BrAIST-Calc: Prediction of Individualized Benefit From Bracing for Adolescent Idiopathic Scoliosis.

STUDY DESIGN: Prospective multicenter study data were used for model derivation and externally validated using retrospective cohort data. OBJECTIVE: Derive and validate a prognostic model of benefit from bracing for adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: The Bracing in Adolescent Idiopathic Scoliosis Trial (BrAIST) demonstrated the superiority of bracing over observation to prevent curve progression to the surgical threshold; 42% of untreated subjects had a good outcome, and 28% progressed to the surgical threshold despite bracing, likely due to poor adherence. To avoid over-treatment and to promote patient goal setting and adherence, bracing decisions (who and how much) should be based on physician and patient discussions informed by individual-level data from high-quality predictive models. MATERIALS AND METHODS: Logistic regression was used to predict curve progression to <45° at skeletal maturity (good prognosis) in 269 BrAIST subjects who were observed or braced. Predictors included age, sex, body mass index, Risser stage, Cobb angle, curve pattern, and treatment characteristics (hours of brace wear and in-brace correction). Internal and external validity were evaluated using jackknifed samples of the BrAIST data set and an independent cohort (n=299) through estimates of discrimination and calibration. RESULTS: The final model included age, sex, body mass index, Risser stage, Cobb angle, and hours of brace wear per day. The model demonstrated strong discrimination ( c -statistics 0.83-0.87) and calibration in all data sets. Classifying patients as low risk (high probability of a good prognosis) at the probability cut point of 70% resulted in a specificity of 92% and a positive predictive value of 89%. CONCLUSION: This externally validated model can be used by clinicians and families to make informed, individualized decisions about when and how much to brace to avoid progression to surgery. If widely adopted, this model could decrease overbracing of AIS, improve adherence, and, most importantly, decrease the likelihood of spinal fusion in this population.

The Costs of Interfacility Transfers for Nonurgent Pediatric Supracondylar Fractures.

BACKGROUND: Unnecessary transfers of nonemergent pediatric musculoskeletal injuries to regional trauma centers can be costly. The severity of fracture displacement in supracondylar humerus fractures dictates the risk of complications, the urgency of transfer and the need for surgical treatment. The purpose of this study is to examine the transfer patterns of Gartland type II pediatric supracondylar humerus fractures to identify strategies for improving patient care, improving health care system efficiency, and reducing costs. We hypothesize that there will be a high rate of unnecessary, emergent transfers resulting in increased cost. METHODS: We retrospectively identified all pediatric patients that underwent treatment for a supracondylar humerus fracture between 2013 and 2018. Patient demographics, injury characteristics, chronological data, and surgical data were collected and analyzed from ambulance run sheets, transferring hospital records, and electronic medical records. Transfer distances were estimated using Google-Maps, while transfer costs were estimated using Internal Revenue Service (IRS) standard mileage rates and the American Ambulance Association Medicare Rate Calculator. A student t test was used to evaluate different treatment groups. RESULTS: Sixty-two patients had available and complete transfer data, of which 44 (71%) patients were safely transferred via private vehicle an average distance of 51.8 miles, and 18 (29%) patients were transferred via ambulance on an average distance of 55.6 miles ( P =0.76). The average transfer time was 4.1 hours by private vehicle, compared with 3.9 hours by ambulance ( P =0.56). The average estimated cost of transportation was $28.23 by private vehicle, compared with $647.83 by ambulance ( P =0.0001). On average, it took 16.1 hours after injury to undergo surgery and 25.7 hours to be discharged from the hospital, without a significant difference in either of these times between groups. There were no preoperative or postoperative neurovascular deficits. CONCLUSION: Patients with isolated Gartland type II supracondylar humerus fractures that are transferred emergently via ambulance are subjected to a significantly greater financial burden with no demonstrable improvement in the quality of their care, since prior research has shown these injuries can safely be treated on an outpatient basis. Potential options to help limit costs could include greater provider education, telemedicine and improved coordination of care. LEVEL OF EVIDENCE: Level III (retrospective comparative study).

Baseline patient reported outcome measurement information system (PROMIS) scores in children with idiopathic scoliosis and their relation to the SRS-22.

