Reliability of radiographic measurements for hip dysplasia using a reduced radiation technique.

The purpose of this study was to examine whether measurement accuracy is impacted with a low radiation radiograph technique. Treatment decisions for hip dysplasia require serial radiographs to monitor acetabular anatomy. However, radiation use creates concern for future malignancy. Standard radiograph technique utilizes a grid to enhance clarity, but requires a larger X-ray dose. We hypothesized grid removal would lower radiation exposure without decreasing measurement accuracy. This is a retrospective cohort study of patients with idiopathic DDH and neuromuscular hip displacement at a single institution from 2019 to 2020 receiving surveillance radiographs. A cohort receiving modified technique radiographs (grid removed) was compared to an age-matched cohort receiving standard technique radiographs. Four examiners measured radiographs on two separate occasions, a minimum of 2 weeks apart. Migration percentage (MP) was measured for neuromuscular patients and acetabular index (AI) for idiopathic DDH. Intraclass correlation coefficient (ICC) with a 95% confidence interval (CI) was used to evaluate inter-observer and intra-observer agreement for measurements. Average radiation dose for both techniques. A total of 134 age-matched patients were included for measurement of MP. Thirty age-matched patients were included for AI measurements. Inter and intra-rater reliability of MP and AI were not different with or without use of the grid. There was a 50-75% decrease in radiation dose per radiograph following grid removal, dependent on patient size. The adjusted radiograph technique showed no significant difference in MP or AI reliability. A slight decrease in picture contrast did not jeopardize measurement reliability and decreased radiation exposure for the patient significantly. This simple technique can be useful for patients requiring multiple radiographs over time.

Workplace Hazards in Orthopaedic Surgery Training: A Nationwide Resident Survey Involving Sharps-related Injuries.

INTRODUCTION: Surgical specialties are at an increased risk for occupational hazards, including sharps-related injuries. The objective of this study was to report the frequency of sharps injuries and evaluate which characteristics influence the number of injuries and reporting behaviors. METHODS: A web-based, anonymous survey was available for 10 weeks to 46 US orthopaedic surgery residency programs (1,207 potential residents) participating in an education research collaborative. The survey was divided into the following areas: demographics, training and attitudes concerning occupational hazards, and sharps injuries and reporting. Logistic regression was used to evaluate the association between the above variables on experiencing sharps injuries with significance threshold set at P < 0.05. RESULTS: In this study, 518 surveys were included yielding a response rate of 42.9% (518/1,207). Nearly 80% of the residents recalled some form of safety training during intern orientation and 62% of the respondents felt that they received adequate occupation safety training specifically related to orthopaedic surgery. Four hundred seventeen residents (80.5%) experienced a sharps injury (mean 2.8). Nearly 20% of the respondents experienced ≥5 sharps injuries. Needle sticks (38.8%) were responsible for the greatest percentage of injuries, followed by Kirschner wires (33.6%), scalpel (22.5%), and bone (17.3%). Only 42% of the residents consistently reported all injuries. Reasons included feelings of no risk (63.1%), too much hassle (58.9%), embarrassment (14.5%), other (8.7%), forgot (5.8%), and unclear what to do (3.3%). Inadequate safety training specific to orthopaedic surgery (odds ratio, 2.32 [95% confidence interval, 1.20 to 4.46]; P = 0.012) and greater training seniority (odds ratio, 2.04 [95% confidence interval, 1.64 to 2.52]; P < 0.0001) were associated with acquiring five or more sharps injuries. DISCUSSION: Sharps injuries are a prevalent and concerning reality for orthopaedic surgical trainees. Despite this common occurrence, only 42% of the residents always reported their injuries. Inadequate training specific to orthopaedic surgery and each subsequent year of postgraduate training are associated with increased sharps injuries. STUDY TYPE: Level III, retrospective observational survey.

Acute Workplace Hazards in Orthopedic Surgery: Resident Survey Regarding Splash and Workplace Violence Events.

