Ankle Mortise Instability in Multiple Hereditary Exostoses.

Ankle valgus is commonly reported in patients with multiple hereditary exostoses (MHE). We report the characteristics of mortise widening in MHE, its progression over time, and the resultant ankle pain and function at skeletal maturity. Mortise medial space (M), talocrural angle (TC), and tibiotalar angle (TT) measurements were collected on preoperative and last follow-up radiographs. Operative data and complications were recorded. American Orthopaedic Foot and Ankle Society (AOFAS) and short form-36 scores at skeletal maturity were collected. A total of 16 patients (19 ankles) had MHE and mortise widening. Thirteen patients had surgery. Preoperatively, no patient complained of instability. However, 11 ankles (57.9%) were painful and 15 (78.9%) were clinically in valgus. Patients underwent surgery at a mean age of 11.8 ± 2.2 y. Operative interventions included medial distal tibia hemiepiphysiodesis for the majority of patients. There were no statistically significant differences between pre and postoperative M, TC, TT angles. Operative patients showed an improved mean M (5.17 ± 1.17 to 4.63 ± 1.06 mm) and TT (8.71 ± 5.40° to 4.54 ±7.58°), however, neither angle reached normal values. TC representing fibular length-maintained measurements within normal limits (82.2 ± 5.3° to 84.8 ±5.8°). Questionnaires were obtained for 10 (52.6%) ankles. Mean age at questionnaires collection was 19.0 ± 3.6 y. Mean AOFAS score was 74.8 ± 17.6 out of 100. Patients scored 6.5 ± 4.1 out of 10 for alignment, 33.0 ± 6.7 out of 40 for pain, 35.3 ± 9.5 out of 50 for function. All short form-36 scores were above the national mean. Improvement of M and TT angles was modest. TC angle was within normal limits but showed an overall fibular shortening and decreased lateral buttress and potential for talar shift, as reflected in AOFAS score. The underwhelming amount of mortise widening correction achieved may not provide for a stable ankle joint.

Outcomes of MPFL Reconstruction Utilizing a Quadriceps Turndown Technique in the Adolescent/Pediatric Population.

PURPOSE: Recurrent instability following a lateral patellar dislocation is a common indication for surgical intervention. Several surgical procedures are described in the literature to address recurrent patellar instability. Medial patellofemoral ligament (MPFL) reconstruction utilizing the quadriceps turndown technique attempts to restore medial stability. Results of the quadriceps turndown technique have previously only been reported in adult populations. The purpose of this study was to assess the safety, efficacy, and patient-reported outcomes following a quadriceps turndown MPFL reconstruction in the pediatric and adolescent population. METHODS: Records of all patients who underwent MPFL reconstruction using a quadriceps turndown technique between 2011 and 2018 were reviewed for demographics, risk factors, complications, mechanism of injury, and concomitant procedures. Return to activities of daily living (ADLs), return to presurgery level of sport, length of bracing, and recurrent instability were assessed with the administration of the Kujala Anterior Knee Pain Score. All analyses were completed using IBM SPSS Statistics 26. RESULTS: Thirty-six knees [14 female (39%), 22 male (61%)] from 34 patients met inclusion/exclusion criteria. The average follow-up length was 35.9±15.2 months. The average age was 16.3±1.8 years at the time of surgery. The average time for resumption of ADLs was 8.1±6.0 weeks after surgery. Ninety-four percent of patients returned to preinjury level of sport at an average of 23.6±12.0 weeks after surgery. Mean Kujala Anterior Knee Pain Score was 90.7±10.3. Female patients (P<0.001) reported significantly lower Kujala scores. Three patients (8%) experienced recurrent instability during ADLs and an additional 4 (11%) reported subjective feelings of instability only during sport or elevated activity. One knee required a return to the operating room for irrigation and debridement due to infection. CONCLUSION: This study demonstrates that the quadriceps turndown technique for MPFL reconstruction is a safe and effective procedure for the management of recurrent patellar instability in pediatric and adolescent patients. LEVEL OF EVIDENCE: Level III-therapeutic.

Do Obese Children Have Poor Patient-reported Outcomes After Closed Reduction and Percutaneous Pin Fixation of Supracondylar Humerus Fractures?