PURPOSE: PROMIS is becoming the most commonly utilized patient-reported outcome measure (PROM) in adult orthopaedics, but its adoption has lagged in pediatrics. Limited baseline data exists in pediatric-specific orthopaedic diagnoses. The objective of this study was to determine baseline PROMIS scores in patients with idiopathic scoliosis and to evaluate for correlations with the SRS-22. METHODS: This was a retrospective analysis of prospectively collected data from six tertiary care pediatric hospitals between July 2016 and July 2018. Patients with a diagnosis of idiopathic scoliosis, adequate radiographs for measurement and completion of PROMIS and SRS-22 questionnaires from the same visit were included. Only the first visit during the study period was included for each subject. Post-operative patients were excluded. Spearman correlations were performed between four PROMIS domains (Pain interference [PI], Mobility [M], Peer Relationships [PR] and Upper Extremity [UE]) and SRS-22 domains. PROMIS scores are calibrated such that 50 is the median value in a population and 10 points is equivalent to one standard deviation. RESULTS: 986 patients with a mean age of 14.6 years were included, 79.8% of which were female. The mean major curve was 33.0° (range: 10-102). The major curve was thoracic in 56.5%, thoracolumbar in 24.4% and lumbar in 19.1% of subjects. The mean PROMIS domain scores were: Pain Interference 44.5 (IQR 17.7); Mobility 52.7 (IQR 12.5); Peer Relationships 55.7 (IQR 15.0); Upper Extremity 53.4 (IQR 7.7). Correlations existed between PROMIS Pain Interference and SRS-22 pain (r = 0.704, p < 0.001) and PROMIS Mobility and SRS-22 function (r = 0.53, p < 0.001). Significant ceiling effects existed in SRS-22 Function (29.9%), Pain (19.2%) and Satisfaction (30.3%) but only for PROMIS Peer Relationships (42.1%). CONCLUSIONS: PROMIS domain scores for patients with AIS are within normal population limits. PROMIS correlates well with SRS-22 in overlapping domains, and fewer domains demonstrate a ceiling effect. There was no relationship between the magnitude of scoliosis and PROMIS domain scores. LEVEL OF EVIDENCE: II.

Assessment of Lateral Rotation Percentage and Rotational Deformity of the Elbow in Type 3 Supracondylar Humerus Fractures: A Biomechanical Study.

BACKGROUND: Supracondylar humerus (SCH) fractures are the most common elbow fractures in children. Historically, displaced (Gartland type 3) SCH fractures have been treated with closed reduction and percutaneous pinning. Fluoroscopic imaging is used intraoperatively in order to assess adequate reduction of the fracture fragments before pinning. On lateral fluoroscopic and radiographic images, a lateral rotation percentage (LRP) can be estimated in order to assess rotational deformity. The purpose of this study was to determine the true rotational deformity of distal humerus fracture fragments in SCH fractures based upon the LRP using a clinically relevant laterally based pinning technique. METHODS: In this study, a sawbones model was used to examine the correlation between calculated LRP and the true degree of rotational deformity with 3 of the most common extension-type SCH fracture types (low transverse, high transverse, and lateral oblique). Because fracture stability was not the focus of this study, a single pin was used to hold the construct and allow for fragment rotation along a fixed axis. In this study, 2 of the authors independently measured rotational deformity and compared this with LRP on fluoroscopic lateral imaging of a sawbones model at 0 to 45 degrees of rotational deformity. RESULTS: The LRP of all 3 patterns demonstrated a near linear increase from 0 to 45 degrees with maximum LRP measured at 45 degrees for each of the 3 patterns. Univariate linear regression demonstrated an increase in LRP for the low transverse pattern of 2.02% for every degree of rotation deformity (R2=0.97), 2.29% for the lateral oblique pattern (R2=0.986), and 1.17% for the high transverse pattern (R2=0.971). Maximum LRP was measured at 45 degrees for all 3 patterns with a mean of 53.5% for the high transverse pattern, 93.5% for the low transverse pattern, and 111.2% for the lateral oblique pattern. A higher LRP was measured with increasing degrees of rotational displacement in the low transverse and lateral oblique patterns for all degrees of rotational deformity compared to the high transverse pattern. CONCLUSION: There is a near linear correlation between the degree of malrotation and the LRP with more superior metaphyseal fracture patterns demonstrating a lower LRP than inferior fracture patterns. CLINICAL RELEVANCE: Using our data one can estimate the degree of malrotation based on the LRP on radiographs in the clinical setting. LEVEL OF EVIDENCE: Not applicable (basic-science article).

