PURPOSE: Structured visual gait assessment is essential for the evaluation of pediatric patients with neuromuscular conditions. The purpose of this study was to evaluate the benefit of slow-motion video recorded on a standard smartphone to augment visual gait assessment. METHODS: Coronal and sagittal plane videos of the gait of five pediatric subjects were recorded on a smartphone, including four subjects with ambulatory cerebral palsy and one subject without gait pathology. Twenty-one video scorers were recruited and randomized to evaluate slow-motion or normal-speed videos utilizing the Edinburgh Visual Gait Score. The slow-motion group (N = 11) evaluated the videos at one-eighth speed, and the normal-speed group (N = 10) evaluated the same videos at normal speed. Interrater reliabilities were determined by calculating intraclass correlation coefficients for each group as a whole, for each Edinburgh Visual Gait Score item, and after stratification by evaluator experience level. RESULTS: The slow-motion group exhibited an intraclass correlation coefficient of 0.65 (95% confidence interval: 0.58-0.73), whereas the normal-speed group exhibited an intraclass correlation coefficient of 0.57 (95% confidence interval: 0.49-0.65). For less-experienced scorers, intraclass correlation coefficients of 0.62 (95% confidence interval: 0.53-0.71) and 0.50 (95% confidence interval: 0.40-0.59) were calculated for slow motion and normal speed, respectively. For more-experienced scorers, intraclass correlation coefficients of 0.69 (95% confidence interval: 0.61-0.76) and 0.67 (95% confidence interval: 0.58-0.75) were calculated for slow motion and normal speed, respectively. CONCLUSIONS: Visual gait assessment is enhanced by the use of slow-motion smartphone video, a tool widely available throughout the world with no marginal cost. LEVEL OF EVIDENCE: level I, randomized study.

The Baumann angle of the humerus has been commonly used as an outcome measure for supracondylar fractures in children. However, there is limited or no information about the reliability of this measurement. The purpose of this study was to determine the inter-observer reliability (IEOR) and intra-observer reliability (IAOR) of the Baumann angle of the humerus. The Baumann angle of the humerus was measured by five observers on the anteroposterior radiographs of 35 children’s elbows, all of which had sustained a nondisplaced supracondylar humeral fracture. The values of IEOR and IAOR were calculated using a Pearson coefficient of correlation. Ranges of differences in the measurement of the Baumann angle of the humerus were established, and the percentage of agreement between observers was then calculated using those ranges. The Baumann angle of the humerus is a simple, repeatable and reliable measurement that can be used for the determination of the outcome of supracondylar humeral fractures in the paediatric population. An excellent IEOR was found for the measurement of the Baumann angle (r = 0.78, p = 0.0001). When the difference between observers in the reported measurement of the Baumann’s angle was calculated to be within seven degrees of each other, at least four of the five observers agreed 100% of the time. Similarly, excellent values of IAOR were found for the measurement of the Baumann’s angle (r = 0.80, p = 0.0001). Level of evidence for this study was III.

Background

Pediatric musculoskeletal (MSK) infections broadly include isolated osteomyelitis (OM), septic arthritis (SA), and combined infections (OM+SA). These diagnoses are often monitored with serum inflammatory markers and serial radiographs to monitor treatment response and development of negative sequelae, despite limited data supporting these practices. The purpose of this study is to evaluate the utility of obtaining serial radiographic follow-up for pediatric osteoarticular infections.

Methods

An institutional review board-approved retrospective review was completed. Children 18 years and below admitted to a single institution with a culture/biopsy-proven diagnosis of OM, SA, or OM+SA. All postdischarge radiographs were reviewed and retrospectively categorized as either routine (scheduled) or reactive. Routine radiographs were obtained regardless of clinical presentation. Reactive radiographs were obtained in patients presenting with the sign of an altered clinical course. Negative sequelae, defined as growth arrest/disturbance, pathologic fracture, recurrent MSK infection, and underlying neoplastic process, were recorded and tracked. Descriptive statistics were used to summarize demographic and outcome variables. Number needed to screen (NNS) was defined as the inverse of the incidence of negative sequelae detected.

