Incidence of Nerve Palsies During Pavlik Harness Treatment for Developmental Dysplasia of the Hip: A Retrospective Cohort Study.

BACKGROUND: The Pavlik harness has been used for approximately a century to treat developmental dysplasia of the hip (DDH). Femoral nerve palsy is a documented complication of Pavlik harness use, with an incidence ranging from 2.5% to 11.2%. Rare reports of brachial plexus palsy have also been documented. The primary purpose of the current study was to evaluate the incidence of various nerve palsies in patients undergoing Pavlik harness treatment for DDH. Secondary aims were to identify patient demographic or hip characteristics associated with nerve palsy. METHODS: We performed a retrospective review of patients diagnosed with DDH and treated with a Pavlik harness from February 1, 2016, to April 1, 2023, at a single tertiary care orthopaedic hospital. Hip laterality, use of a subsequent rigid abduction orthosis, birth order, breech positioning, weight, and family history were collected. The median (and interquartile range [IQR]) or mean (and standard deviation [SD]) were reported for all continuous variables. Independent 2-sample t tests and Mann-Whitney U tests were conducted to identify associations between the variables collected at the initiation of Pavlik harness treatment and the occurrence of nerve palsy. RESULTS: Three hundred and fifty-one patients (547 hips) were included. Twenty-two cases of femoral nerve palsy (4% of all treated hips), 1 case of inferior gluteal nerve palsy (0.18%), and 2 cases of brachial plexus palsy (0.37%) were diagnosed. Patients with nerve palsy had more severe DDH as measured by the Graf classification (p < 0.001) and more severe DDH as measured on physical examination via the Barlow and Ortolani maneuvers (p = 0.003). CONCLUSIONS: Nerve palsies were associated with more severe DDH at the initiation of Pavlik harness use. Upper and lower-extremity neurological status should be scrutinized at initiation and throughout treatment to assess for nerve palsies. The potential for femoral, gluteal, and brachial plexus palsies should be included in the discussion of risks at the beginning of treatment. Families may be reassured that nerve palsies associated with Pavlik harness can be expected to resolve with a short break from treatment. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Flatfoot Reconstruction for Painful Pediatric Idiopathic Flexible Flatfoot: Prospective Study Demonstrates Improved Alignment, Function, and Patient-reported Outcomes.

BACKGROUND: This prospective study was undertaken to report outcomes following reconstructive surgery for patients with painful pediatric idiopathic flexible flatfoot. METHODS: Twenty-five patients with pediatric idiopathic flexible flatfoot were evaluated pre- and post flatfoot reconstruction with lateral column lengthening (LCL). All patients had lengthening of the Achilles or gastrocnemius, while 13 patients had medial side soft tissue (MSST) procedures, 7 underwent medial cuneiform plantarflexion osteotomy (MCPO), and 5 had medializing calcaneal osteotomy. Measures of static foot alignment-both radiographic parameters and clinical arch height indices-were compared, as were measures of dynamic foot alignment and loading, including arch height flexibility and pedobarography. Preoperative and postoperative patient-reported outcome (PRO) scores were compared between those treated with or without MSST procedures. RESULTS: The median subject age was 13.8 years (range: 10.3 to 16.5) at the time of surgery. All radiographic parameters improved with surgery ( P <0.001). The mean sitting arch height index showed a modest increase after surgery ( P =0.023). Arch height flexibility was similar after surgery. The mean center-of-pressure excursion index increased from 14.1% to 24.0% ( P <0.001), and the mean first metatarsal head (MH) peak pressure dropped ( P <0.001), while the mean fifth MH peak pressure increased ( P =0.018). The ratio of peak pressure in the fifth MH to peak pressure in the second MH increased ( P =0.010). The ratio of peak pressure in the first MH to peak pressure in the second MH decreased when an MCPO was not used ( P <0.002), but it remained stable when an MCPO was included. Mean scores in all PRO domains improved ( P <0.001). Patients treated without MSST procedures showed no difference in PROMIS Pain Interference scores compared to those without MSST procedures. CONCLUSIONS: Flatfoot reconstruction surgery using an LCL with plantarflexor lengthening results in improved PROs. LCL changes but does not normalize the distribution of MH pressure loading. The addition of an MCPO can prevent a significant reduction in load-sharing by the first MH.

