Epidemiology of Physeal Fractures and Clinically Significant Growth Disturbances Affecting the Distal Tibia, Proximal Tibia, and Distal Femur: A Retrospective Cohort Study.

INTRODUCTION: Childhood fractures involving the physis potentially result in premature physeal closure that can lead to growth disturbances. Growth disturbances are challenging to treat with associated complications. Current literature focusing on physeal injuries to lower extremity long bones and risk factors for growth disturbance development is limited. The purpose of this study was to provide a review of growth disturbances among proximal tibial, distal tibial, and distal femoral physeal fractures. METHODS: Data were retrospectively collected from patients undergoing fracture treatment at a level I pediatric trauma center between 2008 and 2018. The study was limited to patients 0.5 to 18.9 years with a tibial or distal femoral physeal fracture, injury radiograph, and appropriate follow-up for determination of fracture healing. The cumulative incidence of clinically significant growth disturbance (CSGD) (a growth disturbance requiring subsequent physeal bar resection, osteotomy, and/or epiphysiodesis) was estimated, and descriptive statistics were used to summarize demographics and clinical characteristics among patients with and without CSGD. RESULTS: A total of 1,585 patients met the inclusion criteria. The incidence of CSGD was 5.0% (95% confidence interval, 3.8% to 6.6%). All cases of growth disturbance occurred within 2 years of initial injury. The risk of CSGD peaked at 10.2 years for males and 9.1 years for females. Complex fractures that required surgical treatment, distal femoral and proximal tibial fractures, age, and initial treatment at an outside hospital were significantly associated with an increased risk of a CSGD. DISCUSSION: All CSGDs occurred within 2 years of injury, indicating that these injuries should be followed for a period of at least 2 years. Patients with distal femoral or proximal tibial physeal fractures that undergo surgical treatment are at highest risk for developing a CSGD. LEVEL OF EVIDENCE: Level III Retrospective Cohort Study.

Outcomes of displaced adolescent distal third tibia fractures: can we do better?

Because adolescent distal third tibia fractures pose treatment challenges, we aimed to identify factors predictive of failure among common treatment methods: casting without manipulation, closed reduction and casting (CRC) and open treatment. Among displaced fractures, we compared outcomes between CRC versus open treatment. Skeletally immature individuals (10-17 years) with extra-articular distal third tibia fractures at a level 1 trauma center (2011-2017) were retrospectively reviewed. Patient demographics, injury and treatment characteristics and complications were recorded. Radiographs were evaluated for unacceptable alignment (angulation >5°, translation >50%, and shortening >1 cm) and time to union. Of 140 individuals, casting was the most common treatment method (n = 81), followed by CRC under anesthesia/sedation (n = 38), and open treatment (n = 34). For fractures casted without manipulation, increased fracture severity based upon our novel grading system [hazard ratio (HR): 10.5, 95% CI, 4.2-27.5, P < 0.0001] was significantly related to treatment failure. Outcomes for a selected group of 47 initially displaced fractures (33 CRC and 14 open treatments) were evaluated. For CRC, 9 (27.3%) healed with malunion and 6 (18.2%) failed initial CRC, resulting in a treatment failure rate of 36.7%. For open treatment, 2 (14.3%) underwent hardware removal, 2 (14.3%) healed with malunion and one developed infection requiring reoperation. No fractures healed with malunion required surgical correction during the study period. The odds of persistent malalignment in CRC was 3.77 [95% CI, 0.44-32.60, P = 0.2274] times open treatment. Adolescent minimally displaced distal tibial fractures can undergo successful treatment with casting. However, displaced fractures have a higher chance of short-term failure with CRC. Close monitoring of displaced fractures in the adolescent is essential during conservative management.

A 3D printed mimetic composite for the treatment of growth plate injuries in a rabbit model.

