Dedicated Early Morning Orthopaedic Trauma Operating Room Is Associated With Shorter Time to Surgery and Decreased Length of Hospital Stay for Children Undergoing Surgical Treatment of Supracondylar Humerus Fractures: A Retrospective Cohort Study.

INTRODUCTION: The purpose of this study was to investigate whether the use of a dedicated early morning orthopaedic trauma operating room (OR) resulted in shorter wait times, decreased surgical times, decreased length of stay (LOS), and decreased complications in children treated with urgent surgical intervention for supracondylar humerus fractures. METHODS: This retrospective comparative cohort study at a level I pediatric trauma center included patients younger than 12 years with supracondylar humerus fractures urgently treated with closed or open reduction and percutaneous pinning. Index surgical cases from April 28, 2013, to February 26, 2020, were included. Patients with prior humerus fracture, concomitant injuries, open fracture, pulseless supracondylar fracture, or missing data were excluded. Patients were analyzed based on the type of OR: dedicated early morning orthopaedic trauma OR or typical daytime orthopaedic OR. The primary outcome was time from presentation to surgery. Secondary outcomes included surgical time, complications, and LOS. RESULTS: A total of 401 patients with a mean age of 5 ± 2 (range: 1 to 11) years and a mean follow-up of 2.0 ± 2.1 (range: 0.5 to 25.0) months were included, of whom 137 patients (34%) underwent surgery in the early morning dedicated orthopaedic trauma OR. The dedicated early morning orthopaedic OR group had significantly less time from presentation to surgery (7.5 versus 9.4 hours; P = 0.0002) and shorter LOS (21.0 versus 24.0 hours; P = 0.004) compared with children treated in the typical daytime orthopaedic OR. Surgical time (31.1 versus 32.6 minutes; P = 0.40) and complication rates (5.8% versus 4.9%; P = 0.65) were similar between the groups. No revision surgery was required in either group. DISCUSSION: Surgical wait times were diminished with use of the dedicated early morning OR, as was LOS. Surgical times and complication rates were similar between groups. Institutions may consider adopting a dedicated early morning orthopaedic trauma OR to improve surgical wait times and decrease LOS. LEVEL OF EVIDENCE: III.

Factors Associated with Postoperative Opioid Use in Adolescents.

BACKGROUND: We aimed to identify factors associated with postoperative prescription opioid use in adolescents. METHODS: Adolescents aged 13-20 years undergoing surgery were prospectively recruited from a children's hospital. Adolescent-parent dyads completed a preoperative survey, measuring clinical and sociodemographic factors, and two postoperative surveys evaluating self-reported opioid use at 30- and 90-days. Poisson regression analysis identified factors associated with the number of pills used within 90-days, adjusting for age, gender, race/ethnicity, surgery type, and pain at discharge. RESULTS: We enrolled 119 adolescents who reported postoperative opioid use following posterior spinal fusion (PSF) (50 %), arthroscopy (23 %), pectus excavatum repair (11 %), tonsillectomy (8 %), and hip reconstruction (7 %). Overall, 81 % of adolescents reported unused opioids. The median pain score at discharge was 7 (IQR:5-8). Adolescents reported using a median of 7 (IQR:2-15) opioid pills, with 20 (IQR:7-30) pills left unused. Compared to all other surgeries, adolescents undergoing PSF reported the highest median pill use (10, IQR:5-29; p = 0.004). Adolescents undergoing tonsillectomy reported the lowest median pill use (1, IQR:0-7; p = 0.03). On regression analysis, older patient age was associated with a 12 % increase in pill use (95 % CI:3%-23 %). Undergoing PSF was associated with a 63 % increase in pill use (95 % CI:15%-31 %). Each additional pain scale point reported at discharge was associated with a 13 % increase in pill use (95 % CI:5%-22 %). CONCLUSIONS: Older age, surgery type, and patient-reported pain at discharge are associated with postoperative prescription opioid use in adolescents. Understanding patient and surgery-specific factors associated with opioid use may guide surgeons to minimize excess opioid prescribing. LEVEL OF EVIDENCE: II.

Quantifying Risk Factors for Slipped Capital Femoral Epiphysis and Postslip Osteonecrosis.