Virtual Reality Distraction Is No Better Than Simple Distraction Techniques for Reducing Pain and Anxiety During Pediatric Orthopaedic Outpatient Procedures: A Randomized Controlled Trial.

BACKGROUND: In-office procedures can be painful and anxiety-provoking for pediatric patients. Minimizing such pain and anxiety in children improves the patient experience and promotes a rewarding and productive patient-caregiver-provider relationship, which may for some young patients be their first memorable encounter with the healthcare system. Although virtual reality (VR) techniques have proven to be helpful in minimizing pain and anxiety during procedures in pediatric intensive care settings, it remains unclear how VR affects objective and subjective measures of pain and anxiety in children undergoing in-office orthopaedic procedures such as cast removal or percutaneous pin removal after fracture healing. QUESTIONS/PURPOSES: Is a VR gaming simulation more effective than either of two forms of noninteractive visual distraction (VR goggles or tablet computer displaying a noninteractive video) for reducing (1) objective measures of pain and anxiety and (2) subjective measures of pain and anxiety in children undergoing in-office cast removal or percutaneous pin removal? METHODS: This study was a randomized controlled trial with two parallel, separately analyzed cohorts: children undergoing in-office cast removal or in-office percutaneous pin removal at a single urban tertiary institution. We approached eligible patients who were scheduled to undergo outpatient cast or percutaneous pin removal and who met prespecified inclusion criteria. We enrolled until 105 patients were available for analysis in each of the cast removal and pin removal cohorts. Of note, the study institution was in an urban epicenter of the coronavirus-19 pandemic, and clinical research was paused sporadically, which resulted in a longer-than-expected enrollment period. In the cast removal cohort, all patients were eligible for inclusion and were enrolled and randomized into one of three groups: VR gaming simulation (n = 37), VR goggles with a noninteractive video (n = 36), or a tablet computer with the same noninteractive video (n = 40). Eleven percent (4), 8% (3), and 3% (1) withdrew from each of the three intervention groups, respectively. In the pin removal cohort, all patients were eligible for inclusion and were enrolled and randomized into the same three groups (37, 44, and 41 patients, respectively). In the pin removal group, 14% (5), 18% (8), and 10% (4) withdrew from each of the three intervention groups, respectively. In all, 235 patients were enrolled in the study and 210 patients (mean ± SD age 9 ± 3 years; 48% [100] girls) were included in the final analyses. There were no clinically important differences in age, gender, preprocedure pain, or anxiety among the intervention groups. Primary outcomes included preprocedure-to-maximum heart rate increase (objective measure) and preprocedure and postprocedure pain and anxiety using a VAS (subjective measures). One-way ANOVA and Bonferroni-adjusted pairwise comparisons were used to calculate between-group differences for the primary outcomes. RESULTS: There were no intervention-level groupwise differences between VR goggles with an interactive game, VR goggles with a noninteractive video, or the tablet computer with the same video in preprocedure-to-maximum heart rate increase in the cast removal cohort (18 ± 21 bpm versus 14 ± 11 bpm versus 20 ± 16 bpm, respectively; largest mean difference -6 bpm [95% CI -16 to 3]; p = 0.36) or pin removal cohort (27 ± 20 bpm versus 23 ± 12 bpm versus 24 ± 19 bpm, respectively; largest mean difference 4 bpm [95% CI -7 to 14]; p = 0.99). Similarly, there were no intervention-level groupwise differences in preprocedure to postprocedure VAS pain in the cast removal cohort (1 ± 1 versus 1 ± 2 versus 0 ± 2, respectively; largest mean difference 0 points [95% CI 0 to 1]; p = 0.89) or pin removal cohort (0 ± 3 versus 2 ± 3 versus 0 ± 3 points, respectively; largest mean difference 1 point [95% CI 0 to 3]; p = 0.13). Finally, there were no intervention-level groupwise differences between the same intervention groups in preprocedure to postprocedure VAS anxiety in the cast removal cohort (-2 ± 2 versus -1 ± 2 versus -1 ± 2 points, respectively; largest mean difference -1 point [95% CI -2 to 1]; p = 0.63) or pin removal cohort (-3 ± 3 versus -4 ± 4 versus -3 ± 3 points, respectively; largest mean difference -1 point [95% CI -2 to 1]; p = 0.99). CONCLUSION: During in-office cast and pin removal in pediatric patients, simple distraction techniques such as tablet video viewing are as effective as higher-fidelity VR headset video and interactive games in minimizing objective measures of procedural pain and subjective measures of pain and anxiety. Because of these findings and because of the associated costs, implementation logistics, and variable tolerance by young patients, widespread use of VR distraction techniques in the pediatric orthopaedic outpatient setting is unnecessary. LEVEL OF EVIDENCE: Level I, therapeutic study.