INTRODUCTION: Orthopedic surgery residents are at risk for daily work-related hazards and exposures. Hazards related specific to this specialty includes radiation exposure, smoke inhalation (from electrocautery), and disease transmission through contact with surgical instruments or sharps during procedures. However, minimal research has been focused on other occupational hazard risks in orthopedic surgery including surgical splash events and workplace violence. This study focused on determining (1) whether or not use of protective eyewear in the workplace would be related to the availability of personal protective equipment (PPE); (2) resident education; and (3) the rate of workplace violence toward orthopedic surgery residents during their training. METHODS: An invitation to participate in a web-based, anonymous survey to 46 US allopathic orthopedic surgery residency programs (1207 potential resident respondents). The survey was conceptually divided into the following areas: (1) demographics; (2) training and attitudes concerning occupational hazards; (3) PPE provision and use; (4) sharps injuries and reporting; and (5) general safety knowledge and violence in the workplace. Those who answered yes to having a splatter event or receiving a threat at the hospital were compared to those who did not. Logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the association between these outcomes and selected independent variables of interest. p-Values of <0.05 were considered statistically significant. RESULTS: From January 18 to March 31, 2016, 518 surveys were received and included for analysis for a response rate of 42.9% (518/1207). One survey was excluded from analysis due to <50% completed response items. Self-reported program types were 64.5% (334/518) public university-affiliated, 23.2% (120/518) private university affiliated, 7.1% (37/518) community, and 5.2% (27/518) military. Residents were 83.0% = male and 17.0% = female. Overall, reported eye protection usage was 95% amongst all residents and 22% of residents reported experiencing a violent threat in the workplace. The risk of experiencing a splatter event was not statistically associated with residency type, gender, or geographic region. Senior residents were at an increased likelihood of experiencing a splatter event (OR 1.22, [95% CI 1.06-1.41], p = 0.006) when compared to PGY-1 residents. The risk of a violent experience at work was not statistically associated with residency type, year of residency training, or gender. Residents in the Northeast were more likely to have a violent experience (OR 2.78 [95% CI 1.41-5.49] p = 0.003). Overall, residents felt that they had adequate training to prevent occupational hazards (mean of 3.9/5 on Likert scale) and respond to hazards (mean of 3.7/5 Likert). CONCLUSIONS: Occupational hazards are not uncommon in orthopedic surgery training with high rates of improper eyewear PPE use and poor awareness of Occupational Safety and Health Administration and AAOS guidelines. Violence in the workplace impacts over one in 4 residents and training programs and hospitals should improve education and report efforts. Continual yearly PPE training and awareness of AAOS guidelines could be intertwined with duty hour and/or case logs in order to ensure residents are exposed to this material on a regular basis.

The Introduction of a Preoperative MRI Protocol Significantly Reduces Unplanned Return to the Operating Room in the Treatment of Pediatric Osteoarticular Infections.

BACKGROUND: Pediatric osteoarticular infection can cause severe morbidity. Some infectious loci may be difficult to identify clinically, and there may be more than one. There is little agreement regarding the appropriate use of preoperative magnetic resonance imaging (MRI) in this setting. After noting an unacceptably high rate of unplanned returns to the operating room for recurrent infection, clinicians at a tertiary care children's hospital noticed many patients had adjacent foci of infection on postoperative MRI. As a result, patients experienced prolonged treatment courses and multiple surgeries. An interdisciplinary team instituted practice guidelines whereby all patients with suspected osteoarticular infection underwent MRI for planned debridement during a reserved morning slot with a surgical suite on hold to proceed directly to surgery if indicated. Images were reviewed in real time to form the surgical plan. Young patients that required sedation for MRI were taken to surgery under the same anesthetic used for MRI without being awakened. The purpose of our retrospective study is to determine if implementing the practice guidelines for acute management of osteoarticular infection reduced unplanned returns to the operating room. METHODS: A total of 93 patients with osteoarticular infection were included in this study. A total of 40 cases, group A, were treated before implementing practice guidelines; 53 cases, group B, were treated after implementing practice guidelines. Our primary outcomes of interest were the identification of adjacent infections prior to surgery and need for repeat surgery, either planned or unplanned. RESULTS: Implementation of these guidelines reduced repeat surgery from 50% of patients to <27% (P=0.0099). Of patients requiring repeat surgery, 85% (n=17) were unplanned in group A versus 60% (n=9) in group B (P=0.0099). Adjacent infections were identified in 47.5% (n=19) of patients in group A, versus 60% (n=32) in group B. Adjacent infections were known before surgery in 32% (n=6) of patients in group A versus 72% (n=23) in group B. There were no statistically significant differences in initial patient characteristics or sites of infection. CONCLUSIONS: Implementing these guidelines reduced the need for repeat surgery in this population. It is difficult to predict with sufficient accuracy which patients need preoperative MRI. While resource intensive, preoperative MRI appears to offer substantial benefit in preoperative planning.

