Seven-year Outcomes of Adolescent Forearm Fractures Treated With Plate Fixation.

BACKGROUND: Pediatric forearm fractures are common injuries and can sometimes require surgical treatment. Few studies have evaluated the long-term outcomes of pediatric forearm fracture plating. We evaluated long-term functional outcomes and satisfaction in children with forearm fractures treated with plate fixation. METHODS: We performed a single-institution case series at a pediatric level 1 trauma center. Inclusion criteria were: patients with radius and/or ulna diaphyseal fractures, index surgery at 18 years of age or younger, plate fixation, and a minimum of 2 years follow-up. We surveyed patients with the QuickDASH outcome measure and supplemented this with functional outcomes and satisfaction questions. Demographics and surgery characteristics were obtained from the electronic medical record. RESULTS: A total of 41 patients met the eligibility criteria, of whom 17 completed the survey with a mean follow-up of 7.2 ± 1.4 years. The mean age at index surgery was 13.1 ± 3.6 years (range, 4 to 17), with 65% males. All patients reported at least one symptom, with aching (41%) and pain (35%) occurring most frequently. There were 2 complications (12%), including one infection and one compartment syndrome treated with fasciotomy. Hardware removal occurred in 29% of patients. There were no refractures. The mean QuickDASH score was 7.7 ± 11.9, with an occupation module score of 1.6 ± 3.9 and a sports/performing arts module score of 12.0 ± 19.7. The mean surgery satisfaction was 92% and scar satisfaction was 75%. All patients returned to prior activities and 88% reported a return to their preoperative baseline level of function. CONCLUSIONS: Plate fixation for pediatric forearm fractures achieves osseous union but not without the potential for long-term sequelae. All patients reported residual symptoms 7 years later. Scar satisfaction and return to baseline function were imperfect. Patient education for long-term outcomes of surgery is essential, especially in the transition to adulthood. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Short-term outcome of unicortical, intramedullary repair of distal biceps ruptures - A retrospective cohort study.

Background: Modern distal biceps reconstruction techniques generally have satisfactory outcomes, but are not without complications. Posterior interosseous nerve (PIN) palsy is a rare but potentially devastating complication of bicortical metal button fixation. Recently, a unicortical, intramedullary, repair technique utilizing a suture anchor has been described. The primary aim of this study was to compare short-term functional and patient-reported outcomes and complication rates in patients receiving unicortical intramedullary repair (UR) with suture anchor against those receiving bicortical repair (BR) with metallic button. We hypothesized that UR would have equally satisfactory outcomes without the complication profile. Methods: Retrospective chart review was conducted for all patients undergoing operative fixation of distal biceps tendon ruptures from 2015 to 2021 at our tertiary referral center. Twenty patients received BR, and eight patients received UR. Patient demographics and surgical complications were compared. QuickDASH scores at two-month and latest in-person and telehealth postoperative visits, as well as elbow and forearm range of motion at last clinical visit, were collected and analyzed. Results: Average patient age in the BR & UR cohorts were 49.3 ± 9.3 and 42.1 ± 6.2 years, respectively, with a male predominance. There was no statistical difference in patient age, sex, hand dominance, injury laterality, injury chronicity, and follow-up duration. Range of motion was comparable and excellent in both groups. Latest follow-up was 3.0 ± 0.5 years in the BR and 1.5 ± 0.4 years in the UR cohorts. QuickDASH scores improved between the two-month and latest time points in each cohort however did not differ significantly in head-to-head comparison. Complications included a case of PIN palsy, distal biceps tendon rerupture, and lateral antebrachial cutaneous nerve (LABC) neuropraxia in the BR group and two cases of LABC neuropraxia in the UR group. The number needed to treat (NNT) for the prevention of one additional case of PIN palsy using UR is 22 patients. Discussion: Short-term functional and patient-reported outcomes in traditional BR and newly reported UR of distal biceps tendon ruptures are comparable and excellent. UR did not have higher failure rate despite follow-up periods beyond what is typically reported for tendon reruptures. In this limited retrospective cohort study, UR also did not encounter postoperative PIN palsy and had an NNT of 22 patients. In the appropriate clinical setting, this provides early evidence supporting the utilization of unicortical intramedullary suture anchor fixation of distal biceps tendon ruptures as well as associated perioperative interventions such as preoperative nerve blocks.