Preoperative supine traction radiographs often result in higher Lenke classifications than supine bending radiographs in adolescent idiopathic scoliosis.

STUDY DESIGN: Retrospective chart and radiographic review. OBJECTIVE: The purpose of this study is to determine if both traction and side-bending radiographs yield the same Lenke classification. Supine side-bending radiographs are used to evaluate curve flexibility and assign Lenke classification in Adolescent Idiopathic Scoliosis (AIS). Supine traction radiographs are another tool used by treating surgeons to gauge flexibility and appropriate levels for spinal fusion in AIS. METHODS: Retrospective chart and radiographic review were performed on AIS patients that underwent a posterior spinal fusion from 2008 to 2017. Cobb angles and Lenke classifications were determined on all upright posterioanterior (PA) spine radiographs, supine traction radiographs, and four supine bending radiographs. Statistical analysis using independent t tests and chi-square tests as appropriate were compared between patients with or without discordant Lenke classifications with p value set at < 0.05 for statistical significance. RESULTS: 184 patients met inclusion criteria, 36 males and 148 females. The average Cobb angle for the proximal thoracic (PT) curve was 27.2°, main thoracic (MT) curve was 60.5°, and thoracolumbar/lumbar (TL/L) curve was 48.0°. Significantly less curve correction was found with supine traction radiographs compared with bending radiographs: PT (23.1° vs 18.9°, p < 0.001), MT (38.9° vs 37.9°, p = 0.015), and TL/L (25.9° vs. 18.0°, p < 0.001). Lenke Classification was found concordant in 151/184 (82.1%). Traction views in the discordant Lenke classification group demonstrated less curve correction than those in the concordant group: PT (27.4° vs. 22.1°, p = 0.011), MT (45.3° vs. 37.5°, p < 0.001), and TL/L (29.3° vs 25.1°, p = 0.019). CONCLUSION: Supine traction and supine bending radiographs provided a concordant Lenke classification 82.1% of the time. However, supine traction radiographs demonstrate less curve correction, a higher Lenke classification, and underestimated the TL/L curve correction to a greater degree. A single supine traction film is not an adequate substitute to side-bending radiographs when determining Lenke classification in patients with Adolescent Idiopathic Scoliosis. LEVEL OF EVIDENCE: III.

Pediatric Orthopaedists Are Not Immune: Characterizing Self-reported Burnout Rates Among POSNA Members.

BACKGROUND: There are no published data characterizing burnout rates for pediatric orthopaedic surgeons. The primary purpose of this study was to identify the rates of self-reported personal and team burnout among members of the Pediatric Orthopaedic Society of North America (POSNA). A secondary aim was to determine whether specific demographic variables were more likely to be associated with self-reported burnout. METHODS: During its 2018 annual meeting, the POSNA Wellness Taskforce launched a web-based survey in which members were asked to respond to 2 previously validated questions related to personal and team burnout. The survey was distributed by a closed POSNA membership e-mail list and responses were analyzed anonymously. Descriptive statistics were calculated. Pearson χ testing was used to analyze differences in burnout rates as a function of age and sex. RESULTS: A total of 615 POSNA members completed the survey, a 47% response rate. Overall, 38% reported personal burnout and 46% reported team burnout. Women were more likely to report both personal (P<0.001) and team burnouts (P<0.005). Members aged 40 to 59 years were more likely to report personal burnout, irrespective of sex (P<0.001). Members aged 50 to 59 years were more likely than those in other age groups to report team burnout (P<0.001). There was no significant association found between the presence of burnout and either race, ethnicity, LGBTQ status, or educational background. CONCLUSIONS: As a group, pediatric orthopaedists report moderately high rates of both personal and team member burnout. Individual-specific factors such as age and sex may play an important role in determining one's risk for experiencing burnout. Recognizing that burnout affects a significant minority of POSNA members is a crucial first step. LEVEL OF EVIDENCE: Level III.

Wellness and Drivers of Burnout.

