Descriptive Epidemiology of Isolated Distal Radius Fractures in Children: Results From a Prospective Multicenter Registry.

INTRODUCTION: More than 1 in 4 pediatric fractures involves the distal radius. Most prior epidemiologic studies are limited to retrospective, single center investigations, and often include adults. This study aims to describe the contemporary epidemiology of pediatric distal radius fractures using prospectively collected data from a multicenter Pediatric Distal Radius Fracture Registry. METHODS: Patients aged 4 to 18 years diagnosed with a distal radius fracture from June 2018 through December 2019 at 4 tertiary care pediatric centers were screened and enrolled in this prospective longitudinal cohort study. Patients were excluded if they presented with bilateral distal radius fractures, polytrauma, or re-fracture. Demographic information, mechanism of injury, fracture characteristics, associated injuries, and procedural information were recorded. All radiographs were reviewed and measured. Descriptive statistics and bivariate analyses were performed. RESULTS: A total of 1951 patients were included. The mean age was 9.9±3.3 years, and 61.3% of patients were male ( P <0.001). Most injuries occurred during a high-energy fall (33.5%) or sports participation (28.4%). The greatest proportion of fractures occurred during the spring months (38.5%). Torus fractures (44.0%) were more common than bicortical (31.3%) or physeal (21.0%) fractures. Of the physeal fractures, 84.3% were Salter-Harris type II. Associated ulnar fractures were observed in 51.2% of patients. The mean age at injury was higher for patients with physeal fractures (11.6±2.9 y) than patients with torus or bicortical fractures (9.4±3.1 and 9.6±3.1 y, respectively; P <0.001). Thirty-six percent of distal radius fractures underwent closed reduction and 3.3% underwent surgical fixation. Patients treated with closed reduction were more likely to be male (68.7% vs. 57.2%; P <0.001), obese (25.3% vs. 17.2%; P <0.001), and have bicortical fractures (62.2% vs. 14.5%; P <0.001). CONCLUSIONS: Distal radius fractures in children have a male preponderance and are most likely to occur in the spring months and during high-energy falls and sports. Physeal fractures tend to occur in older children while torus and bicortical fractures tend to occur in younger children. LEVEL OF EVIDENCE: Level I-prognostic.

Prospective Evaluation of Tarsal Coalition Excision Show Significant Improvements in Pain and Function.

BACKGROUND: Excision of pediatric tarsal coalition has been successful in most patients. However, some patients have ongoing pain after coalition excision. This study prospectively assessed patient-based clinical outcomes before and after surgical excision of tarsal coalition, with particular emphasis on comparison to radiologic imaging. METHODS: We prospectively studied 55 patients who had symptomatic coalition excision for 2 years postoperatively. Patients filled out the modified American Orthopaedic Foot and Ankle Society score, the University of California Los Angeles activity score, and the simple question "does foot pain limit your activity" at 4 different time points: preoperative, 6 months postoperative, 12 months postoperative, and 24 months postoperative. Comparisons were done utilizing patient demographics, imaging parameters, and patient-reported outcomes. RESULTS: Compared with preoperative levels, patients showed improvements in all outcome parameters. Patients with calcaneonavicular coalitions showed initial rapid improvement with later slight decline, while patients with talocalcaneal coalitions showed more steady improvement; both were similar at 2 years postoperatively. CONCLUSIONS: This prospective study demonstrated remarkable clinical improvements after tarsal coalition excision regardless coalition type, though postoperative courses differed between calcaneonavicular and talocalcaneal types. Finally, a subset of patients has ongoing activity limiting foot pain after coalition excision which could not be explained by the data in this study. LEVEL OF EVIDENCE: Level II-prospective cohort study.

What Is New in Pediatric Bone Health.

