Utilization of shear wave elastography to quantify and predict response to upper extremity botulinum toxin injections in patients with cerebral palsy: A pilot study.

OBJECTIVE: Shear wave elastography (SWE) was used to quantify change in upper extremity muscle stiffness in patients with unilateral spastic cerebral palsy (USCP) following botulinum toxin A (BTX-A) therapy. We hypothesized that SWE measures would decrease following ultrasound-guided BTX-A injection, and correlate with functional improvement. METHODS: SWE measures of BTX-A treated muscles were recorded immediately pre-injection, and at 1-, 3- and 6-months post-injection. At the same timepoints, functional assessment was performed using the Modified Ashworth Scale (MAS), and passive and active range of motion (PROM and AROM) measures. Correlation of SWE with MAS, PROM and AROM, as well as the relationship between change in SWE and change in MAS, PROM and AROM was determined using Spearman's rank correlation coefficient and generalized estimating equation modeling. RESULTS: 16 muscles were injected and longitudinally assessed. SWE and MAS scores decreased following BTX-A injection (p = 0.030 and 0.004, respectively), reflecting decreased quantitative and qualitative muscle stiffness. Decreased SWE reached statistical significance at 1- and 3-months, and 1-, 3- and 6-months for MAS. When comparing relative change in SWE to relative change in AROM, larger change in SWE strongly correlated with positive change in AROM (p-value range:<0.001-0.057). BTX-A responders also demonstrated lower baseline SWE (1.4 m/s) vs. non-responders (1.9 m/s), p = 0.035. CONCLUSION: Ultrasound-guided BTX-A injections in patients with USCP resulted in decreased quantitative and qualitative muscle stiffness. Strong correlation between change in SWE and AROM, as well as the significant difference in baseline SWE for BTX-A responders and non-responders, suggests SWE may provide a useful tool to predict and monitor BTX-A response.

Early Results of 3-Dimensional Planning and Customized Cutting Guides for the Treatment of Severe Madelung Defofrmity.

PURPOSE: Surgical treatment of Madelung deformity can present challenges due to a need for multiplanar correction. Developing customized cutting guides for osteotomies may improve surgical outcomes by enhancing the surgeon's understanding and surgical correction. METHODS: All patients who underwent forearm osteotomies for Madelung deformity using computed tomography planning with 3-dimensional-printed customized cutting guides were retrospectively reviewed (n = 8). Seven patients underwent a double osteotomy of the radius, and 1 underwent a single osteotomy. RESULTS: Ulnar tilt was improved in all cases. Correction of deformity was significant on anteroposterior but not on lateral views. The mean preoperative and postoperative radial bow was measured in 2 planes, with an average preoperative bow of 32° (± 21°) on anteroposterior radiographs and 36° (± 17°) on lateral radiographs, and an average bow of 10° (± 6°) on anteroposterior radiographs and 7° (± 6°) on lateral films after surgery. The predicted radial bow was calculated to be 9.1° (± 8°). CONCLUSIONS: Three-dimensional planning allows predictable deformity correction across multiple but not all parameters. Future studies comparing clinical and radiographic outcomes of guided versus nonguided osteotomies are required to justify the additional expense and preoperative planning efforts. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Deep Learning Assistance Closes the Accuracy Gap in Fracture Detection Across Clinician Types.