BACKGROUND: Slipped capital femoral epiphysis (SCFE) is a disorder of the proximal femoral physis occurring in late childhood and adolescence. Previously postulated risk factors include obesity and endocrinopathies. The purpose of this investigation was to identify risk factors for developing SCFE, as well as postslip osteonecrosis (ON), among the United States pediatric population. METHODS: A national database investigation was performed using PearlDiver Technologies, Inc., queried for SCFE and ON using International Classification of Disease codes (2010 to 2020). Regression analyses to determine the risk of developing a SCFE, and ON after a patient has already been diagnosed with a SCFE ("postslip"). Propensity matching between SCFE and control groups generated a pseudo-randomization model to compare the relative risk. RESULTS: There were 11,465 patients with SCFE available in the database, matched with 134,680 controls. After matching, vitamin D deficiency, obesity, hypothyroidism, and growth hormone use were risk factors for developing SCFE [relative risk ranges from 1.42 (95% CI: 1.21-1.39, vitamin D deficiency) to 3.45 (95% CI: 3.33-3.57, obesity)]. ON risk factors were vitamin D deficiency [1.65 (1.26-2.14)] and hypothyroidism [1.49 (1.10-2.07)]. CONCLUSIONS: This United States national database study quantified risk factors of developing an SCFE and postslip ON. Obesity is the most significant risk factor for the development of a slip, but not ON. Growth hormone use, hypothyroidism, and vitamin D deficiency are also risk factors for SCFE development, whereas only the latter two were associated with ON. These findings demonstrate the public health implications of obesity and comorbid conditions in pediatric hip pathology. LEVEL OF EVIDENCE: Level III.

Prescription Opioid Use for Adolescents With Neurocognitive Disability Undergoing Surgery: A Pilot Study.

INTRODUCTION: Parents frequently report retaining unused opioid pills following their child's surgery due to fear of untreated postoperative pain. Assessment of pain in adolescents with neurocognitive disability is challenging. We hypothesized that parents of adolescents with neurocognitive disability may report less opioid use and higher opioid pill retention. METHODS: Adolescents (13-20 y) undergoing elective surgery (posterior spinal fusion, hip reconstruction, arthroscopy, tonsillectomy) were prospectively enrolled from a tertiary children's hospital from 2019 to 2020. Only adolescents prescribed opioids at discharge were included. Parents completed a preoperative survey collecting sociodemographic characteristics and two postoperative surveys at 30- and 90-d. Neurocognitive disability was determined at time of enrollment by caregiver report, and included adolescents with cerebral palsy, severe autism spectrum disorder, and discrete syndromes with severe neurocognitive disability. RESULTS: Of 125 parent-adolescent dyads enrolled, 14 had neurocognitive disability. The median number of opioid pills prescribed at discharge did not differ by neurocognitive disability (29, interquartile range {IQR}: 20.0-33.3 versus 30, IQR: 25.0-40.0, P = 0.180). Parents of both groups reported similar cumulative days of opioid use (7.0, IQR: 3.0-21.0 versus 6.0, IQR:3.0-10.0, P = 0.515) and similar number of opioid pills used (4, IQR: 2.0-4.5 versus 12, IQR: 3.5-22.5, P = 0.083). Parents of both groups reported similar numbers of unused opioid pills (17, IQR: 12.5-22.5 versus 19, IQR: 8.0-29.0, P = 0.905) and rates of retention of unused opioids (15.4% versus 23.8%, P = 0.730). CONCLUSIONS: The number of opioid pills prescribed did not differ by neurocognitive disability and parents reported similar opioid use and retention of unused opioid pills. Larger studies are needed to identify opportunities to improve postoperative pain control for children with neurocognitive disability.

Age and CRP Associated With Improved Tissue Pathogen Identification in Children With Blood Culture Negative Osteomyelitis: Results From the CORTICES Multicenter Database.

