Interobserver and Intraobserver Agreement are Unsatisfactory When Determining Abstract Study Design and Level of Evidence.

BACKGROUND: Understanding differences between types of study design (SD) and level of evidence (LOE) are important when selecting research for presentation or publication and determining its potential clinical impact. The purpose of this study was to evaluate interobserver and intraobserver reliability when assigning LOE and SD as well as quantify the impact of a commonly used reference aid on these assessments. METHODS: Thirty-six accepted abstracts from the Pediatric Orthopaedic Society of North America (POSNA) 2021 annual meeting were selected for this study. Thirteen reviewers from the POSNA Evidence-Based Practice Committee were asked to determine LOE and SD for each abstract, first without any assistance or resources. Four weeks later, abstracts were reviewed again with the guidance of the Journal of Bone and Joint Surgery (JBJS) LOE chart, which is adapted from the Oxford Centre for Evidence-Based Medicine. Interobserver and intraobserver reliability were calculated using Fleiss' kappa statistic (k). χ2 analysis was used to compare the rate of SD-LOE mismatch between the first and second round of reviews. RESULTS: Interobserver reliability for LOE improved slightly from fair (k=0.28) to moderate (k=0.43) with use of the JBJS chart. There was better agreement with increasing LOE, with the most frequent disagreement between levels 3 and 4. Interobserver reliability for SD was fair for both rounds 1 (k=0.29) and 2 (k=0.37). Similar to LOE, there was better agreement with stronger SD. Intraobserver reliability was widely variable for both LOE and SD (k=0.10 to 0.92 for both). When matching a selected SD to its associated LOE, the overall rate of correct concordance was 82% in round 1 and 92% in round 2 (P<0.001). CONCLUSION: Interobserver reliability for LOE and SD was fair to moderate at best, even among experienced reviewers. Use of the JBJS/Oxford chart mildly improved agreement on LOE and resulted in less SD-LOE mismatch, but did not affect agreement on SD. LEVEL OF EVIDENCE: Level II.

Missed Fracture Dislocation of the Fifth Toe in a Two-Year-Old Child: A Case Report.

Fracture dislocation injuries of the toes are rare among pediatric population. These injuries when acute are mostly treated conservatively and a good reduction must be ensured. We present the case of a 2-year-old girl who presented with missed chronic fracture dislocation of the proximal interphalangeal joint of the fifth toe, which was managed by open reduction and internal fixation and had a good outcome at over 1 year of follow up. We believe that this is the first case of this injury to be published in the peer-reviewed literature.

Radial Neck Fractures in Children and Adolescents: An Examination of Operative and Nonoperative Treatment and Outcomes.

BACKGROUND: Although most pediatric radial neck fractures can be treated with either immobilization alone or closed reduction and immobilization, a small subset result in permanent loss of motion despite surgical management. We sought to characterize the most problematic fractures and correlate final outcomes with both presenting fracture characteristics and the reduction achieved through surgical intervention. METHODS: One hundred ninety-three consecutive children with a radial neck fracture, satisfactory initial treatment data, and follow-up range-of-motion (ROM) data presenting between 1999 and 2012 to our level 1 trauma center were evaluated. The O'Brien classification was used to evaluate angulation on radiographs. Final ROM outcomes were categorized into excellent, good, fair, and poor. ROM data were not used in the operative group if follow-up was <12 weeks (<6 wk in the nonoperative group) or if there was no follow-up after cast removal. RESULTS: Thirteen percent of all patients presenting with radial neck fractures required operative treatment (average age 9.1 y). Of patients treated operatively with adequate ROM data, 26.4% healed with fair or poor outcomes. Patients requiring open management were of older average age (average 10 y old, P=0.02) and had a significantly greater risk of a fair or poor ROM outcome than those treated with closed operative techniques (P=0.02). Patients treated nonoperatively were of a younger average age than those in the operative cohort (8.2 vs. 9.1 y, P=0.03). Patients treated operatively were more likely to develop complications (P=0.004); however, presence of a complication was not predictive of fair or poor outcomes in either the operative (P=0.117) or nonoperative (P=0.264) groups. CONCLUSIONS: Older children are more likely to have more severely displaced radial neck fractures requiring open surgical management, thus resulting in a greater risk of fair or poor outcomes. In the series as a whole, more complications were seen when operative management was required. Final outcomes were not shown to be significantly related to preoperative displacement, postoperative reduction, presence of associated injuries, energy of injury, or treatment complications. LEVELS OF EVIDENCE: Level III­therapeutic.

Bilateral C6 spondylolysis with spondylolisthesis in 3 adolescent siblings.

BACKGROUND: Cervical spondylolysis with spondylolisthesis is a rare condition in the pediatric population. The nature of this condition and clinical presentation are important to provide appropriate management. METHODS: This is a case report of 3 adolescent siblings who had C6 cervical spondylolysis with spondylolisthesis. RESULTS: Two cases were diagnosed insidiously with absence of neurological deficits and no instability on imaging and were treated conservatively. One case had a traumatic presentation associated with instability on imaging and was managed with cervical fusion and instrumentation. All 3 patients were doing well on a follow-up of >2 years. CONCLUSIONS: These cases suggest that cervical spondylolysis could be familial. The treatment was offered based on clinical presentation and presence of instability on radiographic studies. LEVEL OF EVIDENCE: Level IV.

