Musculoskeletal injections for palliative treatment of neuromuscular hip dysplasia patients: how I do it.

This review describes our institution's standardized technique as well as potential pitfalls for therapeutic steroid injections in children with symptomatic neuromuscular hip dysplasia. Symptomatic, painful neuromuscular hip dysplasia can dramatically affect quality of life. Steroid injections are used to identify the source of perceived pain, temporarily treat pain while awaiting surgical intervention, or for therapeutic management for nonoperative hip joints.

Clinical impact of diagnostic image-guided injections for musculoskeletal pain work-up in adolescent and adult patients at a children's hospital: initial results.

OBJECTIVE: To assess the clinical impact of diagnostic musculoskeletal (MSK) injections on treatment decision-making in adolescent and adult patients at a children's hospital. MATERIALS AND METHODS: Retrospective study in patients who underwent diagnostic MSK injections by fluoroscopy or ultrasound (US) between 8/2020 and 3/2023 at a children's hospital. Patients received ropivacaine and triamcinolone acetonide at pain site, reporting quantitative FACES pain score prior to, immediately following, and 2-3 days following injection. Impact on patient care was subsequently assessed. RESULTS: A total of 109 diagnostic fluoroscopic or US MSK injection referrals (mean: 17.6 years old) were included, most commonly hip (76.2%), ankle (9.2%), and iliopsoas tendon sheath (8.3%). Pain improvement occurred in 89.0% immediately and 67.9% 2-3 days after MSK injection, with net 84.4% exhibiting improvement based on pain scores and clinical exams. When there was pain improvement at the site of injection, there was a statistically higher incidence of operative intervention or additional therapeutic injections compared with the cohort that did not have symptom improvement (88% versus 35.3%, P < 0.0001). For the 15.6% (N = 17) of referrals that did not have pain improvement, 17.6% (n = 3) ultimately had an operative intervention at a separate site from the diagnostic injection, as an alternative etiology for the pain was found. CONCLUSION: Image-guided MSK injections play an important role in the management of musculoskeletal disorders. 84.4% of referrals experienced symptom relief, improving confidence for treatment decision-making. Importantly, 15.6% of patients were found to have an alternative etiology for symptoms, altering management altogether.

Ipsilateral Supracondylar and Medial Epicondyle Humerus Fractures in Pediatric Patients: A Retrospective Analysis of Incidence, Epidemiology, Treatment, and Outcomes.

BACKGROUND: Pediatric supracondylar humerus (SCH; AO/OTA13-M/3.1) and medial epicondyle fractures (AO/OTA13u-M/7.1) are common. Concomitant SCH with ipsilateral medial epicondyle fractures remain scarcely reported. We investigated the epidemiology, treatment, and outcomes of this rare, combined injury. METHODS: A retrospective review of pediatric patients with concomitant SCH and medial epicondyle fractures at a level 1 hospital from 2010 to 2020 was performed. Patient data, treatments, and outcomes were assessed. Radiographs were reviewed for fracture classification and alignment. Patients aged above 18 years and those with inaccessible imaging were excluded. Descriptive statistics were performed. RESULTS: Of 3344 patients undergoing surgery for SCH fractures, 14 (6 females, mean: 10.59 y) with concomitant SCH and medial epicondyle fractures were included. Overall, 28.6% of patients exhibited preoperative nerve palsies (3 PIN, 1 median nerve). There was 1 flexion type and 13 Gartland type III SCH fractures. Medial epicondyle fracture displacement averaged 4.13 mm (range: 2 to 7 mm). Thirteen medial epicondyle fractures occurred medial to the physis with 1 through the physis. Eight patients (57.1%) had medial fixation-7 medial pins, 1 medial screw-which captured both the medial epicondyle and medial column of the SCH fracture. Six medial epicondyles were treated closed. The average time to pin pull was 33.1 days (range: 27 to 51 d) with average follow-up of 138.6 days (range: 27 to 574 d). Overall, 50% of patients completed physical therapy (PT). Complications occurred in 4 cases: prominence of a medial pin, 1 patient required additional PT and dynamic splinting for loss of functional extension, 1 patient underwent a manipulation under anesthesia 3.5 months postoperatively for flexion contracture, and 1 patient developed medial epicondyle nonunion and SCH malunion that underwent corrective osteotomy 10.5 months postoperatively. CONCLUSIONS: Concurrent SCH and medial epicondyle fractures exhibited a high rate of nerve palsy (28.6%) and complications (28.6%) and were frequently referred to physical therapy. While patients treated without medial fixation went on to union, this combined injury might represent a relative indication for medial pinning of the SCH fracture. Further studies on this rare injury pattern are needed to determine optimal treatment methods. LEVEL OF EVIDENCE: Level IV-therapeutic.

Evaluating Chat Generative Pre-trained Transformer Responses to Common Pediatric In-toeing Questions.