BACKGROUND: Nearly 1 in 5 American children are obese. The primary purpose of this study is to evaluate the relationship between childhood obesity and perioperative complications, patient-reported outcomes (PRO), and functional recovery after closed reduction and percutaneous pinning (CRPP) of type II and III supracondylar humerus fractures. METHODS: Retrospective review of patients treated operatively with CRPP of Wilkins modification of the Gartland classification type II and III supracondylar humerus fractures was performed over a 1-year timeframe (July 1, 2016 to July 1, 2017). One hundred forty-four patients under the age of 16 treated were identified. Obesity was defined as body mass index (BMI) at or above the 95th percentile for age. Obesity as a risk factor for poor outcomes was assessed. The primary outcome measure was postoperative PRO [quick-DASH, Patient Reported Outcomes Measurement Information System (PROMIS)-UE, PROMIS Global Health, and PROMIS Pain scores]. RESULTS: Mean age at surgery was 5.9 years (SD=2.1, 1.07 to 12.2) and mean age at final follow-up (3.3 y) was 8.8 (SD=2.14, 4 to 16). Mean patient BMI was 17.2 (SD=4.48, 12.4 to 56.2). Sixty-six patients were female (45.8%) and 78 patients were male (54.2%). In all, 31 of 144 patients (21.5%) met criteria for obesity. Obesity (95th percentile for BMI or above) was not associated with a higher rate of complications overall (χ2=1.29, P=0.256), range of motion loss (χ2=0.2, P=0.655) or requirement of postoperative physical therapy (χ2=0.17, P=0.678). Seventy-five patients were available and willing to participate in the outcomes score assessments. Mean follow-up for this cohort of 75 patients was 3.3 years (SD=0.31, 2.85 to 3.88). There were no differences in PROMIS pain, PROMIS upper extremity function, PROMIS general health, or quick-DASH scores when comparing obese with nonobese patients. CONCLUSIONS: Obesity is a growing concern in the United States and its effect on long-term outcomes after CRPP of supracondylar humerus fractures is unknown. The present study demonstrates no difference in complications or PRO among obese patients compared with nonobese patients. LEVEL OF EVIDENCE: Level IV-retrospective cohort study.

Four-in-one Extensor Realignment for the Treatment of Obligatory or Fixed, Lateral Patellar Instability in Skeletally Immature Knee.

BACKGROUND: Congenital (fixed) and obligatory (habitual) patellar dislocations in children are a complex clinical and surgical challenge. Numerous individual surgical techniques have been described. This study aims to assess results, patient satisfaction, and complications after a combined Roux-Goldthwait procedure, vastus medialis obliquus advancement, Galeazzi procedure, and extensive, lateral release (4-in-1 extensor realignment) in the skeletally immature knee with obligatory, or fixed lateral patellar instability. METHODS: Records of children with congenital fixed or obligatory patellar instability, who underwent the 4-in-1 procedure at a single institution, were reviewed. Clinical results included ability and time for the return to activities of daily living (ADL) and sport, recurrent instability and/or dislocation, and necessity of long-term bracing. Continued pain was assessed by the Kujala Score. Complications including infection, recurrent instability, and the necessity for secondary procedures were recorded. RESULTS: A total of 34 patients (46 knees) mean age 10.3±2.4 years, underwent the 4-in-1 procedure with a mean postoperative follow-up of 51.6±31.5 (range, 12 to 146) months. Sixteen patients (22 knees) responded to a phone interview and questionnaire. All 16 patients returned to ADL in a mean time of 10.3±2.4 weeks. Ninety-one percent returned to sport in a mean time of 23.1±15.5 weeks. Long-term bracing was required for 6 knees after the surgery. The mean Kujala Score was 93.0±5.2 (range, 83 to 100). Complications included 6 of 34 patients (18%) with recurrent instability at the latest follow-up and 2 with superficial wound infection. CONCLUSIONS: Patients with obligatory or fixed lateral, patellar instability who undergo the 4-in-1 procedure have good short-term results with low complication rates. Return to ADL and sporting activity with minimal pain can be expected, usually without the need for long-term bracing. The 4-in-1 procedure is a viable option for skeletally immature patients with obligatory or fixed, lateral patellar instability. LEVEL OF EVIDENCE: Level IV-Therapeutic study.

Pediatric Medial Epicondyle Fracture Management: A Systematic Review.

