Outcomes of the "Calcaneo-stop" procedure for treating symptomatic flexible flatfoot in children: A systematic review and meta-analysis of 2394 feet.

BACKGROUND: This study evaluates the efficacy of the calcaneo-stop (C-Stop) procedure's effectiveness in treating symptomatic flexible flatfoot (FFF) in children. METHODS: A systematic review and meta-analysis were conducted using PubMed, Embase, and Cochrane databases to identify studies until 2023 on the outcomes of the C-Stop procedure in children with FFF. The risk of bias was assessed using MINORS criteria. RESULTS: Of 85 studies screened, 20 involving 2394 feet from 1415 patients (mean age 11.2 ± 1.3 years) were included. Post-procedure, significant improvements were noted in pain reduction (93.5%), heel alignment (95.21%), and radiological measures, including reductions in Kite (7.32º), Meary (11.65º), Costa-Bartani angles (17.11º), talar declination (12.63º) and increase in Calcaneal Pitch Angle (5.92º). AOFAS scores increased by 22.32 points on average, with 94.83% reporting high satisfaction. Complication rate was low (7.8%). CONCLUSIONS: The C-Stop procedure is effective for treating FFF in children, offering significant clinical, radiological, and functional improvements with high patient satisfaction and a low complication rate. LEVEL OF EVIDENCE: Level IV, Systematic review of Level-IV studies.

Outcomes of Ponseti Method for the Treatment of Clubfeet in Children With Arthrogryposis.

INTRODUCTION: The Ponseti serial casting method is the method of choice in treating children with congenital clubfeet. The arthrogrypotic clubfoot has traditionally been considered challenging to treat, with higher rates of recurrence and the need for more corrective surgeries. However, initial reports have found promising results in using the Ponseti method to treat arthrogrypotic feet. This study aims to compare the outcomes of idiopathic versus arthrogrypotic clubfeet following initial treatment with the Ponseti serial casting method. METHODS: A retrospective review of medical records from a single institution was conducted. Data was collected from children ages 0 to 18 with idiopathic or arthrogrypotic clubfoot treated from 2002 to 2022 with Ponseti-style serial casting with a minimum 2-year follow-up. Recurrence was defined as the need for additional casting or subsequent surgeries following initial correction. Data was collected on relevant patient demographics, previous treatment, casting records, Achilles tenotomies, and surgical treatments. RESULTS: A total of 352 patients (546 feet) met inclusion criteria. In all, 334 idiopathic and 18 arthrogrypotic patients were analyzed with an average follow-up duration of 3.4 and 4.2 years, respectively. Twelve patients had distal arthrogryposis, and 6 had amyoplasia. In all, 93.4% of idiopathic and 72.2% of arthrogrypotic patients successfully achieved correction with Ponseti casting and Achilles tenotomy. Recurrence rates were significantly higher in the arthrogrypotic group at 83.3% compared with 44.6% in the idiopathic group (P=0.001). A posterior or posterior medial release was performed in 35.0% of idiopathic and 66.7% arthrogrypotic feet. CONCLUSIONS: We report the largest series of arthrogrypotic clubfeet treated by Ponseti casting to the best of our knowledge. In contrast to earlier reports, our investigation underscores that while the Ponseti method may be able to secure initial correction in arthrogrypotic clubfeet, on average, at a 3-year follow-up, the prognosis is less favorable. These patients exhibit higher recurrence and often require operative treatment. Notably, a posterior medial release may eventually be needed in up to 6 of 10 patients. LEVEL OF EVIDENCE: Level III-therapeutic studies-investigating the results of treatment.

The shifting trends in the epidemiology and risk factors of non-accidental fractures in children.