BACKGROUND: This review paper aims to report on the last 5 years of relevant research on pediatric bone health in regard to nutrition and obesity, ethnic disparities, common orthopaedic conditions, trauma, spine, and sports medicine. METHODS: A search of the PubMed database was completed using the following terms: bone health, Vitamin D, pediatric, adolescent, sports medicine, fractures, spine, scoliosis, race, ethnicity, obesity, Slipped Capital Femoral Epiphysis, Osteogenesis Imperfecta, Duchenne's Muscular Dystrophy, neuromuscular, and cancer. Resultant papers were reviewed by study authors and determined to be of quality and relevance for description in this review. Papers from January 1, 2015 to August 31, 2020 were included. RESULTS: A total of 85 papers were selected for review. General results include 7 key findings. (1) Obesity inhibits pediatric bone health with leptin playing a major role in the process. (2) Socioeconomic and demographic disparities have shown to have a direct influence on bone health. (3) Vitamin D deficiency has been linked to an increased fracture risk and severity in children. (4) Formal vitamin D monitoring can aid with patient compliance with treatment. (5) Patients with chronic medical conditions are impacted by low vitamin D and need ongoing monitoring of their bone health to decrease their fracture risk. (6) Vitamin D deficiency in pediatrics has been correlated to low back pain, spondylolysis, and adolescent idiopathic scoliosis. Osteopenic patients with AIS have an increased risk of curve progression requiring surgery. Before spine fusion, preoperative screening for vitamin D deficiency may reduce complications of fractures, insufficient tissue repair, loosening hardware, and postoperative back pain. (7) Increasing youth sports participation has resulted in increased bone health related injuries. However, improved understanding of Relative Energy Deficiency in Sport effects on bone health has recently occurred. CONCLUSIONS: Increasing awareness of bone health issues in children will improve their recognition and treatment. Further research is needed on diagnosis, treatment, outcomes, and most importantly prevention of pediatric bone health diseases.

Epiphysiodesis for Leg Length Discrepancy: A Cost Analysis of Drill Versus Screw Technique.

Research has demonstrated similar efficacy of drill epiphysiodesis and percutaneous epiphysiodesis using transphyseal screws for the management of adolescent leg length discrepancy. A cost analysis was performed to determine which procedure is more cost-effective. Patients seen for epiphysiodesis of the distal femur and/or proximal tibia and fibula between 2004 and 2017 were reviewed. A decision analysis model was used to compare costs. Two hundred thirty-five patients who underwent either drill (155/235, 66%) or screw (80/235, 34%) epiphysiodesis were analyzed with an average age at initial procedure of 13 years (range, 8.4 to 16.7 years). There was no significant difference in average initial procedure cost or total cost of all procedures across treatment groups (n = 184). The cost difference between drill and screw epiphysiodesis is minimal. In order for screw epiphysiodesis to be cost-favored, there would need to be a significant decrease in its cost or complication rate. (Journal of Surgical Orthopaedic Advances 30(3):181-184, 2021).

Decreasing Resource Utilization Using Standardized Clinical Assessment and Management Plans (SCAMPs).

BACKGROUND: Standardized clinical assessment and management plans (SCAMPs) are a novel quality improvement initiative shown to improve patient care, diminish practice variation, and reduce resource utilization. Unlike clinical practice guidelines, a SCAMP is a flexible algorithm that undergoes iterative updates based on periodic data collection and review. We recently implemented a SCAMP for the closed treatment of pediatric torus fractures. The purpose of this study is to analyze the effect of SCAMP implementation on resource utilization, practice variability, cost of care, and outcomes. METHODS: This study was a retrospective review of prospectively collected data on 273 patients with pediatric torus fractures. The pre-SCAMP cohort included 116 subjects from 2008 to 2010. The SCAMP cohort included 157 subjects from 2011 to 2013. The pre-SCAMP cohort was treated according to the judgment of attending fellowship-trained pediatric orthopaedic surgeons. The SCAMP cohort was treated with a standardized algorithm including radiographs and splint application at initial presentation, with a single follow-up at 3 weeks. Patient demographics were analyzed to verify comparability between cohorts. Follow-up data including clinic visits, x-rays and practice variability was recorded. Costing analysis was conducted using time-derived activity-based costing methodology. Outcomes were compared using Poisson regression analysis. Incident rate ratios (IRR) with 95% confidence limits were estimated. RESULTS: No differences in clinical results were observed between the pre-SCAMP and SCAMP cohorts, and all patients demonstrated return to baseline activity at final follow-up. Patient demographics were comparable across cohorts. The SCAMP cohort had a 48% reduction in clinic visits [IRR, 0.52; 95% confidence interval (CI), 0.44-0.60; P<0.001], 60% reduction in x-rays (IRR, 0.40; CI, 0.33-0.47; P<0.001), and a 23% reduction in x-rays per clinic visit (IRR, 0.77; 95% CI, 0.65-0.91; P<0.001). Furthermore, SCAMP implementation resulted in a 49% reduction in the overall cost of care. CONCLUSIONS: SCAMPs provide a novel alternative to CPGs to implement cost effective changes in Orthopaedic practice. For pediatric torus fractures, SCAMP implementation resulted in decreased practice variability, resource utilization, and overall cost of care while maintaining clinical outcomes. LEVEL OF EVIDENCE: Level 3.