BACKGROUND: Missed fractures are the most common diagnostic errors in musculoskeletal imaging and can result in treatment delays and preventable morbidity. Deep learning, a subfield of artificial intelligence, can be used to accurately detect fractures by training algorithms to emulate the judgments of expert clinicians. Deep learning systems that detect fractures are often limited to specific anatomic regions and require regulatory approval to be used in practice. Once these hurdles are overcome, deep learning systems have the potential to improve clinician diagnostic accuracy and patient care. QUESTIONS/PURPOSES: This study aimed to evaluate whether a Food and Drug Administration-cleared deep learning system that identifies fractures in adult musculoskeletal radiographs would improve diagnostic accuracy for fracture detection across different types of clinicians. Specifically, this study asked: (1) What are the trends in musculoskeletal radiograph interpretation by different clinician types in the publicly available Medicare claims data? (2) Does the deep learning system improve clinician accuracy in diagnosing fractures on radiographs and, if so, is there a greater benefit for clinicians with limited training in musculoskeletal imaging? METHODS: We used the publicly available Medicare Part B Physician/Supplier Procedure Summary data provided by the Centers for Medicare & Medicaid Services to determine the trends in musculoskeletal radiograph interpretation by clinician type. In addition, we conducted a multiple-reader, multiple-case study to assess whether clinician accuracy in diagnosing fractures on radiographs was superior when aided by the deep learning system compared with when unaided. Twenty-four clinicians (radiologists, orthopaedic surgeons, physician assistants, primary care physicians, and emergency medicine physicians) with a median (range) of 16 years (2 to 37) of experience postresidency each assessed 175 unique musculoskeletal radiographic cases under aided and unaided conditions (4200 total case-physician pairs per condition). These cases were comprised of radiographs from 12 different anatomic regions (ankle, clavicle, elbow, femur, forearm, hip, humerus, knee, pelvis, shoulder, tibia and fibula, and wrist) and were randomly selected from 12 hospitals and healthcare centers. The gold standard for fracture diagnosis was the majority opinion of three US board-certified orthopaedic surgeons or radiologists who independently interpreted the case. The clinicians' diagnostic accuracy was determined by the area under the curve (AUC) of the receiver operating characteristic (ROC) curve, sensitivity, and specificity. Secondary analyses evaluated the fracture miss rate (1-sensitivity) by clinicians with and without extensive training in musculoskeletal imaging. RESULTS: Medicare claims data revealed that physician assistants showed the greatest increase in interpretation of musculoskeletal radiographs within the analyzed time period (2012 to 2018), although clinicians with extensive training in imaging (radiologists and orthopaedic surgeons) still interpreted the majority of the musculoskeletal radiographs. Clinicians aided by the deep learning system had higher accuracy diagnosing fractures in radiographs compared with when unaided (unaided AUC: 0.90 [95% CI 0.89 to 0.92]; aided AUC: 0.94 [95% CI 0.93 to 0.95]; difference in least square mean per the Dorfman, Berbaum, Metz model AUC: 0.04 [95% CI 0.01 to 0.07]; p < 0.01). Clinician sensitivity increased when aided compared with when unaided (aided: 90% [95% CI 88% to 92%]; unaided: 82% [95% CI 79% to 84%]), and specificity increased when aided compared with when unaided (aided: 92% [95% CI 91% to 93%]; unaided: 89% [95% CI 88% to 90%]). Clinicians with limited training in musculoskeletal imaging missed a higher percentage of fractures when unaided compared with radiologists (miss rate for clinicians with limited imaging training: 20% [95% CI 17% to 24%]; miss rate for radiologists: 14% [95% CI 9% to 19%]). However, when assisted by the deep learning system, clinicians with limited training in musculoskeletal imaging reduced their fracture miss rate, resulting in a similar miss rate to radiologists (miss rate for clinicians with limited imaging training: 9% [95% CI 7% to 12%]; miss rate for radiologists: 10% [95% CI 6% to 15%]). CONCLUSION: Clinicians were more accurate at diagnosing fractures when aided by the deep learning system, particularly those clinicians with limited training in musculoskeletal image interpretation. Reducing the number of missed fractures may allow for improved patient care and increased patient mobility. LEVEL OF EVIDENCE: Level III, diagnostic study.

Combined clinic and home-based therapeutic approach for the treatment of bilateral radial deficiency for a young child with Holt-Oram syndrome: A case report.