A Case Report of Congenital Hallux Valgus from an Incomplete Preaxial Polydactyly without a Supernumerary Digit.

INTRODUCTION: While hallux valgus is a common deformity occurring in adults and adolescents, congenital hallux valgus is rare. There is a paucity of information available about the deformity and even less information about its cause. In fact, discrepancies exist within literature as to its etiology. This is a case report of bilateral congenital hallux valgus that appears to have been caused by preaxial polydactyly of the great toe, without a supernumerary digit, which to date has not been reported in literature. Markedly increased intermetatarsal and hallux valgus angles were present in both feet. Furthermore, bilateral interval improvement of the angulation occurred spontaneously without operative or non-operative intervention. This case reveals another potential cause of congenital hallux valgus not previously described. Our patient demonstrates that preaxial polydactyly could be another possible etiology of congenital hallux valgus. This case also demonstrates that magnetic resonance imaging (MRI) may be required for accurate diagnosis. CASE REPORT: The subject of this case report is a 6-month-old boy who presented with what appeared to be severe bilateral congenital hallux valgus. However, an MRI was suggestive of preaxial polydactyly without a supernumerary digit. At 26 months of age, clinical follow-up demonstrated that the deformity had improved and the patient was doing well clinically without intervention. CONCLUSION: Congenital hallux valgus is an uncommon deformity. Our patient demonstrates that the etiology may be incomplete preaxial polydactyly without a supernumerary digit. Overtime, even without treatment, the deformity appeared to improve, and the patient had no clinical complaints. The lack of an accessory ossicle or supernumerary digit makes our patient's case unique.

What Leads to Lead: Results of a Nationwide Survey Exploring Attitudes and Practices of Orthopaedic Surgery Residents Regarding Radiation Safety.

BACKGROUND: Excessive radiation to health-care providers has been linked to risks of cancer and cataracts, but its negative effects can be substantially reduced by lead aprons, thyroid shields, and leaded glasses. Hospitals are required to provide education and proper personal protective equipment, yet discrepancies exist between recommendations and compliance. This article presents the results of a survey of U.S. orthopaedic surgery residents concerning attitudes toward radiation exposure and personal protective equipment behavior. METHODS: An invitation to participate in a web-based, anonymous survey was distributed to 46 U.S. allopathic orthopaedic surgery residency programs (1,207 potential resident respondents). The survey was conceptually divided into the following areas: demographic characteristics, training and attitudes concerning occupational hazards, personal protective equipment provision and use, and general safety knowledge. Prevalence ratios (PRs) and 95% confidence intervals (CIs) were calculated for the association between these characteristics and compliance with thyroid shield or lead gown wear. RESULTS: In this study, 518 surveys were received, with 1 survey excluded because of insufficient response, leaving 517 surveys for analysis (42.8% response rate). Ninety-eight percent of residents believed that personal protective equipment should be provided by the hospital or residency program. However, provision of personal protective equipment was not universal, with 33.8% reporting none and 54.2% reporting provision of a gown and thyroid shield. The prevalence of leaded glasses usage was 21%. Poor lead gown compliance and thyroid shield wear were associated with difficulty finding the corresponding equipment: PR, 2.51 (95% CI, 1.75 to 3.62; p < 0.001) for poor lead gown compliance and PR, 2.14 (95% CI, 1.46 to 3.16; p < 0.0001) for poor thyroid shield wear. Not being provided with personal protective equipment was also significantly associated with low compliance with both lead gowns (PR, 1.47 [95% CI, 1.04 to 2.08]; p = 0.03) and thyroid shields (PR, 1.69 [95% CI, 1.18 to 2.41]; p = 0.004). Respondents from the Southeast, West, or Midwest had lower compliance with lead gown usage. Forgetting was the number 1 reason to not wear a lead apron (42%). CONCLUSIONS: Radiation exposure is associated with increased risk of serious health problems. Our findings identified that the availability of lead personal protective equipment leads to increased compliance among residents surveyed. In addition to yearly occupational hazard training specific to orthopaedic surgery, greater efforts by residency programs and hospitals are needed to improve access to lead personal protective equipment and compliance for orthopaedic residents.