Closed Versus Open Supracondylar Fractures of the Humerus in Children: A Comparison of Clinical and Radiographic Presentation and Results.

BACKGROUND: The purpose of this investigation was to compare the presentation and postoperative results of children treated for open and closed, completely displaced type III supracondylar humerus fractures (SCFs). METHODS: Thirty patients with open and 66 patients with closed, completely displaced type III SCFs were evaluated. Open fractures underwent irrigation and debridement, and all patients were treated by open or closed reduction and pin fixation. Medical records were reviewed to obtain demographic information as well as preoperative and postoperative clinical data regarding mechanism of injury, neurovascular status, associated injuries, postoperative range of motion, infections, and pain. Radiographs were evaluated to quantify displacement, Baumann's angle, humeral capitellar angle, position of the anterior humeral line, and adequacy of reduction. Outcomes were assessed using Flynn criteria. Mean clinical follow-up for the open and closed fracture groups was 8.9 and 5.7 months, respectively. RESULTS: Both groups were similar with respect to age, sex distribution, weight and body mass index, laterality of involvement, and mechanism of injury. At presentation, 35% of closed SCFs and 23% of open SCFs presented with abnormal neurovascular status. There was a higher prevalence of diminished/absent pulses or distal limb ischemia in patients with open injuries (27%) compared with closed fractures (18%). Conversely, severely displaced closed fractures were more commonly associated with nerve injury/palsy at presentation (35%) than those with open fractures (23%). Spontaneous nerve recovery was seen in 87% within 3 to 6 months. Postoperative loss of reduction and malunion were more common in the closed fracture group. However, 84% of patients achieved good-to-excellent results by Flynn criteria, with no appreciable difference based upon open versus closed fractures. CONCLUSIONS: With timely wound and fracture treatment, the clinical and radiographic results of children treated for open SCFs is similar to those with closed type III injuries, with little increased risk for infection, malunion, or neurovascular compromise. LEVEL OF EVIDENCE: Level III.

Reducing the Incidence of Cast-related Skin Complications in Children Treated With Cast Immobilization.

BACKGROUND: Cast immobilization remains the mainstay of pediatric orthopaedic care, yet little is known about the incidence of cast-related skin complications in children treated with cast immobilization. The purposes of this quality improvement project were to: (1) establish a baseline rate of cast-related skin complications in children treated with cast immobilization, (2) identify trends in children who experienced cast-related skin complications, (3) design an intervention aimed at decreasing the rate of cast-related skin complications, and (4) determine the effectiveness of the intervention. METHODS: A prospective interrupted time-series design was used to determine the incidence of cast-related skin complications overtime and compare the rates of skin complications before and after an intervention designed to decrease the incidence of cast-related heel complications. All consecutive patients who were treated with cast immobilization from September 2012 to September 2014 were included. A cast-related skin complications data collection tool was used to capture all cast-related skin complications. A high rate of heel events was noted in our preliminary analysis and an intervention was designed to decrease the rate of cast-related skin complications, including the addition of padding during casting and respective provider education. RESULTS: The estimated cast-related skin events rate for all patients was 8.9 per 1000 casts applied. The rate for the total preintervention sample was 13.6 per 1000 casts which decreased to 6.6 in the postintervention sample. When examining the heel-only group, the rate was 17.1 per 1000 lower extremity casts applied in the preintervention group and 6.8 in the postintervention group. CONCLUSIONS: Incorporating padding to the heel of lower extremity cast was an effective intervention in decreasing the incidence of cast-related skin complications in patients treated with cast immobilization. LEVEL OF EVIDENCE: Level II.

Subtalar Coalitions: Does the Morphology of the Subtalar Joint Involvement Influence Outcomes After Coalition Excision?

Posteromedial subtalar (PMST) coalitions are a recently described anatomic subtype of tarsal coalitions. We compared with clinical patient-based outcomes of patients with PMST and standard middle facet (MF) coalitions who had undergone surgical excision of their coalition. The included patients had undergone surgical excision of a subtalar tarsal coalition, preoperative computed tomography (CT), and patient-based outcomes measures after surgery (including the American Orthopaedic Foot and Ankle Society [AOFAS] scale and University of California, Los Angeles [UCLA], activity score). Blinded analysis of the preoperative CT scan findings determined the presence of a standard MF versus a PMST coalition. The perioperative factors and postoperative outcomes between the MF and PMST coalitions were compared. A total of 51 feet (36 patients) were included. The mean follow-up duration was 2.6 years after surgery. Of the 51 feet, 15 (29.4%) had a PMST coalition and 36 (70.6%) had an MF coalition. No difference was found in the UCLA activity score; however, the mean AOFAS scale score was higher for patients with PMST (95.7) than for those with MF (86.5; p = .018). Of the patients with a PMST, none had foot pain limiting their activities at the final clinical follow-up visit. However, in the group with an MF subtalar coalition, 10 (27.8%) had ongoing foot pain limiting activity at the final follow-up visit (p = .024). Compared with MF subtalar tarsal coalitions, patients with PMST coalitions showed significantly improved clinical outcomes after excision. Preoperative identification of the facet morphology can improve patient counseling and expectations after surgery.

