length and alignment. LEVEL OF EVIDENCE: Level III.

Response of circulating metabolites to an oral glucose challenge and risk of cardiovascular disease and mortality in the community.

BACKGROUND: New biomarkers to identify cardiovascular disease (CVD) risk earlier in its course are needed to enable targeted approaches for primordial prevention. We evaluated whether intraindividual changes in blood metabolites in response to an oral glucose tolerance test (OGTT) may provide incremental information regarding the risk of future CVD and mortality in the community. METHODS: An OGTT (75 g glucose) was administered to a subsample of Framingham Heart Study participants free from diabetes (n = 361). Profiling of 211 plasma metabolites was performed from blood samples drawn before and 2 h after OGTT. The log2(post/pre) metabolite levels (Δmetabolites) were related to incident CVD and mortality in Cox regression models adjusted for age, sex, baseline metabolite level, systolic blood pressure, hypertension treatment, body mass index, smoking, and total/high-density lipoprotein cholesterol. Select metabolites were related to subclinical cardiometabolic phenotypes using Spearman correlations adjusted for age, sex, and fasting metabolite level. RESULTS: Our sample included 42% women, with a mean age of 56 ± 9 years and a body mass index of 30.2 ± 5.3 kg/m2. The pre- to post-OGTT changes (Δmetabolite) were non-zero for 168 metabolites (at FDR ≤ 5%). A total of 132 CVD events and 144 deaths occurred during median follow-up of 24.9 years. In Cox models adjusted for clinical risk factors, four Δmetabolites were associated with incident CVD (higher glutamate and deoxycholate, lower inosine and lysophosphatidylcholine 18:2) and six Δmetabolites (higher hydroxyphenylacetate, triacylglycerol 56:5, alpha-ketogluturate, and lower phosphatidylcholine 32:0, glucuronate, N-monomethyl-arginine) were associated with death (P < 0.05). Notably, baseline metabolite levels were not associated with either outcome in models excluding Δmetabolites. The Δmetabolites exhibited varying cross-sectional correlation with subclinical risk factors such as visceral adiposity, insulin resistance, and vascular stiffness, but overall relations were modest. Significant Δmetabolites included those with established roles in cardiometabolic disease (e.g., glutamate, alpha-ketoglutarate) and metabolites with less defined roles (e.g., glucuronate, lipid species). CONCLUSIONS: Dynamic changes in metabolite levels with an OGTT are associated with incident CVD and mortality and have potential relevance for identifying CVD risk earlier in its development and for discovering new potential therapeutic targets.

Health-related quality of life and caregiver burden after hip reconstruction and spinal fusion in children with spastic cerebral palsy.

AIM: To evaluate the effect of hip reconstruction or spinal fusion on health-related quality of life (HRQoL) in non-ambulatory children with spastic cerebral palsy (CP) and caregiver burden. METHOD: This was a prospective, longitudinal study of changes in HRQoL and caregiver burden over the 5 years after surgical correction of hip instability or scoliosis in children with bilateral spastic CP classified in Gross Motor Function Classification levels IV or V. Serial parent proxy measures of HRQoL and caregiver burden were obtained before and 6 weeks, and 3, 6, 9, 12, 24, and 60 months after surgery using the Caregiver Priorities and Child Health Index of Life with Disabilities and the Assessment of Caregiver Experience with Neuromuscular Disease. Scores 5 years or more after surgery were compared to pre-surgery scores using paired Student's t-tests. Serial outcome trajectories were estimated by linear mixed modeling. RESULTS: Of 69 participants (40 males, 29 females; mean age 11y 6mo, SD 4y 1mo, range 3y 10mo-20y 7mo), 43 had hip reconstruction and 26 had spinal fusion. Clinically significant improvements in HRQoL were detected (average increase 7.6 points) 5 years or more postoperatively, with hip reconstruction providing greater benefit. Domains improved by surgery included positioning, transferring/mobility, comfort/emotions, and health. Caregiver burden did not change as these children remain maximally dependent. INTERPRETATION: Surgical treatment of hip and spine deformity improves HRQoL, especially for painful hip instability, but does not change caregiver burden.

Generalized Joint Laxity Is Associated With Dynamic Hip Ultrasonography Measures in Female Athlete Patients Who Are Not Hypermobile.