Psychomotor Testing for Orthopedic Residency Applicants: A Pilot Study.

OBJECTIVE: The purpose of this study was to develop an objective motor skills testing system to aid in the evaluation of potential orthopedic residents. DESIGN: Participants attempted a battery of 5 motor skills tests (4 novel tests and the Grooved Pegboard [GPT] Test) in one 10-minute session. A percentile-based scoring system was created for each test based on raw scores. One-way analysis of variance was used to compare testing scores among 3 cohorts. Each novel test and overall scores were compared with GPT scores as a relative measure of validity. SETTING: The 2015 orthopedic surgery residency interview season at an academic institution. PARTICIPANTS: Thirty orthopedic residents and 72 nonresidents (15 community volunteers and 57 orthopedic surgery residency applicants). RESULTS: Overall, residents performed better than nonresidents (p < 0.0001) and applicants performed worse than residents or volunteers (p < 0.0001). There were positive correlations between the GPT score and overall battery score (r = 0.63), screw and nut test (r = 0.40), and mimic a structure test (r = 0.26). The fracture reduction test and drilling test scores did not correlate to performance on the GPT. CONCLUSIONS: Psychomotor testing for surgical applicants is an area in need of study. This investigation successfully piloted a novel battery of tests, which is easily reproducible and thus may be feasible for use in the orthopedic surgery residency interview setting. Longitudinal evaluation is required to explore correlation with future operative skill.

Is the orthopedic fellowship interview process broken? A survey of program directors and residents.

Most orthopedic surgery residents pursue fellowship training. The fellowship interview process requires considerable time and financial investment from residents and residency programs. We conducted a study of the time, financial, and program disruption impact the fellowship interview process has on residents and residency programs. Two mixed-response questionnaires were sent to orthopedic surgery residency directors and postgraduate year 4 and 5 residents. Responses were received from 45 program directors and 129 residents. Sixty-two percent of the directors thought the interview process was extremely disruptive to their program. On average, the residents applied to 19 programs, received 14 interview offers, attended 11 interviews, were away from residency training 11 days, and spent $5875 on travel. About 70% of directors and residents wanted changes made to the orthopedic fellowship interview process. Sixty percent of the directors wanted interviews conducted in a central location. Our results highlight that time away from residency training, financial costs associated with the fellowship interview process, and disruption of the residency program are substantial.

Predicting MSSA in Acute Hematogenous Osteomyelitis in a Setting With MRSA Prevalence.

