Parent Reported Perspectives on Pediatric Radiation Exposure in a Pediatric Orthopedic Clinic.

BACKGROUND: Few studies have investigated the perspective of caregivers as it pertains to their children having xrays performed. This study sought to identify which factors contribute to the varying views that caregivers have toward giving their children x-rays. METHODS: The data was collected through an anonymous survey administered during visits to the pediatric orthopedic surgery clinic. The survey was completed by the patient's parent, guardian, or caregiver, and was administered by a treating physician. The data was analyzed using Fisher exact tests. RESULTS: A total of 62 surveys were obtained from caregivers in the pediatric orthopedic clinic. The analysis found that 23.3% of parents reported concerns regarding their child having an x-ray. One hundred percent of those parents that reported concern attributed this to the risk associated with radiation exposure. Along with the radiation exposure risk, 10% believed that another test would be more useful, and 10% were concerned that their insurance did not cover the x-ray procedure. In contrast, 46.8% of the parents felt that their visit would not be complete without having an x-ray. Of this group, 38.5% felt an x-ray was necessary for diagnosis, 19.5% felt something would be missed without the x-ray, and 42% felt concerned about both missing something and not being able to properly diagnose. CONCLUSIONS: This study found that almost 25% of caregivers surveyed expressed concerns regarding the risks of radiation exposure to their child while having an x-ray. This underscores an opportunity to educate caregivers about the risks associated with x-ray radiation exposure as well as to quantify radiation exposure risk from x-ray as compared to ambient environmental radiation exposure. In addition, almost 40% of caregivers felt their visit was incomplete without an x-ray. Thus, it is indispensable for the physician to communicate with the caregiver on the significance of the x-ray and explain whether or not it would be required.

Impact of tranexamic acid on blood loss and transfusion rate in children with cerebral palsy undergoing hip reconstruction with two or more osteotomies.

PURPOSE: Tranexamic acid (TXA), a synthetic lysine analogue, has been used in orthopedic procedures to limit blood loss and prevent allogeneic blood transfusions. However, data are scarce on its use in hip reconstruction of patients with cerebral palsy (CP). This study examines the effect of TXA on patients with CP undergoing hip reconstruction with at least two osteotomies. METHODS: This is a single-center, retrospective study of patients with CP who underwent hip reconstruction with two or more osteotomies from January 2013 to April 2019. There were 43 patients, with a mean age of 9.9 years. Age, procedure, preoperative and postoperative hemoglobin/hematocrit, estimated blood loss (EBL), transfusions and length of stay were recorded. The patients were split into the following two groups: 24 patients who had received intraoperative TXA and 19 who had not. RESULTS: Age, EBL, mean preoperative and postoperative hemoglobin or hematocrit, preoperative to postoperative hematocrit drop, and length of stay were similar for the two groups (p > 0.05). The risk for intraoperative transfusion (21 vs. 17%), postoperative transfusion (26 vs. 8%), and any transfusion (42 vs. 21%) appeared to be greater in the group that did not receive TXA, but this difference did not achieve statistical significance. CONCLUSION: This pilot study shows patients with CP undergoing hip reconstruction with two or more osteotomies; the use of TXA, while not statistically significant, shows a trend toward a decreased need for allogeneic blood transfusion.

Area Deprivation Index and Magnitude of Scoliosis at Presentation to a Tertiary Referral Scoliosis Clinic in Massachusetts.

BACKGROUND: There is growing interest in identifying predictors of large scoliosis curves at initial presentation, but few data to guide such preventive efforts. The association of neighborhood socioeconomic deprivation with curve magnitude in this context has not been previously evaluated. The purpose of our study was to determine the correlation of socioeconomic deprivation with scoliosis curve magnitude at initial presentation. Secondarily, we assessed the correlation of body mass index (BMI) with curve severity. METHODS: We retrospectively identified 202 patients presenting with adolescent idiopathic scoliosis to a single tertiary care center in Massachusetts from January 2015 to August 2018. The Area Deprivation Index (ADI), a validated composite measure of neighborhood socioeconomic deprivation, was calculated for each patient. Curve magnitude, age, sex, BMI, race, and insurance status were recorded. Pearson correlation was used to determine the association of the ADI and BMI with scoliosis severity. RESULTS: There was no correlation between the ADI and the magnitude of scoliosis at presentation (r=0.055; P=0.43). Greater BMI was moderately correlated with increased scoliosis curve magnitude (r=0.28; P<0.001). There was no association between curve magnitude and patient age, sex, race, or insurance status. CONCLUSIONS: The finding that neighborhood socioeconomic deprivation did not correlate with greater scoliosis severity at presentation may be suggestive of equitable access to specialized scoliosis care. Future research should determine whether this reassuring finding is unique to Massachusetts--a state with high rates of health insurance coverage--or generalizable to other US states. In addition, our study further corroborates the notion that greater BMI is associated with larger scoliosis curves, and calls for targeted interventions to facilitate early scoliosis detection in the growing childhood obese population. LEVEL OF EVIDENCE: Level II-prognostic study and retrospective study.