INTRODUCTION: Promoting physician wellness in the current environment of increasing burnout presents a great challenge to the Pediatric Orthopaedic Society and its members. Pediatric Orthopaedic Society of North America (POSNA) has been a leader in recognizing this problem and organizing to combat it. The increasing rates of job dissatisfaction, burnout, depression, and suicide demand comprehensive and focused action to identify and address the drivers of burnout. Continuing to ignore this problem endangers our organization, our members, our families, and our patients. METHODS: A review of relevant literature and the work of the POSNA wellness committee was completed. RESULTS: Addressing the epidemic of burnout requires a sustained effort to address intrinsic factors such as health, performance, and resilience as well as external factors that affect practice efficiency and environment. DISCUSSION AND CONCLUSIONS: The goal of this effort is restoration of joy to the practitioners in medicine and more compassionate care for the patients who seek it.

Brace Yourselves: Outcomes of Ponseti Casting and Foot Abduction Orthosis Bracing in Idiopathic Congenital Talipes Equinovarus.

BACKGROUND: Foot abduction orthoses (FAO) are believed to decrease recurrence following treatment of congenital talipes equinovarus (CTEV) as described by Ponseti. The purpose of this project is to examine the outcomes of FAO bracing following treatment by the Ponseti method in a cohort of idiopathic CTEV patients. METHODS: After IRB approval, a cohort of patients aged 3 to 46 days with idiopathic CTEV was identified in a previous prospective study of brace compliance by family report and sensor. Dimeglio score and family demographic information were collected. Initial treatment was by the Ponseti method, with or without Achilles tenotomy. Following correction, patients had three months of full-time FAO bracing during which parents kept a log of compliance. Patients were followed until recurrence (need for further treatment) or age 5. RESULTS: In total, 42 patients with 64 affected feet met the above criteria and were included in the final analysis. Twenty-six feet (40%) went on to develop recurrence requiring further treatment, including casting, bracing, or surgery. Because of poor tolerance of the original FAO, 20 feet were transitioned to an alternative FAO, and 14 of these (70%) went on to recur (P<0.01). The casting duration (P=0.02) had a statistically significant relationship to recurrence. Patients who were casted for 9 weeks or more had a higher rate of recurrence (57.1% vs. 27.8%; P=0.02). Age at treatment start, Dimeglio score, demographic factors, and compliance during full-time bracing, whether by report or sensor, did not show a significant relationship with recurrence. CONCLUSIONS: The study showed a statistically significant relationship between the difficulty of CTEV correction and the risk of recurrent deformity requiring treatment. This relationship could be used to provide prognostic information for patients' families. Caregiver-reported compliance was not significantly related to recurrence. LEVEL OF EVIDENCE: Level III-Prognostic Retrospective Cohort Study.

Is It Growth or Natural History? Increasing Spinal Deformity After Sanders Stage 7 in Females With AIS.

BACKGROUND: Accurate prognosis and treatment decisions in adolescent idiopathic scoliosis (AIS) demand a reliable radiographic marker of growth cessation. Specifically, Sanders Stage 7 (SS7) is a useful marker of spine growth cessation in females and is proposed as a bracing endpoint. The purpose of this study was to determine the amount of curve progression noted in female individuals with AIS after achieving SS7. We hypothesize that a subset of patients continues to progress at a greater rate than the natural history at SS7. METHODS: This retrospective review included female patients with AIS treated at a single institution from May 2008 to 2018. Patients required a hand radiograph demonstrating SS7 and concurrent spine radiograph measuring <50 degrees, plus 2-year follow-up spine radiograph. Curve types were categorized by the modified Lenke Classification. Risser grade, menarche, height, weight, and bracing data were collected. Progression was defined as an increase of the main curve ≥5 degrees. Comparison between groups was analyzed using independent t tests and χ or Fisher exact tests as appropriate. Binary logistic regressions were used to construct a model predictive of progressing beyond 50 degrees or undergoing surgery. RESULTS: A total of 89 patients met inclusion criteria, average main curve magnitude 33 degrees (SD 9) at SS7 and 38 degrees (SD 11) at 2-year follow-up. Forty-five (51%) patients progressed ≥5 degrees and 17 (19%) progressed at least 10 degrees. Seventy patients had curves <40 degrees at SS7 and 22 (31%) progressed to >40 degrees at 2 years. Eleven (12%) patients progressed to >50 degrees or had surgery at 2-year follow-up. Receiver operating characteristic curve analysis identified a threshold of 39.5 degrees curvature at SS7 associated with progression to >50 degrees or surgery (area under the curve=0.94, P<0.001, sensitivity=100%, specificity=87%). Patients with initial curves >40 degrees did have additional height gained (2.1 cm; SD 1.5), but this was not different than those <40 degrees, P>0.05. In addition, no other variables had statistically significant association with those that progressed (P>0.05). CONCLUSIONS: A curve >40 degrees at SS7 is at high risk for progressing to a curve measuring >50 degrees or requiring surgery. Those with curves below this threshold still have potential to make clinically significant progression after skeletal maturity. Follow-up of patients beyond SS7 is essential for curves measuring >40 degrees. Reaching SS7 with a curve <50 degrees may not be the endpoint for curve progression, even if predictive of the end of spinal growth. LEVEL OF EVIDENCE: Level III-retrospective research study.