BACKGROUND: Acute hematogenous osteomyelitis (AHO) is a relatively common condition in children, and identifying the offending pathogen with blood or tissue cultures aids in diagnosis and medical management while reducing treatment failure. Recent 2021 AHO clinical practice guidelines from the Pediatric Infectious Disease Society recommend obtaining routine tissue cultures, particularly in cases with negative blood cultures. The purpose of this study was to identify variables associated with positive tissue cultures when blood cultures are negative. METHODS: Children with AHO from 18 pediatric medical centers throughout the United States through the Children's ORthopaedic Trauma and Infection Consortium for Evidence-based Study were evaluated for predictors of positive tissue cultures when blood cultures were negative. Cutoffs of predictors were determined with associated sensitivity and specificity. RESULTS: One thousand three children with AHO were included, and in 688/1003 (68.6%) patients, both blood cultures and tissue cultures were obtained. In patients with negative blood cultures (n=385), tissue was positive in 267/385 (69.4%). In multivariate analysis, age ( P <0.001) and C-reactive protein (CRP) ( P =0.004) were independent predictors. With age >3.1 years and CRP >4.1 mg/dL as factors, the sensitivity of obtaining a positive tissue culture when blood cultures were negative was 87.3% (80.9-92.2%) compared with 7.1% (4.4-10.9%) if neither of these factors was present. There was a lower ratio of methicillin-resistant Staphylococcus aureus in blood culture-negative patients who had a positive tissue culture 48/188 (25.5%), compared with patients who had both positive blood and tissue cultures 108/220 (49.1%). CONCLUSION: AHO patients with CRP ≤ 4.1 mg/dL and age under 3.1 years are unlikely to have clinical value from tissue biopsy that exceeds the morbidity associated with this intervention. In patients with CRP > 4.1 mg/dL and age over 3.1 years, obtaining a tissue specimen may add value; however, it is important to note that effective empiric antibiotic coverage may limit the utility of positive tissue cultures in AHO. LEVEL OF EVIDENCE: Level III-Retrospective comparative study.

Outcomes for Patients With Developmental Hip Dysplasia Who Present After Six Months of Age.

PURPOSE: Late presentation of hip dysplasia persists despite robust screening methods. After 6 months of age, treatment with a hip abduction orthosis becomes challeng-ing, and all other treatment modalities have higher reported rates of complications. METHODS: We performed a retrospective review of all patients from 2003 to 2012 who had the sole diagnosis of de-velopmental hip dysplasia, who presented before 18 months of age, and who had at least 2 years of follow-up. The cohort was then grouped based on their presentation before (BSM) or after (ASM) 6 months of age. The groups were compared for demographics, exam findings, and outcomes. RESULTS: We identified 36 patients with presentation after 6 months and 63 patients who presented before 6 months. Hav-ing a normal newborn hip exam and unilateral involvement were risk factors for late presentation (p < 0.001). Only 6% (2/36) patients in the ASM group were successfully treated non-operatively; the ASM group underwent an average of 1.33 procedures. The odds of utilizing an open reduction for the primary procedure for the late presenting patient was 4.91 times higher than the early presenting group (p = 0.001). Limited hip range of motion, particularly hip external rotation, was the only significantly different out-come (p = 0.03). There was no significance difference in the complications (p = 0.24). CONCLUSION: Management of patients with developmental hip dysplasia presenting after 6 months of age requires more surgical intervention but can result in satisfactory outcomes.

Modernizing Our Understanding of Total Hip Arthroplasty in the Pediatric and Young Adult Patient: A Single-center Experience.

INTRODUCTION: Pediatric hip disorders represent a broad range of pathology and remain a significant source of morbidity for children and young adults. Surgical intervention is often required for joint preservation, but when salvage is not possible, joint replacement may be indicated to eliminate pain and preserve function. Although there have been significant updates in the management of both pediatric hip disease and the field of total hip arthroplasty (THA), there is a paucity of literature reflecting advancements in the area of pediatric and young adult (PYA) arthroplasty. No study has investigated the impact of approach on outcomes after PYA THA. The purpose of this study is to describe the indications, techniques, and early outcomes of THA in the PYA population in a modern practice setting. METHODS: We performed a retrospective descriptive analysis of all patients undergoing primary THA performed at a tertiary care children's hospital from 2004 to 2019. Ninety-three hips in 76 patients were evaluated. Demographics, intraoperative variables, postoperative pain and function ratings, and complication and revision rates were collected. RESULTS: Eighty-five hips in 69 patients were included. Patients were aged 12 to 23 years old, with males and females represented equally (33 vs. 36, respectively). The most common cause of hip pain was avascular necrosis (AVN, 56/85, 66%), most commonly due to slipped capital femoral epiphysis (13/56, 23%) idiopathic AVN (12/56, 21%), and chemotherapy (12/56, 21%). Half of all hips had been previously operated before THA (43/85). Thirty-six procedures were performed via the posterolateral approach (36/85, 42%), 33 were performed via direct anterior approach (33/85, 39%), and 16 were performed via the lateral approach (LAT, 16/85, 19%). At final follow-up, 98% (83/85) of patients had complete resolution of pain, 82% (70/85) had no notable limp, and 95% (81/85) had returned to all activities. There were 6 complications and 1 early revision. Average Hip disability and Osteoarthritis Outcomes Score for Joint Replacement scores increased by 37 points from 56 to 93. The overall revision-free survival rate for PYA THA was 98.8% (at average 19-mo follow-up). CONCLUSIONS: Modern PYA THA is dissimilar in indications and surgical techniques to historic cohorts, and conclusions from prior studies should not be generalized to modern practice. In our practice, PYA patients most commonly carry a diagnosis of AVN, and THA can be performed with modern cementless fixation with large cup and head sizes and ceramic-on-cross-linked polyethylene bearings utilizing any approach. Further study is required to better characterize middle-term and long-term results and patient-reported outcomes. LEVEL OF EVIDENCE: Therapeutic Level IV-retrospective case series.