Salto Talaris Total Ankle Arthroplasty: Clinical Results at a Mean of 5.2 Years in 78 Patients Treated by a Single Surgeon.

BACKGROUND: In recent years, the number of total ankle arthroplasty procedures performed has increased dramatically. We sought to report the clinical results of the largest cohort of patients treated with a modern fixed-bearing total ankle arthroplasty by a single surgeon. METHODS: We retrospectively reviewed the charts of 78 consecutive patients (81 ankles) who underwent total ankle arthroplasty with a minimum clinical follow-up of 2 years. Sixty-three patients completed standardized questionnaires including the Foot and Ankle Disability Index (FADI), the Short Musculoskeletal Function Assessment (SMFA), the Short Form (SF)-36v2, and a visual analog scale (VAS) for pain. In addition, each patient underwent serial range-of-motion examination and radiographic implant evaluation at each follow-up appointment. RESULTS: Implant survival was 97.5% at a mean follow-up time of 5.2 years. There was 1 revision of a tibial component and 1 revision of a talar component. Thirty-six patients underwent a concurrent procedure at the time of the index surgery, with the most common being removal of previous hardware. Seventeen patients underwent additional procedures following the index surgery, with the most common being gutter debridement. Total range of motion averaged 35.5° preoperatively and 39.9° postoperatively (p = 0.02). Fifty-seven ankles (70%) had >2 years of radiographic follow-up, and 25 ankles (31%) displayed evidence of lucency around a metallic component at the final radiographic follow-up. Outcome scores at a mean of 5.2 years revealed promising results for the cohort, with a mean VAS pain score of 17.7 and a mean FADI score of 79.1. CONCLUSIONS: Modern fixed-bearing total ankle arthroplasty had excellent implant survival, improved plantar flexion and total range of motion, and had good-to-excellent functional outcome at a mean follow-up of 5.2 years. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Role of Nanog in the maintenance of marrow stromal stem cells during post natal bone regeneration.

Post natal bone repair elicits a regenerative mechanism that restores the injured tissue to its pre-injury cellular composition and structure and is believed to recapitulate the embryological processes of bone formation. Prior studies showed that Nanog, a central epigenetic regulator associated with the maintenance of embryonic stem cells (ESC) was transiently expressed during fracture healing, Bais et al. In this study, we show that murine bone marrow stromal cells (MSCs) before they are induced to undergo osteogenic differentiation express ∼50× the background levels of Nanog seen in murine embryonic fibroblasts (MEFs) and the W20-17 murine marrow stromal cell line stably expresses Nanog at ∼80× the MEF levels. Nanog expression in this cell line was inhibited by BMP7 treatment and Nanog lentivrial shRNA knockdown induced the expression of the terminal osteogenic gene osteocalcin. Lentivrial shRNA knockdown or lentiviral overexpression of Nanog in bone MSCs had inverse effects on proliferation, with knockdown decreasing and overexpression increasing MSC cell proliferation. Surgical marrow ablation of mouse tibia by medullary reaming led to a ∼3-fold increase in Nanog that preceded osteogenic differentiation during intramembranous bone formation. Lentiviral shRNA knockdown of Nanog after surgical ablation led to an initial overexpression of osteogenic gene expression with no initial effect on bone formation but during subsequent remodeling of the newly formed bone a ∼50% decrease was seen in the expression of terminal osteogenic gene expression and a ∼50% loss in trabecular bone mass. This loss of bone mass was accompanied by an increased ∼2- to 5-fold adipogenic gene expression and observed increase of fat cells in the marrow space. In summary these data show that Nanog is expressed during surgically induced marrow bone formation and is functionally involved in post natal marrow stromal cell maintenance and differentiation.