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Purpose: Proximal junctional kyphosis (PJK) has been reported to occur at a rate of about 30% in traditional growing rods (GR) and magnetically controlled growing rods (MCGR). Growth guidance systems (GGS) have non-rigid, gliding fixation along rods, which may mitigate PJK. There have been no studies done in shilla around PJK, hence this study aimed to assess the occurrence, risk factors, and timeline of PJK., Methods: A prospective, multicenter database was queried for EOS patients who underwent surgery utilizing GGS., Inclusion Criteria: < 10 years at index surgery and > 2 year follow-up., Results: Sixty-five patients (thirty-six female) met inclusion criteria. Mean age at index surgery was 6.2 y/o (2-9); mean follow-up was 66 m. Most common etiologies were syndromic (n = 23). Mean thoracic kyphosis at pre-op was 41.8°, post-op was 35.5°, and final was 42.2°. Mean PJA at pre-op was 6.15°, post-op 1 was 4.2°, and final was 15.6°. Incidence of PJK at post-op was 35% and final was 43%. Pre-op sagittal balance and change in sagittal balance from pre-op to post-op were associated with post-op PJK (p = 0.05, 0.02). Change in spinal height from pre-op to post-op was associated with PJK at final (p = 0.04). Interestingly, increased PJA at pre-op was significantly associated with decreased PJK at post-op and final (p = 0.01, 0.03)., Conclusion: PJK was identified in 43% of patients post-operatively after GGS for EOS. Pre-op PJA was negatively correlated with an increased incidence of PJK. Changes in sagittal balance, in either direction, was the strongest predictor for development of PJK post-operatively., (© 2023. The Author(s), under exclusive licence to Scoliosis Research Society.)

Purpose: Brace treatment is the most common nonoperative treatment to prevent curve progression in adolescent idiopathic scoliosis (AIS). The goal of this review and analysis is to characterize curve behavior after completion of brace treatment and to identify factors that may facilitate the estimation of long-term curve progression., Method: A review of the English language literature was completed using the MEDLINE (PUBMED) database of publications after 1990 until September 2020. Studies were included if they detailed a minimum of 1 year post-brace removal follow-up of AIS patients. Data retrieved from the articles included Cobb angle measurements of the major curves at "in-brace," weaning, and follow-up visit(s) for all patients described and for subset populations., Results: From 75 articles, 18 relevant studies describing a follow-up period of 1-25 years following brace removal were included in the analyses. The reviewed literature demonstrates that curves continue to progress after brace treatment is completed with three main phases of progression: (i) immediate (upon brace removal) where a mean curve progression of 7° occurs; (ii) short term (within five years of brace removal) where a relatively high progression rate is evident (0.8°/year); and (iii) long term (more than five years after brace removal) where the progression rate slows (0.2°/year). The magnitude and rate of curve progression is mainly dependent on the degree of curve at weaning as curves weaned at < 25° progress substantially less than curves weaned at ≥ 25° at 25 years., Conclusion: Curves continue to progress after brace removal and the rate and magnitude of progression are associated with the curve size at weaning, with larger curves typically exhibiting more rapid and severe progression. This analysis provides physicians and patients the ability to estimate long-term curve size based on the curve size at the time of weaning., Level of Evidence: IV., (© 2023. The Author(s).)

Purpose: PROMIS is becoming the most commonly utilized patient-reported outcome measure (PROM) in adult orthopaedics, but its adoption has lagged in pediatrics. Limited baseline data exists in pediatric-specific orthopaedic diagnoses. The objective of this study was to determine baseline PROMIS scores in patients with idiopathic scoliosis and to evaluate for correlations with the SRS-22., Methods: This was a retrospective analysis of prospectively collected data from six tertiary care pediatric hospitals between July 2016 and July 2018. Patients with a diagnosis of idiopathic scoliosis, adequate radiographs for measurement and completion of PROMIS and SRS-22 questionnaires from the same visit were included. Only the first visit during the study period was included for each subject. Post-operative patients were excluded. Spearman correlations were performed between four PROMIS domains (Pain interference [PI], Mobility [M], Peer Relationships [PR] and Upper Extremity [UE]) and SRS-22 domains. PROMIS scores are calibrated such that 50 is the median value in a population and 10 points is equivalent to one standard deviation., Results: 986 patients with a mean age of 14.6 years were included, 79.8% of which were female. The mean major curve was 33.0° (range: 10-102). The major curve was thoracic in 56.5%, thoracolumbar in 24.4% and lumbar in 19.1% of subjects. The mean PROMIS domain scores were: Pain Interference 44.5 (IQR 17.7); Mobility 52.7 (IQR 12.5); Peer Relationships 55.7 (IQR 15.0); Upper Extremity 53.4 (IQR 7.7). Correlations existed between PROMIS Pain Interference and SRS-22 pain (r = 0.704, p < 0.001) and PROMIS Mobility and SRS-22 function (r = 0.53, p < 0.001). Significant ceiling effects existed in SRS-22 Function (29.9%), Pain (19.2%) and Satisfaction (30.3%) but only for PROMIS Peer Relationships (42.1%)., Conclusions: PROMIS domain scores for patients with AIS are within normal population limits. PROMIS correlates well with SRS-22 in overlapping domains, and fewer domains demonstrate a ceiling effect. There was no relationship between the magnitude of scoliosis and PROMIS domain scores., Level of Evidence: II., (© 2021. Scoliosis Research Society.)