Gait Analysis Characteristics in Relapsed Clubfoot.

BACKGROUND: Relapse rates of clubfoot deformity after initial correction range between 19% and 68% regardless of treatment approach. Most studies focus on relapse before age 4. Little research has focused on late clubfoot relapse. The purpose of this study was to compare the gait characteristics of children with late clubfoot relapse (age ≥5 y) following treatment with the Ponseti method only compared with intra-articular and extra-articular surgeries. METHODS: A retrospective review was conducted of all patients with idiopathic clubfoot ≥5 years old who underwent computerized gait analysis for clubfoot relapse between 2001 and 2021. Joint range of motion, muscle strength, gait kinematics, and kinetics were compared among 3 groups based on prior clubfoot treatment: (1) Ponseti casting, (2) Extra-articular (EA) surgery, and (3) Intra-articular (IA) surgery. RESULTS: Sixty-eight subjects (107 feet) were included (39 bilateral). Thirty-one percent of feet had been treated with Ponseti casting alone; 57% had IA surgery, and 12% had EA surgery. The average age when presenting with late relapse was 8.2 years, 9.0 years and 10.7 years for the Ponseti, and IA and EA groups, respectively. The IA group had greater passive dorsiflexion than the other 2 groups (P<0.002), greater inversion weakness than the other 2 groups (P<0.0001), greater dorsiflexion during the stance phase of gait compared with the Ponseti group (P=0.001), and lower maximum power production at push-off compared with the other 2 groups (P=0.009). CONCLUSION: Late relapse can occur after all types of clubfoot correction. Consistent with existing literature, patients who have undergone posteromedial release surgery have significantly greater plantarflexor weakness resulting in poorer plantarflexor moment and power production during gait. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Do Weightbearing Restrictions Cause Excess Weight Gain in Children With LEGG-Calvé-Perthes Disease?

BACKGROUND: Restricted weight bearing is commonly prescribed in Legg-Calvé-Perthes Disease (LCPD), raising concerns of causing overweight or obesity. This study utilizes prospectively collected data to address the following questions: (1) does body mass index (BMI) Z-score increase over the course of LCPD follow-up; (2) is having a BMI category of normal, overweight, or obese at baseline associated with BMI Z-score changes over the course of follow-up; and (3) is the duration of weight bearing restrictions (no restrictions, <3, 3 to <6, 6 to 9, or >9 mo) associated with BMI Z-score changes. METHODS: Data of 130 children aged 5 to 12 years with unilateral early-stage LCPD were extracted from an international database. Nation-specific BMI Z-scores and percentile-based weight categories were determined, and the duration of follow-up and weight bearing restrictions were calculated. Longitudinal changes in BMI Z-scores were evaluated for the 3 study questions using mixed effects linear regression models with surgery as a covariate. Sensitivity analyses were used to determine the influence of socio-cultural background (USA vs. India) for each study question. RESULTS: During the 35.5±15.9 months of follow-up, no statistically significant increase in BMI Z-scores was observed across the entire cohort, or following stratification by baseline weight categories or the duration of the weight bearing restriction. Sensitivity analyses indicated that patients in the USA had no change in their BMI Z-score. When stratified by weight categories, the normal weight of US children had a small increase in their BMI Z-score (0.005 per mo, 95% confidence interval: 0.0002, 0.009), but this was not seen in other BMI categories. The cohort of Indian children had a small but significant decrease in their BMI Z-score (-0.005/mo, 95% CI: -0.009, -0.0002). After stratification by weight categories, a small decrease of the BMI Z-score was observed only in the Indian overweight children (-0.016 per mo, 95% CI: -0.027, -0.005) and no other BMI category. CONCLUSIONS: Weightbearing restrictions over the course of follow-up for our cohort of children with early-stage LCPD were not associated with clinically meaningful increases of BMI Z-scores. Weight gain is multi-factorial and probably not caused by weight bearing restrictions alone. LEVEL OF EVIDENCE: III Diagnostic Study.