Posterior ankle impingement disguised as peroneal tendon subluxation in young athletes - a case report.

Posterior ankle impingement is a cause of posterior ankle pain common in those who perform frequent plantarflexion activities. Three young patients presented with posterior ankle pain which was initially attributed to peroneal tendon subluxation. However, detailed physical exam and imaging confirmed the diagnosis of posterior ankle impingement as the actual cause of pain. The peroneal tendon subluxation was not causal but an unrelated co-incidental finding. After failed prolonged conservative management (rest, immobilization and physical therapy), the patients underwent posterior ankle arthroscopic debridement for the impingement resulting in return to prior sporting activity without limitation and no recurrence of pain at 19 months follow-up. Posterior ankle impingement diagnosis could be masked by co-incidental asymptomatic peroneal tendon subluxation in pediatric patients.

Four Risk Factors for Arthrofibrosis in Tibial Spine Fractures: A National 10-Site Multicenter Study.

BACKGROUND: Tibial spine fractures (TSFs) are relatively rare pediatric injuries. Postoperative arthrofibrosis remains the most common complication, with few studies having examined factors associated with its development. PURPOSE: To identify risk factors for arthrofibrosis and required MUA or lysis of adhesions in the largest known cohort of patients with TSFs. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: This was a multicenter study of 249 patients ≤18 years old who had a TSF between January 2000 and February 2019. Patients were separated into cohorts based on whether they developed arthrofibrosis, defined as a 10° deficit in extension and/or 25° deficit in flexion at postoperative 3 months or a return to the operating room for manipulation under anesthesia (MUA) and/or lysis of adhesions. RESULTS: A total of 58 (23.3%) patients developed postoperative arthrofibrosis, with 19 (7.6%) requiring a return to the operating room for MUA. Patients with arthrofibrosis were younger (mean ± SD, 11.3 ± 2.7 vs 12.3 ± 2.8 years; P = .029). They were more likely to have a nonsport, trauma-related injury (65.4% vs 32.1%; P < .001) and a concomitant ACL injury (10.3% vs 1.1%; P = .003). Those with arthrofibrosis had longer operative times (135.0 vs 114.8 minutes; P = .006) and were more likely to have been immobilized in a cast postoperatively (30.4% vs 16.6%; P = .043). In multivariate regression, concomitant anterior cruciate ligament (ACL) injury (odds ratio [OR], 20.0; P = .001), traumatic injury (OR, 3.8; P < .001), age <10 years (OR, 2.2; P = .049), and cast immobilization (OR, 2.4; P = .047) remained significant predictors of arthrofibrosis. Concomitant ACL injury (OR, 7.5; P = .030) was additionally predictive of a required return to the operating room for MUA. CONCLUSION: Surgeons should be cognizant of arthrofibrosis risk in younger patients with concomitant ACL tears and traumatic injuries not resulting from athletics. Furthermore, postoperative immobilization in a cast should be avoided given the high risk of arthrofibrosis. Concomitant ACL injury is associated with a higher return to the operating room for MUA.

Spontaneous Hemarthrosis of the Knee - Late Complication of Flexible Femur Nailing: A Case Report.

We present a case report of acute spontaneous knee hemarthosis due to erosion of the nail through the knee joint capsule in a boy, seven months following retrograde flexible nailing for fractured femur. Careful positioning of the location of the insertion site of flexible nails and proper nail tip management are important to avoid this rare late complication.

Fibrous dysplasia of the proximal femur: surgical management options and outcomes.

PURPOSE: The management of proximal femoral deformity in fibrous dysplasia (FD) is a challenge to the orthopaedic surgeon. The purpose of this study was to analyze the various presentations of FD of proximal femur and the results of the various treatment modalities for the same. METHODS: This is a retrospective cohort study of 23 patients (24 femora) with FD who underwent surgery for the proximal femur. The study sample included 14 males, nine females. Ten patients had a monostotic disease, eight patients had polyostotic disease, and five patients had McCune-Albright syndrome. RESULTS: Group 1: shepherd crook deformity-included five patients who underwent femoral neck osteotomy. Four patients had intramedullary (IM) nailing with neck cross-pinning and all patients showed union. One patient was stabilized with external fixation, which failed. Group 2: nine patients (ten femora) presented with frank pathological fracture. Nine underwent fixation with IM nailing, one with locking plate and screws. Three patients had to undergo more than one procedure and all fractures showed good union. Group 3: nine patients who presented with bone cyst and pain. All patients underwent biopsy; four of them had curettage with bone graft. CONCLUSION: Shepherd crook deformity can be treated by a well-planned osteotomy and fixation with intramedullary implants with neck cross-pinning. Frank pathological fractures fixation with an intramedullary nail has excellent results even if not accompanied by resolution of the fibrodysplastic lesion. More than one procedure may be required. External fixation is not an optimal choice for fixation of femoral osteotomies in FD.