BACKGROUND: Holt-Oram syndrome (HOS) is a rare, genetic condition characterized by the combination of congenital heart defect and hypoplasia in one or both upper extremities. Children with HOS commonly present with varied joint and limb involvement including radial longitudinal deficiency impacting hand function. Evidence-based guidelines regarding orthotic wear and therapeutic techniques are lacking. PURPOSE: The aim of this case report was to present the results of a long-term occupational therapy program for a patient with HOS pre and postpollicization. STUDY DESIGN: Case report. METHODS: A 4-month-old patient with bilateral radial longitudinal deficiencies began outpatient occupational therapy for custom orthosis fabrication and treatment which included long term clinic and home-based intervention. Techniques included passive range of motion, orthosis wear, therapeutic taping, and modified constraint induced movement therapy. Longitudinal assessment of musculoskeletal alignment and functional hand use was performed using goniometry for passive and active range of motion, the Assisting Hand Assessment (AHA), and The Thumb Grasp and Pinch Assessment (T-GAP). RESULTS: Improvement in passive and active range of motion was achieved as well as improved activity level function as measured by the AHA and T-GAP postpollicization and intervention. CONCLUSIONS: A combined clinic and home-based therapeutic approach can be effective for children with HOS to improve alignment and function pre and postpollicization to further enhance hand function. Comprehensive, long-term assessment is necessary to fully evaluate and communicate improvement.

Reliability and agreement between two wearable inertial sensor devices for measurement of arm activity during walking and running gait.

STUDY DESIGN: This is a validation study. BACKGROUND: Tracking limb movement with body worn sensors allows clinicians to measure limb dynamics to guide treatment for patients with movement disorders. The current gold standard, 3-dimensional optical motion capture, is costly, time-consuming, requires specific training, and is conducted in specialized laboratories. PURPOSE: The purpose of our study was to a compare consumer-grade inertial sensor to a laboratory-grade sensor to provide additional methods for capturing limb dynamics. METHODS: The participants wore an Apple Watch and a laboratory-grade Xsens sensor on each wrist during 3 conditions: walk, fast-walk, and run. Acceleration data were collected simultaneously on each device per wrist for all conditions. Intraclass correlation coefficients and Bland-Altman plots were calculated to measure intra-/interdevice reliability, evaluate bias, and limits of agreement. RESULTS: Intradevice ICCs showed good reliability during walk and fast-walk (0.79-0.87) and excellent reliability during run (0.94-0.97) conditions. Inter-device ICCs yielded moderate reliability during walk (0.52 ± 0.22) and excellent reliability in fast-walk and run (0.93 ± 0.02, 1.00 ± 0.01) conditions. Bland-Altman plots showed small biases with 90% or more of the data contained within the limits of agreement. DISCUSSION: Our study demonstrates reliability and agreement between the two devices, suggesting that both can reliably capture upper extremity motion data during gait trials. CONCLUSION: Our findings support further study of consumer-grade motion trackers to measure arm activity for clinical use. These devices are inexpensive, user-friendly, and allow for data collection outside of the laboratory.

Assessment of a deep-learning system for fracture detection in musculoskeletal radiographs.

Missed fractures are the most common diagnostic error in emergency departments and can lead to treatment delays and long-term disability. Here we show through a multi-site study that a deep-learning system can accurately identify fractures throughout the adult musculoskeletal system. This approach may have the potential to reduce future diagnostic errors in radiograph interpretation.

Polydactyly a review and update of a common congenital hand difference.