BACKGROUND: Increased severity of illness in patient with acute hematogenous osteomyelitis (AHO) with methicillin-resistant Staphylococcus aureus (MRSA) necessitates prompt intervention, but overtreatment of methicillin-sensitive S. aureus (MSSA) may contribute to antibiotic resistance. Therefore, predicting methicillin sensitivity in suspected AHO is desirable. A previously published prediction algorithm has not performed well in settings with high prevalence of MRSA. We sought to develop a predictive equation using presenting factors to predict MRSA in our patient population with a predominance of MRSA. METHODS: A retrospective chart review was performed. Consecutive cases of AHO with positive blood or bone cultures were identified at a single children's hospital. Presenting features were recorded including duration of symptoms, weight-bearing, prior antibiotic use, vital signs, complete blood count, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP). Univariate comparison was made between the groups with MRSA and MSSA. Continuous variables were compared with t tests and discrete variables were compared using the Fischer exact test. Logistic regression was performed using a forward stepwise regression to develop a model to predict MRSA. RESULTS: A total of 68 patients formed the study group, and 60% had MRSA (41 MRSA, 27 MSSA). Temperature, respiratory rate, heart rate, white blood cell count, absolute neutrophil count (ANC), ESR), and CRP were significantly higher in MRSA cases, whereas platelets were lower. Logistic regression resulted in a model utilizing temperature, ANC, and CRP. This model correctly predicted 87% of cases (92% of MRSA and 79% of MSSA) with an area under the curve of 0.919±0.035 with a 95% confidence interval of 0.851, 0.987. CONCLUSION: A logistic regression model incorporating temperature, ANC, and CRP correctly predicts methicillin resistance of S. aureus in 87% of cases. The model differs from one developed at an institution with a low rate of MRSA. Prediction of MRSA could help direct antibiotic management, whereas prediction of MSSA could help prevent overuse of antibiotics directed against MRSA. LEVEL OF EVIDENCE: Diagnostic study level IV.

The Use of Chewing Gum Postoperatively in Pediatric Scoliosis Patients Facilitates an Earlier Return to Normal Bowel Function.

PURPOSE: In surgical correction of scoliosis in pediatric patients, gastrointestinal complications including postoperative ileus can result in extended hospital stays, poorer pain management, slower progression with physical therapy, and overall decreased patient satisfaction. In patients undergoing gastrointestinal, gynecological, and urological surgery, gum chewing has been shown to reduce time to flatus and passage of feces. The authors hypothesized that chewing gum could also speed return to normal bowel function in pediatric patients undergoing surgical correction of scoliosis. METHODS: The researchers obtained institutional review board approval for a prospective, randomized, controlled trial. Eligible patients included all adolescent idiopathic scoliosis patients undergoing posterior spinal fusion. Exclusion criteria included previous gastrointestinal surgery or preexisting gastrointestinal disease. Patients were randomized by coin flip. The treatment group chewed sugar-free bubble gum 5 times a day for 20 to 30 minutes beginning on postoperative day 1; the control group did not chew gum. Patients were asked a series of questions regarding subjective gastrointestinal symptoms each day. Time to flatus and first passage of feces were recorded as indicators of return to normal bowel function. Normality of data was assessed using normal probability plots. RESULTS: A total of 83 patients completed the study (69 females and 14 males; mean age, 14.4 years). Of the 42 patients in the chewing gum group, 8 elected to stop chewing gum regularly before discharge for to a variety of reasons. Patients who chewed gum experienced first bowel movement on average 145.9 hours after surgery, 30.9 hours before those who did not chew gum (p = .04). Gum-chewing patients first experienced flatus an average of 55.2 hours after surgery, compared with 62.3 hours for controls. This trend did not reach statistical significance (p = .12). No difference was noted in duration of hospital stay, medications administered as required, or subjective symptoms. CONCLUSION: Chewing gum after posterior spinal fusion for scoliosis is safe and may speed return of normal bowel function. Chewing gum after surgical correction of scoliosis facilitates an earlier return to normal bowel function, which may improve patient satisfaction in the early postoperative period.

Prospective evaluation of the use of Mitchell shoes and dynamic abduction brace for idiopathic clubfeet.