BACKGROUND: Fractures are a common presentation of non-accidental trauma (NAT) in the pediatric population. However, the presentation could be subtle, and a high degree of suspicion is needed not to miss NAT. OBJECTIVE: To analyze a comprehensive database, providing insights into the epidemiology of fractures associated with NAT. PARTICIPANTS AND SETTING: The TriNetX Research Network was utilized for this study, containing medical records from 55 healthcare organizations. TriNetX was queried for all visits in children under the age of 6 years from 2015 to 2022, resulting in a cohort of over 32 million. METHODS: All accidental and non-accidental fractures were extracted and analyzed to determine the incidence, fracture location, and demographics of NAT. Statistical analysis was done on a combination of Python and Epipy. RESULTS: Overall, 0.36 % of all pediatric patients had a diagnosis of NAT, and 4.93 % of fractures (34,038 out of 689,740 total fractures) were determined to be non-accidental. Skull and face fractures constituted 17.9 % of all NAT fractures, but rib/sternum fractures had an RR = 6.7 for NAT. Children with intellectual and developmental disability (IDD) or autism spectrum disorder (ASD) had a 9 times higher risk for non-accidental fractures. The number of non-accidental fractures significantly increased after 2019. CONCLUSIONS: The study findings suggest that nearly 1 out of all 20 fractures in children under age 6 are caused by NAT, and that rib/sternum fractures are most predictive of an inflicted nature. The study also showed a significant increase in the incidence of NAT, during and after the pandemic.

Does patella lowering as part of multilevel surgery improve knee kinematics in children with cerebral palsy and crouch gait? A meta-analysis of comparative studies.

Purpose: To evaluate differences in knee kinematic outcomes of patellar-lowering surgery, specifically patellar tendon advancement or patellar tendon shortening, compared with no-patellar-lowering surgery in multilevel surgery for children with cerebral palsy and crouch gait. Methods: Four databases were searched to retrieve studies published from inception until 2023. Three reviewers independently screened for studies with observational or randomized control designs, comparing two groups of patients with cerebral palsy and crouch gait who underwent multilevel surgery (with patellar-lowering surgery versus no-patellar-lowering surgery), where various gait analysis outcomes were reported (CRD42023450692). The risk of bias was assessed with the Risk Of Bias In Non-randomised Studies - of Interventions (ROBINS-I) tool. Results: Seven studies (249 patients and 368 limbs) met the eligibility criteria. Patients undergoing patellar-lowering surgery demonstrated statistically significant improvements in knee flexion at initial contact (mean difference = -6.39; 95% confidence interval = [-10.4, -2.75]; p = 0.0006; I2 = 84%), minimum knee flexion in stance (mean difference = -14.27; 95% confidence interval = [-18.31, -10.23]; p < 0.00001; I2 = 89%), and clinical knee flexion contracture (mean difference = -5.6; 95% confidence interval = [-9.59, -1.6]; p = 0.006; I2 = 95%), with a significant increase in anterior pelvic tilt (mean difference = 2.97; 95% confidence interval = [0.58, 5.36]; p = 0.01; I2 = 15%). However, improvements in gait deviation index and decrease in peak knee flexion in swing did not reach statistical significance. Subgroup analysis reduced heterogeneity and revealed (1) greater improvement using patellar tendon shortening versus patellar tendon advancement techniques; (2) lack of knee flexion contracture improvement in high-quality or longer-term studies; (3) longer-term improvement only in minimum knee flexion in stance, with a decrease in peak knee flexion in swing; and (4) an inability to assess the potential benefit of rectus femoris procedure and hamstring preservation. Conclusions: Overall, the combination of patellar-lowering surgery with multilevel surgery demonstrated superior improvements in stance-phase knee kinematics compared with multilevel surgery alone, despite an increase in anterior pelvic tilt and a longer-term knee flexion reduction during the swing phase. Level of evidence: Level III, Systematic review of level III studies.

Rate and Risk Factors for Contralateral Slippage in Adolescents Treated for Slipped Capital Femoral Epiphysis: A Comprehensive Analysis of 3,528 Cases.