Posteromedial subtalar coalitions: prevalence and associated morphological alterations of the sustentaculum tali.

BACKGROUND: A variant form of subtalar coalition isolated to the posterior sustentaculum has been previously described, though its prevalence is not known and its relationship to the middle facet has not been characterized. OBJECTIVE: To determine the prevalence and morphological alterations of isolated posteromedial subtalar coalitions. MATERIALS AND METHODS: Computed tomography (CT) images of the foot or ankle performed from 2004 to 2012 were reviewed and 97 patients (mean age: 13.3+/-2.9 years; range: 9-19 years) with subtalar coalition were identified. In 41 (42%) of these, the condition was bilateral, yielding a total of 138 subtalar coalitions. In the 33 patients where CT demonstrated isolated posteromedial subtalar coalitions, multiplanar reformats along the long axis of the sustentaculum tali were generated, from which the anteroposterior dimensions of the sustentaculum tali and middle facet were measured. Posterior sustentaculum measurements defining the posterior extension of the sustentaculum beyond the middle facet were directly measured by two radiologists. Ratios of middle facet to posterior sustentaculum measurements were calculated. Thirty-three patients undergoing CT for ankle fracture served as controls. RESULTS: Ninety-seven of 138 coalitions (70.2%) affected the middle facet and 2/138 (1.4%) involved the posterior facet. There were 39 (28.2%) posteromedial subtalar coalitions in 33 patients. Mean AP measurements of the middle facet and posterior sustentaculum in patients with posteromedial subtalar coalitions were 12.6 mm and 18.2 mm, respectively, compared to 16.6 mm and 9.2 mm in controls (P<0.001). Mean middle facet/posterior sustenaculum (MF/PS) ratios were 0.74 for posteromedial subtalar coalitions vs. 1.92 for controls (P<0.001). CONCLUSION: Posteromedial subtalar coalitions comprise more than one-quarter of subtalar coalitions, and are associated with an intact, but shorter, middle facet and longer sustentaculum tali. This observation may aid in accurate diagnosis and management of this relatively common disorder.

Maternal cigarette, alcohol, and coffee consumption in relation to risk of clubfoot.

BACKGROUND: Clubfoot is associated with maternal cigarette smoking in several studies, but it is not clear if this association is confined to women who smoke throughout the at-risk period. Maternal alcohol and coffee drinking have not been well studied in relation to clubfoot. METHODS: The present study used data from a population-based case-control study of clubfoot conducted in Massachusetts, New York, and North Carolina from 2007 to 2011. Mothers of 646 isolated clubfoot cases and 2037 controls were interviewed about pregnancy events and exposures, including the timing and frequency of cigarette smoking, alcohol intake, and coffee drinking. RESULTS: More mothers of cases than controls reported smoking during early pregnancy (28.9% vs. 19.1%). Of women who smoked when they became pregnant, those who quit in the month after a first missed period had a 40% increase in clubfoot risk and those who continued to smoke during the next 3 months had more than a doubling in risk, after controlling for demographic factors, parity, obesity, and specific medication exposures. Adjusted odds ratios for women who drank >3 servings of alcohol or coffee per day throughout early pregnancy were 2.38 and 1.77, respectively, but the numbers of exposed women were small and odds ratios were unstable. CONCLUSIONS: Clubfoot risk appears to be increased for offspring of women who smoke cigarettes, particularly those who continue smoking after pregnancy is recognisable, regardless of amount. For alcohol and coffee drinkers, suggested increased risks were only observed in higher levels of intake.

Patient-reported Outcomes of Tarsal Coalitions Treated With Surgical Excision.