With aging and pathology, cells of the nucleus pulposus (NP) de-differentiate towards a fibroblast-like phenotype, a change that contributes to degeneration of the intervertebral disc (IVD). Laminin isoforms are a component of the NP extracellular matrix during development but largely disappear in the adult NP tissue. Exposing human adult NP cells to hydrogels made from PEGylated-laminin-111 (PEGLM) has been shown to regulate NP cell behaviors and promote cells to assume a biosynthetically active state with gene/protein expression and morphology consistent with those observed in juvenile NP cells. However, the mechanism regulating this effect has remained unknown. In the present study, the integrin subunits that promote adult degenerative NP cell interactions with laminin-111 are identified by performing integrin blocking studies along with assays of intracellular signaling and cell phenotype. The findings indicate that integrin α3 is a primary regulator of cell attachment to laminin and is associated with phosphorylation of signaling molecules downstream of integrin engagement (ERK 1/2 and GSK3β). Sustained effects of blocking integrin α3 were also demonstrated including decreased expression of phenotypic markers, reduced biosynthesis, and altered cytoskeletal organization. Furthermore, blocking both integrin α3 and additional integrin subunits elicited changes in cell clustering, but did not alter the phenotype of single cells. These findings reveal that integrin- mediated interactions through integrin α3 are critical in the process by which NP cells sense and alter phenotype in response to culture upon laminin and further suggest that targeting integrin α3 has potential for reversing or slowing degenerative changes to the NP cell.

Introduction: Investigations in associations between subjective health-related quality of life (HRQoL) measures and objective clinical assessments in patients with early-onset scoliosis (EOS) are limited. The purpose of this study is to investigate the association between pulmonary function rated by parents and pulmonary function testing (PFT) in patients with EOS., Materials/methods: In this cross-sectional study, patients with EOS at any stage of treatment from 2011 to 2018 were identified in 2 registries including 33 centers. Parents' perception of pulmonary function was evaluated using pulmonary function (PF) domain in the Early-Onset Scoliosis 24 item Questionnaire (EOSQ-24). PFT measures included FVC% predicted, FEV1/FVC, and TLC% predicted. All PFT predicted values utilized arm span. PFT and EOSQ-24 questionnaire were completed within 180 days of each other with an average day difference of 26 days., Results: 176 patients (mean age: 10.4 years old, female: 56%) were identified. 33% of patients were of congenital/structural etiology, 27% neuromuscular, 26% syndromic, and 14% idiopathic. Wide variance and lower scores of PF domain were reported by parents at lower FVC% predicted values (< 50%). As FVC% predicted values increased, PFD scores increased with simultaneous decreases in variance with few exceptions., Conclusion: More variability and frequent lower pulmonary function values are reported by parents when percent forced vital capacity (FVC%) is < 50%. This likely reflects the degree to which children adapt to restrictive lung disease and the limits on adaptation that occur increasingly as lung function falls below 50% predicted. As a direct linear association with high correlation was expected, more research into the character of what the PF domain is measuring is necessary., Level of Evidence: IV.