OBJECTIVE: Chat generative pre-trained transformer (ChatGPT) has garnered attention in health care for its potential to reshape patient interactions. As patients increasingly rely on artificial intelligence platforms, concerns about information accuracy arise. In-toeing, a common lower extremity variation, often leads to pediatric orthopaedic referrals despite observation being the primary treatment. Our study aims to assess ChatGPT's responses to pediatric in-toeing questions, contributing to discussions on health care innovation and technology in patient education. METHODS: We compiled a list of 34 common in-toeing questions from the "Frequently Asked Questions" sections of 9 health care-affiliated websites, identifying 25 as the most encountered. On January 17, 2024, we queried ChatGPT 3.5 in separate sessions and recorded the responses. These 25 questions were posed again on January 21, 2024, to assess its reproducibility. Two pediatric orthopaedic surgeons evaluated responses using a scale of "excellent (no clarification)" to "unsatisfactory (substantial clarification)." Average ratings were used when evaluators' grades were within one level of each other. In discordant cases, the senior author provided a decisive rating. RESULTS: We found 46% of ChatGPT responses were "excellent" and 44% "satisfactory (minimal clarification)." In addition, 8% of cases were "satisfactory (moderate clarification)" and 2% were "unsatisfactory." Questions had appropriate readability, with an average Flesch-Kincaid Grade Level of 4.9 (±2.1). However, ChatGPT's responses were at a collegiate level, averaging 12.7 (±1.4). No significant differences in ratings were observed between question topics. Furthermore, ChatGPT exhibited moderate consistency after repeated queries, evidenced by a Spearman rho coefficient of 0.55 ( P = 0.005). The chatbot appropriately described in-toeing as normal or spontaneously resolving in 62% of responses and consistently recommended evaluation by a health care provider in 100%. CONCLUSION: The chatbot presented a serviceable, though not perfect, representation of the diagnosis and management of pediatric in-toeing while demonstrating a moderate level of reproducibility in its responses. ChatGPT's utility could be enhanced by improving readability and consistency and incorporating evidence-based guidelines. LEVEL OF EVIDENCE: Level IV-diagnostic.

How Reliable Is the Measurement of the Lateral Center Edge Angle on Scoliosis Radiographs for Detecting Acetabular Dysplasia?

PURPOSE: Hip dysplasia reportedly occurs in up to 12% of the general population and may be higher in patients with adolescent idiopathic scoliosis (AIS). When using lateral center edge angle (LCEA) measurements to help identify hip dysplasia, it is uncertain if this measurement can be performed reliably on scoliosis radiographs due to parallax. The purpose of this study is to evaluate the reliability of measuring LCEA on scoliosis radiographs compared with standard pelvis radiographs. METHODS: This study evaluated 40 hips on 20 patients (mean age 12.5 years ± 3.1; 50% Female) who received PA scoliosis radiographs and AP pelvis radiographs within 1 year of each other. Review was performed by 4 pediatric radiologists (2 general, 2 MSK), 2 pediatric orthopaedic surgeons, and 1 research fellow. Radiographic measurement of the LCEA for each hip was first performed on the scoliosis radiograph. After a minimum of 3 days, the LCEA was measured on a pelvis radiograph of the same individual obtained within 1 year of the scoliosis radiograph. Pearson coefficient was used to measure agreement between scoliosis and pelvis radiograph measurements. Intraclass correlation coefficient (ICC) was used to evaluate intraobserver and interobserver agreement. ICC values <0.5 were classified as poor reliability, 0.5 to 0.75 were classified moderate, 0.75 to 0.90 were classified good, and >0.9 indicated excellent reliability. RESULTS: The mean difference between scoliosis and pelvis radiographs was 54 ± 79 days. There was good-to-excellent interobserver agreement on LCEA measurements made between readers on scoliosis radiographs (ICC: 0.94, 95% CI: 0.90-0.96, P <0.001) and pelvis radiographs (ICC: 0.91, 95% CI: 0.83-0.95, P <0.001), and moderate-to-excellent intraobserver agreement for scoliosis radiographs (ICC range: 0.68 to 0.98; P <0.001) and pelvis radiographs (ICC range: 0.62 to 0.96; P <0.001). There was a strong correlation between LCEA measurements made on scoliosis and pelvis radiographs ( r2 =0.66, P <0.001), and the intermodality agreement between scoliosis and pelvis radiograph LCEA measurements were moderate to good (ICC range: 0.68 to 0.89, P <0.001). CONCLUSIONS: Overall, there was good-to-excellent agreement between readers on scoliosis and pelvis radiographs, respectively, and moderate-to-excellent intraobserver agreement between LCEA measurements made on scoliosis radiographs and pelvis radiographs, respectively. LCEA measurements made on scoliosis radiographs strongly correlated to the measurements made on pelvis radiographs, and the intermodality ICC was also considered moderate to good. Dedicated pelvis radiographs may not be necessary during scoliosis workup and follow-up surveillance, thereby decreasing radiation exposure, cost, and improving patient care workflow. LEVEL OF EVIDENCE: Level IV-diagnostic study.

Child traumatic physical abuse rates and comparisons during the COVID-19 pandemic: Retrospective paediatric single institution review in Texas.