BACKGROUND: After a unilateral slipped capital femoral epiphysis (SCFE), the contralateral hip is at risk for a subsequent SCFE. However, further information with regard to risk factors involved in the development of contralateral SCFE must be investigated. The purpose of this study was to report the rate and risk factors for subsequent contralateral SCFE in adolescents treated for unilateral SCFE by exploring a mix of known and potential risk factors. METHODS: A case-control study utilizing aggregated multi-institutional electronic medical record data between January 2003 and March 2023 was conducted. Patients <18 years of age diagnosed with SCFE who underwent surgical management were included. Variables associated with contralateral SCFE were identified using multivariable logistic regression models that adjusted for patient characteristics and time of the surgical procedure, providing adjusted odds ratios (ORs). The false discovery rate was accounted for via the Benjamini-Hochberg method. RESULTS: In this study, 15.3% of patients developed contralateral SCFE at a mean (and standard error) of 296.53 ± 17.23 days and a median of 190 days following the initial SCFE. Increased thyrotropin (OR, 1.43 [95% confidence interval (CI), 1.04 to 1.97]; p = 0.022), diabetes mellitus (OR, 1.67 [95% CI, 1.22 to 2.49]; p = 0.005), severe obesity (OR, 1.81 [95% CI, 1.56 to 2.57]; p < 0.001), history of human growth hormone use (OR, 1.85 [95% CI, 1.10 to 3.38]; p = 0.032), low vitamin D (OR, 5.75 [95% CI, 2.23 to 13.83]; p < 0.001), younger age in boys (under 12 years of age: OR, 1.85 [95% CI, 1.37 to 2.43]; p < 0.001) and in girls (under 11 years of age: OR, 1.47 [95% CI, 1.05 to 2.02]; p = 0.026), and tobacco exposure (OR, 2.43 [95% CI, 1.49 to 3.87]; p < 0.001) were significantly associated with increased odds of developing contralateral SCFE. CONCLUSIONS: In the largest study on this topic, we identified the rate, odds, and risk factors associated with development of contralateral SCFE. We found younger age, hypothyroidism, severe obesity, low vitamin D, diabetes mellitus, and a history of human growth hormone use to be independent risk factors. Our findings can aid clinical decision-making in at-risk patients. LEVEL OF EVIDENCE: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

The Effect of Human Growth Hormone Treatment on the Development of Slipped Capital Femoral Epiphysis: A Cohort Analysis With 6 Years of Follow-up.

BACKGROUND: Slipped capital femoral epiphysis (SCFE) is a common hip disorder in adolescents that can result in substantial complications, impacting the quality of life. Human Growth Hormone (HGH) administration may elevate the risk of SCFE, though the relationship remains unclear. Clarifying this association could enable better monitoring and earlier diagnosis of SCFE in patients receiving HGH. The aim of the study is to investigate the association between HGH administration and the incidence of SCFE. METHODS: This retrospective cohort study utilized data from the TriNetX research database from January 2003 to December 2022. The study included 2 cohorts: an HGH cohort including 36,791 patients aged below 18 years receiving HGH therapy and a control group consisting of patients who did not receive HGH therapy. A 1:1 propensity score matching technique was employed to ensure comparability between the HGH and no-HGH cohorts. The primary outcome measure was the development of SCFE identified by International Classification of Diseases codes. For comparative analysis, both risk ratios (RR) and hazard ratios were computed to evaluate the association between HGH therapy and the development of SCFE. RESULTS: The HGH cohort had an increased risk of SCFE compared with the no-HGH cohort (RR: 3.5, 95% CI: 2.073, 5.909, P <0.001) and had an increased hazard of developing SCFE (hazard ratio: 2.627, 95% CI: 1.555, 4.437, P <0.001). Patients with higher exposure to HGH (defined as >10 prescriptions) had an RR of 1.914 (95% CI: 1.160, 3.159, P =0.010) when compared with their counterparts with ≤10 prescriptions. CONCLUSIONS: In the largest study to date, HGH administration was associated with an elevated risk of SCFE in children in a dose-dependent manner. LEVEL OF EVIDENCE: Level III-therapeutic retrospective cohort study.

Risk Factors for Stiffness After Surgical Treatment of Pediatric Humeral Lateral Condyle Fractures: Results of a Multicenter Study.