Introduction: Few risk factors for fracture in magnetically controlled growing rods (MCGR) have been identified. We hypothesize an increased rate of rod fracture in small diameter rods compared to large diameter rods in patients with early-onset scoliosis (EOS). The purpose of this study was to determine the association between the diameter of MCGR constructs and the rate of rod fracture., Methods: Patients with EOS who underwent MCGR implantation-primary or conversion-from 2013 to 2018 were identified from two registries including 40 centers. Rod diameter sizes greater than 5.0 mm or less than or equal to 5.0 mm were defined as "Large" and "Small" rods, respectively. Only dual-rod constructs were included. The primary outcome measure collected was rod fracture at any point in treatment up to the most recent follow-up. Cox regression was utilized for unequal follow-up to compare rate of breakage at the last follow-up between cohorts., Results: 527 patients with 1,054 rods were included. 552 (52.4%) rods had a diameter of less than or equal to 5.0 mm and 461 (43.7%) rods had a diameter of greater than 5.0 mm. 41 (3.9%) rods were missing a recorded rod diameter and were not included in the analysis to determine the association between the rate of fracture and rod diameter. 20 (1.9%) total rod fractures occurred: 9 (1.6%) rods with diameters of ≤ 5.0 mm, 10 (2.2%) rods with diameters of > 5.0 mm, and 1 uncategorized rod (p = 0.529). No difference in the rate of rod fracture or survival distribution was found between rod diameters of > 5.0 mm and ≤ 5.0 mm even after stratification by ambulatory status, major coronal curve, weight, or location of anchors., Discussion: Rod fracture appears to be a rare event in dual MCGR constructs and rod diameter does not seem to be associated with the incidence or rate of rod fracture. Surgeons may consider other criteria for selecting rod diameter in their patients such as patient size, amount of surgical correction, single vs. dual constructs, and risk of hardware prominence.

Cells of the nucleus pulposus (NP) are essential contributors to extracellular matrix synthesis and function of the intervertebral disc. With age and degeneration, the NP becomes stiffer and more dehydrated, which is associated with a loss of phenotype and biosynthetic function for its resident NP cells. Also, with aging, the NP cell undergoes substantial morphological changes from a rounded shape with pronounced vacuoles in the neonate and juvenile, to one that is more flattened and spread with a loss of vacuoles. Here, we make use of the clinically relevant pharmacological treatment verteporfin (VP), previously identified as a disruptor of yes-associated protein-TEA domain family member-binding domain (TEAD) signaling, to promote morphological changes in adult human NP cells in order to study variations in gene expression related to differences in cell shape. Treatment of adult, degenerative human NP cells with VP caused a shift in morphology from a spread, fibroblastic-like shape to a rounded, clustered morphology with decreased transcriptional activity of TEAD and serum-response factor. These changes were accompanied by an increased expression of vacuoles, NP-specific gene markers, and biosynthetic activity. The contemporaneous observation of VP-induced changes in cell shape and prominent, time-dependent changes within the transcriptome of NP cells occurred over all timepoints in culture. Enriched gene sets with the transition to VP-induced cell rounding suggest a major role for cell adhesion, cytoskeletal remodeling, vacuolar lumen, and MAPK activity in the NP phenotypic and functional response to changes in cell shape., Competing Interests: J. M. B. received royalties from Globus, Wolters Kluwer, and K2M unrelated to this study. M. C. G. received royalties from DePuy and Innomed and holds personal stock of Johnson & Johnson and Procter & Gamble and served as an Advisor and a Consultant, and conducted travel for DePuy and Medtronic, outside the present work. L. A. S. has financial holdings in Cytex Therapeutics and Phasebio Pharmaceuticals that have interests that are not relevant to the subject of this publication. The remaining authors declare no potential conflicts of interest., (© 2020 The Authors. JOR Spine published by Wiley Periodicals LLC. on behalf of Orthopaedic Research Society.)

Background: Pediatric orthopaedic surgery fellowships in North America have been organized, assigned, and administered through the San Francisco Match Program since 2011. However, trends in application numbers and match rates have not been assessed to this point. The purpose of this study is to describe these trends and applicants' perspective of the fellowship match., Methods: The San Francisco Match databank was queried for program and applicant data from 2011 to 2018. Specifically, we obtained data regarding the number of applicants, programs, match rates, and match results. Each year, applicants also completed an anonymous post-match survey administered by the Pediatric Orthopaedic Society of North America fellowship committee, which included information on the number of applications, interview process, estimated costs, and suggested changes. Descriptive statistics were used to summarize the data, and univariate statistics were used to assess differences in categorical and continuous variables., Results: From 2011 to 2018, 524 applicants participated in the pediatric orthopaedic fellowship match, and the mean number of annual applicants was 66 (range, 55 to 76). The mean number of fellowship programs and available positions during the same time period was 43 (range, 40 to 47) and 69 (range, 63 to 74), respectively. Each fellowship interview was estimated by the applicant to cost a mean of $458 (range, $372 to $566), and annual application costs across all applicants were extrapolated to be over $200,000/year. The mean overall match rate was 81% (range, 74% to 91%). The mean match rate for North American applicants was 98.7% and international applicants were 40.9% (P<0.01). Approximately, 93% of applicants obtained one of their top 5 choices of fellowship program (range, 78% to 100%), and 50% of matched applicants obtained their top choice each year (range, 43% to 56%)., Conclusion: In the pediatric orthopaedic fellowship match, the number of applicants and fellowship programs has remained relatively stable over the study period, and the majority of applicants match one of their top choices for fellowship. Proposed changes to the match should focus on decreasing the financial burden on applicants., Level of Evidence: Level II.