Results

A total of 131 patients were included for analysis, with a mean age of 11.9 years (SD: 4.96 y). Ninety (69%) patients were diagnosed and treated for OM, 25 (19%) for SA, and 16 (12%) for combined infections. A total of 329 radiographs were obtained following discharge. Of those obtained, 287 (88%) were routine, resulting in the detection of 2 (0.7%) negative sequelae and a resultant NNS of 143 radiographs (95% confidence interval: 36-573). The remaining 39 were reactive radiographs, resulting in the detection of 2 (5.1%) negative sequelae with an NNS of 20 radiographs (95% confidence interval: 5-78).

Conclusions

While radiographs remain a widely utilized tool to screen for the development of negative sequelae in pediatric osteoarticular infections, they rarely alter management in the absence of other concerning clinical signs or symptoms such as recurrent fevers, swelling of the extremity, or limb deformity. Moreover, routine radiographic surveillance should be replaced with a reactive radiographic protocol.

Level of evidence

Level III-retrospective comparative study.

Distal radius fractures are widespread in the pediatric population. Standardized treatment protocols have not been well defined. We sought to examine the diversity of current practice patterns in the treatment of these fractures by surveying hand, pediatric, and general orthopedic surgeons. Hand, pediatric, and general orthopedic surgeons were surveyed using an internet-based questionnaire on the management of pediatric distal radius fractures. Each surgeon was asked to select a criterion from among choices of 'acceptable' alignment criteria at the onset of the survey. Ten cases were then provided to represent a broad spectrum of injuries from minimally angulated torus fractures to complete, displaced fractures. In addition to the variation in injury pattern, the patients in the survey differed in age at the time of injury (3-15 years of age). For each case, surgeons were asked to select a preferred treatment, first on the basis of injury films, and then again after reviewing 1-week follow-up radiographs. A total of 781 surgeons completed the survey. In patients younger than 9 years of age, a residual sagittal angulation of 20° or less, coronal angulation of 10° or less, and 1 cm or less of bayonet apposition was deemed 'acceptable' by 88, 90, and 69% of respondents, respectively. In older patients, these percentages were 58, 64, and 29%, respectively. When specific cases were reviewed, 20.3% of surgeons recommended treatment different from their own theoretical 'acceptable' criteria. When subspecialty training was analyzed, hand surgeons and general orthopedic surgeons were 2.9 and 1.6 times more likely to recommend surgery, respectively, as compared with pediatric surgeons after viewing the initial radiograph. Private practice surgeons were 1.5 times more likely to recommend surgery compared with academic surgeons based on the initial injury radiographs. Our survey highlights the discordance between theoretical acceptable criteria of surgeons and their practice habits, as well as the substantial disparities in treatment recommendations based on subspecialty training. Further study is warranted to determine whether these variations in treatment affect patient outcomes. This survey is a level IV observational study.

Objective

To examine the efficacy of virtual reality (VR) to prepare surgical trainees for a pediatric orthopedic surgery procedure: pinning of a slipped capital femoral epiphysis (SCFE).

Design

Participants were randomly assigned to a standard, study guide (SG) group or to a VR training group. All participants were provided a technique video and SG; the VR group additionally trained via an Osso VR surgical trainer (ossovr.com) with real-time feedback and coaching from an attending pediatric orthopedic surgeon. Following training, participants performed a SCFE guidewire placement on a SawBones model embedded in a soft-tissue envelope (SawBones model 1161). Participants were asked to achieve "ideal placement" based on the training provided. Participants were evaluated on time, number of pin "in-and outs," penetration of the articular surface, angle between the pin and the physis, distance from pin tip to subchondral bone and distance from the center-center point of the epiphysis.

Setting

Orthopedic Institute for Children, Los Angeles, CA.

Participants

Twenty fourth-year medical students, first- and second-year orthopedic residents without experience with the SCFE procedure.