Idiopathic Genu Valgum and Its Association With Obesity in Children and Adolescents.

BACKGROUND: Obesity as a cause of lower extremity deformity in children has been well established. This deformity is most often seen as tibia vara, however, at our institution we have observed more obese children and adolescents over age 7 years with excessive or progressive idiopathic genu valgum. Our hypothesis is that children with idiopathic genu valgum have high rates of obesity which impact the severity of their disease. METHODS: Retrospective review of existing data was performed on 66 consecutive children/112 limbs over age 7 years with idiopathic genu valgum, seen from 2010 to 2013. Children with known metabolic or skeletal disease were excluded. Genu valgum was defined as mechanical axis in zone II or III and mechanical tibiofemoral angle ≥4 degrees on standing anteroposterior radiograph of the lower extremities. Body mass index (BMI) was calculated and classified by Center for Disease Control percentiles. Skeletal maturation was rated by closure of pelvic and peri-genu physes. Severity of genu valgum was also assessed by femoral and tibial mechanical axes and the mechanical axis deviation. RESULTS: Mean patient age was 12.2±2.2 years. 47% of patients had BMI≥30 and 71% were categorized as obese (>95th percentile). No sex differences were identified. Skeletal maturation explained 25% of the variance in the mechanical axis deviation and 22% of the mechanical tibiofemoral angle. BMI predicted 9.8% of the tibial valgus. Because of its skewed distribution, BMI percentile was a less useful parameter for assessment. CONCLUSIONS: The 71% obesity rate found in our children with idiopathic genu valgum is significantly higher than the normal population. Higher BMI is associated with more tibial valgum but skeletal maturation was the main predictor of overall valgus severity. This suggests that obesity may play a role in the etiology of idiopathic genu valgum which progresses with skeletal maturation, thereby increasing the risk of osteoarthritis in adulthood. LEVEL OF EVIDENCE: Level III.

Hamstring lengthening in females with cerebral palsy have greater effect than in males.

Children with spastic diplegia cerebral palsy often demonstrate crouched gait patterns, and typically undergo hamstring lengthenings. The objective of this retrospective study was to determine if the surgical response to medial and lateral hamstring lengthenings is different between males and females. Preoperative and postoperative kinematic data of 109 (71 males and 38 females) patients with cerebral palsy were evaluated. Females demonstrated larger decreases in popliteal angle, larger decreases in mid-stance knee flexion, and higher incidences of knee hyperextension postoperatively. Results indicate that females have larger responses to hamstring lengthenings than males.

The Pediatric Orthopaedic Society of North America (POSNA) Adopts a Member Health and Wellness Charter.

The Pediatric Orthopaedic Society of North America took actions to address the well-being of its members. The epidemic of physician burnout interferes with the delivery of high-quality care that our patients and families need and deserve, and at the same time places the care-providers at an increased risk of depression and suicide. The actions taken by Pediatric Orthopaedic Society of North America serve as a model for other professional medical societies to emulate.

Effect of Amputation Level on Quality of Life and Subjective Function in Children.