AIM: The COVID-19 pandemic drastically altered human behaviour and socialisation and may have created an environment that could lead to increased incidence of domestic abuse and non-accidental trauma, or child physical abuse (CPA). Initial reports about the effect of the COVID-19 pandemic on the rates of CPA have been mixed. The purpose of this study is to describe the effects of COVID-19 on rates of CPA in a large metropolitan paediatric hospital and level I paediatric trauma centre. METHODS: We identified and compared all CPA admissions under 18 years from May 2019 to February 2020 and considered that to be the pre-COVID time frame. The ensuing 12-month period of March 2020 to February 2021 was considered to be the intra-COVID time frame. RESULTS: There were 49 (0.32%) unique CPA patients pre-COVID and 83 (0.85%) unique CPA patients intra-COVID (P < 0.001) with lower total admissions for any reason during the intra-COVID time frame. Monthly CPA cases were increased (P < 0.03) during the intra-COVID time period (mean 6.9, 95% confidence interval: 5.8-12.7) compared to the pre-COVID time period (mean 4.9, 95% confidence interval: 3.3-8.2). CONCLUSION: During the COVID-19 pandemic, there were decreased overall hospital admissions in the period of mandated shutdowns and isolation. However, we saw an increased rate of CPA admissions compared to the time period prior to the pandemic. Knowledge of such data, trends and circumstances will help keep health-care providers alert and vigilant in identifying children at risk for maltreatment, and may impact child abuse protocols and guidelines.

Computed Tomography Analysis of Distal Tibia Physeal Fracture Patterns: A Classification and Technique for Optimizing Screw Trajectory.

BACKGROUND: Fractures involving the anterolateral distal tibia, often referred to as Tillaux or Triplane fractures, are often treated operatively to achieve an anatomic reduction of the ankle joint articular surface. Although axial images from computed tomography scans are commonly obtained to measure displacement, no studies have examined these fracture patterns in the axial plane. This information may be useful to guide screw trajectory with only fluoroscopic imaging intraoperatively. METHODS: We queried an institutional radiology report database for all "Tillaux" or "triplane" fractures and manually reviewed to identify fractures with an anterolateral tibia fragment. The axial image immediately caudal to the physis or physeal scar was used for measurements. The angle between the incisura and the fracture line exiting the incisura was measured. The width of the fracture fragment and the anterior distal tibia was then measured perpendicular to the incisura, representing the width that would be seen on an intraoperative mortise. A cluster analysis was performed to identify fracture patterns. RESULTS: The average age of patients included in the study was 16 ± 2 years. Sixty-nine patients met inclusion criteria 32 patients with Tillaux fractures (46.4%) and 37 patients with triplane fractures (53.6%) met study inclusion criteria for a total of 69 patients. The cluster analysis demonstrated 3 fracture patterns. For type 1 (n=16), the mean was 24.5 ± 6.5 degrees from the incisura and the mean distance from the tibiofibular joint was 21.1 ± 6.3%. For type 2 (n=20), the mean was 58.6 ± 7.2 degrees and the mean distance was 48.7 ± 8.9%. For type 3 (n=33), the mean was 88.6 ± 6.3 degrees and the mean distance was 49.1 ± 9.7%. CONCLUSIONS: This is the first study to identify that pediatric distal tibia physeal fractures occur in 3 common patterns with consistent fragment sizes and fracture planes. This information can optimize screw start point and trajectory in the axial plane when referencing a mortise x-ray and C-arm beam. LEVEL OF EVIDENCE: Diagnostic, Level III.

How Often Do Patients Presenting With Severe Adolescent Idiopathic Scoliosis Have Underlying Hip Dysplasia?

INTRODUCTION: Adolescent idiopathic scoliosis radiographic screening will often include the hips. The purpose of this study is to evaluate the prevalence of hip dysplasia by lateral center edge angle (LCEA) on scoliosis radiographs in patients presenting with severe range (>45 deg) idiopathic curves. METHODS: We reviewed 200 consecutive patients (400 hips) with idiopathic scoliosis with major coronal curves ≥45 degrees between October 2009 and October 2022. The presenting scoliosis radiograph PA were reviewed for the following variables: major coronal curve direction, coronal balance, and lateral center edge angles. An LCEA value ≤18 was considered dysplastic. To assess potential measurement variability related to parallax of the scoliosis radiographs, the intermodality intraclass correlation coefficient (ICC) was measured from a subset of 20 hip LCEA values from patients with both scoliosis and pelvis radiographs. RESULTS: A total of 200 patients [mean age: 13.6 (1.8) years; Female: 79%] were reviewed. The mean major curve (SD) was 58.6 degrees (11.4 deg). Overall 19% (37/200) patients or 11% (43/400) of hips had hip dysplasia. Of the dysplastic hips, 16% (6/43, P <0.001) were bilateral and 57% (21/43, P =0.04) were right sided. There was no association between dysplastic hip laterality and ipsilateral or contralateral coronal balance ( P =0.26) or curve direction ( P =0.49). The interobserver ICC for assessment of LCEA on scoliosis radiographs was 0.85, and the intermodality ICC between pelvic and scoliosis radiographs was 0.78. CONCLUSION: Hip dysplasia was present in 19% of patients presenting with large major curves, and many of these patients had right sided hip dysplasia. There was no association between hip dysplasia laterality and the patient's major curve direction or coronal balance. There was good intermodality reliability (ICC=0.78) between LCEA values in patients who had both scoliosis and pelvis radiographs, and good inter-rater reliability between raters. Radiographic interpretation of adolescent idiopathic scoliosis should focus not only on the description of the curve and ruling out underlying segmentation anomalies but should also include critical assessment of the hips to exclude co-existing hip dysplasia. LEVEL OF EVIDENCE: Therapeutic study-level IV.