INTRODUCTION: Pediatric humeral lateral condyle fractures are the second most common elbow fractures. Their treatment presents challenges due to physeal and intra-articular involvement. Postoperative stiffness is a common concern that can limit limb functionality. This study aims to identify risk factors for postoperative stiffness in a large cohort of these fractures across multiple institutions. METHODS: A large, multicenter retrospective review of medical records from 6 level I trauma centers was conducted. Data from children aged 1 to 12 years with lateral condyle fractures treated between 2005 and 2019 were collected. Elbow stiffness was defined in the present study as having a limited elbow ROM that led to requiring a physical or occupational therapy referral or needing surgical treatment to address stiffness. Relevant patient demographics, fracture characteristics, treatment approaches, and complications were analyzed. RESULTS: Six hundred sixty-five fractures were analyzed. The average patient age was 8.8 years with 21% experiencing stiffness. The stiffness group had older patients, a higher incidence of elbow dislocations, a higher rate of open reduction, and more severe fracture patterns. Multivariate regression analysis identified open reduction, increased age, and concurrent elbow dislocation as significant risk factors for stiffness. Patients with stiffness commonly utilized only physical or occupational therapy (96%), while a small percentage (4%) required surgical interventions. CONCLUSIONS: This study highlights the risk factors for postoperative stiffness in pediatric humeral lateral condyle fractures, namely increased age, concomitant elbow dislocation, and treatment with open reduction. Families of older patients or severe fracture patterns requiring open reduction and those with concurrent elbow instability should be counseled about their increased risk of stiffness. The authors recommend initially attempting a closed reduction in high-risk patients to help mitigate the risk of postoperative stiffness. Early initiation of range of motion exercises may also be beneficial for at-risk patients. LEVEL OF EVIDENCE: Level III: Therapeutic studies-Investigating the results of treatment.

Is There a Role for Isolated Closed Reduction in the Emergency Department Without Fixation for Displaced Proximal Humerus Fractures in Adolescents?

OBJECTIVE: Pediatric proximal humerus fractures (PHFx) are uncommon and makeup ~2% of all pediatric fractures. Traditionally, most cases are treated nonoperatively with closed reduction (CR) or immobilization with no reduction (INR) with excellent outcomes. Indications for CR without fixation remain unclear as immobilization in the position of reduction (shoulder abduction and external rotation) is not practical. We aim to determine the need for CR among adolescents with displaced PHFx treated nonoperatively. METHODS: We conducted an IRB-approved prospective multicenter study involving 42 adolescents aged 10 to 16 years, treated for displaced PHFx across 6 institutions between 2018 and 2022. CR was performed under conscious sedation in the emergency department, with data collected during follow-up visits at 6 weeks and 3 months. Radiographic measurements, range of motion, and patient-reported outcomes, including the Patient-Reported Outcomes Measurement Information System Upper Extremity and Physical Function, Shoulder Pain and Disability Index, and QuickDash scores, were compared between the INR and CR groups. RESULTS: Among 42 fractures, 23 (55%) were treated with INR and 19 (45%) with CR, followed by placement in a hanging arm cast or sling. Of the cases, 62% were high-energy injuries. Radiographic alignment and range of motion were similar between groups at preoperative, 6 weeks, and 3 months with no significant differences noted.Patient-Reported Outcomes Measurement Information System Upper Extremity, Physical Function, QuickDash, and Shoulder Pain and Disability Index scores at 6 weeks and 3 months showed no significant differences between cohorts. Significant improvement was observed between 6 weeks and 3 months for every patient-reported outcome in both cohorts. CONCLUSIONS: For displaced PHFx treated nonoperatively, our data suggests INR has a similar radiographic and clinical outcome when compared with CR. Our results question the necessity of performing CR in this group of patients. LEVEL OF EVIDENCE: Level II-therapeutic studies: prospective cohort study.

Understanding Financial Relationships Between Orthopedic Surgeons and Industry for Research.