Cells of the adult nucleus pulposus (NP) are critically important in maintaining overall disc health and function. NP cells reside in a soft, gelatinous matrix that dehydrates and becomes increasingly fibrotic with age. Such changes result in physical cues of matrix stiffness that may be potent regulators of NP cell phenotype and may contribute to a transition toward a senescent and fibroblastic NP cell with a limited capacity for repair. Here, we investigate the mechanosignaling cues generated from changes in matrix stiffness in directing NP cell phenotype and identify mechanisms that can potentially preserve a biosynthetically active, juvenile NP cell phenotype. Using a laminin-functionalized polyethylene glycol hydrogel, we show that when NP cells form rounded, multicell clusters, they are able to maintain cytosolic localization of myocardin-related transcription factor (MRTF)-A, a coactivator of serum-response factor (SRF), known to promote fibroblast-like behaviors in many cells. Upon preservation of a rounded shape, human NP cells similarly showed cytosolic retention of transcriptional coactivator Yes-associated protein (YAP) and its paralogue PDZ-binding motif (TAZ) with associated decline in activation of its transcription factor TEA domain family member-binding domain (TEAD). When changes in cell shape occur, leading to a more spread, fibrotic morphology associated with stronger F-actin alignment, SRF and TEAD are up-regulated. However, targeted deletion of either cofactor was not sufficient to overcome shape-mediated changes observed in transcriptional activation of SRF or TEAD. Findings show that substrate stiffness-induced promotion of F-actin alignment occurs concomitantly with a flattened, spread morphology, decreased NP marker expression, and reduced biosynthetic activity. This work indicates cell shape is a stronger indicator of SRF and TEAD mechanosignaling pathways than coactivators MRTF-A and YAP/TAZ, respectively, and may play a role in the degeneration-associated loss of NP cellularity and phenotype.-Fearing, B. V., Jing, L., Barcellona, M. N., Witte, S. E., Buchowski, J. M., Zebala, L. P., Kelly, M. P., Luhmann, S., Gupta, M. C., Pathak, A., Setton, L. A. Mechanosensitive transcriptional coactivators MRTF-A and YAP/TAZ regulate nucleus pulposus cell phenotype through cell shape.

Background: Modern treatment of early onset scoliosis (EOS) includes implantation of traditional growing rods (TGR) or magnetically controlled growing rods (MCGR) for posterior-based distraction if nonoperative treatment plans failed. The recent MCGR innovation has largely been expected to improve patient and family burden by avoiding frequent return to the operating room. At least one study has shown no HRQoL difference between TGR and MCGR, but none have specifically investigated a cohort of conversion patients whose families have experienced both., Methods: An EOS database was queried for all patients treated with TGR, MCGR, and those converted from TGR to MCGR who had at least 1 pretreatment and 1 posttreatment HRQoL assessment (EOSQ-24). Data on demographics, diagnoses, and major curve size, as well as EOSQ-24 domain scores were studied., Results: There were 156 TGR, 114 MCGR, and 32 conversion patients, with an average of 2.0 years between first and final EOSQ-24 surveys. There was no significant difference in outcome in any EOSQ-24 domain between the converts and the other 2 treatment groups. There was a significant post-op improvement in MCGR versus TGR in transfers and energy level (P=0.01; P=0.01)., Conclusions: Although patient families and their surgeons may subjectively report improved HRQoL after conversion from TGR lengthenings to in-office MCGR lengthenings, these improvements were seen in transfer and fatigue domains, not burden or satisfaction. Although the EOSQ-24 is a well-validated EOS metric, it may not be sensitive enough to overcome the QoL floor-effect associated with the diagnosis itself, or perhaps the improvement in QoL must be assessed over a longer interval to assess meaningful change., Level of Evidence: Level III-retrospective comparative study.