Back to Basics: Pediatric Casting Techniques, Pearls, and Pitfalls.

Cast application is a critical portion of pediatric orthopaedic surgery training and is being performed by a growing number of non-orthopaedic clinicians including primary care physicians and advanced practice providers (APPs). Given the tremendous remodeling potential of pediatric fractures, correct cast placement often serves as the definitive treatment in this age population as long as alignment is maintained. Proper cast application technique is typically taught through direct supervision from more senior clinicians, with little literature and few resources available for providers to review during the learning process. Given the myriad complications that can result from cast application or removal, including pressure sores and cast saw burns, a thorough review of proper cast technique is warranted. This review and technique guide attempts to illustrate appropriate upper and lower extremity fiberglass cast application (and waterproof casts), including pearls and pitfalls of cast placement. This basic guide may serve as a resource for all orthopaedic and non-orthopaedicproviders, including residents, APPs, and medical students in training. Level of Evidence: IV.

Talocalcaneal Tarsal Coalition Size: Evaluation and Reproducibility of MRI Measurements.

BACKGROUND: The size of talocalcaneal tarsal coalitions (TCCs) is one of the main factors that is thought to influence patient outcomes after resection. Magnetic resonance imaging (MRI) is increasingly being used to diagnose and characterize TCCs. However, there is no reproducible MRI-based measurement of TCC size reported in the literature. The purpose of this study was to create a method to reproducibly measure TCC size using MRI. METHODS: Twenty-seven patients with TCCs diagnosed by a hindfoot coronal proton density (PD) MRI between 2017 and 2020 were included. Five independent raters measured coalition width, healthy posterior facet width, and healthy middle facet width on individual slices of coronal PD hindfoot MRIs using discrete MRI measurement guidelines. Individual slice measurements were summed to determine total size of the coalition and the remaining healthy cartilage of the posterior and middle facets. Inter-rater reliability of MRI measurements between the 5 independent examiners was evaluated using intraclass correlation coefficient (ICC). ICC was calculated for total coalition width, total healthy posterior facet width, total coalition width/total healthy posterior facet width, total coalition width/total healthy middle facet width, total coalition width/total healthy subtalar facet width (posterior facet+middle facet), and total coalition width/total subtalar facet width (coalition+posterior facet+middle facet). RESULTS: The ICC scores for all but one of the MRI measurements indicated good to excellent inter-rater reliability among the 5 examiners. The ICC was 0.932 (95% confidence interval: 0.881-0.966) for measurement of total coalition width/total healthy posterior facet width and 0.948 (95% confidence interval: 0.908-0.973) for measurement of total coalition width/total subtalar facet width (middle+posterior+coalition). CONCLUSIONS: Measurements of coalition size using novel MRI guidelines were reproducible with good to excellent inter-rater reliability. These guidelines allow for determination of TCC size using coronal PD MRI. LEVEL OF EVIDENCE: Level II-diagnostic reproducibility study.

Prone vs Supine Positioning for Femoral Derotation Osteotomy: Kinematic and Physical Examination Outcomes Suggest Both Can Achieve Desired Results.