Descriptive Epidemiology of Upper Extremity Septic Arthritis in Children-Review of a Retrospective Multicenter Database.

BACKGROUND: There is limited information on the presentation and management of upper extremity septic arthritis (UESA) in children. Our purpose was to report on the characteristics and short-term treatment outcomes of pediatric UESA from a multicenter database. METHODS: Patients with UESA were identified from a multicenter retrospective musculoskeletal infection database. Demographics, laboratory tests, culture results, number of surgeries, and complications were collected. RESULTS: Of 684 patients with septic arthritis (SA), 68 (10%) patients had UESA. Septic arthritis was most common in the elbow (53%), followed by the shoulder (41%) and wrist (4%). The median age at admission was 1.7 years [interquartile range(IQR, 0.8-8.0 y)] and 66% of the cohort was male. Blood cultures were collected in 65 (96%) patients with 23 (34%) positive results. Joint aspirate and/or tissue cultures were obtained in 66 (97%) patients with 49 (72%) positive results. Methicillin-sensitive Staphylococcus aureus (MSSA) was the most common causative organism overall, but Streptococcus was the most common pathogen in the shoulder. Sixty-six (97%) patients underwent irrigation and debridement, with 5 (7%) patients requiring 2 surgeries and 1 patient (1%) requiring 3 surgeries. The median length of stay was 4.9 days (IQR, 4.0-6.3 d). Thirty-one (46%) children had adjacent musculoskeletal infections and/or persistent bacteremia. No patients experienced venous thromboembolism, and 4 patients with associated osteomyelitis experienced a musculoskeletal complication (3 avascular necrosis, 1 pathologic fracture). One child had re-admission and 3 children with associated osteomyelitis had a recurrence of UESA. Comparison between elbow and shoulder locations showed that children with septic arthritis of the shoulder were younger (4.6 vs. 1.0 y, P =0.001), and there was a difference in minimum platelet count (280 vs. 358 ×10 9 cells/L, P =0.02). CONCLUSIONS: UESA comprises 10% of cases of septic arthritis in children. The elbow is the most common location. Shoulder septic arthritis affects younger children. MSSA is the most common causative organism in UESA, but Streptococcus is common in shoulder septic arthritis. Irrigation and debridement result in excellent short-term outcomes with a low complication rate. Re-admissions and repeat surgical interventions are rare. LEVEL OF EVIDENCE: Level IV, prognostic.

Tranexamic acid use decreases transfusion rate in children with cerebral palsy undergoing proximal femoral varus derotational osteotomy.