Pyoderma Gangrenosum Affecting the Dorsal Hand: A Case Report.

Pyoderma gangrenosum is an uncommon neutrophilic dermatosis characterized by an ulcerative lesion with a violaceous border. Most frequently, these lesions present in the lower extremity and are associated with underlying immune-mediated comorbidities. Infrequently, these lesions may present in the upper extremity, which presents difficult challenges for upper extremity surgeons as the lesions are frequently misdiagnosed as an infectious process. This often leads to inappropriate surgical debridement and antibiotic administration. Local trauma to the lesion can lead to a process of pathergy and worsening of the lesion. Here, we report on a case of cutaneous pyoderma gangrenosum affecting the dorsal hand, originally misidentified as an atypical infection with subsequent unsuccessful surgical debridement. After involvement of a multidisciplinary team, appropriate diagnosis was made, and treatment with local immunosuppressive agents achieved resolution of the lesion.

Racial differences in late-onset Blount disease.

Purpose: Blount disease is most common among obese Black children. The reason for Blount's racial predisposition is unclear. Given that obesity is a risk factor for Blount disease and the known associations between race, obesity, and socioeconomic status in the United States, we hypothesized that socioeconomic status and severity of obesity differ between Black and non-Black children with late-onset Blount disease. We additionally examined differences in treatment types between Black and non-Black children. Methods: One hundred twenty-five patients from two institutions were included. Age at presentation, age of onset, body mass index, race, sex, and treatment type were recorded. These variables were compared between Black and non-Black children. Insurance type and estimated household income were used as markers of socioeconomic status. Results: Of the 125 patients with late-onset Blount disease, body mass index percentiles were higher for Black patients (96th ± 12th percentile) than non-Black patients (89th ± 22nd percentile) (p = 0.04). Black patients also had lower estimated incomes (US$48,000 ± US$23,000 vs US$62,000 ± US$30,000) (p = 0.01) and much higher rates of Medicaid enrollment (69% vs 24%) (p < 0.01) than did non-Black patients. Regarding treatment types, osteotomy was more common among Black patients (60%) than non-Black patients (38%) (p = 0.033). Conclusion: The race-related associations we found between obesity and socioeconomic status suggest that non-genetic factors may contribute to observed racial differences in the prevalence of Blount disease. Level of evidence: level III.

Pedicle Screw Plowing in Adolescent Idiopathic Scoliosis: How Common Is It and Is It a Problem?

STUDY DESIGN: Multicenter retrospective review. OBJECTIVE: To calculate overall incidence of pedicle screw "plowing" in adolescent idiopathic scoliosis (AIS) patients who underwent posterior spinal fusion (PSF). To identify risk factors for pedicle screw plowing and associated postoperative outcomes, including loss of correction and revision rate. SUMMARY OF BACKGROUND DATA: Curve correction of AIS generates perpendicular stresses that can cause pedicle screws to lose alignment and "plow" through pedicles craniocaudally. METHODS: We reviewed records of 1057 patients who underwent PSF for AIS from 2002 to 2015. Preoperative and first postoperative erect radiographs were evaluated by two observers to determine (1) presence of plowing and (2) subsequent loss of correction (LOC). Plowing was defined as more than 25° sagittal angulation compared with pedicle axis or entry of the most dorsal part of the screw outside the pedicle projection. LOC was defined as postoperative change in focal angulation of an instrumented spinal level, when in consensus of both reviewers. Bivariate analyses were performed (alpha = 0.05). RESULTS: Nineteen thousand five hundred sixty nine screws were assessed across our cohort of 1057 patients. Both observers agreed that 48 patients (4.5%) demonstrated plowing of more than or equal to one pedicle screw. For 72 screws (0.4%), both observers noted plowing, most commonly through the cranial cortex of the pedicle (65/72 screws) and at the lowest instrument vertebra (LIV) (17/72 screws). Factors associated with plowing included larger curves (P = 0.02); lower mean pedicle screw density (P = 0.0003); skeletal immaturity as measured by open triradiate cartilage (P = 0.04); and younger chronological age at time of surgery (P = 0.04). LOC occurred in 13 patients, most commonly at LIV (P < 0.0001). Revision rate for loss of screw fixation was higher in the plowing group (P = 0.003). CONCLUSION: Pedicle screw plowing occurred in 4.5% of AIS patients, especially in those skeletally immature and with decreased implant density. Plowing commonly occurred in the cranial direction and was associated with LOC, particularly at the LIV.Level of Evidence: 3.