BACKGROUND: Our aim was to discern whether children with amputations have differences in subjective function based on amputation level. We hypothesized that children with more proximal amputations would report poorer function and quality of life. METHODS: An IRB-approved, retrospective chart review of patients aged 0 to 21 years old with lower extremity amputations was performed. Demographic information, type of amputation, type of prosthesis, and the Pediatric Outcomes Data Collection Instrument (PODCI) was collected from parents and children (above 10 y old). Patients were divided into 4 groups based on the level of amputation (ankle; transtibial; knee; transfemoral), and PODCI scores were compared between groups. PODCI subscores were also compared between unilateral versus bilateral amputations, high-demand versus low-demand prostheses, and congenital versus acquired amputations. RESULTS: We identified 96 patients for analysis (39 ankle, 21 transtibial, 27 knee, and 9 transfemoral amputations). The sports/physical functioning subscale of the PODCI showed the only statistically significant difference between amputation level and outcome with ankle-level amputations reporting higher scores than knee-level amputations (parent: 78.3±16.4 vs. 60.0±25.3, P=0.006; child: 87.4±15.3 vs. 65.4±31.5, P=0.03). Although not significantly different from either the ankle, knee, or transfemoral groups, patients with transtibial amputations reported intermediate scores (parent: 68.5±27.5; child: 78.9±25.5). There were no significant differences among amputation level for PODCI transfers, pain/comfort, global function, or happiness subscales. In subgroup analysis, same-level congenital amputees had similar scores to acquired amputees (P>0.05). When compared with unilateral knee amputations patients, patients with bilateral knee amputations had significantly worse transfer (62.4 vs. 88.3; P=0.02), sports/physical functioning (34.2 vs. 66.2; P=0.01), and global domains (58.4 vs. 80.5; P=0.02). CONCLUSIONS: Subjective sports and physical functioning of pediatric amputees were significantly worse after knee amputation when compared with ankle-level amputations. Although not statistically significant at all levels, our data suggest a graded decline in sports/physical functioning with higher level amputations. Amputation level did not affect pain, happiness, or basic mobility. LEVEL OF EVIDENCE: Level III.

Classification of Cruciate Ligament Dysplasia and the Severity of Congenital Fibular Deficiency.

BACKGROUND: Dysplasia of the cruciate ligaments has been found in many patients with congenital fibular deficiency. A recent classification system has shown that radiographic tibial spine changes can predict the hypoplasia and aplasia of the cruciate ligaments. We used this radiographic classification to determine the frequency of these abnormalities and how they correlate with the severity of fibular deficiency and lateral femoral condylar hypoplasia. METHODS: Using a hospital database search for fibular deficiency, 99 patients ≥6 years with unilateral fibular deficiency were identified. Existing radiographs of both knees were available for 75 patients and reviewed for the tibial spine changes and Achterman and Kalamchi classification of the fibular deficiency. Measurements of femoral condyle heights in 74 of 75 patients were recorded before any surgery to the distal femoral physis to assess lateral femoral condylar hypoplasia. RESULTS: Twenty-two patients had hypoplasia of the lateral tibial spine+normal medial spine, 29 had absence of the lateral tibial spine+hypoplastic medial spine, and 11 had absence of both tibial spines. Five tibial spines were normal and 8 were unclassifiable. The severity of the tibial spine dysplasia, particularly absence of the lateral tibial spine, correlated with the severity of the fibular deficiency. (P<0.0001) The mean lateral femoral condylar hypoplasia, measured by involved: uninvolved lateral condyle heights, was 0.85±0.11. Those with some preservation of the lateral tibial spine had less lateral femoral condylar hypoplasia (P=0.0009). This lateral femoral condylar hypoplasia was positively associated with the severity of the fibular absence (P=0.039) and foot ray deficiency (P=0.036). CONCLUSIONS: The severity of cruciate ligament dysplasia in fibular deficiency is directly correlated with the severity of fibular absence, lateral femoral condylar hypoplasia, and the absence of foot rays. This suggests that the embryological factors involved have a complex interplay for all of these clinical findings. LEVEL OF EVIDENCE: Level III.

Foot size asymmetry following Ponseti treatment versus comprehensive surgical releases for unilateral clubfeet.

Using age and height matched cohorts with unilateral idiopathic clubfeet (n=40 each), we retrospectively reviewed pedobarographic studies to determine the impact of treatment, Ponseti versus comprehensive surgical releases (CSR), on the foot length, width, and contact area. The foot pressures were determined by self-selected walking across a force plate. Ponseti treatment results in more symmetrical foot lengths, widths, and total contact areas with an improvement of 1.3 shoe sizes difference compared with treatment with CSR. This suggests that there is improved growth in the clubfoot in those treated with Ponseti management compared with those treated with CSR.

Oral Sucrose for Pain Relief During Clubfoot Casting: A Double-Blinded Randomized Controlled Trial.

