The Effect of Socioeconomic Deprivation on Radiographic Deformities in Children With Blount Disease.

BACKGROUND: Blount disease can occur at any time during the growth process, primarily with a bimodal distribution in children younger than 4 years old and adolescents. The disease process most commonly presents in Black adolescents, with disease severity positively correlated with obesity. Given the known associations among race, obesity, and socioeconomic status, we investigated the relationship between the degree of social deprivation and severity of lower extremity deformities among a community-based cohort with Blount disease. METHODS: A retrospective review of hospital records and radiographs of patients with previously untreated Blount disease was conducted. Patients were classified as having early-onset or late-onset Blount disease based on whether the lower limb deformity was noted before or after the age of 4 years. The area deprivation index (ADI), a nationally validated measure that assesses socioeconomic deprivation by residential neighborhood, was calculated for each patient as a surrogate for socioeconomic status. Higher state (range: 1 to 10) or national (range: 1 to 100) ADI corresponds to increased social deprivation. Full-length standing radiographs from index clinic visits were evaluated by 2 reviewers to measure frontal plane deformity. The association of ADI with various demographic and radiographic parameters was then analyzed. RESULTS: Of the 65 patients with Blount disease, 48 (74%) children were Black and 17 (26%) were non-black children. Nineteen children (32 limbs) had early-onset and 46 children (62 limbs) had late-onset disease. Black patients had significantly higher mean state (7.6 vs. 5.4, P =0.009) and national (55.1 vs. 37.4, P =0.002) ADI values than non-black patients. Patients with severe socioeconomic deprivation had significantly greater mechanical axis deviation (66 mm vs. 51 mm, P =0.008). After controlling demographic and socioeconomic factors, the results of multivariate linear regression showed that only increased body mass index (ß=0.19, 95% CI: 0.12-0.26, P <.001) and state ADI (ß=0.021, 95% CI: 0.01-0.53, P =.043) were independently associated with greater varus deformity. CONCLUSIONS: Socioeconomic deprivation was strongly associated with increased severity of varus deformity in children with late-onset Blount disease. Our analysis suggests that obesity and socioeconomic factors are the most influential with regard to disease progression. LEVEL OF EVIDENCE: Level III.

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.

Tenosynovial Giant Cell Tumor Mimicking Acute Septic Arthritis of the Hip: A Case Report.

A 12-year-old boy presented to the pediatric emergency department with a 5-day history of atraumatic, progressively worsening right hip pain and inability to ambulate. He was afebrile and had elevated inflammatory markers (Erythrocyte Sedimentation Rate [ESR]: 42 mm/hr, C-Reactive Protein [CRP]: 6.6 mg/dL) with a normal white blood cell count of 6050 cells/mm3. Given the clinical concern for septic arthritis, joint aspiration of the right hip was done and demonstrated a bloody appearance with a WBC count of 54,999 cells/mm3 and RBC count of 7,000 cells/mm3. MRI of the right hip demonstrated an intra-articular mass suggestive of tenosynovial giant cell tumor/pigmented villonodular synovitis. Subsequent biopsy and excision of the mass confirmed the diagnosis. The acute presentation of tenosynovial giant cell tumor with features mimicking septic arthritis is uncommon. This rare presentation of an already uncommon diagnosis should be considered in a child with an equivocal presentation for severe hip pain because misdiagnosis may lead to unnecessary or inadequately planned surgical treatment of the condition.

Lower-Extremity Segment-Length Prediction Accuracy of the Sanders Multiplier, Paley Multiplier, and White-Menelaus Formula.