Use of Vancomycin Powder in Spinal Deformity Surgery in Cerebral Palsy Patients is Associated With Proteus Surgical Site Infections.

PURPOSE: Surgical site infection (SSI) rates in pediatric spinal deformity surgery for cerebral palsy (CP) patients are higher than that in idiopathic scoliosis. The use of vancomycin powder is associated with decreased risk of SSI in neuromuscular patients. Prior studies in adult and pediatric early-onset scoliosis patients have shown that vancomycin powder alters microbacterial profile in patients that develop SSI. However, the effects of topical vancomycin powder on microbiology in spinal deformity surgery for CP patients has not been studied. METHODS: An international multicenter database of CP neuromuscular scoliosis patients was used in this retrospective cohort study. All patients that underwent posterior spinal instrumented fusion for CP neuromuscular scoliosis from 2008 to 2019 were queried, and 50 cases complicated by postoperative SSI were identified. Intraoperative antibiotic details were documented in 49 cases (98.0%). Microbiology details were documented in 45 cases (91.8%). Microbiology for patients that received topical vancomycin powder were compared with patients that did not. A multivariate regression model was used to control for potential confounders. RESULTS: There were 45 patients included in this study. There were 27 males (60.0%) and 18 females (40.0%). Mean age at surgery was 14.8±2.4 years. There were 24 patients that received topical vancomycin powder (53.3%). The mean time from index surgery to SSI was 4.3±11.3 months.On univariate analysis of microbiology cultures by vancomycin powder cohort, there were no significant differences in culture types. Proteus spp. trended on significance with association with vancomycin powder use (P=0.078). When controlling for potential confounders on multivariate analysis, intraoperative topical vancomycin powder was associated with increased risk for proteus infection (adjusted odds ratio: 262.900, 95% confidence interval: 1.806-38,267.121, P=0.028). DISCUSSION: In CP patients undergoing pediatric spinal deformity surgery, the use of vancomycin powder was independently associated with increased risk for proteus infections. Further study into antibiotic regimens for spinal deformity surgery in the CP population should be performed. LEVEL OF EVIDENCE: Level III-retrospective cohort study.

Using the Remnant Anterior Cruciate Ligament to Improve Knee Stability: Biomechanical Analysis Using a Cadaveric Model.

BACKGROUND: Injured anterior cruciate ligament (ACL) tissue retains proprioceptive nerve fibers, vascularity, and biomechanical properties. For these reasons, remnant ACL tissue is often preserved during the treatment of ACL injuries. PURPOSE: To assess through a cadaveric model whether reorienting and retensioning the residual ACL via an osteotomy improves knee stability after partial ACL tear, with substantial remnant tissue and intact femoral and tibial attachments. STUDY DESIGN: Controlled laboratory study. METHODS: In 8 adult cadaveric knees, we measured anterior tibial translation and rotational laxity at 30° and 90° of flexion with the ACL in its native state and in 3 conditions: partial tear, retensioned, and ACL-deficient. The partial-tear state consisted of a sectioned anteromedial ACL bundle. RESULTS: In the native state, the translation was 10 ± 2.7 mm (mean ± SD) at 30° of flexion and 8.4 ± 3.6 mm at 90° of flexion. Anterior translation of the knees in the partial-tear state (14 ± 2.7 mm at 30° and 12 ± 2.7 mm at 90°) was significantly greater than baseline (P < .001 for both). Translation in the ACL-retensioned state (9.2 ± 1.7 mm at 30° and 7.2 ± 2.1 mm at 90°) was significantly less than in the ACL-deficient state (P < .001 for both), and translation was not significantly different from that of the intact state. For ACL-deficient knees, translation (20 ± 4.3 mm at 30° and 16 ± 4.4 mm at 90°) was significantly greater than all other states (P < .001 for all). Although rotational testing demonstrated the least laxity at 30° and 90° of flexion in the retensioned and intact states and the most laxity in the ACL-deficient state, rotation was not significantly different among any of the experimental states. CONCLUSION: In a cadaveric model of an incomplete ACL tear, a reorienting and retensioning core osteotomy at the tibial insertion of the remnant ACL improved anteroposterior translation of the knee without compromising its rotational laxity. CLINICAL RELEVANCE: The findings of this study support the concept of ACL tissue reorienting and retensioning in the treatment of ACL laxity as an area for future investigation.