Background: Femoral derotation osteotomy (FDO) for correction of internal rotation gait resulting from cerebral palsy (CP) can be performed with the patient in the prone or supine position. It is not known whether patient positioning during FDO affects the change in hip rotation. Purpose/Questions: We sought to compare the change in hip rotation following FDO performed on patients with CP in the prone or supine position through kinematic analysis. Methods: We conducted a consecutive retrospective cohort study of children with CP, ages 3 to 18 years and with Gross Motor Function Classification System (GMFCS) levels I to III, who underwent prone or supine FDO and pre- and postoperative motion analysis. The prone group included 37 patients (68 limbs) between 1990 and 1995. The supine group included 26 patients (47 limbs) between 2005 and 2015. The groups were matched for gender, age, and GMFCS level. The primary outcome was hip rotation in degrees during stance phase. Secondary outcomes included temporal-spatial parameters, hip abduction, hip and knee extension, and hip and knee passive range of motion (ROM). Results: The prone group had more bilateral patients (100%) than the supine group (81%). The supine group underwent more concomitant procedures. There was no difference between the prone and supine groups in postoperative stance hip rotation; both groups had significantly improved stance hip rotation, step width, and hip rotation passive ROM, pre- to postoperatively. Prone patients had improved postoperative hip extension, pelvic tilt, velocity, and cadence. Conclusions: There was no significant different in stance hip rotation between supine and prone FDO groups. Advocates of prone positioning for FDO suggest it allows more accurate assessment of rotation. Supine positioning may be more convenient when additional procedures are required. Based on our findings, either approach can achieve the desired result.

Sustentaculum Tali Fracture Adjacent to Talocalcaneal Tarsal Coalitions: A Report of 2 Cases.

CASE: An 11-year-old boy demonstrated chronic medial hindfoot pain. A 12-year-old boy experienced acute pain and swelling in his right medial ankle and hindfoot after a fall. This is the first report of sustentaculum tali fractures adjacent to a talocalcaneal tarsal coalition, likely resulting from a stress riser created by a rigid subtalar joint. CONCLUSION: These 2 cases represent unique causes of foot pain in the setting of tarsal coalitions, never before described. Patient-reported outcome measures demonstrated expected improved outcomes after excision of tarsal coalition. Awareness to this possibility will help clinicians treating foot and ankle conditions in children optimize their care.

Bifocal Patellar Tendon Avulsion Fractures in Children and Adolescents: Diagnosis and Treatment Considerations for a Unique Injury Pattern.

PURPOSE: To highlight important diagnostic and treatment considerations in patients who present with bifocal patellar tendon avulsion fractures from the tibial tubercle and inferior patellar pole. METHODS: Radiographic presentation, surgical technique, and complications of 5 children who sustained bifocal patellar tendon avulsion fractures with ≥6 months postoperative follow-up were retrospectively reviewed. Hospital for Special Surgery (HSS) Brief Functional Activity Scale (HSS Pedi-FABS), Patient-Reported Outcomes Measurement Information System (PROMIS) pain interference, PROMIS mobility, and Pediatric International Knee Documentation Committee Scale (Pedi-IKDC) were assessed at most recent follow-up. RESULTS: Five children (4 boys, 1 girl) presented with bifocal patellar tendon avulsion fractures with a median follow-up of 12.8 months (range 7.7 to 26.4). In 1 case, advanced imaging was not pursued, and the bifocal nature of injury was subsequently discovered intraoperatively. In all other cases, magnetic resonance imaging (MRI) correctly characterized the bifocal injuries and revealed the full extent of fractures and soft tissue injury. Surgical management involved suture anchor repair with heavy nonabsorbable sutures. Postoperative functional and patient-reported outcomes were within the range of population healthy/normative values (for those that were available for comparison, e.g., Pedi-IKDC), and clinically relevant improvement was noted when comparing preoperative and postoperative patient-reported outcome measures of both pain and mobility. CONCLUSIONS: Advanced imaging (e.g., MRI) is required to understand the full extent of injury and should be obtained in the setting of traumatic patella alta to evaluate for the presence of a bifocal lesion and plan surgical intervention accordingly. These patients demonstrate satisfactory functional and patient-reported outcomes after operative repair. LEVEL OF EVIDENCE: IV, therapeutic case series.

Biomechanical Comparison of Two Pediatric Blade Plate Designs in Proximal Femoral Osteotomies.