Ponseti treatment for clubfoot has been successful, but recurrence continues to be an issue. After correction, patients are typically braced full time with a static abduction bar and shoes. Patient compliance with bracing is a modifiable risk factor for recurrence. We hypothesized that the use of Mitchell shoes and a dynamic abduction brace would increase compliance and thereby reduce the rate of recurrence. A prospective, randomized trial was carried out with consecutive patients treated for idiopathic clubfeet from 2008 to 2012. After casting and tenotomy, patients were randomized into either the dynamic or static abduction bar group. Both groups used Mitchell shoes. Patient demographics, satisfaction, and compliance were measured with self-reported questionnaires throughout follow-up. Thirty patients were followed up, with 15 in each group. Average follow-up was 18.7 months (range 3-40.7 months). Eight recurrences (26.7%) were found, with four in each group. Recurrences had a statistically significant higher number of casts and a longer follow-up time. Mean income, education level, patient-reported satisfaction and compliance, and age of caregiver tended to be lower in the recurrence group but were not statistically significant. No differences were found between the two brace types. Our study showed excellent patient satisfaction and reported compliance with Mitchell shoes and either the dynamic or static abduction bar. Close attention and careful education should be directed towards patients with known risk factors or difficult casting courses to maximize brace compliance, a modifiable risk factor for recurrence.

Adolescent hallux valgus revisited.

Treatment of adolescent hallux valgus with first metatarsal double osteotomy is well described in the literature. Unfortunately, first metatarsal phalangeal joint stiffness and deformity recurrence have been reported at relatively high rates. The authors revisit a technique aimed at preventing these complications.

A prospective study on the effectiveness of cotton versus waterproof cast padding in maintaining the reduction of pediatric distal forearm fractures.

BACKGROUND: Distal forearm fractures, one of the most common fractures seen in the pediatric population, are regularly treated by closed reduction and casting. Our study investigates the effectiveness of Gore-Tex-lined casting in maintaining the reduction of 100% displaced distal forearm fractures compared with traditional cotton-lined casts. METHODS: We screened all patients from February 2007 to July 2009 who presented to Children's Hospital in Birmingham, AL with a distal radius fracture. Only patients with 100% displaced distal radius fractures were eligible to be assigned to either the cotton-lined or Gore-Tex-lined cast groups. Power analysis was performed to identify an adequate patient sample size. The mean maximum change between initial post-reduction x-rays and follow-up x-rays for anterior-posterior (AP) angulation, AP displacement, lateral angulation, and lateral displacement of the radius were calculated for both cotton and Gore-Tex groups. The rate of subsequent intervention and/or unacceptable results for each group was also analyzed. RESULTS: Seven hundred and twenty-two patients were treated with distal radius fractures at our hospital with 59 patients eligible for inclusion in our study. Thirty-six of our patients were treated with cotton-lined casts, and 23 patients were treated with Gore-Tex-lined cast. The mean maximum change in AP angulation, AP displacement, lateral angulation, and lateral displacement of the radius after initial reduction was 9.2 degrees, 6.9%, 13.9 degrees, and 13.6%, respectively, for the cotton-lined cast group and 7.7 degrees, 6.1%, 14.6 degrees, and 9.6%, respectively, for the Gore-Tex-lined cast group. There were no statistical differences between the means of the 4 measurements (P=0.33, 0.69, 0.73, and 0.10, respectively). There were also no significant differences between groups for final AP and lateral angulation and displacement. Subgroup analysis showed no significant differences in all measurements between cotton and Gore-Tex groups. CONCLUSION: Gore-Tex and cotton-lined casts are equally effective in their ability to maintain the reduction of 100% displaced distal forearm fractures. Thus, Gore-Tex-lined casts can be offered to pediatric patients immediately after closed reduction of distal radius fractures of any severity. LEVEL OF EVIDENCE: Therapeutic level II.

Derotational casting for progressive infantile scoliosis.