Association of Body Mass Index With Severity and Lesion Location in Adolescents With Osteochondritis Dissecans of the Knee.

BACKGROUND: The association between body mass index (BMI) and severity of osteochondritis dissecans (OCD) of the knee at presentation is poorly understood. HYPOTHESIS: We hypothesized that adolescents in higher BMI percentiles for age and sex would have OCD lesions that were more severe at their initial presentation and located more posteriorly on the condyle as compared with adolescents in lower BMI percentiles. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: This study included patients aged 10 to 18 years who were treated for knee OCD at a tertiary care hospital from 2006 to 2017. Patients with noncondylar OCD or missing BMI data within 3 months of presentation were excluded. Patients were stratified per the Centers for Disease Control and Prevention guidelines as underweight, normal weight, overweight, or obese, and the groups were compared according to age, side of lesion, 4 markers of lesion severity (cystic changes, loose fragments, subchondral fluid, and subchondral edema), and surgical treatment. Lesion angle was measured in reference to a line parallel to the femoral axis drawn through the center of a best-fit circle covering the distal condyle. Data were analyzed using chi-square tests, relative risk, Student t tests, analysis of variance, and linear regression of cumulative running percentages. Bonferroni correction was performed when applicable. RESULTS: A total of 77 patients met our inclusion criteria (mean age, 14.2 years; range, 10.1-18.8): 2 were underweight, 50 had normal BMI, 13 were overweight, and 12 were obese. We found correlations between BMI percentile and surgical treatment (R 2 = .732), subchondral fluid (R 2 = .716), subchondral edema (R 2 = .63), loose fragments (R 2 = .835), and the presence of at least 1 marker of lesion severity (R 2 = .857) (P < .0001 for all). No correlation was observed for cystic changes (R 2 = .026). There were significant associations between BMI ≥80th percentile and subchondral edema (risk ratio, 2.5; 95% CI, 1.3-4.8), medial condylar lesions (risk ratio, 1.3; 95% CI, 1.01-1.7), and lesions more anterior on the condyle (P < .05). CONCLUSION: Higher BMI in adolescents was strongly correlated with multiple markers of severity of knee OCD at initial presentation as well as with more anterior lesions.

Role of the Pubic Symphysis in Osseous Pelvic Development: A Novel Model of Bladder Exstrophy in Rabbits.

BACKGROUND: It has been posited that the osseous pelvic anomalies seen in patients with classic bladder exstrophy (CBE) result from disruption of the pubic symphysis. This hypothesis, however, has not been tested. In the present animal study, our objective was to determine whether the tension of the pubic symphysis helps maintain the shape of the pelvic ring, or whether the growing bones maintain a ring shape even without the tension of the symphysis. METHODS: In total, 12 neonatal New Zealand White rabbits underwent pubic symphysiotomy (experimental group, n=9) or sham surgery (control group, n=3) on days 3 or 4 of life. Rabbits were scanned with cone-beam computed tomography at 1, 4, 12, and 20 weeks postoperatively to monitor changes in the following pelvic parameters, which are known to be altered in CBE: anterior segment angle, anterior segment length, intertriradiate distance, interpubic distance, and posterior segment angle. Changes within the experimental and control groups were evaluated using repeated-measures analysis of variance and post hoc Tukey honest significant difference testing. Two-tailed t tests were used to compare treatment groups at each time point. RESULTS: Both groups showed increases in anterior segment length and intertriradiate distance during the study period; rabbits in the experimental group also showed a steady increase in interpubic distance (F=43.9; P<0.001). Experimental rabbits had significantly larger mean values for anterior segment angle, intertriradiate distance, interpubic distance, and posterior segment angle than did control rabbits at all time points. We found no difference in mean anterior segment length between control and experimental groups at any time point. The difference in interpubic distance was particularly pronounced by 20 weeks (experimental group, 13±2.7 mm; control group, 1.1±0.1 mm; P<0.001). CONCLUSIONS: The pubic symphysis is essential for normal pelvic development. Its absence led to early pelvic angulation and progressive pubic separation in a rabbit model. However, we found no significant difference in the mean anterior segment length, and it is likely that other factors are also implicated in the growth disturbance seen in CBE. LEVEL OF EVIDENCE: Level V.