ABSTRACT: Previous studies demonstrated the safety of tranexamic acid (TXA) use in cerebral palsy (CP) patients undergoing proximal femoral varus derotational osteotomy (VDRO), but were underpowered to determine if TXA alters transfusion rates or estimated blood loss (EBL). The purpose of this study was to investigate if intraoperative TXA administration alters transfusion rates or EBL in patients with CP undergoing VDRO surgery.We conducted a retrospective review of 390 patients with CP who underwent VDRO surgery between January 2004 and August 2019 at a single institution. Patients without sufficient clinical data and patients with preexisting bleeding or coagulation disorders were excluded. Patients were divided into 2 groups: those who received intraoperative TXA and those who did not.Out of 390 patients (mean age 9.4 ±â€Š3.8 years), 80 received intravenous TXA (TXA group) and 310 did not (No-TXA group). There was no difference in mean weight at surgery (P = .25), Gross Motor Function Classification System level (P = .99), American Society of Anesthesiologist classification (P = .50), preoperative feeding status (P = .16), operative time (P = .91), or number of procedures performed (P = .12) between the groups. The overall transfusion rate was lower in the TXA group (13.8%; 11/80) than the No-TXA group (25.2%; 78/310) (P = .04), as was the postoperative transfusion rate (7.5%; 6/80 in the TXA group vs 18.4%; 57/310 in the No-TXA group) (P = .02). The intraoperative transfusion rate was similar for the 2 groups (TXA: 7.5%; 6/80 vs No-TXA: 10.3%; 32/310; P = .53). The EBL was slightly lower in the TXA group, although this was not significant (TXA: 142.9 ±â€Š113.1 mL vs No-TXA: 177.4 ±â€Š169.1 mL; P = .09). The standard deviation for EBL was greater in the No-TXA group due to more high EBL outliers. The percentage of blood loss based on weight was similar between the groups (TXA: 9.2% vs No-TXA: 10.1%; P = .40). The number needed to treat (NNT) with TXA to avoid one peri-operative blood transfusion in this series was 9.The use of intraoperative TXA in patients with CP undergoing VDRO surgery lowers overall and postoperative transfusion rates.Level of evidence: III, Retrospective Comparative Study.

Pre-operative nutrition assessments do not improve outcomes in cerebral palsy patients undergoing varus derotational osteotomy.

ABSTRACT: Pre-operative nutritional assessments have been used as a "cornerstone" to help optimize nutritional status and weight in children with cerebral palsy (CP) to lower the risk of postoperative complications. However, the potential value of nutritional assessments on surgical outcomes in patients with CP undergoing major orthopedic surgery remains unproven.Do pre-operative nutritional assessments reduce complication rates of varus derotational osteotomy surgery in children with CP? Are complication rates higher in patients with a gastrostomy tube (G-tube) and can they be decreased by pre-operative nutritional assessment?One-hundred fifty-five patients with CP who underwent varus derotational osteotomy from January 1, 2012 through December 31, 2017 at a tertiary pediatric hospital with minimum 6 months follow-up were retrospectively identified. One-hundred-ten (71%) were categorized as "non-ambulatory" (Gross Motor Function Classification System [GMFCS] IV-V), and 45 (29%) as "ambulatory" (GMFCS I-III). Variables assessed included age, GMFCS level, G-tube, body mass index (BMI) percentile, complications, and if patients underwent pre-operative nutritional assessment.One-hundred-eleven patients (71.6%) underwent pre-operative nutritional assessment. Sixty-two of 155 patients (40.0%) had G-tubes. In non-ambulatory patients with G-tubes, BMI percentile changes were not significantly different between patients with a pre-operative nutritional assessment compared to those without at 1 (P = .58), 3 (P = .61), 6 (P = .28), and 12 months (P = .21) postoperatively. In non-ambulatory patients who underwent pre-operative nutritional assessment, BMI percentile changes were not significantly different between those with and without G-tubes at 1 (P = .61), 3 (P = .71), 6 (P = .19), and 12 months (P = .10). Pulmonary complication rates were significantly higher in non-ambulatory patients with G-tubes than in non-ambulatory patients without G-tubes (20% vs 4%, P = .03). Pre-operative nutritional assessments did not influence postoperative complication rates for non-ambulatory patients with or without a G-tube (P = .12 and P = .16, respectively). No differences were found in postoperative complications between ambulatory patients with and without G-tubes (P = .45) or between ambulatory patients with or without nutritional assessments (P = .99).Nutritional assessments, which may improve long term patient nutrition, should not delay hip surgery in patients with CP and progressive lower extremity deformity. Patients and their families are unlikely to derive any short-term nutritional improvement using routine pre-operative evaluation and surgical outcomes are unlikely to be improved.Level of Evidence: III, retrospective comparative.

Is Radiographic Imaging Necessary for Identifying Late Developmental Dysplasia of the Hip in Breech Infants with Normal Ultrasounds?