PURPOSE OF REVIEW: The purpose of this review is to describe various forms of hand polydactyly and their different treatment approaches. Hand polydactyly is commonly classified as ulnar (small finger) or radial (thumb). Polydactyly can be sporadic, genetic, and/or associated with syndromic conditions. RECENT FINDINGS: Both ulnar and radial polydactyly can be surgically treated to optimize hand aesthetics and function. Timing of surgery is based on multiple factors, most notably including safety of anesthesia and socialization of the affected child. The pediatrician should be aware of potential associated conditions, such as chondroectodermal dysplasia or Ellis-van Creveld syndrome for ulnar polydactyly. SUMMARY: Polydactyly is a common congenital hand difference and can be broadly be classified by radial or ulnar involvement. Polydactyly warrants hand surgical referral, as surgical treatment is often indicated. Pediatricians should be aware of treatment options, as well as of commonly associated anomalies and syndromes.

Epidemiology of syndactyly in New York State.

BACKGROUND: There is paucity of literature focusing on the incidence and surgical management of syndactyly. In this study, we describe the incidence and rates of surgical management of patients with syndactyly in New York State. AIM: To describe the incidence and surgical management of patients with syndactyly using an America's population-based database. METHODS: We conducted a retrospective study using the New York State Statewide Planning and Research Cooperative System. All patients with a diagnosis of syndactyly at birth were identified and followed longitudinally to determine yearly incidence as well as demographic and surgical factors. Descriptive statistics and univariate analyses were used. RESULTS: There were 3306 newborns with a syndactyly diagnosis between 1997 and 2014 in New York State. The overall incidence was 0.074% or 7 cases per 10000 live births. A small number of patients underwent surgical correction in New York State (178 patients, 5.4%). Among the surgical patients, most of the operations were performed before the age of two (79%). Approximately 87% of surgeries were performed at teaching hospitals, and 52% of procedures were performed by plastic surgeons. Skin grafting was performed in 15% of cases. Patients having surgery in New York State were more likely to have Medicaid insurance compared to patients not having surgery (P = 0.02). CONCLUSION: Syndactyly occurs in approximately 7 per 10000 live births, and the majority of patients undergo surgical correction before age two. There may be several barriers to care including the availability of specialized hand surgeons, access to teaching hospitals, and insurance status.

Incidence of Nerve Repair Following Endoscopic Carpal Tunnel Release Is Higher Compared to Open Release in New York State.

BACKGROUND: Carpal tunnel release (CTR) has traditionally been performed through an open approach, although in recent years endoscopic CTR has gained in popularity. QUESTIONS/PURPOSES: We sought to assess whether a difference exists between the rates of nerve repair surgery following open versus endoscopic CTR in New York State (NYS). METHODS: Patients undergoing endoscopic and open CTR from 1997 to 2013 were identified from the Statewide Planning and Research Cooperative System (SPARCS) database from the NYS Department of Health using Current Procedural Terminology, 4th Revision (CPT-4) codes 29848 and 64721, respectively. The primary outcome measure was subsequent nerve repair surgery (as identified using CPT-4 codes 64831-64837, 64856, 64857, 64859, 64872, 64874, and 64876). Other variables analyzed included patient age, sex, payer, and surgery year. RESULTS: There were 294,616 CTRs performed in NYS from 1997 to 2013. While the incidence of open CTR remained higher than endoscopic CTR, the proportion of endoscopic CTR steadily increased, from 16% (2984/19,089) in 2007 to 25% (5594/22,271) in 2013. For the 134,143 patients having a single CTR, the rate of subsequent nerve repair was significantly higher following endoscopic CTR (0.09%) compared to open CTR (0.04%). The Cox model showed that factors significantly associated with a higher risk of subsequent nerve repair surgery were endoscopic CTR and younger age. CONCLUSIONS: Endoscopic CTR has been increasingly performed in NYS and associated with a higher rate of subsequent nerve repair. This rate likely underestimates the incidence of nerve injuries because it only captures those patients who had subsequent surgery. While this catastrophic complication remains rare, further investigation is warranted, given the rise of endoscopic CTR in the setting of equivalent outcomes, but favorable reimbursement, versus open CTR.

The Fragility Index in Hand Surgery Randomized Controlled Trials.