PURPOSE: There are little patient-reported data on functional outcomes of tarsal coalition resection in children and adolescents. The purpose of this study is to evaluate the medium-term (>2 y) outcomes in patients who have had surgical excision of their symptomatic tarsal coalition and to compare patient-based outcomes in patients who have calcaneonavicular (CN) coalitions to those with talocalcaneal (TC) coalitions. METHODS: A billing query was conducted to identify patients who had surgical excision of their tarsal coalition between 2003 and 2008. Eligible patients were mailed questionnaires consisting of a modified American Orthopaedic Foot and Ankle Society (AOFAS) score and the University of California at Los Angeles (UCLA) activity scale. Patients were also specifically asked if their activity level was limited by their foot pain. Only patients who returned questionnaires were included. Demographics and diagnostic images were reviewed. A nonresponder analysis was completed. Complications such as infection and reoperation were reported. RESULTS: Sixty-three patients (22 females, 41 males) who returned questionnaires were included in the analysis. Twenty-four patients had bilateral surgery. TC coalitions were present in 20 patients (32%); CN coalitions were present in 43 patients (68%).Overall, mean modified AOFAS score was 88.3 and mean UCLA activity score was 8.33 at an average of 4.62 years after surgery. Patients who had TC coalitions had similar modified AOFAS scores (88.4) and UCLA activity scores (8.4) when compared with those with CN coalitions (88.0 and 8.3, both not significant).Of the 73% (46/63) patients who reported that their activity levels were not limited by their foot pain, the mean AOFAS score was 93.9 and the mean UCLA activity score was 8.9; 32 of these were CN and 14 were TC coalitions. Of the 27% (17/63) patients who reported that their activity levels were limited by their foot pain, the mean AOFAS score was 72.9 and the mean UCLA activity score was 6.9; 11 of these were CN and 6 were TC coalitions. There was a statistically significant difference in these groups both in modified AOFAS score (P<0.0001) and UCLA activity score (P=0.006). There was no difference in outcomes between those who were treated for a TC and CN coalition. CONCLUSIONS: Patient-reported outcomes after surgical excision of tarsal coalition reveal that >70% of patients' activities are not limited by pain and their functional outcome is terrific. A few patients continue to have problems with ongoing foot pain and activity limitations. The type of coalition does not seem to be an indicative factor in determining outcome.

Likelihood of surgery in isolated pediatric fifth metatarsal fractures.

BACKGROUND: Fractures of the fifth metatarsal bone are common and surgery is uncommon. The "Jones" fracture is known to be in a watershed region that often leads to compromised healing, however, a "true Jones" fracture can be difficult to determine, and its impact on healing in pediatric patients is not well described. The purpose of this study was to retrospectively assess patterns of fifth metatarsal fracture that led to surgical fixation in an attempt to predict the likelihood for surgery in these injuries. METHODS: A retrospective review was performed on patients aged 18 and under who were treated for an isolated fifth metatarsal fracture from 2003 through 2010 at our pediatric hospital. Patient demographics, treatment, and complications were noted. Radiographs were reviewed for location of fracture and fracture displacement. Patients and fracture characteristics were then compared. RESULTS: A total of 238 fractures were included and 15 were treated surgically. Most surgical indications were failure to heal in a timely manner or refracture and all patients underwent a trial of nonoperative treatment. Jones criteria for fracture location were predictive of needing surgery (P<0.01) but confusing in the clinic setting. Fractures that occurred between 20 and 40 mm (or 25% to 50% of overall metatarsal length) from the proximal tip went on to surgery in 18.8% (6/32) of the time, whereas those that occurred between <20 mm had surgery in 4.9% (9/184). This was a statistically significant correlation (P=0.0157). CONCLUSIONS: Although fractures of the fifth metatarsal are common, need for surgery in these fractures is not. However, a region of this bone is known to have trouble healing, and it can be difficult to identify these "at-risk" fractures in the clinical setting. We found simple ruler measurement from the proximal tip of the fifth metatarsal to the fracture to help determine this "at-risk" group and found a significant difference in those patients with a fracture of <20 mm compared with those 20 to 40 mm from the tip; this can help guide treatment and counsel patients. LEVEL OF EVIDENCE: Level 3.

Medication use in pregnancy in relation to the risk of isolated clubfoot in offspring.