BACKGROUND: There remains controversy surrounding the treatment of pediatric medial epicondyle fractures. This systematic review examines the existing literature with the aim to elucidate optimal management strategies. METHODS: A systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was executed. All data collection was completed by August 01, 2018. Functional outcomes, diagnostic imaging, athlete management, union rates, ulnar nerve symptoms, surgical methods, surgical positioning, and posttreatment protocols were categorized and recorded. Frequency-weighted mean values were calculated with associated SDs. RESULTS: Thirty-seven studies with 1022 patients met the inclusion criteria. Functional outcomes for patients were mostly good following operative and nonoperative management. The most common complication was a slight loss of elbow extension (7.6±5.9 degrees) and flexion (13.3±5.8 degrees). Operative treatment was associated with higher union rates than nonoperative management (700/725, 96% vs. 69/250, 28%; P<0.001). Standard diagnostic imaging techniques to measure displacement were unreliable with a newly proposed axial view having high inter-rater and intrarater reliability. The most common surgical method used was open reduction and internal fixation with Kirschner wires. Whereas surgical management of patients with associated ulnar nerve symptoms led to symptom resolution, nonoperative management occasionally led to the development of these symptoms. Elbow range of motion was initiated at ~2.8±1.4 (range, 0 to 8 wk) weeks after surgery and 3.4±1.2 (range, 3 to 5 wk) weeks without surgery (P<0.001). CONCLUSIONS: Although there is still no consensus on treatment of pediatric medial epicondyle fractures, both operative and nonoperative approaches result in good outcomes. LEVEL OF EVIDENCE: Level IV-therapeutic.

Differentiating stable buckle fractures from other distal radius fractures: the 1-cm rule.

BACKGROUND: Treatment pathways for isolated distal radius fractures in children are becoming more tailored to specific fracture types and include different management plans for stable buckle fractures versus potentially unstable distal radius fractures. OBJECTIVE: To propose a measurement rule to aid in differentiating stable buckle fractures from other distal radius fractures in children. MATERIALS AND METHODS: A medical record search identified 203 children with closed distal radius fractures during a 14-month period. A consensus of two senior readers served as a reference standard to distinguish buckle fractures from other distal radius fractures. We measured fracture-to-physis distance on posteroanterior (PA) and lateral radiographs for each of the isolated distal radius fractures. We analyzed diagnostic accuracy, using fracture-to-physis distance as a predictor for buckle fractures, in children ages 3-16 years. We used a receiver operating characteristic (ROC) curve to determine the cut-off values tested. RESULTS: There were 148 buckle fractures (73%) and 55 isolated potentially unstable distal radius fractures (27%). For children 7-16 years, buckle fracture-to-physis distance was <1 cm in only 1/106 (0.9%) on the PA projection and none on the lateral projection. Diagnostic accuracy for buckle fracture diagnosis was 82% using a cut-off of 14 mm (PA) and 13 mm (lateral). In children 3-6 years old, the buckle fracture-to-physis distance was <1 cm in 1/42 (2.4%) on the PA radiographs and another 1/42 (2.4%) on the lateral radiographs. Diagnostic accuracy was low for younger children for all tested distances. CONCLUSION: We propose utilizing a measurement rule to increase diagnostic accuracy for buckle fractures in children ≥7 years old. An isolated distal radius fracture in a child 7 years or older is not likely to be a buckle fracture if the fracture-to-physis distance is <1 cm.

Characterization of a robust serine protease from Bacillus subtilis K-1.

Process apt microbial proteases due to their wide range industrial applications have become the focus of intense scientific research during recent years. Considering the hostile process milieu, the proteases intended for application must be robust enough to withstand the extremes of temperature and pH, and presence of organic solvents and other potential enzyme inhibitors. Current study presents the characterization of a robust protease from a previously isolated bacterium Bacillus subtilis K-1 (BSK-1). Purification of BSK-1 protease (5.21-fold) was achieved to homogeneity by salt (ammonium sulfate) precipitation, and ion-exchange (diethyl-aminoethyl-sephadex) and size exclusion chromatography (Sephadex G-100). Molecular weight of BSK-1 protease was determined by SDS-PAGE analysis (42 kDa). Though the optimum temperature and pH for BSK-1 protease activity was 50 °C and 10, respectively, but, the protease exhibited remarkable activity and stability over elevated temperatures (60-80 °C) and a broad pH range (pH 7-11). Protease showed resistance towards several organic solvents/other potential enzyme inhibitors. Drastic activity loss in presence of phenylmethylsulfonyl fluoride indicated that the enzyme is a serine protease. Kinetic parameters (Km and Vmax ) for BSK-1 protease were found to be 0.14 mg ml-1 and 1176 mg min-1 , respectively. Putative amino acid sequence of BSK-1 protease (derived from nucleotide sequence of protease gene) suggested that the enzyme belonged to peptidases S8/S53 super family with multidomain of S8. BSK-1 protease being stable under harsh conditions may serve a model system for understanding the molecular basis of stability, and may help designing novel proteases that are suitable for industrial applications.