PURPOSE: Randomized controlled trials (RCTs) are the gold standard for comparing clinical interventions. Statistical significance as reported via a P value has been used to determine if a difference between clinical interventions exists in an RCT. However, P values do not clearly convey information about the robustness of a study's conclusions. An emerging metric, called the fragility index (the number of subjects who would need to change outcome category to raise the P value above the .05 threshold), is an indirect measure of how likely a repeat of the trial would reach the same conclusions. This study addressed the fragility of RCTs using dichotomous outcomes in hand surgery. METHODS: Using systematic searching of the MEDLINE database, we identified hand surgery RCTs published in 11 high-impact journals published in the last decade (2007-2017). Studies were identified that involved 2 parallel arms, allocated patients to treatment and control in a 1:1 ratio, and reported statistical significance for a dichotomous variable. The fragility index was calculated using Fisher's exact test, using previously published methods. RESULTS: Five hand surgery RCTs were identified for inclusion reporting a range of fragility indices from 0 to 26. Two of the trials (40%) had a fragility index of 2 or less. Two of the trials (40%) reported that the number of patients lost to follow-up exceeded the fragility index, meaning that results of the patients lost to follow-up could theoretically completely reverse the study conclusions. CONCLUSIONS: The range of fragility indices reported in the recent hand surgery literature is consistent with previous reporting within orthopedic surgery. CLINICAL RELEVANCE: The fragility index is a useful metric to analyze the robustness of the study conclusions that should complement other methods of critical evaluation including the P value or effect sizes. Our results emphasize the need for future efforts to strengthen the robustness of RCT conclusions.

Management of Joint Contractures in the Spastic Upper Extremity.

Upper extremity contractures in the spastic patient may result from muscle spasticity, secondary muscle contracture, or joint contracture. Knowledge of the underlying cause is critical in planning successful treatment. Initial management consists of physical therapy and splinting. Botulinum toxin can be helpful, as a therapeutic treatment in relieving spasticity and as a diagnostic tool in determining the underlying cause of the contracture. Surgical management options include release or lengthening of the causative muscle/tendon unit and joint capsular release, as required. Postoperative splinting is important to maintain the improved range of motion and protect any associated tendon lengthening or transfer.

Deep neural network improves fracture detection by clinicians.

Suspected fractures are among the most common reasons for patients to visit emergency departments (EDs), and X-ray imaging is the primary diagnostic tool used by clinicians to assess patients for fractures. Missing a fracture in a radiograph often has severe consequences for patients, resulting in delayed treatment and poor recovery of function. Nevertheless, radiographs in emergency settings are often read out of necessity by emergency medicine clinicians who lack subspecialized expertise in orthopedics, and misdiagnosed fractures account for upward of four of every five reported diagnostic errors in certain EDs. In this work, we developed a deep neural network to detect and localize fractures in radiographs. We trained it to accurately emulate the expertise of 18 senior subspecialized orthopedic surgeons by having them annotate 135,409 radiographs. We then ran a controlled experiment with emergency medicine clinicians to evaluate their ability to detect fractures in wrist radiographs with and without the assistance of the deep learning model. The average clinician's sensitivity was 80.8% (95% CI, 76.7-84.1%) unaided and 91.5% (95% CI, 89.3-92.9%) aided, and specificity was 87.5% (95 CI, 85.3-89.5%) unaided and 93.9% (95% CI, 92.9-94.9%) aided. The average clinician experienced a relative reduction in misinterpretation rate of 47.0% (95% CI, 37.4-53.9%). The significant improvements in diagnostic accuracy that we observed in this study show that deep learning methods are a mechanism by which senior medical specialists can deliver their expertise to generalists on the front lines of medicine, thereby providing substantial improvements to patient care.

Online Patient Ratings Are Not Correlated with Total Knee Replacement Surgeon-Specific Outcomes.