BACKGROUND: Serial cast correction by using the Cotrel derotation technique is one of several potential treatments for progressive infantile scoliosis. This study reviews our early experience to identify which, if any, patients are likely to benefit from or fail this technique. METHODS: We followed all patients treated at our institutions for progressive infantile scoliosis since 2003 prospectively at 1 institution and retrospectively at the other 2. Data, including etiology, Cobb angles, rib vertebral angle difference, Moe-Nash rotation, and space available for the lung, were recorded over time. RESULTS: Fifty-five patients with progressive infantile scoliosis had more than 1 year of follow-up from the initiation of casting. The diagnosis of progressive scoliosis was made based upon either a progressive Cobb angle or a rib vertebral angle difference of more than 20 degrees at presentation. All but 6 patients responded to cast correction. Nine patients have undergone surgery to date, 6 because of worsening and 3 by parent choice. As shown in the table, initiation of cast correction at a younger age, moderate curve size (<60 degrees), and an idiopathic diagnosis carry a better prognosis than an older age of initiation, curve >60 degrees, and a nonidiopathic diagnosis. The space available for the lung improved from 0.89 to 0.93. No patient experienced worsening of rib deformities. CONCLUSIONS: Serial cast correction for infantile scoliosis often results in full correction in infants with idiopathic curves less than 60 degrees if started before 20 months of age. Cast correction for older patients with larger curves or nonidiopathic diagnosis still frequently results in curve improvement along with improvement in chest and body shape. SIGNIFICANCE: Derotational cast correction seems to play a role in the treatment of progressive infantile scoliosis with cures in young patients and reductions in curve size with a delay in surgery in older and syndromic patients. LEVEL OF EVIDENCE: Level 4, therapeutic study.

Predicting scoliosis progression from skeletal maturity: a simplified classification during adolescence.

BACKGROUND: Both the Tanner-Whitehouse-III RUS score, which is based on the radiographic appearance of the epiphyses of the distal part of the radius, the distal part of the ulna, and small bones of the hand, and the digital skeletal age skeletal maturity scoring system, which is based on just the metacarpals and phalanges, correlate highly with the curve acceleration phase in girls with idiopathic scoliosis. However, these systems require an atlas and access to the scoring system, making their use impractical in a busy clinical setting. We sought to develop a simplified system that would correlate highly with scoliosis behavior but that would also be rapid and reliable for clinical practice. METHODS: A simplified staging system involving the use of the Tanner-Whitehouse-III descriptors was developed. It was tested for intraobserver and interobserver reliability by six individuals on thirty skeletal age radiographs. The system was compared with the timing of the curve acceleration phase in a cohort of twenty-two girls with idiopathic scoliosis. RESULTS: The average intraobserver unweighted kappa value was 0.88, and the average weighted kappa value was 0.96. The percentage of exact matches between readings for each rater was 89%, and 100% of the differences were within one unit. The average interobserver unweighted kappa value was 0.71, and the average weighted kappa value was 0.89. The percentage of exact matches between two reviewers was 71%, and 97% of the interobserver differences were within one stage or matched. The agreement was highest between the most experienced raters. Interobserver reliability was not improved by the use of a classification-specific atlas. The correlation of the staging system with the curve acceleration phase was 0.91. CONCLUSIONS: The simplified skeletal maturity scoring system is reliable and correlates more strongly with the behavior of idiopathic scoliosis than the Risser sign or Greulich and Pyle skeletal ages do. The system has a modest learning curve but is easily used in a clinical setting and, in conjunction with curve type and magnitude, appears to be strongly prognostic of future scoliosis curve behavior.

Results of screw epiphysiodesis for the treatment of limb length discrepancy and angular deformity.