BACKGROUND: Idiopathic clubfoot treatment is treated by manipulation and casting utilizing the Ponseti technique which can make the infant fussy and irritable. The goal of this study was to determine which intervention could decrease this pain response in infants undergoing Ponseti casting for idiopathic clubfeet. Our hypothesis was that the administration of oral sucrose solution or milk would be the most effective in accomplishing that goal. METHODS: We conducted a double-blinded randomized controlled trial at a tertiary pediatric orthopaedic center on 33 children (average age=17.94 d; SD=20.51 d) undergoing clubfoot manipulation and casting and their guardians. Each cast was considered a new event and was randomized to an oral 20% sucrose solution (S), water (W), or milk (M) in a bottle (breast or nonbreast). We assessed the Neonatal Infant Pain Scale (NIPS), heart rate, and oxygen saturation before, during, and after the casting. RESULTS: A total of 131 casts were randomized and 118 analyzed (37 M, 42 S, 39 W). Each child underwent an average of 3.97 casts (SD=1.74). There were no significant differences seen between the groups before casting in their mean NIPS score (M=2.2; SD=2.38, S=1.84, SD=2.18, W=1.61, SD=2.12). However during casting, mean NIPS score for both milk, 0.91 (SD=1.26, P=0.0005) and sucrose, 0.64 (SD=1.27, P<0.0001) were significantly less than water, 2.27 (SD=2.03) but not different from each other (P=0.33). Postcasting, the sucrose NIPS score, 0.69 (SD=1.53) continued to be significantly less than milk, 2.11 (SD=2.37, P=0.0065. There was no correlation between heart rate or oxygen saturation and NIPS. CONCLUSIONS: Sucrose solution and milk during Ponseti casting and manipulation were effective in decreasing the pain response in children undergoing manipulation and casting for clubfeet. The sucrose solution administration continued the pain relief into the postcasting period. In addition to the benefits of improving the patient experience during casting, a less irritable child may result in better casting. LEVEL OF EVIDENCE: Level 1 evidence.

Pain and overcorrection in clubfeet treated by Ponseti method.

Long-term outcomes of Ponseti casting have consistently shown improvement over soft-tissue release. The incidence of foot pain and overcorrection in clubfeet treated by Ponseti method has not been reported. We studied the rate of overcorrection and its association with pain in clubfeet treated with Ponseti casting. A retrospective review of clubfoot patients treated with Ponseti method with at least 8 years of follow-up was carried out. Patient charts were reviewed for demographic data, recurrence, type and number of procedures, and patient-reported complaints of foot pain. Pedobarographs were used to document overcorrection. Eighty-one patients comprising 115 clubfeet were included in the study. There were 14 (12.2%) feet with valgus overcorrection and 101 feet that had achieved a normal, plantigrade position. Overall, 50% of patients with overcorrected clubfeet and 32% with corrected, plantigrade clubfeet experienced pain. Overcorrection was found to be predictive of pain complaints (P<0.001). Hence, valgus overcorrection occurs after Ponseti casting, with an incidence of 12%.

Design and descriptive data of the randomized Clubfoot Foot Abduction Brace Length of Treatment Study (FAB24).

The aim of this study was to describe the design and baseline characteristics of participants enrolled in the prospective randomized-controlled Clubfoot Foot Abduction Brace Length of Treatment Study (FAB24). Foot abduction bracing is currently the standard of care for preventing clubfoot relapse. Current recommendations include full-time bracing for the first 3 months and then 8-12 h a day for 4 years; however, the optimal length of bracing is not known. The FAB24 trial is a clinical randomized study to determine the effectiveness of 2- versus 4-year foot abduction bracing. Participant enrollment for FAB24 was conducted at eight sites in North America and included enrollment and randomization of 139 participants with isolated clubfoot. This clinical trial will generate evidence-based data that will inform and improve patient care.

Three Methods Of Guided Growth For Pediatric Lower Extremity Angular Deformity Correction.

BACKGROUND: Different methods of guided growth are used for correction of angular deformity in growing children. The differences between these different methods are not well described in the literature. METHODS: A retrospective review was undertaken comparing the effectiveness and complication rates of titanium staples, titanium eight-plates, and the stainless steel Pedi-plate at a tertiary pediatric hospital after IRB approval. RESULTS: 77 patients were included in the analysis. Average follow up was 18 months after implantation (range 7-22). Stainless steel implants showed significantly lower complication rate compared to the other groups with significantly faster rate of deformity correction when compared to titanium staples. CONCLUSION: Our data can be used to guide implant choices for guided growth.