Study Design: This is a review of the current literature on early-onset scoliosis (EOS) techniques and treatment written by the Growing Spine Committee of the Scoliosis Research Society., Objectives: The Growing Spine Committee of the Scoliosis Research Society sought to update the information available on the definition and treatment of EOS, including new information about existing techniques., Summary of Background Data: EOS represents a diverse, heterogeneous, and clinically challenging group of spinal disorders occurring in children under the age of 10. Our understanding of EOS has changed dramatically in the last 15 years, and management of EOS has changed even more rapidly in the last five years., Methods: The Growing Spine Committee of the Scoliosis Research Society has embarked upon a review of the most current literature on EOS techniques and treatment., Results: This white paper provides recent updates on current techniques, including a summary of new modalities, indications, contraindications, and clinical results., Conclusions: Although treatment of EOS is still challenging and complicated, the evolution of options and knowledge presents hope for better understanding and management in the future., Level of Evidence: Level V., (Copyright © 2017 Scoliosis Research Society. Published by Elsevier Inc. All rights reserved.)

Purpose: Spine surgeons have increasingly used intraoperative application of topical vancomycin powder (TVP) to prevent surgical site infections (SSIs). The goals of this study were to define the rate of pharmacological adverse reaction to TVP in young patients undergoing posterior spinal surgery and to summarise institutional variation in TVP dosing., Methods: This retrospective observational study included ten spine centres in the United States and one in Europe. Patients with early onset scoliosis who underwent posterior spine surgery were eligible for inclusion. Age, weight, TVP dose and surgery type were recorded. Surgeries where patient age was > 12 years were excluded. Pharmacological adverse reactions were defined as clinical instances of Red Man Syndrome, rash, nephrotoxicity, proteinuria, hepatotoxicity or ototoxicity. The rate of pharmacological adverse reaction to TVP was calculated. Dosing practices were summarised., Results: Patient age was in the range of seven months to 12 years (median ten years). Of 1398 observations, there was one possible pharmacological adverse reaction. This was in a ten-year-old, 20.4-kg female patient with neuromuscular sco-liosis undergoing growing rod implantation. She was dosed with 1500 mg of TVP and immediately developed a transient rash without systemic symptoms. This abated over minutes without any medical intervention. There were no other adverse reactions in the sample. The population rate of pharmacological adverse reaction was 0.072% (95% confidence interval 0 to 0.4). Significant variability in dosing practices existed between centres., Conclusion: Pharmacological adverse reactions to TVP are rare. Future work may establish evidence-based guidelines for TVP dosing based on patient weight and other variables.

Introduction of magnetically controlled growing rods (MCGR) for early onset scoliosis treatment was anticipated to improve quality of life for patients and their families. A cohort of patients converted from traditional growing rods to MCGR may be best suited to detect this improvement and have not previously been examined. Using the validated EOSQ-24, no HRQoL differences were detected between TGR, MCGR, or converted patient cohorts.

Despite having lower HRQoL domain scores pre-operatively, EOS patients treated with magnetically-controlled growing (MCGR) had similar EOSQ-24 domain scores after two years of treatment compared to patients treated with traditional growing rods (TGR).

A study of 119 early onset scoliosis (EOS) who underwent magnetically controlled growing rod (MCGR) treatment suggests that more than 4 distractions per year yields greater rates of rod lengthening but no significant differences in spine length gain compared to less than 4 distractions per year.

In a cohort of 310 consecutive congenital scoliosis patients, a retrospective analysis of abnormalities in ten organ systems was performed. Overall, intraspinal defects were observed in 43% of patients and defects in other organ systems were found in 77% of patients. Urogenital anomalies occurred in 39% of patients. Cardiac anomalies occurred in 54% of patients, a rate more than two times higher than previously reported. The association between defects in various organ systems was also elucidated.

Traditional growing rods (TGR), magnetically controlled growing rods (MCGR) and growth guidance systems (GGS) have demonstrated comparable radiographic outcomes in the treatment of early- onset scoliosis (EOS). The purpose of this study was to compare direct medical costs of GGS compared to TGR and MCGR using an economic model. Over a 6-year episode of care GGS had lower cumulative costs than MCGR and TGR, saving an estimated $25,226 vs TGR (16% decrease) and $29,916 vs MCGR (18% decrease).