OBJECTIVE: This study sought to understand trends in industry payments for research awarded to orthopedic surgeons. MATERIALS AND METHODS: The Centers for Medicare & Medicaid Services Open Payments database was queried for the years 2016 to 2021 for industry payments for research. Financial analyses were performed to understand temporal trends and differences by orthopedic subspecialty and principal investigator characteristics such as sex. The threshold for statistical significance was set at .05. RESULTS: A total of 2014 orthopedic surgeons were identified, among whom 542 adult reconstruction (27%) and 460 sports medicine (23%) surgeons were major beneficiaries. Seventy-one female orthopedic surgeons comprised the minority (4%). Total research payments awarded during the study period aggregated to $266,633,592, with adult reconstruction ($88,819,047; 33%) and sports medicine ($57,949,822; 22%) receiving the highest amounts. Total research payments awarded trended upward yearly except for a decline in 2020 that subsequently rebounded (P<.001). Median annual research payment per orthopedic surgeon was $13,375. Median total industry payments per orthopedic surgeon differed between specialties (P <.001), with the highest amounts for adult reconstruction ($44,063) and sports medicine ($34,567) and the lowest amounts for hand ($12,052) and foot and ankle ($19,233). Median total payments did not differ significantly when stratified by sex (P=.276) and region (P=.906). Specialties in which the respective top three companies offered the majority of the research funding were musculoskeletal oncology (90%), pediatric orthopedics (66%), and shoulder and elbow (64%). CONCLUSION: These results can be used as a primer for orthopedic surgeons seeking to leverage industry relationships to fund translational research. [Orthopedics. 2024;47(3):172-178.].

Patients With Preexisting Anxiety and Mood Disorders Are More Likely to Develop Complex Regional Pain Syndrome After Fractures.

BACKGROUND: Complex regional pain syndrome (CRPS) is a multifactorial condition that may affect patients who sustain a fracture in the upper and lower extremities. Prior investigations have formed a foundation for exploring a possible association between psychiatric disorders and the development of CRPS; however, current studies are conflicted regarding the existence and temporality of a relationship between psychiatric disorders and the potential development of CRPS. QUESTIONS/PURPOSES: (1) Are patients with preexisting anxiety and mood disorders (AMDs) at increased risk of receiving a diagnosis of CRPS after upper or lower extremity fractures? (2) Are patients with preexisting AMDs at increased risk of being diagnosed with CRPS after surgical fixation of their fracture? METHODS: A large, retrospective cohort study was conducted using the TriNetX electronic medical record platform, which contains data from more than 100 million patients. This platform gathers data from healthcare organizations in the United States and Europe and collects comprehensive data over time that includes temporality rather than simply the binary presence or absence of conditions. The cohort included 760,595 patients older than 18 years with upper or lower extremity fractures between 2003 and 2022. Included patients had a minimum 1-year follow-up. We defined AMDs as any diagnosis of anxiety, depressive episode or disorder, a manic episode, or bipolar disorder. Patients with polytrauma or concurrent upper and lower extremity fractures were excluded to reduce confounders. CRPS I diagnosis was identified via International Classification of Diseases, Tenth Edition codes. Propensity score matching was performed to balance cohorts based on age, gender, and race. Hazard ratios and Aalen-Johansen cumulative incidence curves for the diagnosis of CRPS were calculated for patients with and without AMD diagnoses before sustaining a fracture. A subanalysis was performed in which we examined individuals in the upper and lower extremity fracture cohorts who underwent surgical treatment. RESULTS: Patients with preexisting AMDs were at a higher risk of experiencing CRPS I than patients without AMDs were (upper extremity: HR 1.8 [95% CI 1.7 to 1.9]; p < 0.01, lower extremity: HR 2.2 [95% CI 2.0 to 2.3]; p < 0.01). Similarly, patients with preexisting AMDs were at higher risk of experiencing CRPS I after fracture fixation than patients without AMDs were (upper extremity: HR 1.3 [95% CI 1.2 to 1.5]; p < 0.01, lower extremity: HR 2.3 [95% CI 2.1 to 2.5]; p < 0.01). CONCLUSION: Awareness of the relationship between AMDs and CRPS I will direct future research about the development of this condition and associated neurologic changes. Additionally, surgeons can address AMDs perioperatively and arrange for the treatment of these AMDs with psychiatrists, neurologists, or social work, as appropriate. Accordingly, patients with AMDs should also be made aware of the inherent risk of CRPS I after an upper or lower extremity fracture to comprehensively educate and care for this at-risk patient population. LEVEL OF EVIDENCE: Level III, therapeutic study.