Radiographic assessments of pediatric supracondylar fractures and mid-term patient-reported outcomes.

Radiographic parameters are commonly used to determine the need for surgical supracondylar humeral (SCH) fracture reduction and the postoperative quality of reduction. We studied whether such parameters are correlated with mid-term patient-reported outcome (PRO) scores in pediatric patients.We retrospectively reviewed data from 213 patients (104 girls) treated surgically for Gartland type-II (n = 84) or type-III (n = 129) SCH fractures from 2008-2016. Mean (± standard deviation) age at surgery was 5.1 ±â€Š2.1 years. Mean time from initial treatment to outcome survey completion was 5.0 ±â€Š2.1 years (range, 2.0-10 years). We evaluated preoperative radiographs for coronal/sagittal fracture displacement, presence of impaction/comminution, Gartland classification, and rotation. Patients, parents were asked via telephone to complete the QuickDASH (Quick Disability of the Arm, Shoulder, and Hand) and PROMIS (Patient-Reported Outcomes Measurement Information System) Strength Impact, Upper Extremity, and Pain Interference questionnaires. Parents were also asked whether the previously fractured arm appeared normal or abnormal. We evaluated postoperative radiographs for coronal/sagittal deformity, Baumann angle, and rotation and classified reductions as near complete/complete or incomplete. Anterior humeral line through the capitellum, Baumann angle in the 7.5th to 92.5th percentile of the sample, or rotation ratio between 0.85 and 1.15 were considered near complete/complete reductions; all others were considered incomplete. Bivariate analysis was used to determine whether radiographic parameters and arm appearance were associated with QuickDASH and PROMIS scores.Patients with Gartland type-III fractures had significantly greater disability on the QuickDASH at follow-up compared with those with Gartland type-II fractures (P < .01). It is unknown if this statistical difference translates to clinical relevance. No other preoperative or postoperative radiographic parameter was significantly associated with PRO scores. There was no association between fractured arm appearance at follow-up and PRO scores.Radiographic parameters that are used to evaluate the need for and quality of pediatric SCH fracture reduction are not significantly associated with mid-term PROMIS and QuickDASH scores.LOE: Prognostic Level III.

Sex-based differences in pediatric supracondylar humerus fractures.

Supracondylar humerus (SCH) fractures are reported to be approximately twice as common among boys as among girls. Little is known about sex-associated differences in fracture patterns and complications. We compared the incidence of pediatric SCH fractures, injury mechanism (high-energy or low-energy), fracture subtypes, associated neurologic injuries, and treatment types by patient sex.We reviewed 1231 pediatric SCH fractures treated at 1 center from 2008 to 2017, analyzing sex distributions overall and by year and fracture subtype. We noted patient demographic characteristics, injury mechanisms, neurologic injuries, and treatments (nonoperative or operative). Binomial 2-tailed, chi-squared, and Student's t tests were used for analysis. Multiple logistic regression was performed to assess associations between sex, age, and injury mechanism. Alpha = 0.05.We found no significant difference in the distribution of girls (52%) vs boys (48%) in our sample compared with a binomial distribution (P = .11). Annual percentages of fractures occurring in girls ranged from 46% to 63%, and sex distribution did not change significantly over time. The mean (± standard deviation) age at injury was significantly younger for girls (5.5 ±â€Š2.5 years) than for boys (6.1 ±â€Š2.5 years) (P < .001). High-energy injury mechanism was associated with older age (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.03-1.06) but not male sex (OR, 1.04; 95% CI, 0.98-1.1). The overall incidence of neurologic injury was 9.5% but boys did not have greater odds of sustaining neurologic injury (OR, 1.03; 95% CI, 1.0-1.1). We found no sex-associated differences in the distribution of Gartland fracture subtypes (P = .13) or treatment type (P = .39).Compared with boys, girls sustain SCH fractures at a younger age. SCH fractures were distributed equally among girls and boys in our sample. Patient sex was not associated with fracture subtype, injury mechanism, neurologic injury, or operative treatment. These findings challenge the perception that SCH fracture is more common in boys than girls.Level III, retrospective study.