Results

Twenty participants were randomized to SG (n = 10) or VR (n = 10). Average time to final pin placement was 19% shorter in VR group (706 vs 573 seconds, p = 0.26). When compared to SG, the VR group had, on average, 70% less pin in-and-outs (1.7 vs 0.5, p = 0.28), 50% less articular surface penetrations (0.4 vs 0.2, p = 0.36), and 18% smaller distance from pin tip to subchondral bone on lateral view (7.1 vs 5.8 mm, p = 0.42). Moreover, the VR group had a lower average angle deviation between pin and line perpendicular to the physis on coronal view (4.9° vs 2.5°, p < 0.05).

Conclusions

VR training is potentially more effective than traditional preparatory methods. This pilot study suggests that VR training may be a viable surgical training tool, which may alleviate constraints of time, money, and safety concerns with resultant broad applicability for surgical education.

BACKGROUND: Long-term implant durability is a key concern when considering total hip arthroplasty (THA) in young patients. The ideal bearing surface used in these patients remains unknown. The purpose of this study was to analyze trends in THA bearing surface use from 2006 to 2016 using a large, pediatric national database. METHODS: This was a retrospective review from January 1, 2006, to December 31, 2016, using the Kids Inpatient Database. International Classification of Diseases, 9th revision and 10th revision codes were used to identify patients who underwent THA and create cohorts based on bearing surfaces: metal-on-metal, metal-on-polyethylene, ceramic-on-polyethylene (CoP), and ceramic-on-ceramic (CoC). Annual utilization of each bearing surface and associated patient and hospital demographics were analyzed. RESULTS: A total of 1004 THAs were identified during the 11-year study period. The annual number of THAs performed increased by 169% from 2006 to 2016. The mean patient age was 17.1 years. The most prevalent bearing surface used in 2006 was CoC (37.3%), metal-on-metal (31.8%) in 2009, and CoP in 2012 and 2016 (50.6% and 64.8%, respectively). From 2006 to 2016, utilization of CoP increased from 5.0% to 64.8%, representing a 1196% increase over the study period. CONCLUSIONS: The number of THAs performed in pediatric patients is increasing significantly. Although CoC was previously the most commonly used bearing surface in this patient population, CoP is currently the most common. Further investigation is needed to determine whether bearing longevity and clinical outcomes with CoP are superior to other bearing surfaces.

INTRODUCTION: Distal third forearm fractures are common fractures in children. While outcomes are generally excellent, some patients fail initial non-operative management and require intervention. The purpose of this study is to identify independent risk factors associated with failure of closed reduction. METHODS: We conducted a retrospective review of distal third forearm fractures in children treated with closed reduction and casting. Patients were divided into two cohorts-those who were successfully closed reduced and those who failed initial non-operative management. Demographic characteristics, cast type, cast index, radiographic fracture, soft tissue characteristics, and quality of reduction were analyzed between groups. RESULTS: A total of 207 children treated for distal third forearm fractures were included for analysis. A total of 190 (91.8%) children maintained their reduction while 17 (8.2%) failed initial non-operative management. Modifiable risk factors associated with loss of reduction on univariate analysis included the use of a long arm cast (p = 0.003), increased post-reduction displacement (p = 0.02), and increased post-reduction angular deformity (p = 0.01). Non-modifiable risk factors included increased body mass index (p = 0.02), increased presenting fracture displacement (p = 0.002), and increased width of the soft tissue envelope at the fracture site (p = 0.0001). The use of long arm casts (13% vs 2%, odds ratio = 6.44) and soft tissue width (60.6 vs 50.4 mm, odds ratio = 1.1) remained significant risk factors for loss of reduction after multivariate analysis. CONCLUSION: Both larger soft tissue envelope at the site of the fracture and long arm cast immobilization are independently associated with an increased risk of failing initial closed reduction in distal third forearm fractures in the pediatric population. LEVEL OF EVIDENCE: level III Case Control Study.