Clubfoot, a common major structural malformation, develops early in gestation. Epidemiologic studies have identified higher risks among boys, first-born children, and babies with a family history of clubfoot, but studies of risks associated with maternal exposures are lacking. We conducted the first large-scale, population-based, case-control study of clubfoot with detailed information on maternal medication use in pregnancy. Study subjects were ascertained from birth defect registries in Massachusetts, New York, and North Carolina during 2007-2011. Cases were 646 mothers of children with clubfoot without other major structural malformations (i.e., isolated clubfoot); controls were mothers of 2,037 children born without major malformations. Mothers were interviewed within 12 months of delivery about medication use, including product, timing, and frequency. Odds ratios were estimated for exposure to 27 medications in pregnancy months 2-4 after adjustment for study site, infant sex, first-born status, body mass index (weight (kg)/height (m)(2)), and smoking. Odds ratios were less than 1.20 for 14 of the medications; of the remainder, most odds ratios were only slightly elevated (range, 1.21-1.66), with wide confidence intervals. The use of antiviral drugs was more common in clubfoot cases than in controls (odds ratio = 4.22, 95% confidence interval: 1.52, 11.73). Most of these results are new findings and require confirmation in other studies.

Prenatal screening for clubfoot: what factors predict prenatal detection?

OBJECTIVE: Routine prenatal ultrasound has often resulted in the early detection of musculoskeletal disorders. The purpose of this study was to determine which socioeconomic factors are associated with prenatal detection of clubfoot. METHODS: The Slone Epidemiology Center at Boston University identified infants in three states (Massachusetts, New York, and North Carolina) who were reported as having a clubfoot. Mothers of these children were contacted and interviewed, and medical records obtained. Data were analyzed by using logistic regression to estimate odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: Overall detection of the clubfoot prenatally was 62.3% (421/676) but this varied considerably by state, 81.1% in Massachusetts (154/190), 58.5% in New York (124/212), and 52.2% in North Carolina (143/274). Multivariate analysis revealed that the strongest predictors for prenatal detection were maternal age ≥35 years (OR: 3.54), non-Hispanic black race (OR: 0.49), the presence of another birth defect (OR: 2.61), residing in Massachusetts (OR: 2.64), and the presence of a bilateral clubfoot (OR: 1.90). CONCLUSIONS: We found a statistically significantly higher rate of prenatal detection of clubfoot in Massachusetts and lower rate in younger mothers (age <35) and black mothers, even after adjustment for other sociodemographic variables.

Displaced intra-articular fractures of the great toe in children: intervene with caution!

BACKGROUND: Intra-articular fractures of the proximal phalanx of the great toe in children are extremely rare and sparsely reported in the literature. We have noted a series of these fractures at our institution. The purpose of this report is to present a retrospective case series of children with intra-articular fractures managed operatively in order to highlight the inherent difficulties in managing these fractures. METHODS: Operative notes and billing records were searched from 2001 to 2011 to identify all children aged 18 years or younger who underwent surgical intervention for an intra-articular fracture of the proximal phalanx of the great toe. Charts and imaging studies were retrospectively reviewed to identify the mechanism of injury, fracture classification, operative details, clinical results, and complications. RESULTS: Seven boys and 3 girls with a mean age of 12.6 years (range, 8.7 to 15.7 y) were identified. The mechanism of injury was a direct blow from a stubbed toe (8 cases) or a dropped object onto the foot (2 cases). There were 7 intra-articular fractures of the proximal phalanx base, 4 of which occurred in the setting of an open physis. Mean fracture displacement was 4.4 mm. Open reduction was necessary in 9 cases, with K-wire fixation used in 9 cases. Median follow-up was 50.5 months (range, 11 to 123 mo). Seven fractures healed at a mean of 7.9 weeks. Nine patients returned to full activity without limitation at latest follow-up. Six patients had significant complications: 2 underwent revision open reduction internal fixation (one for postoperative redisplacement and the other for painful nonunion), 1 suffered a refracture, 1 developed posttraumatic arthritis requiring interphalangeal joint fusion, 1 developed an asymptomatic fibrous nonunion with avascular necrosis of the fragment, and 1 had K-wire migration necessitating early surgical removal. CONCLUSIONS: Intra-articular fractures of the great toe primarily occur in adolescents after direct impact injuries. The most common location was the proximal phalangeal base. There is a high complication rate after surgical intervention, although most patients were asymptomatic at latest follow-up. LEVEL OF EVIDENCE: IV (retrospective case series).

Satisfactory patient-based outcomes after surgical treatment for idiopathic clubfoot: includes surgeon's individualized technique.