Outcomes of Elastic Stable Intramedullary Nailing for Surgical Treatment of Pediatric Tibial Shaft Fractures.

BACKGROUND: This retrospective study aimed to assess radiographic and clinical outcomes, characterize demographic, injury, and fracture characteristics, and elucidate the rate of postoperative complications and associated factors in a large cohort of children treated with elastic stable intramedullary nail for diaphyseal tibial fractures at two large pediatric referral centers. METHODS: Medical records were reviewed for demographic clinical and radiographic parameters at injury, surgery, and all subsequent clinical visits until radiographic healing was observed and/or for a minimum of 6 months postoperatively. RESULTS: A total of 146 patients (79.5% male) were included. The mean (SD) age was 11.8 (63.0) years. Radiographic union occurred by 3 months in 56.6% of patients. Nine patients had delayed union, and four had nonunion. By 3 months postoperatively, 97.2% of patients had progressed to full weight bearing and 92.5% had full range of motion of the knee and ankle. Subgroup analyses revealed that patients with open fractures were found to be more than eight times at increased risk of developing delayed union (.6 months, odds ratio = 8.71). CONCLUSION: Elastic stable intramedullary nail remains a safe and effective treatment of open and closed pediatric diaphyseal tibial fractures. A small yet notable risk of residual angular deformity, delayed union, and nonunion remains, although rates may be better than previously reported.

Fate of acetabular dysplasia after closed and open reduction of hips in children with developmental hip dislocation.

Acetabular underdevelopment (acetabular dysplasia) is a common finding in children with hip dislocation, and residual acetabular dysplasia can remain after hip reduction. Residual dysplasia leads to unsatisfactory long-term outcomes and osteoarthritis. Dynamics of acetabular dysplasia [measured as Acetabular Index (AI)] in a pediatric cohort that underwent open (OR) or closed reduction are reported. Retrospective data from six tertiary pediatric orthopedic centers were gathered. Hips were classified as having 'Critical', 'Monitoring', or 'Normal' acetabular dysplasia based on age-adjusted normative AI measurements. From 193 hips, 108 (56%) underwent open reduction. Children younger than 24 months had a strong AI decline but children > 24 months did not. Among 78 hips with critical dysplasia at time of OR, 36 (46.2%) remained critical and 19 (24.4%) underwent an acetabular osteotomy (AO) during follow-up. CR hips had a similar AI decline in patients younger and older than 12 months. Among 51 hips with critical dysplasia at the time of CR, 13 (25.5%) remained critical and 21 (41.2%) underwent AO during follow-up. Acetabular dysplasia improves with AI decreasing in children who undergo OR and CR under the age of 2 years with slower acetabular remodeling afterwards. Around 2/3 of patients with AI in the critical range at CR or OR either underwent AO or had significant acetabular dysplasia at final follow-up. Our data supports considering simultaneous AO at the time of OR for hips with AI in the critical range or children who undergo hip open reduction after 24 months of age. Level of Evidence: Level III.

Patient-reported outcomes of adolescents with tibia shaft fractures: comparison of closed reduction and casting vs. elastic stable intramedullary nailing.