Purpose. The goal of our study was to investigate the prevalence of late DDH cases in breech infants who had a normal screening hip ultrasound and subsequent follow-up hip x-ray imaging. Methods. Infants with a history of intrauterine breech position, normal hip ultrasound within 3-months of birth, and follow-up hip x-rays within 2-years were included. Acetabular indices were measured on a supine AP pelvis radiograph. Results. Fifty-six patients had breech presentation at birth, a normal hip ultrasound, and returned for radiographic evaluation within 2 years. Of those, 11/112 (10%) of hips had late DDH based on their radiographic images at 1 standard deviation greater than normative values from age-adjusted controls. No infants showed hip dysplasia at 2 standard deviations greater than normative values from age-adjusted controls. Conclusions. Our results support previous studies that follow up should be considered for infants with breech presentation and normal hip ultrasounds near birth. Level of evidence. II.

An Inverted Acetabular Labrum Is Predictive of Pavlik Harness Treatment Failure in Children With Developmental Hip Dysplasia.

INTRODUCTION: The failure rate of Pavlik harness treatment for developmental dysplasia of the hip (DDH) has been reported as high as 55%. The purpose of this study is to investigate the effect of an inverted acetabular labrum on outcomes of Pavlik harness treatment for DDH. METHODS: A retrospective review was conducted on DDH patients at a tertiary care pediatric hospital from 2004 to 2016. DDH patients that underwent index treatment with Pavlik harness and had minimum 12 months follow-up were included. Medical charts were reviewed for demographics, treatment, and outcomes. Outcomes were compared between patients with an inverted labrum versus those without an inverted labrum. RESULTS: A total of 156 patients with 229 dysplastic hips were included. The mean age at initiation of Pavlik harness treatment was 1.9±1.4 months and mean follow-up was 37.7±23.0 months. Bilateral DDH was diagnosed in 46% (73/156) of patients. In all, 37% (75/229) of hips failed Pavlik harness index treatment. Second-line treatment was rigid hip abduction bracing in 91% (68/75) of hips, closed reduction in 5% (4/75) of hips, and open reduction in 4% (3/75) of hips. An inverted labrum was present in 10% (22/229) of all hips. The incidence of Pavlik harness treatment failure was 91% (20/22) in the inverted labrum group compared with 27% (55/207) in the control group (P<0.001). Closed or open reduction was required in 86% (15/22) of the inverted labrum group compared with 3% (7/207) of hips in the control group (P<0.001). The incidence of avascular necrosis was 18% (4/22) in hips with an inverted labrum compared with 0.4% (1/207) in the control group (P<0.001). CONCLUSIONS: In children with DDH undergoing index treatment in a Pavlik harness, the presence of an inverted acetabular labrum is strongly predictive of treatment failure. Dysplastic hips with an inverted labrum also have a significantly higher risk of requiring closed or open reduction and developing avascular necrosis compared with those without an inverted labrum. LEVEL OF EVIDENCE: Level III.

Hip Morphology in Early-stage LCPD: Is There an Argument for Anatomic-specific Containment?

BACKGROUND: Early containment surgery has become increasingly popular in Legg-Calvé-Perthes Disease (LCPD), especially for older children. These procedures treat the proximal femur, the acetabulum, or both, and most surgeons endorse the same surgical option regardless of an individual patient's anatomy. This "one-surgery-fits-all" approach fails to consider potential variations in baseline anatomy that may make one option more sensible than another. We sought to describe hip morphology in a large series of children with newly diagnosed LCPD, hypothesizing that variation in anatomy may support the concept of anatomic-specific containment. METHODS: A retrospective review of a prospectively collected multicenter database was conducted for patients aged 6 to 11 at diagnosis. To assess anatomy before significant morphologic changes secondary to the disease itself, only patients in Waldenström stages IA/IB were included. Standard hip radiographic measurements including acetabular index, lateral center-edge angle, proximal femoral neck-shaft angle (NSA), articulotrochanteric quartiles, and extrusion index (EI) were made on printed anteroposterior pelvis radiographs. Age-specific percentiles were calculated for these measures using published norms. Significant outliers (≤10th/≥90th percentile) were reported where applicable. RESULTS: A total of 168 patients with mean age at diagnosis of 8.0±1.3 years met inclusion criteria (81.5% male). Mean acetabular index for the entire cohort was 16.8±4.1 degrees; 58 hips (34.5%) were significantly dysplastic compared with normative data. Mean lateral center-edge angle was 15.9±5.2 degrees at diagnosis; 110 (65.5%) were ≤10th percentile indicating dysplasia (by this metric). Mean NSA overall was 136.5±7.0 degrees. Fifty-one (30.4%) and 20 (11.9%) hips were significantly varus (≤10th percentile) or valgus (≥90th percentile), respectively. Thirty-five hips (20.8%) were the third articulo-trochanteric quartiles or higher suggesting a higher-riding trochanter at baseline. Mean EI was 15.5%±9.0%, while 63 patients (37.5%) had an EI ≥20%. CONCLUSIONS: The present study finds significant variation in baseline anatomy in children with early-stage LCPD, including a high prevalence of coexisting acetabular dysplasia as well as high/low NSAs. These variations suggest that the "one-surgery-fits-all" approach may lack specificity for a particular patient; a potentially wiser option may be an anatomic-specific containment operation (eg, acetabular-sided osteotomy for coexisting dysplasia, varus femoral osteotomy for valgus NSA). LEVEL OF EVIDENCE: Level IV.