A Novel Approach to Synthesise a Dual-Mode Luminescent Composite Pigment for Uncloneable High-Security Codes to Combat Counterfeiting.

A strategy is demonstrated to protect valuable items, such as currency, pharmaceuticals, important documents, etc. against counterfeiting, by marking them with luminescent security codes. These luminescent security codes were printed by employing luminescent ink formulated from a cost effective dual-mode luminescent composite pigment of Gd1.7 Yb0.2 Er0.1 O3 and Zn0.98 Mn0.02 S phosphors using commercially available PVC Gold medium. In the composite, Gd1.7 Yb0.2 Er0.1 O3 and Zn0.98 Mn0.02 S account for upconversion and downconversion processes, respectively. The synthesis procedure of the composite involves the admixing of Gd1.7 Yb0.2 Er0.1 O3 nanorods and Zn0.98 Mn0.02 S phosphor, synthesised by hydrothermal and facile solid-state reaction methods, respectively. The structural, morphological, microstructural, and photoluminescent features of Gd1.7 Yb0.2 Er0.1 O3 nanorods, Zn0.98 Mn0.02 S phosphor and composite were characterised by using XRD, SEM, TEM, and photoluminescence (PL) techniques, respectively. The distribution of PL intensity of the printed pattern was examined by using confocal PL mapping microscopy. The obtained results reveal that security codes printed using ink formulated from this bi-luminescent composite pigment provide dual-stage security against counterfeiting.

Bioprocess optimization for production of thermoalkali-stable protease from Bacillus subtilis K-1 under solid-state fermentation.

Cost-effective production of proteases, which are robust enough to function under harsh process conditions, is always sought after due to their wide industrial application spectra. Solid-state production of enzymes using agro-industrial wastes as substrates is an environment-friendly approach, and it has several advantages such as high productivity, cost-effectiveness, being less labor-intensive, and less effluent production, among others. In the current study, different agro-wastes were employed for thermoalkali-stable protease production from Bacillus subtilis K-1 under solid-state fermentation. Agricultural residues such as cotton seed cake supported maximum protease production (728 U ml(-1)), which was followed by gram husk (714 U ml(-1)), mustard cake (680 U ml(-1)), and soybean meal (653 U ml(-1)). Plackett-Burman design of experiment showed that peptone, moisture content, temperature, phosphates, and inoculum size were the significant variables that influenced the protease production. Furthermore, statistical optimization of three variables, namely peptone, moisture content, and incubation temperature, by response surface methodology resulted in 40% enhanced protease production as compared to that under unoptimized conditions (from initial 728 to 1020 U ml(-1)). Thus, solid-state fermentation coupled with design of experiment tools represents a cost-effective strategy for production of industrial enzymes.

Protein-C deficiency presenting as pulmonary embolism and myocardial infarction in the same patient.

Plasma protein-C exerts anticoagulatory effects by inactivating factors V and VIII. Hereditary protein C deficiency is transmitted as an autosomal dominant disorder. Homozygous individuals usually develop purpura fulminans as newborns; heterozygous protein C-deficient individuals are at increased risk for venous thrombosis and pulmonary embolism. However, arterial thrombosis occurring as a result of congenital protein-C deficiency is still controversial. We describe a young patient with heterozygous protein-C deficiency who experienced both pulmonary embolism as well as myocardial infarction due to thrombotic occlusion without underlying major risk factors. Acute myocardial infarction in young without underlying major risk factors may be evaluated for protein c deficiency.