BACKGROUND: Several methods are available to estimate leg lengths at maturity to facilitate the determination of timing of epiphysiodesis. We compared the Paley multiplier, Sanders multiplier, and White-Menelaus methods in an epiphysiodesis-aged cohort. We assessed intra- and interrater reliability for Sanders skeletal stages and Greulich and Pyle atlas skeletal age. METHODS: Actual growth was recorded in healthy, unoperated femoral and tibial segments from an epiphysiodesis database. The predicted and actual lengths were compared with use of the Paley multiplier and White-Menelaus methods, Greulich and Pyle skeletal age, and the Sanders multiplier using Sanders stages. Intra- and interrater reliability were assessed in a separate group of 76 skeletal age films. RESULTS: The cohort included 148 femora and 195 tibiae in 197 patients. Femoral length at maturity was slightly underestimated by the Sanders multiplier and staging, was overestimated by the Paley multiplier and skeletal age, and was most accurately predicted with use of the White-Menelaus formula and skeletal age. All methods overestimated tibial length at maturity. The whole-leg prediction accuracy of the Sanders multiplier and White-Menelaus formula were comparable and were more accurate than that of the Paley multiplier. For Sanders skeletal staging, the interrater reliability varied from 0.86 to 0.88 and the intrarater reliability varied from 0.87 to 0.96. For Greulich and Pyle skeletal age, the interrater reliability varied from 0.87 to 0.89 and the intrarater reliability varied from 0.91 to 0.95. CONCLUSIONS: Use of the Sanders multiplier and skeletal stages was more accurate than the Paley multiplier and skeletal age in this cohort. Use of the White-Menelaus formula and skeletal age was slightly more accurate in predicting femoral length and slightly less accurate in predicting tibial length compared with the Sanders multiplier. Intra- and interrater reliability were similar between Sanders skeletal stages and Greulich and Pyle atlas skeletal age. The White-Menelaus formula and skeletal age was the recommended method for predicting lower-extremity segment lengths at maturity and epiphysiodesis effect. Although easier to recall without referencing an atlas and not sex-specific, Sanders skeletal staging does not correspond directly to years of growth remaining, and thus cannot be used with the White-Menelaus formula. CLINICAL RELEVANCE: The Greulich and Pyle atlas to determine skeletal age and the White-Menelaus formula to determine growth remaining are reliable predictors of epiphysiodesis effect in the lower extremities.

The direct anterior approach for acetabular augmentation in primary total hip arthroplasty.

Addressing acetabular bone defects can be difficult and depends on the amount of bone loss. Augments, either with bone or highly porous metals, are options that still allow the use of a hemispherical cup. Almost all previous research and publication on acetabular augments have focused on revision hip arthroplasty utilizing either a modified lateral or a posterolateral surgical approach. We describe 3 cases of augmenting acetabular bone defects through a direct anterior approach for primary total hip arthroplasty. We achieved proper cup placement, alignment, and augment incorporation while reconstructing complex acetabular deficiencies. All patients had complete pain relief and a satisfactory clinical outcome with stable radiographs at follow-up. With appropriate training, acetabular augmentation can be performed safely and efficiently with excellent clinical results through this approach.

Complications Associated with Intra-Articular and Extra-Articular Corticosteroid Injections.

Side effects of corticosteroids can occur in association with both intra-articular and extra-articular injections. Less-severe reactions include skin reactions and flare responses. Although rare, worrisome complications such as infections, tendon ruptures, and osteonecrosis can occur. It is important to note the effect of corticosteroids on blood glucose levels, particularly for patients with diabetes. Corticosteroid injections have visual side effects with a known relation to central serous chorioretinopathy.

A focus on blood glucose monitoring: relation to glycemic control and determinants of frequency.

OBJECTIVE: To re-examine the relation of blood glucose monitoring to glycemic control among adolescents with type 1 diabetes and to evaluate the relation of demographic, behavioral, and psychosocial characteristics of adolescents who monitor more and less frequently. RESEARCH DESIGN AND METHODS: Participants were 132 adolescents with type 1 diabetes (average age = 12 yr) and their parents, recruited from Children's Hospital of Pittsburgh. Adolescents were interviewed annually for five consecutive years after routine clinic appointments. At each assessment, data from blood glucose meters were downloaded and glycosylated hemoglobin A1c was recorded from medical records. RESULTS: More frequent blood glucose monitoring was related to better glycemic control. Adolescents who monitored more frequently were younger, from higher social status families, on insulin pumps, and had higher self-efficacy. Age-related declines in blood glucose monitoring occurred among adolescents with low self-esteem, high stressful life events, and lower parental support. CONCLUSIONS: Given the importance of blood glucose monitoring for good glycemic control, future research should enhance adolescents' self-efficacy for monitoring and intervene with those who are at risk for age-related declines in blood glucose monitoring.