BACKGROUND: Despite potential concerns regarding their validity, physician-rating websites continue to grow in number and utilization and feature prominently on major search engines, potentially affecting patient decision-making regarding physician selection. QUESTIONS/PURPOSES: We sought to determine whether patient ratings on public physician-rating websites correlate with surgeon-specific outcomes for high-volume total knee replacement (TKR) surgeons in New York State (NYS) from 2010 to 2012. METHODS: Online patient ratings were compared to surgeon-specific outcomes from the Statewide Planning and Research Cooperative System (SPARCS) database from the NYS Department of Health. For each surgeon, we determined the infection rate, re-admission rate, and revision surgery rate within the study period, as well as the mean inpatient length of stay, for TKR from the SPARCS database. Online ratings were collected from two physician-rating websites (Vitals.com and HealthGrades.com). RESULTS: One hundred seventy-four high-volume TKR surgeons were identified in NYS from 2010 to 2012. The mean rates of in-hospital infection, 90-day infection, 30-day re-admission, 90-day re-admission, and revision surgery were 0.25, 1.00, 4.89, 8.43, and 1.31%, respectively. The mean number of ratings for individual surgeons on HealthGrades.com and Vitals.com were 24.0 (range: 0 to 109) and 19.3 (range: 0 to 114), respectively, and mean overall ratings were 4.2 and 4.1 (out of 5) stars, respectively. As with online patient ratings of individual surgeons, variability was observed in the total adverse event rate distribution for individual surgeons. Despite sufficient variability in both online patient rating and surgeon-specific outcomes for high-volume TKR surgeons in NYS, no correlation was observed. CONCLUSION: There was no correlation between surgeon-specific TKR outcome measures and online patient ratings. We therefore advise that patients exert caution when interpreting ratings on these websites.

A matched quantitative computed tomography analysis of 3 surgical approaches for osteochondral reconstruction of the capitellum.

BACKGROUND: The location of capitellar osteochondritis dissecans (OCD) lesions in the sagittal plane guides the surgical approach used for autologous osteochondral transplantation. We sought to compare the capitellar region accessible for orthogonal graft placement through 3 approaches: (1) posterior anconeus-split approach; (2) lateral approach with lateral collateral ligament (LCL) preservation (LCL-preserving lateral approach); and (3) lateral approach with LCL release (LCL-sacrificing lateral approach). METHODS: The 3 approaches were sequentially performed on 9 cadaveric elbows: posterior anconeus-split approach, LCL-preserving lateral approach, and LCL-releasing lateral approach. The extent of perpendicular access was delineated with Kirschner wires. Each specimen underwent computed tomography. The accessible region was quantified as degrees on the capitellum and converted into time on a clock, where 0° corresponds to the 12-o'clock position. Generalized estimating equation modeling was used to investigate for significant within-specimen, between-approach differences. RESULTS: The LCL-preserving and LCL-sacrificing lateral approaches provided more anterior perpendicular access than the posterior anconeus-split approach (mean, 0° vs 83°; P < .001). The posterior anconeus-split approach provided more posterior perpendicular access (mean, 215.0°; P < .001) than the LCL-preserving (mean, 117°; P < .001) and LCL-sacrificing (mean, 145°; P < .001) lateral approaches. The LCL-sacrificing lateral approach provided more posterior exposure than the LCL-preserving lateral approach (mean, 145° vs 117°; P < .001). The mean arc of visualization was greater for the LCL-sacrificing lateral approach than for the LCL-preserving lateral approach (145° vs 117°, P < .001). CONCLUSIONS: A capitellar OCD lesion can be perpendicularly accessed from a posterior anconeus-split approach if it is posterior to 83° (2:46 clock-face position). A laterally based approach may be required for lesions anterior to this threshold. These data inform clinical decisions regarding the appropriate surgical approach for any OCD lesion.

Location of Osteochondritis Dissecans Lesions of the Capitellum.