Killer toxin from a novel killer yeast Pichia kudriavzevii RY55 with idiosyncratic antibacterial activity.

The killer phenomenon of yeast may have technological implications in many areas like beverage fermentation, food technology, biological control in agriculture, and in medicine. In the present study the killer phenomenon in Pichia kudriavzevii (P. kudriavzevii RY55) is being reported for the first time. The P. kudriavzevii RY55 toxin exhibited excellent antibacterial activity against several pathogens of human health significance such as Escherichia coli, Enterococcus faecalis, Klebsiella sp., Staphylococcus aureus, Pseudomonas aeruginosa and Pseudomonas alcaligenes. Killer toxin was purified to homogeneity by using ammonium sulphate precipitation and ion exchange chromatography and characterized for few properties. P. kudriavzevii RY55 killer toxin may be of vast significance in the development of novel antimicrobial chemotherapeutic agents, new bio-based safer candidates for food preservation and biocontrol, and starter cultures for fermentation industries.

Primary Cutaneous Peripheral T-Cell Lymphoma-Not Otherwise Specified (pcPTCL-NOS) in Pregnancy.

A 25-year-old, 7-month pregnant woman presented with rapidly progressive multiple ulcerated nodules present for 5 months on her left thigh. The lesions began as small red-colored papules, becoming nodular within few days. Initially, she was treated with systemic antibiotics and analgesics, and later a local physician performed incision and drainage. The lesions further increased, becoming indurated and ulcerated. Two months after her delivery, the lesions had extended to the middle of the medial side of her left thigh. On admission, she had a history of fever and weight loss, but there was no trauma. She delivered a full-term healthy baby boy. Past and family history was not significant. Examination revealed 15-20 ill-defined, erythematous, immobile, and irregular nodules of varying sizes, measuring 4 × 5 cm2, and extending from the inguinal region to the middle portion on medial aspect of the left thigh (Figure 1). Some of the nodules ulcerated with yellow color discharge with crusting, attributed to secondary bacterial infection. Multiple palpable and matted inguinal lymph nodes were present in the left inguinal region.

Region-wise severity analysis of diabetic plantar foot thermograms.

OBJECTIVES: Diabetic foot ulcers (DFU) can be avoided if symptoms of diabetic foot complications are detected early and treated promptly. Early detection requires regular examination, which might be limited for many reasons. To identify affected or potentially affected regions in the diabetic plantar foot, the region-wise severity of the plantar foot must be known. METHODS: A novel thermal diabetic foot dataset of 104 subjects was developed that is suitable for Indian healthcare conditions. The entire plantar foot thermogram is divided into three parts, i.e., forefoot, midfoot, and hindfoot. The division of plantar foot is based on the prevalence of foot ulcers and the load on the foot. To classify the severity levels, conventional machine learning (CML) techniques like logistic regression, decision tree, KNN, SVM, random forest, etc., and convolutional neural networks (CNN), such as EfficientNetB1, VGG-16, VGG-19, AlexNet, InceptionV3, etc., were applied and compared for robust outcomes. RESULTS: The study successfully developed a thermal diabetic foot dataset, allowing for effective classification of diabetic foot ulcer severity using the CML and CNN techniques. The comparison of different methods revealed variations in performance, with certain approaches outperforming others. CONCLUSIONS: The region-based severity analysis offers valuable insights for targeted interventions and preventive measures, contributing to a comprehensive assessment of diabetic foot ulcer severity. Further research and development in these techniques can enhance the detection and management of diabetic foot complications, ultimately improving patient outcomes.

Reverse Dynamization Accelerates Regenerate Bone Formation and Remodeling in a Goat Distraction Osteogenesis Model.