Bethlem Myopathy (Collagen VI-Related Dystrophies): A Retrospective Cohort Study on Musculoskeletal Pathologies and Clinical Course.

BACKGROUND: Collagen VI-related myopathies with pathologic COL6A1, COL6A2, and COL6A3 variants manifest as a phenotypic continuum of rare disorders, including Bethlem myopathy (BM), characterized by early onset muscle weakness, proximal joint contractures, and distal joint laxity. Herein we discuss the concomitant orthopedic manifestations of BM, potential management strategies, and patient outcomes. METHODS: An IRB-approved retrospective cohort study (n=23) from 2 pediatric institutions with a confirmed diagnosis of BM. Charts were reviewed for demographic data, age of disease presentation and diagnosis, COL6 genotype, diagnosis method, ambulation status, need for assistance, musculoskeletal abnormalities, other systemic comorbidities, advanced imaging and screening diagnostics, previous surgical interventions, and progression of the disease. RESULTS: The mean age was 11.65 years (range 3 to 19 y). Mean age at initial presentation with symptoms was 4.18 years old, whereas diagnosis was delayed until 8.22 years old on average. Muscle weakness was the most common presenting symptom (65.2%), and 73.9% of patients required some use of assistive or mobility devices. Overall, 30.4% of patients were diagnosed with scoliosis; 57.1% required operative intervention for their scoliosis; 43.5% of patients had acetabular dysplasia; 10% required open reduction of a dislocated hip; 10% required closed reduction with hip spica application; 10% required bilateral periacetabular osteotomies for instability; 91.3% of patients developed foot and ankle deformities; 33.3% of patients underwent posteromedial-lateral equinovarus releases; 28.6% required an Achilles tendon lengthening, and 86.9% of patients had muscle tendon contractures, the most common locations being the ankle (55%) and elbow (40%). CONCLUSION: Although often less severe than other more common neuropathies and myopathies like Charcot-Marie-Tooth disease and Duchenne muscular dystrophy, BM does lead to progressive musculoskeletal deformity and disability. Its relative rarity makes it less familiar to providers and likely contributes to delays in diagnosis. Scoliosis, hip dysplasia, and equinus and varus ankle deformities are the most common musculoskeletal deformities. Physicians and surgeons should appropriately counsel patients and families about the clinical course of this disorder and the potential need for mobility assistance or surgical procedures. LEVEL OF EVIDENCE: III, Prognostic. study.

Outcomes of Open Reduction in Children With Developmental Hip Dislocation: A Multicenter Experience Over a Decade.

BACKGROUND: Open reduction of the hip is commonly performed in children with severe developmental dysplasia of the hip, or in cases that are refractory to nonoperative forms of treatment. The open reduction has been associated with numerous complications including avascular necrosis (AVN) of the femoral head, the need for reoperation, and residual radiographic dysplasia. This study seeks to determine the effects of preoperative severity of dysplasia, associated procedures (femoral and acetabular osteotomies), age on AVN, and the need for reoperation. METHODS: Children with developmental dysplasia of the hip and a minimum of 2 years of follow-up who underwent open reduction were identified. The following data points were recorded: sex, laterality of hip involvement, simultaneous procedures, surgical approach used, age, acetabular index, and International Hip Dysplasia Institute grade. We analyzed the effects of preoperative International Hip Dysplasia Institute, age, surgical approach (anterior/medial), bilateral reduction, and simultaneous femoral shortening or pelvic osteotomy on the outcomes of AVN and reoperation. RESULTS: One hundred eighty-five hips in 149 patients were included in this study with an average follow-up of 4 years (range: 2 to 5 y). The average age at index surgery was 23 months (range: 1 to 121 mo). Overall, 60 hips (32.4%) required secondary surgical procedures at an average age of 58.5 months. High-grade AVN was noted in 24 hips (13.0%) and was found to be associated with the severity of the hip dislocation ( P = 0.02). A higher rate of reoperation was found in children over 18 months at the time of open reduction who did not receive an acetabular osteotomy ( P = 0.012). CONCLUSION: Approximately 1/3 of patients require another operative intervention within the first 4 years after open reduction of the hip. We found the severity of hip dislocation to be associated with a higher risk of AVN development. These findings support performing an acetabular osteotomy in children over 18 months of age at the time of open reduction to decrease the likelihood of requiring future reoperation during the first 4 years after the index procedure. LEVEL OF EVIDENCE: Level III.

Factors affecting need for blood transfusion in paediatric patients undergoing open surgery for hip dysplasia.