Obesity as a Predictor of Outcomes in Type III and Type IV Supracondylar Humerus Fractures.

OBJECTIVES: To investigate the association of obesity with fracture characteristics and outcomes of operatively treated pediatric supracondylar humerus fractures. DESIGN: Retrospective multicenter. SETTING: Two Level I pediatric hospitals. PATIENTS: Patients (age <18 years) with operatively treated Gartland type III and type IV fractures 2010-2014. INTERVENTION: Closed or open reduction and percutaneous pinning of supracondylar humerus fractures. MAIN OUTCOME MEASURE: Incidence of Gartland IV fracture, preoperative nerve palsy, open reduction and complication rates. RESULTS: Patients in the obese group had a significantly higher likelihood of having a Gartland IV fracture (not obese: 17%; obese: 35%; P = 0.007). There was a significantly higher incidence of nerve palsy on presentation in the obese group (not obese: 20%; obese: 33%; P = 0.03). No significant differences were found between groups regarding incidence of open reduction, compartment syndrome, and rates of reoperation. CONCLUSIONS: The present study demonstrates that obese children with a completely displaced supracondylar humerus fractures have an increased risk of Gartland type IV and preoperative nerve palsy compared with normal weight children. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Are Some Randomized Clinical Trials Impossible?

Congenital tibial pseudarthrosis is a rare condition seen in neurofibromatosis type 1 (NF1), and treatment is complex. A randomized, placebo-controlled trial of bone morphogenetic protein (rhBMP-2; INFUSE bone graft) at time of tibial surgery was developed by the Neurofibromatosis Clinical Trials Consortium. Patients were randomized to receive rhBMP-2 that would, or would not, be added to the standard surgical procedure consisting of resection of pseudarthrosis tissue, insertion of a rigid intramedullary rod, and placement of autogenous iliac crest bone graft. Despite involvement of 16 centers with wide experience with NF1 orthopaedic management, only 5 patients (of 54 required) were able to be enrolled in the study during a 3-year time period. Because of the inability to recruit sufficient patients, this study was closed in June 2019, with plans to terminate. The obstacles that were encountered during the study are summarized. The authors question whether a randomized, placebo-controlled trial of a rare pediatric orthopaedic condition is possible to accomplish. Recommendations are provided to guide future studies of orthopaedic manifestations of NF1.Level of Evidence: Level V.

Hip Dysplasia Is Not More Common in W-Sitters.

Parents are frequently cautioned by therapists, teachers, physicians, and online resources about potential negative effects of w-sitting in children (including hip dysplasia), despite lack of evidence. To examine relationships between w-sitting and hip dysplasia, a prospective cohort study was conducted of 104 patients (196 hips), aged 9.9 (standard deviation = 5.7) years, who underwent hip/pelvis radiography at a pediatric tertiary care center. Measures of hip dysplasia were taken from radiographs. Parents/patients completed a questionnaire regarding the patients' sitting habits. Associations between hip dysplasia and w-sitting were analyzed statistically. About 48/104 parents/patients (46%) reported current or past w-sitting: 11/104 (11%) current, preferred position; 23/104 (22%) current, nonpreferred position, 14/104 (13%) w-sat in past, and 56/104 (54%) never w-sat. There was no difference in measures of hip dysplasia (P > .12) or hip dysplasia frequency between w-sitters (9%) and non-w-sitters (10%; P = .81), or among w-sitting persistence groups (P = .26). W-sitting in children is not associated with hip dysplasia.