BACKGROUND: Blade plates are frequently used for internal fixation following proximal femoral varus rotational osteotomy to treat hip dysplasia in children with cerebral palsy. Recently, cannulated blade plates with the option for a proximal locking screw have demonstrated ease of insertion and low complication rates. Although there are two commonly used blade plates with a proximal screw option, no comparison of their biomechanical profiles has been undertaken. QUESTIONS/PURPOSES: Our study sought to compare the structural properties under axial loading, as well as the biomechanical contribution of a proximal screw, of two different 90° cannulated blade plates designed for pediatric proximal femurs. Plate A has a hole distal to the blade designed to attach a plate inserter, through which a 3.5-mm non-locking cortical screw could be placed. Plate B has a threaded hole distal to the blade designed to accept a 3.5-mm locking screw. METHODS: Plate A and plate B were inserted into 33 left pediatric synthetic proximal femurs. Axial loading to failure of plate A with and without a proximal screw was compared to that of plate B with and without a proximal screw. An additional 10 samples using plate B, with and without a proximal locking screw, were tested in tension to quantify the effect of the proximal screw on pullout strength. RESULTS: Plate B failed at a higher axial load than plate A. The addition of a proximal screw did not affect the axial load to failure for either plate. Pullout testing revealed that blade plates fixed with the proximal screw failed in tension at a significantly higher load (856.3 ± 120.9 N) than those without proximal fixation (68.1 ± 9.3 N, p < 0.001). CONCLUSIONS: Plate B failed at a higher axial load in biomechanical testing, likely related to differences in its design. The addition of a proximal screw did not increase the axial loading properties of the blade plate construct but did increase the pullout strength by a factor of 12. These results may be used to influence implant selection and post-operative rehabilitation following proximal femoral osteotomies in children.

Pediatric Septic Arthritis and Osteomyelitis in the USA: A National KID Database Analysis.

BACKGROUND: Prior reports suggest that osteoarticular infections may be increasing over time. QUESTIONS/PURPOSES: We sought to determine if incidence rates, median in-hospital costs, and length of stay (LOS) of osteomyelitis, septic arthritis (SA), and combined infections have changed over time for pediatric patients, and how they compare to previously reported rates. METHODS: The Kids' Inpatient Database (KID), a US national sample of pediatric hospital discharge records from 1997, 2000, 2003, 2006, 2009, and 2012, was used to determine yearly estimated counts of infections in children 20 years of age or younger. US census data was used to calculate yearly incidence rates. Trend tests using linear contrast analysis were used to compare estimated median LOS and inflation-adjusted median costs over time for each type of infection. RESULTS: From 1997 through 2012, the incidence rate of osteomyelitis increased from 7.9 to 10.5 per 100,000, SA was unchanged from 5.3 to 5.2 per 100, and combined infections increased from 0.8 to 1.3 per 100,000. Median LOS from 1997 to 2012 showed no significant change for osteomyelitis (5.0 to 4.9 days), SA (4.4 to 4.1 days), or combined infections (6.5 to 6.8 days). Median in-hospital costs from 1997 to 2012 increased for osteomyelitis ($7735 to $11,823), SA ($5041 to $10,574), and combined infections ($12,691 to $16,260). CONCLUSION: In pediatric patients, the estimated incidence rate of SA appeared stable, while rates of osteomyelitis and combined infections increased. These estimated rates fall within previously reported ranges. Despite stable LOS, costs have increased over time.

Biomechanical Comparison of Suture-External Button Fixation vs Internal Suspension Fixation for Tendon Transfers of the Feet.

BACKGROUND: Fixation of tendon transfers in pediatric feet typically involves passing a suture that is secured to a tendon, through an intraosseous tunnel, and tying it over an external button on the plantar foot, with appropriate tension. After adequate time is allowed for bone-tendon healing, the suture and button are removed. This construct can be complicated by suture breakage with loss of fixation, and/or skin ulceration under the button. Internal suspension systems of tendons and ligaments in adults have demonstrated excellent fixation strength and minimal intraosseous tunnel displacement, with no risk of skin ulceration and no need for suture and button removal. This study compared the biomechanical properties of the suture-external button and internal suspension fixation techniques in cadavers. The primary outcome and secondary outcomes were displacement of suture-fixation construct during dynamic loading, and static loading, respectively. METHODS: Nine adult cadaver feet were obtained. Both the external button and internal suspension techniques were tested once in each cadaver, in random order. Relative displacement of the fixation construct within the bone tunnel was recorded with video capture during dynamic and static loading. A custom Matlab script processed video and materials testing data. Static and cyclic displacements were analyzed between fixation groups using a paired t test (alpha value =0.05). RESULTS: Internal suspension fixation had significantly less mean displacement of the tendon within the bone tunnel than the external button technique during dynamic (0.3 mm internal suspension system, 0.7 mm external button, P = .0115) and static loading (0.4 mm internal suspension system, 2.2 mm external button, P = .0019). CONCLUSIONS: Internal suspension systems may provide superior fixation compared to the traditional external button for tendon transfers, with the added benefit of avoiding the risk of skin ulceration and the need for suture and button removal. CLINICAL RELEVANCE: It appears internal suspension method of tendon transfer fixation would be an acceptable alternative to traditional methods of fixation with an external button.