The purpose of this study was to evaluate the technique of screw epiphysiodesis for effectiveness, predictability, and reversibility. We reviewed the cases of our first 60 patients (105 physes) treated with percutaneous screw epiphysiodesis or hemiepiphysiodesis. All cases were followed up to maturity or screw removal if growth remained after full correction. A total of 30 patients underwent the procedure for limb length inequality. Final inequality was compared with the predicted epiphysiodesis effect. A total of 30 patients (66 physes) underwent screw hemiepiphysiodesis for the correction of angular deformity. The degree of correction per month was calculated, the reversibility of the procedure was analyzed, and complications were evaluated. In the length group, at the end of treatment, the final limb length difference in the femur averaged 0.15 cm (SD, +/-0.37 cm) from the epiphysiodesis effect predicted by using the multiplier method. In the tibia, this difference was 0.05 cm (SD, +/-0.57 cm). In the angular group, the average correction in the distal femur was 6.91 degrees (SD, +/-3.75 degrees) or 0.75 degrees per month (SD, +/-0.45 degrees per month). In the proximal tibia, the average correction was 3.88 degrees (SD, +/-3.57 degrees) or 0.37 degrees per month (SD, +/-0.34 degrees per month). In all 13 cases where the screws were removed at the time of angular correction with significant growth remaining, growth resumed. Complications were minor and were related to incorrect placement of screws or minor hardware irritation. Percutaneous screw epiphysiodesis is a reliable, minimally invasive method with reliable results in both length and angular correction, with minimal morbidity, and with an acceptable complication rate.

A technique for calculating limb length inequality and epiphyseodesis timing using the multiplier method and a spreadsheet.

PURPOSE: Limb length inequality and epiphyseodesis timing calculations are common in pediatric orthopedics. The multiplier method developed by Paley et al. has significantly simplified the calculation of ultimate limb length. The calculation of limb length inequality has also become very simple for congenital limb length inequalities. However, the equations for limb length inequality from acquired differences and epiphyseodesis timing are not simple, and are prone to arithmetic errors. METHODS: To limit these errors, we have developed a spreadsheet which finds the appropriate multipliers, solves the equations, and computes the predicted limb length inequality and the appropriate age for an epiphyseodesis. RESULTS: This method of using a spreadsheet and the multiplier calculations is quite simple and quick to use in practice. The calculations can be cut and pasted into computerized charts for future reference. CONCLUSIONS: We recommend this method for clinical use and make it available for public use.

Correction of genu recurvatum secondary to Osgood-Schlatter disease: a case report.

Complications secondary to Osgood-Schlatter disease are rare, and there have been few reports on their treatment. Partial growth arrest of the proximal tibial physis as a result of Osgood-Schlatter disease has been infrequently described. Genu recurvatum from partial physeal arrest can cause cosmetic deformity, instability, pain, and weakness. We report a case of genu recurvatum secondary to Osgood-Schlatter disease treated successfully with proximal tibial osteotomy and distraction with a Taylor spatial frame.

Comparison of arthroplasty and arthrodesis for the rheumatoid wrist.

PURPOSE: To compare the outcomes of wrist arthrodesis and arthroplasty in the treatment of rheumatoid arthritis using validated outcome patient surveys and a review of surgical complications in 2 matched cohorts. METHODS: Forty-six patients with 51 operated wrists (24 arthrodeses and 27 arthroplasties) were reviewed retrospectively at a follow-up range of 1 to 5 years. Patients completed the Disabilities of the Arm, Shoulder and Hand (DASH) inventory, the Patient-Rated Wrist Evaluation (PRWE), and a questionnaire designed specifically for this study. Surgical complications were obtained by chart review. RESULTS: Treatment groups were well matched by patient characteristics and radiographic staging. There were no statistical differences in the survey scores between the 2 groups. Patients in the arthroplasty group, however, reported a trend toward greater ease with personal hygiene and fastening buttons. Complication rates were similar with a 56% complication rate in the arthrodesis group (22% major, 35% minor) and a 52% complication rate in the arthroplasty group (11% major, 41% minor). CONCLUSIONS: The DASH and PRWE may not be designed properly to measure impairment caused by wrist disease in patients with generalized arthritis. The results show that patients with rheumatoid arthritis can and do accommodate to a wrist arthrodesis. It should not be construed, however, that patients with rheumatoid arthritis would not prefer or obtain greater benefit from a wrist arthroplasty [corrected].