Growth plate injuries affecting the pediatric population may cause unwanted bony repair tissue that leads to abnormal bone elongation. Clinical treatment involves bony bar resection and implantation of an interpositional material, but success is limited and the bony bar often reforms. No treatment attempts to regenerate the growth plate cartilage. Herein we develop a 3D printed growth plate mimetic composite as a potential regenerative medicine approach with the goal of preventing limb length discrepancies and inducing cartilage regeneration. A poly(ethylene glycol)-based resin was used with digital light processing to 3D print a mechanical support structure infilled with a soft cartilage-mimetic hydrogel containing chondrogenic cues. Our biomimetic composite has similar mechanical properties to native rabbit growth plate and induced chondrogenic differentiation of rabbit mesenchymal stromal cells in vitro. We evaluated its efficacy as a regenerative interpositional material applied after bony bar resection in a rabbit model of growth plate injury. Radiographic imaging was used to monitor limb length and tibial plateau angle, microcomputed tomography assessed bone morphology, and histology characterized the repair tissue that formed. Our 3D printed growth plate mimetic composite resulted in improved tibial lengthening compared to an untreated control, cartilage-mimetic hydrogel only condition, and a fat graft. However, in vivo the 3D printed growth plate mimetic composite did not show cartilage regeneration within the construct histologically. Nevertheless, this study demonstrates the feasibility of a 3D printed biomimetic composite to improve limb lengthening, a key functional outcome, supporting its further investigation as a treatment for growth plate injuries.

Idiopathic scoliosis: cracking the genetic code and what does it mean?

Idiopathic scoliosis is one of the most common complex genetic disorders of the musculoskeletal system. The clinical parameters relating to onset, curve progression, and severity in relation to clinical prognosis and current treatment modalities have been defined, but do not address the cause of this disorder. In an effort to define causative genetic elements, multiple studies have delineated potential genetic loci that are statistically related to idiopathic scoliosis in a variety of populations. The question remains how future genetic testing and genomic profiling may be of aid in the therapeutic algorithms related to this disorder.

Evaluation of high-risk patients undergoing spinal surgery: a matched case series.

BACKGROUND: Neuromuscular (NM) spinal deformities necessitating surgical intervention present a difficult challenge to the medical community. Underlying comorbidities lead to extended hospital stays, significant complications, and social challenges in the extensive perioperative period. In response to this problem, a therapeutic algorithm, the Care Pathway for Spinal Surgery (CAPSS) has been developed at our institution to address this complex medical issue. METHODS: In 1999, a multidisciplinary team developed a treatment protocol, CAPSS, that emphasized perioperative work up and operative scheduling under the direction of a dedicated care coordinator. A case series analysis was conducted to compare the surgical outcomes from before and after CAPSS implementation. Statistical analyses were performed on a carefully paired subset of NM patients (N=9). Outcome measures were hospital length of stay (LOS), pediatric intensive care unit LOS, number of days intubated, surgical estimated blood loss, postoperative curve magnitude, percent curve correction, and perioperative complications. RESULTS: Statistical analyses indicated that the use of CAPSS provided significant reduction in overall LOS, pediatric intensive care unit LOS, and perioperative complication rate within this patient group. CONCLUSIONS: CAPSS is an effective method to improve perisurgical care within the NM patients with spinal deformity necessitating operative stabilization. LEVEL OF EVIDENCE: III-Retrospective comparative study.

Implementation of a Ponseti Clubfoot Program Decreases Major Surgery: A Quality Improvement Initiative.

Clubfoot describes a congenital condition. If untreated, clubfoot can cause long-term functional issues. The Ponseti method is the gold-standard treatment; it emphasizes casting over surgery. We identified a high rate of major recurrence in patients with isolated clubfoot at our institution. We implemented a quality improvement intervention to address the recurrences. METHODS: We established a clubfoot program that aimed to (1) develop a standardized treatment pathway; (2) improve care team education; (3) improve coordination of care with families; and (4) improve documentation. The purpose of this study was to outline our quality improvement intervention and evaluate its success. Data were retrospectively collected from isolated clubfeet before (2003-2007, phase I) and after (2012-2014, phase II) implementation of the clubfoot program. We compared the differences in treatment and major recurrence between the 2 phases using generalized logistic or linear mixed models. Modified Poisson regression models were used to evaluate the association between provider nonadherence and recurrence. RESULTS: The pre- (phase I) and post- (phase II) implementation groups included 91 patients (131 feet) and 68 patients (101 feet), respectively. The incidence of major recurrence (odds ratio: 59.5, 95% confidence interval: 7.8-454.4, P < 0.0001) was lower during phase II compared to phase I. Nonadherence with the care pathway was associated with an increased risk of recurrence (risk ratio: 4.1, 95% confidence interval: 1.2-14.3, P = 0.0274). CONCLUSIONS: The implementation of a clubfoot program was associated with a decrease in major clubfoot surgery and improved adherence to established guidelines for clubfoot management.