PURPOSE: The location of capitellar osteochondritis dissecans (OCD) lesions in the sagittal plane guides the surgical approach, and lesion location in the coronal plane influences surgical management. Although most lesions have been reported to occur between 4 o'clock and 4:30 (120° to 135° anterior to the humerus), some lesions are located elsewhere in the capitellum. The primary aim was to define the region of the capitellum affected by OCD lesions using a novel clock-face localization system. METHODS: We reviewed 104 magnetic resonance imaging examinations diagnosing a nontraumatic capitellar OCD lesion. In the sagittal plane, lesion margins were recorded as degrees on the capitellum and converted into a clock-face format in which 0° corresponds to 12:00 with the forearm facing to the right. The 0° axis (12-o'clock axis) was defined as a line parallel to the anterior humeral line that intersects the capitellum center. The following coronal measurements were recorded: lesion width, capitellar width, and distance between the lateral capitellum and lateral lesion. Two independent observers took measurements. RESULTS: In the sagittal plane, average lesion location was 92° to 150° (3:04-5:00, clock face) and ranged from 52.1° to 249.5° (1:44-8:19, clock face). Average lesion dimensions were 10.7 mm (mediolateral width) and 5.2 mm (anteroposterior depth). Interrater reliability was high (intraclass correlation coefficient = 0.98). CONCLUSIONS: Using a magnetic resonance imaging-based clock-face localization system, we found that capitellar OCD lesions affect a broad region of the capitellum in the sagittal plane. CLINICAL RELEVANCE: The clock-face localization system allows for precise description of capitellar OCD lesion location, which may facilitate intraoperative decision and longitudinal monitoring.

Reliability of the Modified Clavien-Dindo-Sink Complication Classification System in Pediatric Orthopaedic Surgery.

BACKGROUND: There is no standardized complication classification system that has been evaluated for use in pediatric or general orthopaedic surgery. Instead, subjective terms such as major and minor are commonly used. The Clavien-Dindo-Sink complication classification system has demonstrated high interrater and intrarater reliability for hip-preservation surgery and has increasingly been used within other orthopaedic subspecialties. This classification system is based on the magnitude of treatment required and the potential for each complication to result in long-term morbidity. The purpose of the current study was to modify the Clavien-Dindo-Sink system for application to all orthopaedic procedures (including those involving the spine and the upper and lower extremity) and to determine interrater and intrarater reliability of this modified system in pediatric orthopaedic surgery cases. METHODS: The Clavien-Dindo-Sink complication classification system was modified for use with general orthopaedic procedures. Forty-five pediatric orthopaedic surgical scenarios were presented to 7 local fellowship-trained pediatric orthopaedic surgeons at 1 center to test internal reliability, and 48 scenarios were then presented to 15 pediatric orthopaedic surgeons across the United States and Canada to test external reliability. Surgeons were trained to use the system and graded the scenarios in a random order on 2 occasions. Fleiss and Cohen kappa (κ) statistics were used to determine interrater and intrarater reliabilities, respectively. RESULTS: The Fleiss κ value for interrater reliability (and standard error) was 0.76 ± 0.01 (p < 0.0001) and 0.74 ± 0.01 (p < 0.0001) for the internal and external groups, respectively. For each grade, interrater reliability was good to excellent for both groups, with an overall range of 0.53 for Grade I to 1 for Grade V. The Cohen κ value for intrarater reliability was excellent for both groups, ranging from 0.83 (95% confidence interval [CI], 0.71 to 0.95) to 0.98 (95% CI, 0.94 to 1.00) for the internal test group and from 0.83 (95% CI, 0.73 to 0.93) to 0.99 (95% CI, 0.97 to 1.00) for the external test group. CONCLUSIONS: The modified Clavien-Dindo-Sink classification system has good interrater and excellent intrarater reliability for the evaluation of complications following pediatric orthopaedic upper extremity, lower extremity, and spine surgery. Adoption of this reproducible, reliable system as a standard of reporting complications in pediatric orthopaedic surgery, and other orthopaedic subspecialties, could be a valuable tool for improving surgical practices and patient outcomes.