Characterizing Use of Growth-friendly Implants for Early-onset Scoliosis: A 10-Year Update.

BACKGROUND: Growth-friendly treatment of early-onset scoliosis (EOS) has changed with the development and evolution of multiple devices. This study was designed to characterize changes in the use of growth-friendly implants for EOS from 2007 to 2017. METHODS: We queried the Pediatric Spine Study Group database for patients who underwent index surgery with growth-friendly implants from July 2007 to June 2017. In 1298 patients, we assessed causes of EOS; preoperative curve magnitude; age at first surgery; patient sex; construct type; lengthening interval; incidence of "final" fusion for definitive treatment; and age at definitive treatment. α=0.05. RESULTS: From 2007 to 2017, the annual proportion of patients with idiopathic EOS increased from 12% to 33% (R=0.58, P=0.006). Neuromuscular EOS was the most common type at all time points (range, 33% to 44%). By year, mean preoperative curve magnitude ranged from 67 to 77 degrees, with no significant temporal changes. Mean (±SD) age at first surgery increased from 6.1±2.9 years in 2007 to 7.8±2.5 years in 2017 (R=0.78, P<0.001). As a proportion of new implants, magnetically controlled growing rods increased from <5% during the first 2 years to 83% in the last 2 years of the study. Vertically expandable prosthetic titanium ribs decreased from a peak of 48% to 6%; growth-guidance devices decreased from 10% to 3%. No change was seen in mean surgical lengthening intervals (range, 6 to 9 mo) for the 614 patients with recorded lengthenings. Final fusion was performed in 88% of patients who had undergone definitive treatment, occurring at a mean age of 13.4±2.4 years. CONCLUSIONS: From 2007 to 2017, neuromuscular EOS was the most common diagnosis for patients treated with growth-friendly implants. Patient age at first surgery and the use of magnetically controlled growing rods increased during this time. Preoperative curve magnitude, traditional growing rod lengthening intervals, and rates of final fusion did not change. LEVEL OF EVIDENCE: Level II.

The Times, They Are A-Changing: Women Entering Academic Orthopedics Today Are Choosing Nonpediatric Fellowships at a Growing Rate.

OBJECTIVE: Pediatrics and hand surgery have historically been the orthopaedic subspecialties with the highest female representations. We sought to identify the gender distribution of orthopedic surgical faculty by subspecialty, geography, and educational background. We hypothesized that the proportion of women entering pediatric orthopaedics has decreased since 1980. DESIGN: The Accreditation Council for Graduate Medical Education was used to generate a list of U.S. orthopedic residencies. Program websites were used to collect data regarding each faculty member's gender, residencies, fellowships, and graduation year. t tests were used to compare quantitative data and Fisher's exact tests to compare categorical data. Significance was defined as p < 0.05. SETTING: Publicly available data from official websites of U.S. orthopedic residencies. PARTICIPANTS: Of 153 residencies, 142 (93%) had accessible faculty lists. RESULTS: Of 3596 orthopedic surgeons, 7.9% were women. Among fellowship-trained faculty, 22% of pediatric orthopedists were women compared with 7.6% of faculty in other orthopedic subspecialties (p < 0.00001). There was a significantly higher percentage of female faculty in the West (13%) than in any other U.S. census region (p < 0.001 vs. Midwest, vs. South, and vs. Northeast). A strong correlation with time was found in number of women completing fellowships other than hand or pediatrics from 1980 to 2014 (R2 = 0.95); a strong inverse correlation with time was found for pediatrics as a percentage of fellowships completed by women during the same period (R2 = 0.94). CONCLUSIONS: Although pediatrics remains the most popular fellowship for female orthopedists, women who enter academic orthopedics are increasingly choosing nonpediatric subspecialties.