BACKGROUND AND OBJECTIVES: The management of intraoperative blood loss in the surgical treatment of paediatric hip dysplasia is resource intensive. There are numerous clinical factors that impact the need for intraoperative transfusion. Identification of patient and surgical factors associated with increased blood loss may reduce the unnecessary use of resources. This study aimed to identify factors predictive of intraoperative transfusion in children undergoing hip dysplasia surgery. MATERIALS AND METHODS: This is a single-centre retrospective review of patients undergoing surgery for hip dysplasia from 1 January 2012 to 15 April 2021. Patient demographic factors, anaesthetic, surgical and transfusion histories were reviewed. Multivariable logistic regression analysis was performed to identify factors predictive of allogeneic red blood cell transfusion requirements during the intraoperative period. RESULTS: This study includes 595 patients who underwent open surgery for hip dysplasia, including 297 (52.6%) classified as developmental dysplasia (DD) and 268 (47.3%) as neuromuscular (NM) with a mean age of 9.1 years (interquartile range 3-14). Intraoperative allogeneic transfusion was identified in 26/297 (8.8%) DD and 73/268 (27.2%) NM patients. Adjusted factors associated with increased odds of intraoperative transfusion were NM (odds ratio [OR] = 2.96, 95% confidence interval [CI] [1.76, 5.00]) and the number of osteotomies performed (OR = 1.82/osteotomy, 95% CI [1.40, 2.35]). Adjusted factors that reduced the odds of transfusion were the use of antifibrinolytics (OR = 0.35, 95% CI [0.17, 0.71]) and regional anaesthesia (OR = 0.52, 95% CI [0.29, 0.94]). CONCLUSION: For children undergoing surgery for hip dysplasia, the number of osteotomies performed is predictive of the need for allogeneic blood transfusion. Antifibrinolytics and regional anaesthesia are associated with reduced risk for allogeneic blood transfusion. Blood management initiatives, such a preoperative optimization of haemoglobin and the use of antifibrinolytics, could target patients at increased risk of intraoperative bleeding and transfusion.

Quadruple Versus Double Flexible Intramedullary Nails to Treat Pediatric Distal-third Tibial Shaft Fractures: A Biomechanical Comparison.

BACKGROUND: The vast majority of pediatric distal-third tibial shaft fractures can be treated with closed reduction and casting. If conservative measures fail, then these fractures are usually treated with 2 antegrade flexible intramedullary nails. A postoperative cast is usually applied because of the tenuous fixation of the 2 nails. Recent studies have described the use of 4 nails to increase the stability of the fixation, a technique that may preclude the need for postoperative casting. The purpose of this biomechanical study is to quantify the relative increase in stiffness and load to failure when using 4 versus 2 nails to surgically stabilize these fractures. METHODS: Short, oblique osteotomies were created in the distal third of small fourth-generation tibial sawbones and stabilized with 2 (double) or 4 (quadruple) flexible intramedullary nails. After pilot testing, 5 models per fixation method were tested cyclically in axial compression, torsion, and 4-point bending in valgus and recurvatum. At the end of the study, each model was loaded to failure in valgus. Stiffness values were calculated, and yield points were recorded. The data were compared using Student's t tests. Results are presented as mean±SD. The level of significance was set at P≤0.05. RESULTS: Stiffness in valgus 4-point bending was 624±231 and 336±162 N/mm in the quadruple-nail and double-nail groups, respectively (P=0.04). There were no statistically significant differences in any other mode of testing. CONCLUSIONS: The quadruple-nail construct was almost 2 times as stiff as the double-nail construct in resisting valgus deformation. This provides biomechanical support for a previously published study describing the clinical success of this fixation construct.

Validation of Pediatric Self-Report Patient-Reported Outcomes Measurement Information System (PROMIS) Measures in Different Stages of Legg-Calvé-Perthes Disease.

OBJECTIVES: Patient-reported outcomes (PRO) assessing health-related quality of life (HRQoL) are important outcome measures, especially in Legg-Calvé-Perthes disease (LCPD) where symptoms (pain and limping), activity restrictions, and treatments vary depending on the stage of the disease. The purpose of this study was to investigate the validity of the Patient-reported Outcomes Measurement Information System (PROMIS) for measuring HRQoL of patients with LCPD in various stages of the disease. METHODS: This is a multicenter validity study. Patients with LCPD between 4 and 18 years old were included and classified into modified Waldenström stages of disease: Early (1 or 2A), Late (2B or 3), or Healed (4). Seven PROMIS domains were collected, including Pain Interference, Fatigue, Mobility, Depression, Anger, Anxiety, and Peer Relationships. Convergent, discriminant, and known group validity was determined. RESULTS: A total of 190 patients were included (mean age: 10.4±3.1 y). All 7 domains showed the worst scores in patients in the Early stage (known group validity). Within each domain, all domains positively correlated to each other (convergent validity). Patients who reported more anxiety, depression, and anger were associated with decreased mobility and increased fatigue and pain. Peer relationships had no to weak associations with other domains (discriminant validity). CONCLUSIONS: PROMIS has construct validity in measuring the HRQoL of patients in different stages of LCPD, suggesting that PROMIS has potential to serve as a patient-reported outcome tool for this population. LEVEL OF EVIDENCE: Diagnostic level III study.

Developmental Dysplasia of the Hip From Birth to Arthroplasty: Clear Indications and New Controversies.

Developmental dysplasia of the hip is the all-encompassing term used to describe the wide spectrum of disorders of the development of the hip that manifest in various forms and at different ages. Developmental dysplasia of the hip often evolves over time because the structures of the hip are normal during embryogenesis but gradually become abnormal. Such variability in pathology is associated with a similarly wide range in management options and recommendations aimed at preventing hip joint arthrosis. These options may be instituted at any time between birth and adulthood as techniques aimed at preserving the native hip or replacing the arthritic hip. Many of these management options are clearly indicated and considered standard practice. However, with the evolution of the understanding of hip biomechanics, better knowledge of the long-term outcomes of hip joint-preserving surgeries, and ever-improving technology influencing hip arthroplasty come new controversies, especially whether to preserve or replace the mature hip.