OBJECTIVES: To investigate ultrasound (US) femoroacetabular translation measurements in female athlete patients. METHODS: A prospective cross-sectional study was conducted in female athlete patients <50 years. Demographic data, Beighton score/hypermobility status, and sport participation were collected. Hip dysplasia was determined using radiographic measurements (lateral center edge angle, anterior center edge angle, Tönnis angle); femoral version angles were measured with CT or MR. Femoroacetabular translation US measures included neutral (N), neutral flexed (NF), extension external rotation/apprehension (EER) positions. Maximal difference (delta) between US measures was calculated. RESULTS: 206/349 female hips were analyzed (median age 21.2 years [range, 12-49.5]). The primary sport group was performing arts (45%, 92/206). Mean Beighton score was 5.2 (SD, 2.5) with 61% (129/206) of hips exhibiting hypermobility (Beighton score ≥5). For each additional unit of Beighton score, N US measurement increased by 0.7 mm (ß = 0.7; 95% confidence interval [CI] = 0.22-1.25; P < .001), NF by 1 mm ( ß = 0.9; 95% CI = 0.3-1.43; P = .002) and EER by 0.8 mm ( ß = 0.8; 95% CI = 0.27-1.37; P < .001) when adjusting for age and dysplasia status. A positive correlation was detected between NF (r = 0.19; 95% CI = 0.05-0.33; P = .007) and EER (r = 0.19; 95% CI = 0.05-0.32; P = .01) with Tönnis angle and a negative correlation between the delta and femoral version (r = -0.20; 95% CI = -0.35 to 0.03; P = .02). No difference in US measures was detected across sport groups (N [P = .24], NF [P = .51], EER [P = .20], delta [P = .07]). CONCLUSION: Beighton score was independently associated with dynamic US measures in female athlete patients who are not hypermobile when controlling for other factors.

Knowledge, Attitudes, and Practices in the Orthopaedic Care of Sexual and Gender Minority Youth: A Survey of Two Pediatric Academic Hospitals.

BACKGROUND: Lesbian, gay, bisexual, transgender, and queer (LGBTQ) children and adolescents continue to experience unmet healthcare needs, partly because of clinician biases, discrimination, and inadequate education. Although clinician attitudes and knowledge related to sexual and gender minority health have been well studied in other medical specialties, these have been scarcely studied in orthopaedics. QUESTIONS/PURPOSES: (1) What are pediatric orthopaedic healthcare professionals' attitudes (perceived importance, openness, comfort, and confidence) toward caring for sexual and gender minority youth? (2) What do pediatric orthopaedic healthcare professionals know about caring for this patient population? (3) What factors are associated with clinician attitude and/or knowledge? (4) What existing initiatives to improve orthopaedic care for this population are clinicians aware of at their home institutions? METHODS: All 123 orthopaedic healthcare professionals at two pediatric academic hospitals in the Midwestern and Northeastern United States were sent a 34-question, internet-based, anonymous survey. The survey queried respondent demographics, attitudes, knowledge, and practice behaviors at their home institutions related to the care of sexual and gender minority youth. Respondent attitudes were queried using the Attitudes Summary Measure, which is a survey instrument that was previously validated to assess clinicians' attitudes regarding sexual and gender minority patients. Items used to assess knowledge and practice behaviors were developed by content experts in LGBTQ health and/or survey design, as well as orthopaedic surgeons to improve face validity and to mitigate push-polling. Attitude and knowledge items used a 5-point Likert scale. Sixty-six percent (81 of 123) of clinicians completed the survey. Of those, 47% (38 of 81) were physicians, 73% (59 of 81) were licensed for fewer than 20 years, 63% (51 of 81) were women, and 53% (43 of 81) described themselves as liberal-leaning. The response proportions were 73% (38 of 52) among eligible physicians specifically and 61% (43 of 71) among other clinicians (nurse practitioners, physician assistants, and registered nurses). To assess potential nonresponse bias, we compared early responders (within 2 weeks) with late responders (after 2 weeks) and found no differences in responder demographics or in questionnaire responses (all p > 0.05). The main outcome measures included responses to the attitude and knowledge questionnaire, as well as the existing practices questionnaire. To answer our research questions regarding clinician attitudes knowledge and awareness of institutional initiatives, we compared participant responses using chi-square tests, the Student t-test, and the McNemar tests, as appropriate. To answer our research question on factors associated with questionnaire responses, we reported data for each question, stratified by hospital, years since licensure, and political leaning. Comparisons were conducted across strata using chi-square tests for Likert response items and ANOVA for continuous response items. All p values less than 0.05 were considered significant. RESULTS: Of the respondents who reported feeling comfortable treating lesbian, gay, and bisexual (sexual minority) youth, a small proportion reported feeling confident in their knowledge about these patients' health needs (99% [80 of 81] versus 63% [51 of 80], 36% reduction [95% confidence interval 23% to 47%]; p < 0.001). Similarly, of those who reported feeling comfortable treating transgender (gender minority) youth, a smaller proportion reported feeling confident in their knowledge of their health needs (94% [76 of 81] versus 49% [37 of 76], 45% reduction [95% CI 31% to 59%]; p < 0.001). There was substantial interest in receiving more education regarding the health concerns of LGBTQ people (81% [66 of 81]) and being listed as an LGBTQ-friendly clinician (90% [73 of 81]). Factors that were associated with select attitude and knowledge items were duration of licensure and political leaning; gender identity, institutional affiliation, educational degree, or having LGBTQ friends and family were not associated. Many respondents were aware of the use of clinic intake forms and the electronic medical record to collect and provide patient gender identity and sexual orientation data at their practice, as well as signage and symbols (for example, rainbow posters) to cultivate LGBTQ-welcoming clinic spaces. CONCLUSION: There were varying degrees of confidence and knowledge regarding the health needs of sexual and gender minority youth among pediatric orthopaedic healthcare professionals. There was considerable interest in more focused training and better use of medical technologies to improve care for this population. CLINICAL RELEVANCE: The study findings support the further investment in clinician training opportunities by healthcare administrators and orthopaedic associations related to the care of sexual and gender minority patients, as well as in the expansion of medical documentation to record and report important patient information such as pronouns and gender identity. Simultaneously, based on these findings, clinicians should engage with the increasing number of educational opportunities, explore their personal biases, and implement changes into their own practices, with the ultimate goal of providing equitable and informed orthopaedic care.