Respiratory Complications After Posterior Spinal Fusion for Neuromuscular Scoliosis: Children With Rett Syndrome at Greater Risk Than Those With Cerebral Palsy.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: To determine how respiratory failure rates and duration of intensive care unit (ICU) stay after posterior spinal fusion (PSF) for neuromuscular scoliosis compare between children with Rett syndrome (RS) versus cerebral palsy (CP). SUMMARY OF BACKGROUND DATA: Rett syndrome and CP are associated with high incidence of neuromuscular scoliosis and respiratory dysfunction. METHODS: We included 21 patients with RS (mean age, 13 ±â€Š3.1 yrs) and 124 with CP (mean age, 14 ±â€Š3.2 yrs) who underwent PSF by one surgeon from 2004 to 2017. Preoperative motor function was assessed using the Gross Motor Function Classification System (GMFCS). Primary outcomes were respiratory failure and duration of ICU stay. Secondary outcomes were pneumonia and prolonged use of positive pressure ventilation (PPV). Using multivariate regression, we identified associations of age, intraoperative vital signs, duration of hospital stay, number of vertebral levels fused, anesthesia and surgery durations, and estimated blood loss with longer ICU stay and respiratory failure. RESULTS: A greater proportion of CP patients (96%) than RS patients (66%) were in GMFCS IV or V (P < 0.01). Respiratory failure was more common in RS patients (43% vs. 19%; P = 0.02), as was PPV (67% vs. 31%; P < 0.01). RS patients had shorter median durations of anesthesia and surgery (P < 0.01). RS patients had a longer median (interquartile range) ICU stay (4 days [1-5] vs. 2 days [2-19]; P = 0.01). Incidence of pneumonia did not differ between groups (P = 0.69). Only RS diagnosis (P = 0.02) and prolonged PPV (P < 0.01) were associated with longer ICU stay. CONCLUSION: Despite better preoperative motor function and shorter anesthesia and surgery durations, patients with RS experienced more respiratory failure, prolonged PPV use, and longer ICU stays after PSF than did children with CP. LEVEL OF EVIDENCE: 4.

10-Min 3D Turbo Spin Echo MRI of the Knee in Children: Arthroscopy-Validated Accuracy for the Diagnosis of Internal Derangement.

BACKGROUND: Ten-minute MRI of the pediatric knee can add value through increased cost-effectiveness and decreased sedation needs but requires validation of its clinical efficacy. PURPOSE: To determine the arthroscopy-based diagnostic accuracy and interreader reliability of 10-min 3D Controlled Aliasing In Parallel Imaging Results In Higher Acceleration (CAIPIRINHA) turbo spin echo (TSE) MRI with two isotropic pulse sequences for the diagnosis of internal derangement in children with painful knee conditions. STUDY TYPE: Prospective. SUBJECTS: Sixty children. FIELD STRENGTH/SEQUENCE: 3T, gradient echo-based scout with automatic anatomical landmark recognition and plane prescription, 3D CAIPIRINHA SPACE TSE. ASSESSMENT: Three fellowship-trained musculoskeletal radiologists evaluated the MRI studies independently and resolved discrepancies through consensus. Outcome variables included image quality, motion artifacts, meniscal abnormalities, anterior and posterior cruciate ligament tears, and cartilage lesions. Arthroscopic surgery served as the standard of reference, which was performed after 37 (range, 1-143) days post-MRI. STATISTICAL TESTS: Diagnostic accuracy analysis of MRI with arthroscopic surgery as the standard of reference. Reliability analysis through calculation of interreader agreements with kappa statistics. RESULTS: All studies were suitable for diagnostic interpretation with good-to-very-good image quality ratings and little-to-no motion degradation ratings in the majority of cases. The sensitivities/specificities/accuracies of 3D CAIPIRINHA TSE MRI were 0.93/0.96/0.94 for 15/60 (25%) medial meniscal tears, 0.95/0.92/0.94 for 21/60 (35%) lateral meniscal tears, 0.83/1.00/0.92 for 6/60 (17%) discoid menisci, 1.00/0.98/0.99 for 16/60 (27%) anterior cruciate ligament tears, 1.0/1.0/1.0 for 2/60 (3%) posterior cruciate ligament tears, 1.00/1.00/1.00 for 5/60 (8%) osteochondritis dissecans lesions, 0.71/0.96/0.84 for 48 (13%) defects in 360 cartilage segments, and 0.85/0.97/0.91 overall. The interreader agreements were overall good-to-very-good (kappa, 0.72-1.00). DATA CONCLUSION: The clinical use of 10-min 3D CAIPIRINHA TSE MRI of the knee in children with painful knee conditions yields an overall high arthroscopy-validated diagnostic accuracy of 91% and good-to-very good interreader reliability for the diagnosis of internal knee derangements. LEVEL OF EVIDENCE: 1 Technical Efficacy: Stage 6 J. Magn. Reson. Imaging 2019;49:e139-e151.