The Root-Ely Modified Test of Rectus Femoris Spasticity Has Reliability in Individuals with Cerebral Palsy.

BACKGROUND: Stiff-knee gait is a common gait deviation in individuals with cerebral palsy (CP) due to rectus femoris (RF) muscle spasticity. The Duncan-Ely test is a velocity-dependent measurement of spasticity that is recorded as positive or negative. At our institution, we use a modification of the Duncan-Ely test, a 5-point ordinal rating scale, which delineates where the catch occurs within the rapid arc of knee flexion. It has been named the Root-Ely test. QUESTIONS/PURPOSES: We sought to determine the intra- and inter-rater reliability of the Duncan-Ely and Root-Ely tests in pediatric patients with CP. METHODS: A convenience sample of 20 ambulatory subjects was recruited; mean age was 10.5 ± 4.5 years, and the Gross Motor Function Classification System (GMFCS) levels were I-III. Five clinicians measured each individual's RF spasticity using the Root-Ely protocol during a single visit. Simple κ statistics with 95% confidence intervals (CI) were utilized for intra-rater reliability and weighted κ statistics with 95% CI for inter-rater reliability. RESULTS: The Root-Ely scale intra-rater reliability was 0.77 to 0.90 and inter-rater reliability was 0.32 to 0.87. Inter-rater reliability was good to excellent among experienced clinicians and fair to moderate in new clinicians. CONCLUSION: The Root-Ely 5-point scale has acceptable intra- and inter-rater reliability in pediatric individuals with CP among experienced clinicians. The Root-Ely test allows experienced clinicians to reliably quantify severity of RF spasticity and may give orthopaedic surgeons a clinical tool to better predict ideal candidates for RF transfers in individuals with CP in order to improve stiff-knee gait.

Clubfoot Etiology: A Meta-Analysis and Systematic Review of Observational and Randomized Trials.

BACKGROUND: Clubfoot is a common congenital anomaly with multiple potential risk factors. Identification of modifiable risk factors may minimize future incidence of clubfoot. The aim of this meta-analysis was to systematically review and analyze the best clinical evidence regarding risk factors associated with clubfoot. METHODS: Medline, Embase, and Cochrane databases were systematically searched from 1967 to May 11, 2016 for studies reporting risk factors for clubfoot. Randomized trials and observational studies were eligible for inclusion, and assessed in duplicate. Study quality was assessed with the Newcastle-Ottawa Scale or Cochrane risk of bias tool; low quality studies were excluded, all randomized trials were included. Two reviewers extracted data independently. This meta-analysis was conducted in accordance with PRISMA guidelines. Pooled effect estimates for the odds of clubfoot were calculated using random or fixed-effects models based on heterogeneity. RESULTS: Forty-two studies (28 case-control, 10 cohort, 4 randomized trials) comprising 31,844 clubfoot cases and 6,604,013 controls were included. Risk factors associated with increased odds of clubfoot included maternal smoking [odds ratio (OR)=1.65; 95% confidence interval (CI), 1.54-1.78], paternal smoking (OR=1.72; 95% CI, 1.05-2.84), maternal body mass index >30 (OR=1.46; 95% CI, 1.29-1.65), family history (OR=7.80; 95% CI, 4.04-15.04), amniocentesis (OR=2.08; 95% CI, 1.34-3.21), selective serotonin reuptake inhibitor exposure (OR=1.78; 95% CI, 1.34-2.37) maternal single status (OR=1.17; 95% CI, 1.11-1.23), gestational diabetes (OR=1.40; 95% CI, 1.13-1.72), nulliparity (OR=1.32; 95% CI, 1.19-1.45), male sex (OR=1.68; 95% CI, 1.48-1.94), and aboriginal Australian race (OR=2.35; 95% CI, 1.63-3.38). CONCLUSIONS: Smoking, maternal obesity, family history, amniocentesis, and some selective serotonin reuptake inhibitor exposures are the most clinically relevant exposures associated with increased odds of clubfoot, with family history representing the greatest risk. Recognition of modifiable risk factors may help in counseling patients, and minimizing clubfoot incidence. LEVEL OF EVIDENCE: Level II.