Evaluation of postoperative fever after surgical correction of neuromuscular scoliosis: implication on management.

BACKGROUND: Scoliosis is a common deformity in patients with neuromuscular disorders which usually necessitates surgical correction. Patients with neuromuscular scoliosis are characterized by increased incidence of associated medical co-morbidities and higher postoperative complication rate; therefore, these patients are often managed with a wide multidisciplinary care team. Postoperative fever is a frequent complication after surgery which is often routinely investigated using different workup tests to rule out infection. These tests lack clear evidence on how they impact the patient care and are associated with increased cost and burden on the health system. OBJECTIVE: The objective of our study was to evaluate the incidence of postoperative fever after surgical correction of neuromuscular scoliosis and evaluate the clinical usefulness of fever diagnostic workup. METHODS: Demographic and clinical data on patients who underwent neuromuscular scoliosis corrective surgery between March 1, 2014 and February 28, 2017 were reviewed at a single institution. The occurrence of postoperative fever (defined by body temperature ≥ 38 °C during the 1st week after surgery) was characterized by maximum temperature (T max), postoperative day of occurrence (POD), and frequency as described by either single or multiple temperature spikes. The diagnostic tests performed for the assessment of postoperative fever were reviewed. The cost per health effect was calculated by dividing the total costs of performed fever workup tests by the number of tests that resulted in change of the patient care. RESULTS: Seventy-six patients (47 females and 29 males) were identified. Cerebral palsy was the most common aetiology in 40 patients (52.6%). The mean age at surgery was 13.5 years (range 3-18 years). The operative time was 490.34 ± 127.21 min. The intraoperative blood loss was 912.3 ± 627.8 cc. The hospital stay was 9.79 ± 5.3 days and the intensive care unit (ICU) stay was 3.26 ± 3.7 days. Wound drains were used in 71 patients for a period of 3.6 ± 2.3 days. Urinary catheters were used for a period of 3.6 ± 1.8 days. Forty-nine patients (64.5%) developed postoperative fever with a temperature of 38.7° ± 0.45° (range 38.10°-39.9°). The most frequent POD for occurrence of fever was the 2nd day in 22 patients (44.9%) The frequency of fever was in the form of multiple temperature spikes in 32 patients (65.3%) or in the form of a single spike in 17 patients (34.7%). There were a total of 20 positive tests out of 132 performed fever workup tests (15.2%). These included nine positive urine analysis (n = 32), five positive urine cultures (n = 28), one positive blood culture (n = 23), and two positive chest X-ray (n = 24). The occurrence of postoperative fever was statistically correlated with the operative time and increased hospital stay and ICU days. The most common identified cause of infection was urinary tract infection in 11 patients followed by respiratory tract infection in four patients and wound infection in one patient. The calculated cost per health effect was $3763. CONCLUSION: Sixty-four percent of patients who underwent surgical correction of neuromuscular scoliosis developed postoperative fever. Postoperative fever was sign of infection in 32.7% of patients and urinary tract infection was the most frequent finding. Only 15.2% of fever diagnostic workup tests were positive. Diagnostic urine tests account for 70% of the positive diagnostic workup. The routine use of blood cultures for the assessment of postoperative fever in such population should be avoided due to the low rate of positive tests and the associated high cost.

Validating an Algorithm to Predict Adjacent Musculoskeletal Infections in Pediatric Patients With Septic Arthritis.

BACKGROUND: Septic arthritis is frequently associated with adjacent infections including osteomyelitis and subperiosteal and intramuscular abscesses. While often clinically indiscernible from isolated septic arthritis, the diagnosis of adjacent infections is important in determining the need for additional surgical intervention. MRI has been used as the diagnostic gold standard for assessing adjacent infection. Routine MRI, however, can be resource-intensive and delay surgical treatment. In this context, there is need for additional diagnostic tools to assist clinicians in determining when to obtain preoperative MRI in children with septic arthritis. In a previous investigation by Rosenfeld et al., an algorithm, based on presenting laboratory values and symptoms, was derived to predict adjacent infections in septic arthritis. The clinical applicability of the algorithm was limited, however, in that it was built from and applied on the same population. The current study was done to address this criticism by evaluating the predictive power of the algorithm on a new patient population. QUESTIONS/PURPOSES: (1) Can a previously created algorithm used for predicting adjacent infection in septic arthritis among pediatric patients be validated in a separate population? METHODS: Records for all pediatric patients (1-18 years old) surgically treated for suspected septic arthritis during a 3-year period were retrospectively reviewed (109 patients). Of these patients, only those with a diagnosis of septic arthritis confirmed by synovial fluid analysis were included in the study population. Patients without confirmation of septic arthritis via synovial fluid analysis, Gram stain, or culture were excluded (34 patients). Patients with absence of MRI, younger than 1 year, insufficient laboratory tests, or confounding concurrent illnesses also were excluded (18 patients), resulting in a total of 57 patients in the study population. Five variables which previously were shown to be associated with risk of adjacent infection were collected: patient age (older than 4 years), duration of symptoms (> 3 days), C-reactive protein (> 8.9 mg/L), platelet count (< 310 x 10 cells/µL), and absolute neutrophil count (> 7.2 x 10 cells/µL). Adjacent infections were determined exclusively by preoperative MRI, with all patients in this study undergoing preoperative MRI. MR images were read by pediatric musculoskeletal radiologists and reviewed by the senior author. According to the algorithm we considered the presence of three or more threshold-level variables as a "positive" result, meaning the patient was predicted to have an adjacent infection. Comparing against the gold standard of MRI, the algorithm's accuracy was evaluated in terms of sensitivity, specificity, positive predictive value, and negative predictive value. RESULTS: In the new population, the sensitivity and specificity of the algorithm were 86% (95% CI, 0.70-0.95) and 85% (95% CI, 0.64-0.97), respectively. The positive predictive value was determined to be 91% (95% CI, 0.78-0.97), with a negative predictive value of 77% (95% CI, 0.61-0.89). All patients meeting four or more algorithm criteria were found to have septic arthritis with adjacent infection on MRI. CONCLUSIONS: Critical to the clinical applicability of the above-mentioned algorithm was its validation on a separate population different from the one from which it was built. In this study, the algorithm showed reproducible predictive power when tested on a new population. This model potentially can serve as a useful tool to guide patient risk stratification when determining the likelihood of adjacent infection and need of MRI. This better-informed clinical judgement regarding the need for MRI may yield improvements in patient outcomes, resource allocation, and cost. LEVEL OF EVIDENCE: Level II, diagnostic study.