UPDATE: This article was updated on December 20, 2023, because of previous errors, which were discovered after the preliminary version of the article was posted online. Figure 4 has been replaced with a figure that presents different p values. Also, on page 1943, the text that had read: "Quantitative microCT confirmed that the total volume of the regenerate in the RD group was much smaller compared with the SF (p = 0.06) and DF (p = 0.007) groups, although it was significantly smaller only compared with the DF group (Fig. 4-A). The total volume of the intact bone (contralateral tibia) was significantly smaller in the RD group compared with the other groups, but the RD group had values closest to those for the intact tibia. Similarly, the RD group had less bone volume compared with the SF and DF groups, and this value was significantly different from the DF group (p = 0.034; Fig. 4-B). Of the 3 groups, the RD group had vBMD that was the closest to that of intact bone. It also had significantly higher vBMD compared with the SF and DF groups (p < 0.0001 for both; Fig. 4-C).The results of torsional testing (Fig. 4-D) confirmed that the regenerate bone formed under conditions of RD was significantly stronger than that formed under SF or DF (p < 0.001 versus SF group, and p = 0.0493 versus DF group)."now reads: "Quantitative microCT confirmed that the total volume of the regenerate in the RD group was significantly smaller compared with the SF and DF groups (p < 0.01 for both groups; Fig. 4-A). The total volume of the intact bone (contralateral tibia) was significantly smaller compared with the SF and DF groups (p < 0.0001 for both). The RD group had values closest to those for the intact tibia, and this difference was not significant (Fig. 4-A). Similarly, the RD group had less bone volume compared with the SF and DF groups, and this value was significantly different from the DF group (p < 0.01; Fig. 4-B). Of the 3 groups, the RD group had vBMD that was the closest to that of intact bone, but the intact bone was significantly different compared with all of the other groups (p < 0.0001 for all groups). The RD group had significantly higher vBMD compared with the SF and DF groups (p = 0.042 and p = 0.046, respectively; Fig. 4-C).The results of torsional testing (Fig. 4-D) confirmed that the regenerate bone formed under conditions of RD was significantly stronger than that formed under SF or DF (p < 0.0001 versus SF group, and p = 0.0493 versus DF group). The intact group was significantly different compared with the SF group (p < 0.0001)."

The concept of reverse dynamization involves modifying the mechanical environment surrounding a fracture to influence the healing response. Initially, less rigid stabilization is performed to allow micromotion, encouraging cartilaginous callus formation. This is followed by a conversion to more rigid fixation to prevent the disruption of neovascularization, thereby accelerating bone healing and remodeling. The effect of reverse dynamization in distraction osteogenesis has not been studied, to our knowledge. The aim of this study was to determine whether reverse dynamization can accelerate the formation and maturation of regenerate bone in a goat distraction osteogenesis model. Midshaft tibial osteotomies were created in 18 goats and stabilized using circular external fixation. After a 5-day latency period, 4 weeks of limb distraction began to obtain a 2-cm gap; this was followed by 8 weeks of regenerate consolidation. The goats were divided into 3 groups: static (rigid) fixation (SF, n = 6); dynamic fixation (DF, n = 6), consisting of continuous micromotion using dynamizers; and reverse dynamization (RD, n = 6), consisting of initial micromotion during the distraction period using dynamizers followed by rigid fixation during the consolidation period. Healing was assessed using radiographs, micro-computed tomography, histological analysis, and mechanical testing. Radiographic evaluation showed earlier regenerate formation in the DF and RD groups compared with the SF group. After the distraction and consolidation periods were completed, the regenerate formed under the conditions of RD had less trabeculation, higher bone mineral density, and smaller total and bone volumes, and were stronger in torsion compared with the SF and DF groups. This appearance is characteristic of advanced remodeling, returning closest to the values of intact bone. The DF group also had evidence of an interzone (radiolucent fibrous zone) at the end of the consolidation period. Application of the reverse dynamization regimen during distraction osteogenesis accelerated formation, maturation, and remodeling of regenerate bone. The findings of this study have important implications in the clinical setting, as reverse dynamization may lead to shorter treatment times and potentially lower prevalence of complications for patients needing distraction osteogenesis.

Targeted Muscle Reinnervation for Limb Amputation to Avoid Neuroma and Phantom Limb Pain in Patients Treated at a Pediatric Hospital.