Tibial shaft fractures are the third most common pediatric long bone fractures. Closed reduction and casting (CRC) is considered initial treatment in this population, however, surgical management using elastic stable intramedullary nailing (ESIN) is also used in adolescents. This study compared patient-reported outcomes in a cohort of adolescents with tibia fractures treated with ESIN or CRC. This single-center retrospective study gathered adolescent patients 10-18 years of age with closed tibia shaft fractures between the years 2015 and 2021 treated by either CRC or ESIN. Measured outcomes include patient demographics, overall casting time, time to full weight bearing, time to full healing, radiographic healing, complications (loss of reduction, malunion >5° and >10°) and Patient-Reported Outcomes Measurement Information System (PROMIS) scores. A total of 141 patients (68% male) were included, with 31 receiving ESIN and 110 having CRC. Patient demographics were similar across groups. At follow-up, CRC had a significant shorter time to healing (11 vs. 15 weeks), but an increased casting duration (7 vs. 4 weeks). Finally, the ESIN group had significantly greater pre-intervention angulation, displacement, and shortening. In both interventions, mobility and pain interference scores showed significant improvements from baseline (2 weeks post-op) at 12, 16, and 24 weeks. No statistically significant differences were noted between CRC and ESIN groups across PROMIS domains of pain interference and mobility. CRC and ESIN are effective in improving pain and mobility in adolescent diaphyseal tibia fractures, but neither intervention is superior based on PROMIS scores at 12, 16 and 24+ weeks. From a patient standpoint, we demonstrate that neither treatment is superior in achieving better-perceived mobility or decreasing pain sooner. Level of Evidence: Level III.

Is There a Benefit to Rigid Fixation in Calcaneal Lengthening Osteotomy in Painful Pediatric Idiopathic Flatfoot Deformity? Comparing Results of Kirschner Wire Versus Plate Fixation.

INTRODUCTION: Flexible flatfoot (FF) is a common pediatric condition that is mostly asymptomatic, and surgical intervention is only considered when painful FF is refractory to conservative treatment. Calcaneal lengthening osteotomy (CLO) is one of the most commonly used procedures to address painful FF. Traditionally, Kirschner wires (K-wires) were used for fixation, but there has been a recent increase in the use of plates. We compared the clinical and radiographic outcomes of these 2 fixation methods. METHODS: This single-center retrospective study included children aged 8 to 18 years with symptomatic FF that received CLO using K-wire or plate fixation. Primary outcomes include weight-bearing radiographic measurements and complications after surgery. Secondary outcomes included patient-reported outcomes. Statistical significance was held at 0.05. RESULTS: Among 102 feet (65 patients), 42 feet (41.2%) underwent K-wire and 60 feet (58.8%) underwent plate fixation. No differences in casting duration ( P =0.525) and time-to-radiographic healing ( P =0.17) were noted. Total complications were higher in the plate cohort (12 vs. 2, P =0.04) due to a higher rate of reoperations (16.7%) for hardware-related pain [10 vs. 0; odds ratio 17.74, 95% CI (1.01, 310.54), P <0.05], and infection rates were similar. Both interventions significantly improved ( P ≤ 0.001) aneteroposterior (AP) Talo-first metatarsal and calcaneal pitch angles. Irrespective of intervention, CLO significantly improved pain at 6 months and mobility scores at 12 months. Neither modality demonstrated superior pain or mobility scores at final follow-up. CONCLUSION: Both K-wire and plate fixations lead to similar radiographic and functional outcomes after CLO in painful, pediatric flatfeet. Compared with K-wire fixation, plates cause a 17.7-fold increased risk of reoperations for painful hardware, with 16.7% of plated cases requiring reoperation. Noting this, along with the higher costs associated with using plates, our study advocates for K-wire fixation for children undergoing CLO. LEVEL OF EVIDENCE: Level III.

Severity of hip dysplasia as the major factor affecting outcome of closed reduction in children with hip dysplasia.

The objective of this study was to analyze a multicenter cohort of children with developmental dysplasia of the hip (DDH) who underwent treatment with closed reduction. We sought to report the effects that severity of hip dysplasia and age have on the development of femoral head avascular necrosis (AVN) and the need for additional procedures. All patients with DDH and minimum 2 years of follow-up who underwent closed reduction were identified. The following variables were recorded: sex, laterality of hip involvement, age, acetabular index (AI), and International Hip Dysplasia Institute (IHDI) grade. The effects of patient age and pre-procedure IHDI grade on the rate of AVN and need for additional procedures after the closed reduction were analyzed using an alpha of 0.05. Seventy-eight total hips were included in the final analysis. The average patient age was 12 months. AVN of the femoral head was reported in 24 hips (30.8%) and 32 hips (41.0%) required additional surgery. Higher pre-op IHDI grade was associated with higher risk of developing Bucholz-Ogden grades II-IV AVN of the femoral head (P = 0.025) and requiring additional surgery (P= 0.033) regardless of patient age. There were no statistically significant differences for the effect of age on the measured outcomes (P > 0.05). These findings suggest that severity of dislocation (IHDI grade) is a significant risk factor for the development of AVN and need for additional procedure.