INTRODUCTION: Treatment of idiopathic clubfoot has shifted towards Ponseti technique, but previously surgical management was standard. Outcomes of surgery have varied, with many authors reporting discouraging results. Our purpose was to evaluate a single surgeon's series of children with idiopathic clubfoot treated with a la carte posteromedial and lateral releases using the Pediatric Outcomes Data Collection Instrument (PODCI) with a minimum of 2-year follow-up. METHODS: A total of 148 patients with idiopathic clubfoot treated surgically by a single surgeon over 15 years were identified, and mailed PODCI questionnaires. Fifty percent of the patients were located and responded, resulting in 74 complete questionnaires. Median age at surgery was 10 months (range, 5.3 to 84.7 mo), male sex 53/74 (71.6%), bilateral surgery 31/74 (41.9%), and average follow-up of 9.7 years. PODCI responses were compared with previously published normal healthy controls using t test for each separate category. Included in the methods is the individual surgeon's operative technique. RESULTS: In PODCIs where a parent reports for their child or adolescent, there was no difference between our data and the healthy controls in any of the 5 categories. In PODCI where an adolescent self-reports, there was no difference in 4 of 5 categories; significant difference was only found between our data (mean = 95.2; SD = 7.427) and normal controls (mean = 86.3; SD = 12.5) in Happiness Scale (P = 0.0031). DISCUSSION: In this group of idiopathic clubfoot patients, treated with judicious posteromedial release by a single surgeon, primarily when surgery was treatment of choice for clubfoot, patient-based outcomes are not different from their normal healthy peers through childhood and adolescence. While Ponseti treatment has since become the treatment of choice for clubfoot, surgical treatment, in some hands, has led to satisfactory results. LEVEL OF EVIDENCE: Level III.

PedsQL correlates to PODCI in pediatric orthopaedic outpatient clinic.

PURPOSE: Quality-of-life (QOL) measures can be a valuable tool to assess the general welfare across a spectrum of patients in a pediatric orthopaedic outpatient clinic and can be a simple way to assess patient-based outcomes particularly for quality initiatives. The Pediatric Outcomes Data Collection Instrument (PODCI) is validated for many orthopaedic conditions but typically takes around 20 minutes to complete (86 questions). The Pediatric Quality of Life Inventory (PedsQL) takes <4 minutes to complete (23 questions) but has not been assessed in an orthopaedic setting. We initiated this study to find the best method for assessing QOL in our outpatient clinic. A short pediatric QOL measure that is correlated to an established orthopaedic-specific QOL measure is needed; therefore, we compared the PedsQL to the PODCI in the outpatient orthopaedic clinic. METHODS: This was a quality initiative project and as such did not require a priori IRB approval. Families of patients 2 to 18 years old who presented for follow-up after upper or lower extremity fractures or brachial plexus injuries in the orthopaedic clinic from October 2010 through August 2011 were asked to fill out both the PODCI and the PedsQL. Patients aged 5 years and older filled out a patient-report PedsQL; patients aged 11 years and older filled out the patient-report PODCI. Parents/guardians completed questionnaires for children of all ages. Most fracture patients (and/or their parent/guardian) repeated the questionnaires after 6 to 12 weeks. Data were then assessed for correlation between the PODCI and PedsQL. RESULTS: A total of 428 parent/guardian reports for 283 patients and 172 self-reports for 104 patients were included. The correlation between the PODCI Global score and the PedsQL Total score for the parent/guardian-reported questionnaires for all injuries was 0.77 (95% confidence interval, 0.72-0.82). When categorized within domains and injuries, parent/guardian-reported correlations ranged from 0.23 to 0.79. In patients aged 11 years and older, the correlation between the PODCI and PedsQL for the patient-reported questionnaire for all injuries was 0.85 (95% confidence interval, 0.80-0.89). When categorized within domains and injuries, patient-reported correlations ranged from 0.30 to 0.99. CONCLUSIONS: Utilizing the substantially shorter PedsQL in a high volume orthopaedic clinic as a substitute for the PODCI for quality improvement measures seems reasonable. Correlation between the PedsQL Global score and the PODCI Total score for orthopaedic patients is strong. Utilizing the patient-reported questionnaires when age appropriate is best. In this era of increased outcome reporting, PedsQL may be a valuable tool.

Descriptive epidemiology of idiopathic clubfoot.