Study Design: Retrospective review., Objectives: To describe clinical characteristics and infection rates in modern vertical expandable prosthetic titanium rib (VEPTR) surgery., Summary of Background Data: Prior studies have demonstrated infection rates from 10% to 30% with VEPTR surgery., Methods: A retrospective query was done on an institutional review board-approved, multicenter prospectively collected database for patients implanted with VEPTR from 2007 to 2013 at eight sites. This identified 213 patients with appropriate data for analysis. Average follow-up was 4.1 years (range 1.7-6.3). Data collected included a Classification of Early-Onset Scoliosis (C-EOS) diagnosis, American Society of Anesthesiologists Physical Status (ASA-PS), major Cobb angle, construct type, clinical symptoms, and microbiology. The distribution of infection rates across all the study sites was compared. The exact p value was estimated by Monte Carlo simulation., Results: Overall, 18% (38/213) of patients implanted with VEPTR developed infection requiring operative debridement. There were significantly different infection rates among the sites, ranging from 2.9% to 42.9% (p = .029). The average time to infection was 70 days (range 8-236) after the infecting procedure. The majority of infections were due to gram-positive bacteria (80%, 44/55), the most prevalent being methicillin-sensitive Staphylococcus aureus (45%, 25/55). There were 20 patients (53%, 20/38) with either partial or complete implant removal to resolve infection; however, only 3 of 38 (8%) of these resulted in abandonment of VEPTR treatment. There was no difference in infection rate across the primary C-EOS diagnosis categories (p = .21) or based on ASA score (p = .53). After controlling for study site, the odds ratio of an infection following an implant procedure versus an expansion was 2.8 (p = .002). There was no difference in the odds ratio of an infection between the other procedure types (implant, expansion, exchange/revision)., Conclusions: There were significant differences in infection rates between sites. The variability in infection rate indicates a need for guided efforts to standardize best practices for infection control in VEPTR surgery., Level of Evidence: III, therapeutic study., (Copyright © 2016 Scoliosis Research Society. Published by Elsevier Inc. All rights reserved.)

Background: The Shilla growth guidance technique has been developed to treat spinal deformities without the necessity of repeated operative lengthenings. The dual stainless steel rods are fixed to the corrected apex of the curve by pedicle screws with limited fusion about the apex. Vertebral growth occurs in a cephalad and caudad direction through extraperiosteally placed sliding pedicle screws. A retrospective review of patients treated with the Shilla growth guidance technique for early-onset spinal deformity was performed to study patients with >2-year follow-up and describe outcome parameters., Methods: From a cohort of 38 patients, 10 patients with a mean age of 7 + 6 years were identified as qualifying for 2-year follow-up inclusion., Results: The average preoperative curve of 70.5 degrees was corrected to 27 degrees at 6 weeks follow-up and maintained at 2-year follow-up. The space available for lung improved an average of 13%. Truncal height (C7 to S1) increased an average of 12%. One patient required rod revision, 1 required rod change to a smaller size rod, and 1 required rod replacement. Two patients required wound debridement for low-grade infection in the early-postoperative period for a total of 5 procedures beyond the index correction. No patient had changes neurologically as a result of surgery. Patients were braced for the first 3 months postoperatively while the fusion was incorporating then not thereafter., Conclusions: At 2-year follow-up, the Shilla procedure has allowed children correction of their spinal deformity with an acceptable complication rate and ability to grow brace free without repeated trips to the operating room for lengthenings. These patients would have had 49 scheduled lengthening procedures after their initial correction if treated by conventional distraction growing rod methods., Level of Evidence: IV case series of therapeutic study investigating results of treatment.

Between January 1, 1994 and December 31, 1997, we evaluated 138 children with displaced supracondylar distal humerus fractures treated by closed reduction and percutaneous pinning. There were 49 type II fractures and 89 type III fractures. Three principal pin configurations were used at the surgeon's discretion: 2 lateral pins (42 fractures), 1 medial and 1 lateral pin (37 fractures), and 1 medial and 2 lateral pins (57 fractures). There was no statistically significant difference in clinical stability between these groups. One type III fracture pinned using two lateral pins showed marked rotational instability. We recommend using two lateral pins when treating type II fractures. Type III fractures should be treated using two lateral pins initially and, if the elbow demonstrates significant intraoperative rotational instability, a medial pin should be added. If a medial pin is necessary, and the ulnar nerve cannot be identified by palpation, a small incision should be made and the pin placed under direct vision.

Nine patients (13 feet) were identified whose primary complaints were of atraumatic-onset, chronic pain in the hindfoot exacerbated with increased activity and who had the diagnosis of idiopathic rigid flatfeet. Eight of 11 were greater than the 95th percentile in weight for their age. Exam under anesthesia showed moderate to significant improvement in hindfoot motion in 9 feet; 4 feet required fractional peroneal lengthenings. Only 5 of 11 patients have had sustained relief of pain and report unlimited activity level. Children and adolescents with painful idiopathic rigid flatfeet without known causation can have significant, persistent, disability and do not uniformly respond well to traditionally-described nonoperative Interventions.