Reliability of the Modified Clavien-Dindo-Sink Complication Classification System in Pediatric Orthopaedic Surgery.

BACKGROUND: There is no standardized complication classification system that has been evaluated for use in pediatric or general orthopaedic surgery. Instead, subjective terms such as major and minor are commonly used. The Clavien-Dindo-Sink complication classification system has demonstrated high interrater and intrarater reliability for hip-preservation surgery and has increasingly been used within other orthopaedic subspecialties. This classification system is based on the magnitude of treatment required and the potential for each complication to result in long-term morbidity. The purpose of the current study was to modify the Clavien-Dindo-Sink system for application to all orthopaedic procedures (including those involving the spine and the upper and lower extremity) and to determine interrater and intrarater reliability of this modified system in pediatric orthopaedic surgery cases. METHODS: The Clavien-Dindo-Sink complication classification system was modified for use with general orthopaedic procedures. Forty-five pediatric orthopaedic surgical scenarios were presented to 7 local fellowship-trained pediatric orthopaedic surgeons at 1 center to test internal reliability, and 48 scenarios were then presented to 15 pediatric orthopaedic surgeons across the United States and Canada to test external reliability. Surgeons were trained to use the system and graded the scenarios in a random order on 2 occasions. Fleiss and Cohen kappa (κ) statistics were used to determine interrater and intrarater reliabilities, respectively. RESULTS: The Fleiss κ value for interrater reliability (and standard error) was 0.76 ± 0.01 (p < 0.0001) and 0.74 ± 0.01 (p < 0.0001) for the internal and external groups, respectively. For each grade, interrater reliability was good to excellent for both groups, with an overall range of 0.53 for Grade I to 1 for Grade V. The Cohen κ value for intrarater reliability was excellent for both groups, ranging from 0.83 (95% confidence interval [CI], 0.71 to 0.95) to 0.98 (95% CI, 0.94 to 1.00) for the internal test group and from 0.83 (95% CI, 0.73 to 0.93) to 0.99 (95% CI, 0.97 to 1.00) for the external test group. CONCLUSIONS: The modified Clavien-Dindo-Sink classification system has good interrater and excellent intrarater reliability for the evaluation of complications following pediatric orthopaedic upper extremity, lower extremity, and spine surgery. Adoption of this reproducible, reliable system as a standard of reporting complications in pediatric orthopaedic surgery, and other orthopaedic subspecialties, could be a valuable tool for improving surgical practices and patient outcomes.

Reliability of the Arch Height Index as a Measure of Foot Structure in Children.

PURPOSE: To determine the intrarater and interrater reliability of the arch height index (AHI) in children developing typically. The AHI is tested with a device that measures foot structure. METHODS: Thirty children, ages 6 to 12 years, participated for a total of n = 60 feet. The AHI measurements were taken by 2 investigators in sitting and standing and repeated twice by each investigator in a single visit. Intrarater and interrater reliabilities were determined using intraclass correlation coefficient (ICC) (2,1) statistical analysis. RESULTS: The mean age was 9.61 ± 1.96 years. The intrarater and interrater reliability had an ICC 0.76 or more in both sitting and standing. The average AHI value was 0.36 ± 0.02 in sitting and 0.32 ± 0.02 in standing. CONCLUSIONS: Pediatric therapists, physicians, and orthotists should consider using the AHI as an objective measure to be used for research, to assess foot structure, monitor change over time, and assist with treatment planning in children.

Simulated Ankle Equinus Affects Knee Kinematics During Gait.