Incidence and Diagnostic Evaluation of Postoperative Fever in Pediatric Patients With Neuromuscular Disorders.

BACKGROUND: Children with neuromuscular disorders have a significant chance of developing scoliosis and/or hip dislocation during childhood and adolescence and often undergo surgical reconstruction. Because of their high rate of medical comorbidities, these patients are at higher risk of postoperative complications and are therefore often comanaged, along with orthopaedics, by pediatric medicine and critical care teams. Fever during the postoperative stay is a frequent occurrence and often prompts extensive diagnostic workup which increases the cost and burden on the health system but have unclear effects on the care of the patient. The objective of our study was to evaluate the frequency of postoperative fever in pediatric patients with neuromuscular disorders after spine and hip deformity correction surgery and evaluate the utility of the diagnostic tests performed for the assessment of postoperative fever. METHODS: We performed an IRB-approved retrospective study on patients who underwent corrective surgery for neuromuscular scoliosis or hip dislocation at a single institution. The occurrence of postoperative fever was characterized by maximum temperature, postoperative day (POD) of occurrence, and frequency as defined by either single or multiple temperature spikes. Diagnostic tests performed for the workup of postoperative fever were reviewed. The cost per health effect was estimated by dividing the total costs of diagnostic tests by the number of tests that changed patient care. RESULTS: In total, 108 patients (62 females and 46 males) were identified. A total of 42 patients (38.9%) underwent posterior spinal fusion and 66 (61.1%) patients underwent hip surgery (pelvic osteotomy in 8 patients, femoral osteotomy in 31 patients, and both pelvic and femoral osteotomy in 27 patients). The mean age at the time of surgery was 11.1 years (range, 3 to 18 y). In total, 66 patients (61.1%) developed postoperative fever (mean temperature, 38.6°C). The frequency of fever was in the form of multiple temperature spikes in 37 patients (56%) and in the form of a single spike in 29 patients (44%). Of the 149 diagnostic tests performed for postoperative fever, there were a total of 16 positive tests (10.7% of total tests ordered; n=16/149) including 5/27 urine analysis, 4/26 urine culture, 4/28 chest x-ray, 1/1 wound culture, 0/1 sputum culture, urine Gram stain 0/1, tracheal aspirate culture 0/1, throat culture 1/1, adenovirus polymerase chain reaction (PCR) 0/5, human metapneumovirus PCR 0/5, parainfluenza PCR 0/5, rhinovirus PCR 0/1, 1/3 bronchoalveolar culture, and 0/7 respiratory virus panel. A total of 37 blood cultures were drawn and all were negative. There was a significant difference (P=0.04) in frequency of negative diagnostic workup performed at the first, second, and third POD as compared with positive diagnostic workup. Total cost of the diagnostic tests was $65,284 and the cost per health effect was $6582 ($65,284/10). Diagnostic tests in patients with postoperative fever were associated with prolonged length of hospital stay in comparison with patients who did not perform any diagnostic workup using the Spearman ρ test (P=0.02). CONCLUSION: In total, 61% of pediatric patients developed postoperative fever after surgical correction of neuromuscular deformity. An infectious source of postoperative fever was identified in 32.4% of patients with postoperative fever who underwent diagnostic workup. Urinary tract infection was the most common finding in patients with postoperative fever. Poor association between the development of postoperative fever and wound infection was found. Only 10.7% of fever diagnostic workup tests were positive in our population. The diagnostic workup tests might be less valuable if performed early on the first, second, and third PODs than those performed late after the third POD with exceptions based on clinical assessment. No patients with postoperative fever had positive blood cultures, therefore the routine use of blood cultures in the evaluation of postoperative fever in such population is not recommended. LEVEL OF EVIDENCE: Level IV-retrospective.