An Abbreviated Scale for the Assessment of Skeletal Bone Age Using Radiographs of the Knee.

Hand and wrist radiographs are the most common means for estimating skeletal bone age. There is no widely used scale for estimating skeletal bone age using knee radiographs. Do skeletal bone age estimates from knee-maturity scales correlate sufficiently with both chronologic age and estimates from a hand-wrist scale to potentially substitute for estimates from the latter? The authors reviewed the records of 503 patients 6 to 19 years old who had hand and knee radiographs obtained within 30 days of each other. They analyzed radiographs using the O'Connor knee scale (based on 10 maturation markers) and a new, abbreviated version of the O'Connor scale (based on 7 markers). The authors also analyzed radiographs of the hands of boys 12.5 to 16 years old and girls 10 to 16 years old using the shorthand method. Multivariate linear regression was used for analysis. Inter- and intrarater reliabilities were assessed. Skeletal bone age derived from the O'Connor and abbreviated knee scales correlated with chronologic age (adjusted R2=0.88 and 0.90, respectively). Compared with estimates from the hand-wrist scale, estimates were lower by a mean of 0.91 years for boys and 0.38 years for girls when using the O'Connor scale and 0.96 years for boys and 0.52 years for girls when using the abbreviated scale. Inter- and intrarater reliabilities were very good (κ=0.82 and 0.90, respectively) and were substantial at each bony landmark measured. Knee radiographs can be used to estimate skeletal bone age using an abbreviated knee scale. [Orthopedics. 2018; 41(5):e676-e680.].

Epidemiological Patterns of Alternative Racquet-Sport Injuries in the United States, 1997-2016.

BACKGROUND: Racquet sports have increased in popularity over the past decade. Although research is available regarding the epidemiological characteristics of tennis injuries, little is known about the frequency and characteristics of injuries in other racquet sports. HYPOTHESIS: Given the increase in all racquet sport participation in the United States (US), it is hypothesized that injuries have accordingly become more frequent. STUDY DESIGN: Descriptive epidemiology study. METHODS: Using the National Electronic Injury Surveillance System database, we reviewed the numbers of badminton and squash/racquetball injuries presenting to a representative sample of US emergency departments (EDs). We used weighted estimates to extrapolate the data to the US population. Incidence estimates were compared with national participation data and stratified. RESULTS: A total of 4330 injuries were reported, representing an estimated 173,000 injuries presenting to US EDs from 1997 through 2016. Despite the increase in the number of players from 2006 through 2016, the annual injury rate for squash/racquetball declined significantly, including the rates for each body region assessed. No similar trend was found for badminton injuries. Within our extrapolated ED cohort, the lower extremities were the most common body region injured (37%). Strains/sprains were the most common injury type in the trunk (73%), lower extremities (65%), and upper extremities (32%), whereas lacerations were most common in the head/neck (49%). In badminton, the youngest players (age range, 5-18 years) sustained twice as many fractures (relative risk [RR], 1.96; 95% CI, 1.14-3.38) and almost 3 times as many lacerations as patients in any other age group. Similarly, the youngest squash/racquetball players were at highest risk for lacerations (RR, 1.45; 95% CI, 1.22-1.73) and head and neck injuries (RR, 1.52; 95% CI, 1.26-1.83). CONCLUSION: Although declines in rates of squash/racquetball injuries were observed, the increasing popularity of badminton, squash, and racquetball necessitates further preventive measures to improve player safety, with an emphasis on the youngest players.