A retrospective review was performed of 106 patients to determine the effect of knee pain as the initial complaint of slipped capital femoral epiphysis (SCFE). Sixteen (15%) patients had a primary complaint of distal thigh or knee pain or both at initial presentation to our institution or to a referring physician. Ninety (85%) patients described primarily hip, groin, or proximal thigh discomfort. Of the 106 patients with SCFE, 65 patients received no operative treatment before being evaluated at our institution and were the subject of the remainder of the study. Of these, 15 (23%) patients had distal thigh or knee pain or both as their chief complaint (group I), and 50 (77%) patients had hip, groin, or proximal thigh pain (group II). There was no difference between the groups with respect to age, gender, or slip stability. Group I patients were more likely to receive a misdiagnosis (p < 0.05) and undergo unnecessary or uninformative radiographs (p < 0.05). Additionally, patients in group I were found to have slips of greater radiographic severity (p < 0.05). Although not statistically significant, there was a trend for group I patients to experience a longer delay to diagnosis and to require a proximal femoral osteotomy as treatment for their slips. We conclude that isolated distal thigh or knee pain or both is a common presentation of SCFE. Furthermore, this symptom complex, when compared with the more classic presentation of SCFE, leads to higher rates of unnecessary radiographs, misdiagnoses, and severe slips, potentially increasing long-term morbidity.

Objective: To establish the etiology of septic arthritis in children after implementation of HIB immunization guidelines., Methods: A retrospective review of all charts with a discharge diagnosis of septic arthritis (ICD-9: 711) from January 1991 to December 1996 at St. Louis Children's Hospital was conducted., Results: Sixty-four patients (male = 58%) were identified, whose median age was 6.0 years. Twenty-one children (33%) were misdiagnosed on initial presentation. An organism was isolated in 38 (59%) of cases. The predominant organisms were Staphylococcus aureus (10 isolates), Group A Streptococcus (4), Enterobacter species (4), Kingella kingae (3), Neisseria meningitides (3), Streptococcus pneumoniae (2), Neisseria gonorrhoeae (2), Candida (2), Staphylococcus epidermidis (2). The only isolate of Haemophilus influenzae type B was in 1992 in an unimmunized 14 month old., Conclusions: These data confirm Staphylococcus aureus as a frequent pathogen and suggest that H influenzae type B is no longer the predominant isolate in young children with septic arthritis. In addition, early septic arthritis in children is frequently misdiagnosed on initial evaluation.

Ischemic necrosis of the femoral head occurring after the treatment of congenital dysplasia of the hip can negatively affect the long-term prognosis of the involved hip. Some investigators have suggested that the presence of the ossific nucleus of the femoral head at the time of closed or open reduction is associated with a lower rate of ischemic necrosis. This finding, if verified, could lead to a delay in the treatment of a dislocated hip until ossification of the femoral head has begun, which may be well after the age when the patient has started to walk. We conducted a computerized search of the medical records at our two tertiary-care children's hospitals to identify all patients with congenital dysplasia of the hip who had had a closed or open reduction between January 1, 1979, and December 31, 1993. One hundred and twenty-four patients (153 hips) who satisfied the criteria for inclusion were identified. The ossific nucleus was present in ninety hips and absent in sixty-three. Closed reduction was used in 112 hips and open reduction, in forty-one. Ischemic necrosis was identified in five hips (3 percent): four (6 percent) of the sixty-three hips that did not have an ossific nucleus and one (1 percent) of the ninety hips that had an ossific nucleus at the time of the reduction. With the numbers available for study, we could not detect a difference between these two groups. The age at reduction (p > 0.99), the method of reduction (p = 0.611), previous treatment with a Pavlik harness (p = 0.592), the use of preliminary traction (p = 0.602), concomitant procedures (p > 0.99), and a failure of the primary closed reduction (p = 0.579) were not associated with the development of ischemic necrosis after reduction. In our analysis of patients who were managed over a fifteen-year period, the data did not support the hypothesis that the presence of an ossific nucleus at the time of reduction of a congenitally dislocated hip is associated with a lower prevalence of ischemic necrosis of the femoral head. Sound operative principles dictate that operative reduction of a congenitally displaced hip should be performed when the child can be safely placed under anesthesia and without regard to the presence or absence of the ossific nucleus.