Clubfoot is a common structural malformation, occurring in approximately 1/1,000 live births. Previous studies of sociodemographic and pregnancy-related risk factors have been inconsistent, with the exception of the strong male preponderance and association with primiparity. Hypotheses for clubfoot pathogenesis include fetal constraint, Mendelian-inheritance, and vascular disruption, but its etiology remains elusive. We conducted a population-based case-control study of clubfoot in North Carolina, Massachusetts, and New York from 2007 to 2011. Mothers of 677 clubfoot cases and 2,037 non-malformed controls were interviewed within 1 year of delivery about socio-demographic and reproductive factors. Cases and controls were compared for child's sex, maternal age, education, cohabitation status, race/ethnicity, state, gravidity, parity, body mass index (BMI), and these pregnancy-related conditions: oligohydramnios, breech delivery, bicornuate uterus, plural birth, early amniocentesis (<16 weeks), chorionic villous sampling (CVS), and plural gestation with fetal loss. Odds ratios (ORs) and 95% confidence intervals (CIs) were adjusted for state. Cases were more likely to be male (OR: 2.7; 2.2-3.3) and born to primiparous mothers (1.4; 1.2-1.7) and mothers with BMI ≥30 kg/m(2) (1.4; 1.1-1.8). These associations were greatest in isolated and bilateral cases. ORs for the pregnancy-related conditions ranged from 1.3 (breech delivery) to 5.6 (early amniocentesis). Positive associations with high BMI were confined to cases with a marker of fetal constraint (oligohydramnios, breech delivery, bicornuate uterus, plural birth), inheritance (family history in 1st degree relative), or vascular disruption (early amniocentesis, CVS, plural gestation with fetal loss). Pathogenetic factors associated with obesity may be in the causal pathway for clubfoot.

Is it worthwhile to routinely ultrasound screen children with idiopathic clubfoot for hip dysplasia?

PURPOSE: Patients with idiopathic clubfoot are considered at increased risk for having developmental dysplasia of the hips (DDH). However, the studies showing this association have been relatively small. Many clinicians who treat idiopathic clubfoot routinely screen the hips of these patients with ultrasound or radiograph due to the concerns of increased risk of DDH. We evaluated a large clubfoot population to determine the risk of DDH and compare this to a population of children without clubfoot. We also evaluated if the clubfoot patients found to have DDH would have been discovered by standard DDH screening. METHODS: We identified infants in 3 states (MA, NY, NC), who were reported to each state's birth defects registry as having a clubfoot. A second cohort of infants without clubfoot was also identified as a control group. Mothers of these children were contacted to be included in the study, and a computer-assisted telephone interview was administered by one of the study nurses, including questions about treatment of DDH. The child's median age at interview was 7 months. Mothers of clubfoot cases were also contacted for follow-up at mean age of 3.3 years. RESULTS: Families of 677 patients with clubfoot and 2037 controls were interviewed. A total of 5/677 (0.74%) patients with clubfoot and 5/2037 (0.25%) controls reported having their infant treated with a brace or harness for hip problems (P=0.134). Of the patients with clubfoot, 2 of them did not need treatment for their DDH and 2 would have been discovered by standard hip screening. Follow-up study at 3.3 years of age found no serious late hip dysplasia. CONCLUSIONS: Treatment of DDH was uncommon in all children; the higher proportion in infants with clubfoot was not statistically different than controls. Of the patients with clubfoot and DDH, standard hip screening would have been appropriate and others did not need treatment. These data suggest that routine hip ultrasound or radiographic screening of idiopathic clubfoot patients is not necessary unless indicated by the standard infant hip screening. LEVEL OF EVIDENCE: Level 3 study.

Prospective evaluation of a prenatal sonographic clubfoot classification system.

BACKGROUND: The purpose of this study was to prospectively evaluate our recently described fetal sonographic classification system for prenatal diagnosis of clubfoot. METHODS: Over 18 months, we prospectively enrolled consecutive pregnant patients evaluated for a prenatally diagnosed clubfoot. Prenatal sonographic scores assigned by a radiologist were compared to final clinical diagnosis and severity given by a pediatric orthopedic surgeon. Pearson's χ(2) test and logistic regression were used in statistical analyses on the subject level. Generalized estimating equations were used in analyses on the foot level to account for intrasubject correlation. RESULTS: There were 50 subjects, with 26 unilateral and 24 bilateral clubfeet, according to the prenatal ultrasound (US). A total of 51 (69%) of 74 feet and 36 (72%) of 50 subjects had a postnatal diagnosis of clubfoot. The accuracy of diagnosis in cases of a severe, moderate, and mild US score was 94, 70, and 25%, respectively (p = 0.003 comparing moderate-severe vs. mild). US severity correlated with the Dimeglio classification scoring system (Spearman's correlation 0.30). CONCLUSION: The fetal sonographic scoring system is predictive of clinical severity after birth, and improves the ability to counsel families with a prenatal diagnosis of clubfoot.