The Economic Burden of Musculoskeletal Disease in Children and Adolescents in the United States.

BACKGROUND: Musculoskeletal conditions are among the most common and costly conditions suffered by Americans. In 2011, there was an estimated $213 billion in annual cost of direct treatment for and lost wages due to musculoskeletal disease in the United States. Data on economic burden, however, comes mostly from the adult population, with significantly less information regarding the burden of these conditions in young patients available. The purpose of this report is to provide data on the economic burden of musculoskeletal diseases in children and adolescents in the United States. METHODS: Eleven diagnosis categories were identified, with health care visits and hospitalization data derived from ICD-9-CM codes for each of the conditions searched. The largest database utilized was the Healthcare Cost and Utilization Project (HCUP) Kids' Inpatient Database (KID). Total visits came from the KID, HCUP NEDS (emergency department), NCHS NHAMCS OP (outpatient), and NCHS NAMCS (physician office) databases. The National Health Interview Survey (NHIS) child sample was additionally searched to obtain patient/parent-reported data. RESULTS: In 2012, more than 19 million children and adolescents received treatment in medical centers, physicians' offices, and hospitals for a musculoskeletal-related condition. The most common reason for treatment (68%) was traumatic injury, followed by a pain syndrome (13%) and deformity (9%). Total hospital charges in 2012 for children and adolescents with a primary musculoskeletal-related diagnosis totaled $7.6 billion. Trauma (43%) and deformity (38%) were the major contributors to total hospital charges. CONCLUSIONS: Although we found that hospital-related charges for musculoskeletal diseases for children and adolescents in 2012 totaled $7.6 billion, this number underestimates the total cost for all pediatric musculoskeletal conditions. Musculoskeletal conditions accounted for 5.4% of hospital charges in the pediatric population. However, only 1.4% of pediatric research funding is designated to musculoskeletal research. Going forward, the data in this report may be used to further research and to stimulate development of better methods with which to measure the direct and indirect costs of musculoskeletal conditions in children. LEVEL OF EVIDENCE: Level IV-economic and decision analysis.

Key Concepts of Musculoskeletal Infection.

Over the past few decades, musculoskeletal infections have increased in both incidence and severity. The clinical manifestations of musculoskeletal infections range from isolated osteomyelitis to multisite infections with systemic complications. Although this increased incidence of musculoskeletal infections correlates with the increased incidence of methicillin-resistant Staphylococcus aureus infections, other nonresistant infectious organisms have been associated with severe musculoskeletal infections; this finding supports the likelihood that an antibiotic resistance profile is not a major factor in bacterial virulence. Instead, a multitude of virulence factors allow infectious organisms to manipulate and evade the immune response of the host. Organisms such as S aureus and Streptococcus pyogenes are able to hijack the acute phase response of the host, which allows for protected proliferation and dissemination. The serum factors produced by the acute phase response, including interleukin-6, C-reactive protein, erythrocytes/fibrinogen, and platelets, can be used to assess musculoskeletal infection severity and monitor treatment. Bacterial genome sequencing has identified virulence factors in a wide variety of clinical manifestations of musculoskeletal infections and may help identify targets for clinical therapy. Currently, however, the management of musculoskeletal infections relies on accurate organism identification and a thorough recognition of the sites of infection and the tissues that are involved. MRI aids in the localization of musculoskeletal infection and identification of sites that require surgical débridement.

Kocher Criteria Revisited in the Era of MRI: How Often Does the Kocher Criteria Identify Underlying Osteomyelitis?

BACKGROUND: The Kocher criteria are established clinical parameters that predict hip septic arthritis (SA) with a 93% or greater positive-predictive value when 3 or 4 variables are present. The incidence of osteomyelitis (OM) in these patients has not been reported. The purpose of this study is to evaluate the incidence of OM in patients who have 3 or 4 positive Kocher criteria. METHODS: A total of 71 consecutive patients (mean age, 4.7 y) treated between January 2007 and July 2013 for suspected hip SA who had 3 or 4 positive Kocher criteria were retrospectively reviewed. The Kocher criteria variables include: non-weight-bearing status, fever>38.5°C, white blood cell>12 K, and erythrocyte sedimentation rate>40 mm/h. All patients underwent ultrasound (US) and magnetic resonance imaging as part of their workup. RESULTS: There were a total of 71 patients with 3 or 4 positive Kocher criteria. Of these, 22.5% (n=16) had a diagnosis of SA and 47.9% (n=34) had a diagnosis of OM. Of the 71 patients, 52.1% (37/71) had a hip effusion on US. When an effusion was identified, 18.9% (7/37) had isolated SA, 18.9% (7/37) had isolated OM, and 24.3% (9/37) had combined SA and OM. When no effusion was identified, a total of 18/34 (52.9%) had underlying OM. CONCLUSIONS: Patients with 3 or 4 Kocher criteria have a high incidence (47.9%) of OM. Even in patients with a hip effusion on US, the incidence of OM was equal to that of SA. These results suggest that the combination of Kocher criteria and US alone is not sufficient to make a diagnosis in patients presenting with hip irritability and consideration should be given to adding magnetic resonance imaging to their workup. LEVEL OF EVIDENCE: Level III-retrospective chart review.