Prevertebral Soft Tissue Thickness of the Cervical Spine in Children: An Insensitive but Specific Aid in the Diagnosis of Occult Trauma.

BACKGROUND: The purpose of this study was to investigate the sensitivity and specificity of current cervical prevertebral soft tissue swelling (PVST) values in a cohort of children with known cervical fractures or dislocations. METHODS: Forty two children (average age 11.9, range 1.4 to 17.0 y) with documented cervical spine injury and 61 children (average age 11.9, range 0.5 to 17.9 y) with cervical pain but no injury were reviewed (January 2004 to December 2015). PVST was measured on lateral cervical radiographs at C2, C3, and C6. Patients were stratified by age (0 to 2 y, 3 to 6 y, 7 to 10 y, 11 to 15 y, and 16 y and above). The Wilcoxon rank sum test was used to compare PVST measurements at each spine level across injury and noninjury cohorts. Sensitivity and specificity were estimated to assess the ability of abnormal reference values to detect when a true injury was present. In addition, positive predictive value and negative predictive value were also estimated. RESULTS: The majority of c-spine injuries (31/42; 76%) involved bony fracture and 57% (24/42) were treated with a collar or brace. Comparison of PVST measurement found no difference at C2 ( P =0.07), C3 ( P =0.07), or at C6 ( P =0.99) across injury and non-injury cohorts. Sensitivity was poor at single-level measures for C2 (26%), C3 (31%), and C6 (24%), while specificity was relatively high (92%, 87%, and 79%, respectively). When an increased value at either C2 or C3 indicated injury, sensitivity increased to 36%, and when an increased measurement at just one of the 3 measured levels indicated injury, the sensitivity increased to 48%, while the specificity decreased to 72%. While retropharyngeal measures were more likely to detect injury than retrotracheal, C6 alone was increased in 5 of the 20 injury patients. CONCLUSIONS: PVST measurements exhibit poor sensitivity but good specificity as indicators for the diagnosis of occult cervical trauma in children. Negative values do not exclude injury; positive values suggest further evaluation. LEVELS OF EVIDENCE: Level III.

Validation of a Novel Magnetic Resonance Imaging Classification for Osteochondritis Dissecans of the Knee.