The purpose of this study was to determine what orthopaedic surgery department leadership characteristics are most closely correlated with securing NIH funding and increasing scholarly productivity. Scopus database was used to identify number of publications/h-index for 4,328 faculty, department chairs (DC), and research directors (RD), listed on departmental websites from 138 academic orthopaedic departments in the United States. NIH funding data was obtained for the 2013 fiscal year. While all programs had a DC, only 46% had a RD. Of $54,925,833 in NIH funding allocated to orthopaedic surgery faculty in 2013, 3% of faculty and 31% of departments were funded. 16% of funded institutions had a funded DC whereas 65% had a funded RD. Department productivity and funding were highly correlated to leadership productivity and funding(p< 0.05). Mean funding was $1,700,000 for departments with a NIH-funded RD, $104,000 for departments with an unfunded RD, and $72,000 for departments with no RD. These findings suggest that orthopaedic department academic success is directly associated with scholarly productivity and funding of both DC and RD. The findings further highlight the correlation between a funded RD and a well-funded department. This does not hold for an unfunded RD.

Purpose

The clinical utility of echocardiography in the setting of a positive blood culture in paediatric patients presenting with osteomyelitis (OM) and/or septic arthritis (SA).

Methods

Retrospective review between 2013 and 2019: Patients < 18 years with OM, SA or combined infection (OM+SA) were included. Patients were excluded for immunodeficiency, loss of follow-up or penetrating infection. Charts with positive blood cultures were reviewed for echocardiography on that admission. Demographic variables were compared utilizing the Student's t-test and Fisher's exact test. A multivariable linear regression model was constructed to examine the association between echocardiography and length of stay, controlling for age, sex, fever, white blood cell (WBC) on admission, antibiotic administration and surgery performed.

Results

Of 157 patients with OM, SA or combined infection, 44 had a positive blood culture. In all, 26 had an echocardiogram, and none showed endocarditis. Echocardiography was independently associated with a 6.2-day length of stay increase. WBC count and surgical intervention demonstrated a trend toward significance in length of stay, with each WBC unit increase associated with a 0.53-day increase. Surgical intervention was associated with an average 6.3-day length of stay decrease.

Conclusion

No patient had a positive echocardiogram, and no changes in management were initiated. However, an echocardiogram increased stay by 6.2 days. In addition to costs associated with increased stay, patients were billed between $1460 and $1700 per echocardiogram. The utility of echocardiograms in the setting of bacteremia associated with musculoskeletal infections in the paediatric population should be re-examined, and guidelines should be updated to reflect the cost-benefit analysis.

Level of evidence

III.

Hemophilic arthropathy is a debilitating condition that can develop as a consequence of frequent joint bleeding despite adequate clotting factor replacement. The mechanisms leading to repeated spontaneous bleeding are unknown. We investigated synovial, vascular, stromal, and cartilage changes in response to a single induced hemarthrosis in the FVIII-deficient mouse. We found soft-tissue hyperproliferation with marked induction of neoangiogenesis and evolving abnormal vascular architecture. While soft-tissue changes were rapidly reversible, abnormal vascularity persisted for months and, surprisingly, was also seen in uninjured joints. Vascular changes in FVIII-deficient mice involved pronounced remodeling with expression of α-Smooth Muscle Actin (SMA), Endoglin (CD105), and vascular endothelial growth factor, as well as alterations of joint perfusion as determined by in vivo imaging. Vascular architecture changes and pronounced expression of α-SMA appeared unique to hemophilia, as these were not found in joint tissue obtained from mouse models of rheumatoid arthritis and osteoarthritis and from patients with the same conditions. Evidence that vascular changes in hemophilia were significantly associated with bleeding and joint deterioration was obtained prospectively by dynamic in vivo imaging with musculoskeletal ultrasound and power Doppler of 156 joints (elbows, knees, and ankles) in a cohort of 26 patients with hemophilia at baseline and during painful episodes. These observations support the hypothesis that vascular remodeling contributes significantly to bleed propagation and development of hemophilic arthropathy. Based on these findings, the development of molecular targets for angiogenesis inhibition may be considered in this disease.