Tonnis Angle and Acetabular Retroversion Measurements in Asymptomatic Hips Are Predictive of Future Hip Pain: A Retrospective, Prognostic Clinical Study.

BACKGROUND: This study evaluated the prevalence of radiographic abnormalities potentially indicative of femoroacetabular impingement on AP pelvic radiographs in asymptomatic adolescents and young adults and aimed to determine whether the abnormalities were predictive of future hip pain. METHODS: AP pelvis images from scoliosis radiographs were obtained from patients 12 to 25 years of age free of any clinical hip/lower extremity symptoms between January 2006 and September 2009. The following radiographic abnormalities were collected: lateral center-edge angle of Wiberg >40° or <25°, Tönnis angle <0° or >10°, acetabular retroversion (crossover sign with a posterior wall sign), acetabular overcoverage (crossover sign without a posterior wall sign), and anterior offset alpha angle, calculated using alpha angle of Nötzli >50°. Patients were retrospectively followed (average 3.11 years) to identify those who subsequently developed hip pain. RESULTS: Of the 233 patients (466 hips) who were asymptomatic at the time of radiographic evaluation, at least one radiographic abnormality was present in 60% (281/466) of the hips. Within that group of hips (n = 281), 69% (195/281) of hips demonstrated a single abnormality, whereas 31% (86/281) of hips were associated with multiple abnormalities. Among all hips (n = 466), a lateral center-edge angle <25° or >40° was the most common radiographic abnormality, present in 27% (127/466) of hips. Anterior offset alpha angle and acetabular overcoverage were the most common abnormalities to present together, found in 5% (25/466) of hips. In the multivariable model, a decreasing Tönnis angle (hazard ratio per 1-degree decrease: 1.25, 95% confidence interval, 1.10-1.42, P = 0.0006) and the presence of acetabular retroversion (hazard ratio: 3.55, 95% confidence interval, 1.15-10.95, P = 0.0272) were predictive of the development of future hip pain. CONCLUSIONS: Our study demonstrates a high prevalence of radiographic abnormalities indicative of femoroacetabular impingement in asymptomatic adolescents and young adults. A decrease in Tönnis angle and the presence of acetabular retroversion were predictive of future hip pain.

Pigmented villonodular synovitis in children: a report of six cases and review of the literature.

We report six children with pigmented villonodular synovitis. They ranged in age from seven to fifteen years. In four patients, the knee was involved. One patient had involvement of the ankle, and one had diffuse involvement along a metacarpal. In five cases, the diagnosis was not suspected clinically or radiographically, and the delay in making the correct diagnosis was as long as two years. Clinical diagnosis in these five patients was usually bacterial synovitis or juvenile rheumatoid arthritis. We feel that the diagnoses of pigmented villonodular synovitis should be considered in any child with chronic joint effusion.

Genetics of familial idiopathic scoliosis.

Idiopathic scoliosis in the adolescent period is a complex genetic disorder of high prevalence and extreme variability. Epidemiological approaches have confirmed the genetic basis of this disorder and have suggested multiple modes of heritability. The current challenge is to identify the genetic determinants of this condition to distinguish individuals who are at risk for severe progression. This review summarizes the literature establishing the genetic basis of this disorder. Studies focused on the identification of genes responsible for the scoliotic phenotype are reviewed, with an emphasis on recent works that have utilized contemporary strategies to isolate genes related to complex diseases. To date, molecular studies have isolated critical regions on chromosomes and X of potential importance to the etiology of scoliosis. An analysis of these works will aid in an understanding of seemingly conflicting results, and will help us determine the focus of future work.