BACKGROUND: The novel Kocher classification is a 3-group magnetic resonance imaging (MRI) classification system for osteochondritis dissecans (OCD) of the knee that was shown to have comparable reliability to that of the established 5-group Hefti classification. The purpose of this study was to evaluate the validity and clinical utility of this simplified system as an alternative to the Hefti classification. METHODS: Demographic data and arthroscopic findings were retrospectively collected from medical and surgical records of 144 consecutive knees in children with arthroscopically diagnosed knee OCD. OCD lesions on preoperative MRIs and surgical reports (serving as the reference standard) were assessed by independent raters and assigned both a Kocher and Hefti classification. Agreement between MRI classification and arthroscopic findings for both systems was assessed using weighted kappa (kw) coefficients. Validation, accuracy, sensitivity, and specificity were measured by comparing a dichotomized Kocher classification for MRI and arthroscopy, and by estimating Cohen kappa (kc) coefficients. Agreement between arthroscopic findings and treatment type was measured using the Spearman correlation coefficient. RESULTS: Inter-rater reliability between the 2 MRI raters was substantial for the Kocher classification [ka=0.66; 95% confidence interval (CI)=0.56-0.75] and moderate for the Hefti classification (ka=0.57; 95% CI=0.47-0.67). There was no difference detected in the agreement statistics for Kocher versus Hefti classifications (P=0.89). Binary agreement using dichotomized Kocher classifications was worse than the 3-group category classification. When dichotomized, combining Kocher grades 1 and 2 demonstrated moderate agreement (kc=0.41; 95% CI=0.25-0.58), and combining grades 2 and 3 demonstrated fair agreement (kc=0.34; 95% CI=0.21-0.48). There was a strong correlation between arthroscopy-based finding and treatment category for both the Kocher classification (r=0.85; 95% CI=0.80-0.89) and the Hefti classification (r=0.82; 95% CI=0.75-0.86). CONCLUSION: The validity and clinical utility of the newer 3-group Kocher classification for knee OCD is comparable to that of the well-established 5-group Hefti classification. Both systems help determine lesion stability and characteristics on MRI, which correlate closely to arthroscopic findings. This simplified classification system, with less uncertainty, provides a foundation for further outcomes research to develop an evidence-based algorithm for effective surgical management of OCD lesions of the knee. LEVEL OF EVIDENCE: Level II-diagnostic study.

Determining Incidence and Risk Factors of Pressure Injury After Orthopaedic Surgery in Children and Adolescents With Neuromuscular Complex Chronic Conditions.

BACKGROUND: Pressure injuries are serious yet often preventable alterations in skin integrity prevalent in orthopaedics, especially in pediatric patients with neuromuscular complex chronic conditions (NCCC). The aims of this study were to (1) estimate incidence of pressure injury in children with NCCC after orthopaedic surgery; (2) determine risk factors for pressure injury development; and (3) describe severity and location of pressure injuries. METHODS: Children and adolescents (<22 y old) with NCCC who underwent orthopaedic surgery at a single tertiary-care children's hospital between 2016 and 2020 were retrospectively identified. A matched case-control design was used to match patients who developed a pressure injury within 1.5 months after surgery to subjects who did not develop a pressure injury using a 1:1 matching based on neuromuscular diagnosis, age, sex, and type of surgery. Patient characteristics, comorbidities, pressure injury characteristics, and a pressure injury risk assessment score utilizing the Braden QD scale were compared across pressure injury groups. RESULTS: Of 564 children with NCCC who underwent orthopaedic surgery, 43 (7.6%) developed a postoperative pressure injury. Pressure injuries were primarily located on the heel, followed by sacral/groin/buttocks, then knee. The most common diagnosis was cerebral palsy with associated neuromuscular scoliosis, and hip reconstruction was the most common surgical procedure. The pressure injury cohort had significantly more patients who were non-ambulatory (GMFCS IV/V), with a seizure disorder, g-tube, nonverbal status, wheelchair usage, and had additional medical devices. Median Braden QD risk score was higher in the injury cohort and a cutoff ≥12 was optimal for predicting pressure injury development. CONCLUSIONS: Pressure injuries after orthopaedic surgery are not uncommon in children with NCCC. The entire care team should be aware of additional risk factors associated with pressure injury development, including the diagnosis of cerebral palsy with neuromuscular scoliosis, seizure disorder, nonverbal status, g-tube, and the presence of multiple medical devices. Implementation of evidence-based pressure injury prevention guidelines on identified high-risk children with NCCC may reduce pressure injury risk and improve the postoperative course. LEVEL OF EVIDENCE: Level III.