Elbow Kinematics During Gait Improve With Age in Children With Hemiplegic Cerebral Palsy.

BACKGROUND: Children with hemiplegic cerebral palsy (hCP) exhibit a typical posture of elbow flexion during gait. However, the change in elbow kinematics and symmetry during gait across age span in both hCP and typically developing (TD) children is not well described. The aim of this study was to quantify the change in elbow kinematics and symmetry across age span in hCP children compared with TD children. METHODS: Upper extremity kinematic data were extracted and analyzed from a database for gait studies performed between 2009 and 2015. A total of 35 hCP and 51 TD children between the ages of 4 and 18 (mean age: TD=11.2±0.6, hCP=9.8±0.5) met inclusionary criteria. The groups were further subdivided into 3 age categories: 4 to 7, 8 to 11, 12+ years old. Elbow angles were extracted and peak elbow flexion, overall range of motion during gait, and asymmetry indices were calculated. A 1-way analysis of variance was performed on each group with post hoc Tukey honestly significant difference pairwise comparisons. RESULTS: Peak elbow flexion during gait increased with age in TD children (P<0.05) and decreased with age in hCP children on the affected side (P<0.05). There was no change on the less affected side of hCP children. TD children demonstrated significantly less elbow flexion (mean=51.9±2.1 deg.) compared with the affected side in hCP (mean=82.1±3.8 deg.) across all age categories (P<0.05). There was no change in elbow asymmetry index (0=perfect symmetry) across age in either controls or hCP children; however, there were differences between hCP and TD groups in younger age groups (TD=28, hCP=62, P<0.05) that resolved by adolescence (TD=32, hCP=40). CONCLUSIONS: During gait, hCP children have greater peak elbow flexion on the affected side than do TD children. Peak elbow flexion angle converged between the 2 groups with age, decreasing in hCP children and increasing in TD children. Furthermore, elbow symmetry during gait improves with age in hCP children, approximating symmetry of TD children by adolescence. These findings have implications for both consideration and optimal timing of surgical intervention to improve elbow flexion in children with hCP. LEVEL OF EVIDENCE: Level III-retrospective case-control study.

Update on operative treatment of scapholunate (SL) instability for radiologists: part 1-SL ligament repair, dorsal capsulodesis and SL ligament reconstruction.

Scapholunate instability is the most common form of carpal instability. Imaging (especially radiography) plays an important role in the staging, management and post-operative follow-up of scapholunate (SL) instability. The goals of this article are to review the pre-operative staging of SL instability, the surgical options for repair and reconstruction of the SL ligament, along with the normal postoperative imaging findings as well as complications associated with these surgical options.

The electrodiagnostic natural history of parsonage-turner syndrome.

INTRODUCTION: Recovery from Parsonage-Turner syndrome (PTS) is generally favorable, although recovery times have been shown to vary, in part because there are no universally accepted outcome measures. In this study, we describe the electrodiagnostic natural history of this condition based on objective electrodiagnostic testing, and propose that complete electrodiagnostic recovery can be seen as early as 1 year. METHODS: Twenty-six subjects with 29 affected nerves confirmed as PTS were followed every 3 months for electrodiagnostic testing, or until full reinnervation was confirmed. RESULTS: Twenty-three cases (79.3%) demonstrated electrodiagnostic evidence of initial recovery at a mean of 5.8 months. Nine cases (31%) showed complete electrodiagnostic recovery at a mean of 1 year. When excluding cases with <1 year of follow-up, 52.9% achieved complete electrodiagnostic recovery. CONCLUSIONS: In contrast to previous reports, full electrodiagnostic recovery of PTS was demonstrated at a mean of 1 year in > 50% of patients with longer term follow-up. Muscle Nerve 56: 737-743, 2017.