We report our results of talocalcaneal coalition (TCC) resection in 25 feet after failed nonoperative treatment. Preoperative computed tomography (CT) scans were used to quantify the amount of heel valgus and the size of the coalition relative to the posterior facet. The ratio of mean TCC cross-sectional area to the surface area of the posterior facet was 53.4%. Mean hindfoot valgus was 17.8 degrees. The mean AOFAS (American Orthopaedic Foot and Ankle Society) hindfoot score was 81.9, at an average of 2.5 years after surgery. Statistical analysis determined a significant association between TCC > 50% the size of the posterior facet and poor outcome (p = 0.014). Similarly, heel valgus > 21 degrees was associated with poor outcome (p = 0.014). However, there were good postoperative results in feet with heel valgus > 21 degrees and in those whose TCC was > 50% of the posterior facet. Therefore we advocate using these CT-scan criteria for preoperative discussions with patients and families and not for determination of the index operative procedure (resection vs. arthrodesis). Hindfoot arthrodesis should only be used as a salvage procedure. We recommend those feet with heel valgus > 21 degrees use an orthosis postoperatively to stabilize the hindfoot or a secondary calcaneal procedure should nonoperative management fail.

We studied five fresh-frozen lower extremity cadaveric specimens to assess the effect of knee effusions on KT-1000 arthrometry. Part 1 consisted of serial 10-ml injections (up to 100 ml) of saline into each knee and measurements of midpatellar knee circumference and anterior displacement using the KT-1000 arthrometer at 67, 89, and 134 N after each 10-ml increment. Part 2 consisted of evacuation of the saline and transection of the anterior cruciate ligament through a 2-cm medial parapatellar arthrotomy. Each knee again underwent the part 1 protocol. Sequential injections in parts 1 and 2 showed incremental increases in knee circumference and KT-1000 arthrometer measurements for all three force levels. A 3-mm increase in anterior translation compared with the value at 0-ml injection was obtained by the 70-ml injection point in both groups. At the 70-ml injection point, the patella was ballottable, thereby affecting anterior measurements-despite posterior force on the patella sensor pad-because of the KT-1000 arthrometer reference level at midpatella. This increase in KT-1000 arthrometer readings could erroneously imply anterior cruciate ligament disruption in the clinical situation of right-to-left comparison. We conclude that clinicians using the KT-1000 arthrometer should aspirate knees that have effusions and a ballottable patella to minimize false-positive readings.

A retrospective study was performed to evaluate the results of intramedullary fixation used in the management of unstable, diaphyseal both-bone forearm fractures in skeletally immature patients. Twenty-five patients with 25 fractures were identified whose fracture management included only intramedullary fixation. Galeazzi, Monteggia, radial head, and distal metaphyseal fractures were excluded from this analysis. Mean age at fracture was 10 + 8 years. There were 15 closed and 10 open fractures (eight grade I and two grade II). Smooth Kirschner wires or Rush rods were used for fixation. Average length of immobilization was 8 + 2 weeks; 6 + 2 in a long-arm cast and 2 + 0 weeks in a short-arm cast. All 25 regained normal elbow motion, with 17 regaining full forearm rotation. Eight patients had an average loss of 13 degrees of supination and 9 degrees of pronation. There were four minor and two major complications (one rod migration and one delayed union). No infections, malunions, or synostoses occurred in this patient group. Using the grading scheme adapted by Price there were 21 excellent results (84%), four good (16%), and no fair or poor results. In our experience, intramedullary fixation of the unstable both-bone forearm fractures is a safe, effective, and user-friendly technique when alignment jeopardizes fracture position at union and eventual forearm motion.

Twelve patients (seven boys, five girls) who had osteogenesis imperfecta were treated with an extensible-rod system in 21 femurs and 15 tibias. Indications for use of extensible rods were multiple fractures, long-bone deformity prohibiting bracing and ambulation, and significant remaining linear growth. The average patient age at the time of placement of the extensible rods was 6 + 8 years (range, 2 + 4-10 + 10). Six femurs were treated with overlapping Rush rods; Bailey-Dubow rods were used in the remaining femurs and in all tibias. The average length of follow-up was 5 + 9 years (range, 2 + 0-3 + 2). Preoperatively, four of the 12 patients had never walked; postoperatively, all were ambulators with varying levels of assistance. Fourteen complications occurred, 12 of which required operative revision of the extensible rods. The average time between primary extensible rodding and revision was 5 + 1 years. No complications have occurred to date related to the use of overlapping Rush rods. No growth disturbance resulted from the use of the extensible-rod systems.