Outcomes of Open Reduction in Children With Developmental Hip Dislocation: A Multicenter Experience Over a Decade.

BACKGROUND: Open reduction of the hip is commonly performed in children with severe developmental dysplasia of the hip, or in cases that are refractory to nonoperative forms of treatment. The open reduction has been associated with numerous complications including avascular necrosis (AVN) of the femoral head, the need for reoperation, and residual radiographic dysplasia. This study seeks to determine the effects of preoperative severity of dysplasia, associated procedures (femoral and acetabular osteotomies), age on AVN, and the need for reoperation. METHODS: Children with developmental dysplasia of the hip and a minimum of 2 years of follow-up who underwent open reduction were identified. The following data points were recorded: sex, laterality of hip involvement, simultaneous procedures, surgical approach used, age, acetabular index, and International Hip Dysplasia Institute grade. We analyzed the effects of preoperative International Hip Dysplasia Institute, age, surgical approach (anterior/medial), bilateral reduction, and simultaneous femoral shortening or pelvic osteotomy on the outcomes of AVN and reoperation. RESULTS: One hundred eighty-five hips in 149 patients were included in this study with an average follow-up of 4 years (range: 2 to 5 y). The average age at index surgery was 23 months (range: 1 to 121 mo). Overall, 60 hips (32.4%) required secondary surgical procedures at an average age of 58.5 months. High-grade AVN was noted in 24 hips (13.0%) and was found to be associated with the severity of the hip dislocation ( P = 0.02). A higher rate of reoperation was found in children over 18 months at the time of open reduction who did not receive an acetabular osteotomy ( P = 0.012). CONCLUSION: Approximately 1/3 of patients require another operative intervention within the first 4 years after open reduction of the hip. We found the severity of hip dislocation to be associated with a higher risk of AVN development. These findings support performing an acetabular osteotomy in children over 18 months of age at the time of open reduction to decrease the likelihood of requiring future reoperation during the first 4 years after the index procedure. LEVEL OF EVIDENCE: Level III.

Distal Radius Salter-Harris II Fracture Loss of Reduction: The Importance of Coronal Plane Angulation in Older Children.

OBJECTIVES: To assess factors affecting the loss of reduction (LOR) in a large cohort of children with Salter-Harris Type II (SH II) distal radius physeal fractures treated with closed reduction. DESIGN: Retrospective chart review. SETTING: Pediatric Level I Trauma Center. PATIENTS/PARTICIPANTS: A total of 141 pediatric patients (73% male, average age: 12.15 ± 2.55 years) that had undergone closed reduction and casting for distal radius physeal fractures from 2006 to 2019 were included in this study. INTERVENTION: Closed reduction and casting. MAIN OUTCOME MEASUREMENTS: Five different radiographic measurements were analyzed at 4 different time points. Follow-up radiographs were assessed in relation to initial reduction. LOR was defined as >5 degrees change of angulation on PA radiographs, >10 degrees change of angulation on lateral radiographs, and/or >25% translation on PA or lateral radiographs. RESULTS: LOR was seen in 28.4% of the patients, most often (68%) in the first 2 weeks after initial reduction. Seven (17.5%) of these patients (average age: 15.2 ± 2.0 years) were treated surgically with closed reduction and percutaneous pinning (CRPP). Patients undergoing CRPP for LOR were an average of 3.4 years older ( P < 0.001) than those who underwent nonoperative treatment of LOR. Patients with initial angulation more than 5 degrees on the PA view to be twice as likely to have LOR ( P = 0.03). CONCLUSIONS: LOR was seen in nearly 1/3 of these patients. Patients with initial higher degree of angulation on the coronal plane are at higher risk for LOR. Age, not the degree of angulation, is the main predictor for potential surgical treatment. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.