Amputees frequently experience chronic neuroma-related residual limb and phantom limb pain (PLP). Targeted muscle reinnervation (TMR) transfers transected nerves to nearby motor nerves to promote healing and prevent neuroma formation and PLP. The purpose of this study was to report outcomes of TMR in a series of children and young adults treated at a pediatric hospital. Methods: Patients undergoing major limb amputation with TMR were included with minimum one year follow-up and completed questionnaires. Primary clinical outcomes included incidence of symptomatic neuromas, PLP, residual limb pain, narcotic use, and neuromodulator use. A follow-up phone survey was conducted assessing five pediatric Patient Reported Outcomes Measurement Information System (PROMIS) metrics adapted to assess residual limb and PLP. Results: Nine patients (seven male and two female patients, avg. age = 16.83 ± 7.16 years) were eligible. Average time between surgery and phone follow-up was 21.3 ± 9.8 months. Average PROMIS Pediatric t-scores for measures of pain behavior, interference, quality-affective, and quality-sensory for both PLP and residual limb pain were nearly 1 standard deviation lower than the United States general pediatric population. One patient developed a symptomatic neuroma 1 year after surgery. Conclusions: Compared with an adult patient sample reported by Valerio et al, our TMR patients at Nationwide Children's Hospital (NCH) showed similar PLP PROMIS t-scores in pain behavior (50.1 versus 43.9) and pain interference (40.7 versus 45.6). Both pediatric and adult populations had similar residual limb pain including PROMIS pain behavior (36.7 adult versus 38.6 pediatric) and pain interference (40.7 adult versus 42.7 pediatric). TMR at the time of amputation is feasible, safe, and should be considered in the pediatric population.

Improving Diagnostic Accuracy for Distinguishing Buckle Fractures From Other Distal Radius Fractures in Children.

Introduction: Accurately distinguishing between stable and unstable isolated distal radius fractures (DRF) in children allows for appropriate fracture-specific treatment. Although fractures with cortical disruption, displacement, or angulation are unstable, distinguishing stable buckle fractures (BF) from more subtle potentially unstable DRF is challenging. Our quality improvement project aimed to improve radiology reporting accuracy for these subtle fractures from 23% to 90% in a large tertiary pediatric hospital. Methods: Exams with a reported isolated distal radius fracture during baseline (January-March 2016) and intervention (April 2016-June 2019) were reviewed for accuracy. We introduced 3 types of interventions: radiologist education (self-directed learning modules and individual feedback), a new standardized report template, and a measurement tool ("The 1 cm Rule"). In addition, a statistical process control chart tracked accuracy data to study process changes over time. Results: During the baseline and intervention period, 22 and 480 radiographs, respectively, had either a stable BF or a potentially unstable isolated DRF. Each intervention type created a centerline shift. Overall, reporting accuracy increased from 23% to 90%. Most reports (95%, 639/676) used the template and standard terminology for reporting DRF. Conclusions: Radiology reporting diagnostic accuracy for distinguishing between stable BF and potentially unstable DRF in children increased to 90% through education, standardized reporting, and a measurement tool to enhance radiologist performance. Our institution plans to expand fracture-specific treatment practices with improved radiology reporting accuracy, including bracing and home management of stable BF diagnosed during an acute care visit.

Influence of seasonal variability on orthopedic surgical outcomes in pediatric patients: a review of surgical site infections.

Surgical site infections (SSIs) are challenging, with highly variable reported rates for children undergoing orthopedic surgery. It has been shown in adults that there is seasonal variability in SSI rates, with peak incidences in the summer months. We reviewed 8766 pediatric orthopedic procedures completed at a quaternary children's hospital over a 43-month period. Data collected included: age, sex, BMI, season of procedure, cultures, and other variables related to risks and treatment of SSIs. Of 4875 male and 3891 female pediatric patients undergoing orthopedic procedures, 47 patients (0.54%) with an average age of 11.3 years (range: 2.0-18.6) developed an SSI. Average time between surgery and diagnosis was 27.7 ± 19.8 days. Sixty percent of SSI patients had a BMI in the 85th percentile or above, and 49% of SSI patients had a BMI above the 95th percentile. Thirty-eight patients had positive cultures, with most common infections being due to methicillin-sensitive Staphylococcus aureus in 11 (29%) cases, polymicrobial in 9 (24%), pseudomonas in 5 (13%), and coagulase-negative Staphylococcus in 5 (13%). SSI rate in winter (0.18%) was significantly lower than in autumn (0.77%, P = 0.006) and summer (0.69%, P = 0.02). The difference did not reach statistical significance from the infection rate in spring (0.53%, P = 0.06). Twenty-nine (62%) SSI cases were considered elective in nature, and the other 18 (38%) cases were for acute traumatic injuries. There is a significantly higher SSI rate in summer and autumn than winter for pediatric patients undergoing orthopedic surgeries. Most patients with SSIs were overweight or obese.