BACKGROUND: It is critical to distinguish gait compensations from true abnormalities when planning interventions to improve gait in individuals with neuromuscular disorders. QUESTIONS/PURPOSES: The aim of this study was to determine the effect of isolated ankle equinus on knee kinematics during the initial contact phase of gait. METHODS: Ten healthy subjects (29 + 4.3 years) participated, and testing occurred in a motion analysis laboratory. This cross-sectional study investigated five gait conditions in each subject: shoe alone, shoe with unilateral ankle foot orthosis locked at neutral, 10°, 20°, and 30° of fixed ankle plantar flexion. Gait kinematics were recorded and calculated with 3D motion analysis. The difference between the shoe and each brace condition was analyzed by repeated-measures ANOVA. The primary outcome was knee flexion at initial contact. RESULTS: With greater than 10° simulated ankle equinus, the primary gait compensation pattern was increased knee flexion at initial contact. A significant degree of knee flexion occurred ranging from 7° to 22°. CONCLUSION: Our data suggests that observed knee flexion at initial contact may be a compensation pattern in individuals with >10° ankle equinus. However, in individuals with ≤10° ankle equinus, observed knee flexion may represent a true gait deviation. This has clinical significance in the realm of cerebral palsy for treatment planning to improve gait.

Evaluation and management of crouch gait.

PURPOSE OF REVIEW: Crouch gait is defined as excessive ankle dorsiflexion, knee and hip flexion during the stance phase. This gait disorder is common among patients with cerebral palsy. The present article brings an up-to-date literature review on the pathoanatomy, natural history, and treatment of this frequent gait abnormality. RECENT FINDINGS: Hamstrings are often not shortened in patients with crouch. Patella alta must be addressed if surgery is performed. Surgical correction of joint contractures and lever arm dysfunction can be effectively achieved through a single-event multilevel surgery. SUMMARY: Crouch gait is a common gait deviation, often seen among ambulatory diplegic and quadriplegic patients, once they reach the pubertal spurt, when weak muscles can no longer support a toe walking pattern because of rapidly increased weight. This form of gait is highly ineffective and might compromise walking ability over time. The anterior knee is overloaded; pain, extensor mechanism failure, and arthritis might develop. Its progressive nature often requires surgical intervention. The cause of crouch gait is multifactorial, and surgery should be tailored to meet the individual's specific anatomic and physiologic abnormalities.

Foot deformities in children with cerebral palsy.

PURPOSE OF REVIEW: The present article describes common foot deformities in children with cerebral palsy and discusses treatment options for each of those deformities. RECENT FINDINGS: Bracing is a useful treatment to correct foot deformities during gait. Surgical correction of foot deformities is typically performed as a part of multilevel single-event gait improvement surgery that has increasingly become the standard of care for ambulatory children with cerebral palsy. Foot realignment may improve knee function during stance, probably because of change of lever arm. SUMMARY: Foot deformities are common among children with cerebral palsy. The three most common among them are equinus, planovalgus and equinovarus/equinocavovarus. Treatment consists of orthotics, physical therapy, spasticity reduction treatment and surgical correction. Guidelines for treatment are individualized and multifactorial. Important considerations include the child's level of function, the severity and flexibility of the deformity, the presence or absence of pain and skin irritation, and the changes in alignment observed over time.

Effect of shoe flexibility on plantar loading in children learning to walk.

BACKGROUND: In a previous pilot study of "cruisers" (nonindependent ambulation), "early walkers" (independent ambulation for 0-5 months), and "experienced walkers" (independent ambulation for 6-12 months), developmental age significantly affected the children's stability when walking and performing functional activities. We sought to examine how shoe structural characteristics affect plantar pressure distribution in early walkers. METHODS: Torsional flexibility was evaluated in four shoe designs (UltraFlex, MedFlex, LowFlex, and Stiff based on decreasing relative flexibility) with a structural testing machine. Plantar pressures were recorded in 25 early walkers while barefoot and shod at self-selected walking speeds. Peak pressure was calculated over ten masked regions for the barefoot and shod conditions. RESULTS: Torsional flexibility, the angular rotation divided by the applied moment about the long axis of the shoe, was different across the four shoe designs. As expected, UltraFlex was the most flexible and Stiff was the least flexible. As applied moment increased, torsional flexibility decreased in all footwear. When evaluating early walkers during gait, peak pressure was significantly different across shoe conditions for all of the masked regions. The stiffest shoe had the lowest peak pressures and the most flexible shoe had the highest. CONCLUSIONS: It is likely that increased shoe flexibility promoted greater plantar loading. Plantar pressures while wearing the most flexible shoe are similar to those while barefoot. This mechanical feedback may enhance proprioception, which is a desirable attribute for children learning to walk.