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Background : Femoral derotation osteotomy (FDO) for correction of internal rotation gait resulting from cerebral palsy (CP) can be performed with the patient in the prone or supine position. It is not known whether patient positioning during FDO affects the change in hip rotation. Purpose/Questions : We sought to compare the change in hip rotation following FDO performed on patients with CP in the prone or supine position through kinematic analysis. Methods : We conducted a consecutive retrospective cohort study of children with CP, ages 3 to 18 years and with Gross Motor Function Classification System (GMFCS) levels I to III, who underwent prone or supine FDO and pre- and postoperative motion analysis. The prone group included 37 patients (68 limbs) between 1990 and 1995. The supine group included 26 patients (47 limbs) between 2005 and 2015. The groups were matched for gender, age, and GMFCS level. The primary outcome was hip rotation in degrees during stance phase. Secondary outcomes included temporal-spatial parameters, hip abduction, hip and knee extension, and hip and knee passive range of motion (ROM). Results : The prone group had more bilateral patients (100%) than the supine group (81%). The supine group underwent more concomitant procedures. There was no difference between the prone and supine groups in postoperative stance hip rotation; both groups had significantly improved stance hip rotation, step width, and hip rotation passive ROM, pre- to postoperatively. Prone patients had improved postoperative hip extension, pelvic tilt, velocity, and cadence. Conclusions : There was no significant different in stance hip rotation between supine and prone FDO groups. Advocates of prone positioning for FDO suggest it allows more accurate assessment of rotation. Supine positioning may be more convenient when additional procedures are required. Based on our findings, either approach can achieve the desired result., Competing Interests: Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Lisa Drefus, BPT; Mary Murray-Weir, MBA, PT; Mark Lenhoff, BSc; Jayme C. Burket-Koltsov, PhD; and Emily R. Dodwell, MD, MPH, declare they have no conflicts of interest. Uri Givon, MD, reports a research grant from Ipsen Innovation and board membership with the American Academy for Cerebral Palsy and Developmental Medicine. David M. Scher, MD, reports personal fees from Orthopediatrics, Inc, outside the submitted work., (© The Author(s) 2021.)

Competing Interests: Conflict of InterestGabriella Safdieh, MD, Jason Silberman, BA, Joseph Nguyen, MPH, Shevaun Doyle, MD, John Blanco, MD, David Scher, MD, Roger Widmann, MD, and Emily Dodwell, MD, MPH, FRCSC, declare that they have no conflicts of interest. Joseph Nguyen, MPH, reports grants from Clinical Translational Science Center (CTSC), National Center for Advancing Translational Sciences (NCATS), outside the submitted work. Daniel Green, MD, MS, reports personal fees from Arthrex and from Pega Medical, outside the submitted work.

Background: Prior reports suggest that osteoarticular infections may be increasing over time., Questions/purposes: We sought to determine if incidence rates, median in-hospital costs, and length of stay (LOS) of osteomyelitis, septic arthritis (SA), and combined infections have changed over time for pediatric patients, and how they compare to previously reported rates., Methods: The Kids' Inpatient Database (KID), a US national sample of pediatric hospital discharge records from 1997, 2000, 2003, 2006, 2009, and 2012, was used to determine yearly estimated counts of infections in children 20 years of age or younger. US census data was used to calculate yearly incidence rates. Trend tests using linear contrast analysis were used to compare estimated median LOS and inflation-adjusted median costs over time for each type of infection., Results: From 1997 through 2012, the incidence rate of osteomyelitis increased from 7.9 to 10.5 per 100,000, SA was unchanged from 5.3 to 5.2 per 100, and combined infections increased from 0.8 to 1.3 per 100,000. Median LOS from 1997 to 2012 showed no significant change for osteomyelitis (5.0 to 4.9 days), SA (4.4 to 4.1 days), or combined infections (6.5 to 6.8 days). Median in-hospital costs from 1997 to 2012 increased for osteomyelitis ($7735 to $11,823), SA ($5041 to $10,574), and combined infections ($12,691 to $16,260)., Conclusion: In pediatric patients, the estimated incidence rate of SA appeared stable, while rates of osteomyelitis and combined infections increased. These estimated rates fall within previously reported ranges. Despite stable LOS, costs have increased over time., Competing Interests: Conflict of InterestGabriella Safdieh, MD, Jason Silberman, BA, Joseph Nguyen, MPH, Shevaun Doyle, MD, John Blanco, MD, David Scher, MD, Daniel Green, MD, MS, Roger Widmann, MD, and Emily Dodwell, MD, MPH, FRCSC, declare that they have no conflict of interest. Joseph Nguyen, MPH, reports grants from Clinical Translational Science Center (CTSC), National Center for Advancing Translational Sciences (NCATS), outside the submitted work.

Background: Stiff-knee gait is a common gait deviation in individuals with cerebral palsy (CP) due to rectus femoris (RF) muscle spasticity. The Duncan-Ely test is a velocity-dependent measurement of spasticity that is recorded as positive or negative. At our institution, we use a modification of the Duncan-Ely test, a 5-point ordinal rating scale, which delineates where the catch occurs within the rapid arc of knee flexion. It has been named the Root-Ely test., Questions/purposes: We sought to determine the intra- and inter-rater reliability of the Duncan-Ely and Root-Ely tests in pediatric patients with CP., Methods: A convenience sample of 20 ambulatory subjects was recruited; mean age was 10.5 ± 4.5 years, and the Gross Motor Function Classification System (GMFCS) levels were I-III. Five clinicians measured each individual's RF spasticity using the Root-Ely protocol during a single visit. Simple κ statistics with 95% confidence intervals (CI) were utilized for intra-rater reliability and weighted κ statistics with 95% CI for inter-rater reliability., Results: The Root-Ely scale intra-rater reliability was 0.77 to 0.90 and inter-rater reliability was 0.32 to 0.87. Inter-rater reliability was good to excellent among experienced clinicians and fair to moderate in new clinicians., Conclusion: The Root-Ely 5-point scale has acceptable intra- and inter-rater reliability in pediatric individuals with CP among experienced clinicians. The Root-Ely test allows experienced clinicians to reliably quantify severity of RF spasticity and may give orthopaedic surgeons a clinical tool to better predict ideal candidates for RF transfers in individuals with CP in order to improve stiff-knee gait., Competing Interests: Compliance with Ethical StandardsLisa C. Drefus, PT, DPT, Siobhan Clarke, PT, DPT, Karen Resnik, PT, DPT, Jayme Koltsov, PhD, Emily R. Dodwell, MD, David M. Scher, MD declare that they have no conflicts of interest.All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2013.Informed consent was obtained from all patients for being included in this study.Disclosure forms provided by the authors are available with the online version of this article.

Background: Percutaneous epiphysiodesis using transphyseal screws (PETS) has been associated with implant failure, implant prominence, angular deformities, and delayed growth inhibition., Questions/purposes: The aim of this study was to assess the complication rate and efficacy (defined as actual growth inhibition divided by expected growth inhibition) of PETS and to identify factors associated with improved efficacy., Methods: Patients who underwent distal femoral and/or proximal tibial PETS between January 2007 and June 2014 were identified. Complications, efficacy, and final limb-length discrepancy (LLD) were calculated using multipliers and inhibition rates based on previous growth. Associations between efficacy and screw insertion angle (SIA), body mass index, and number of threads crossing the physis were calculated., Results: Eight-two patients (126 treated physes) were included. The mean pre-operative LLD was 27.7 mm (SD = 7.5). Following epiphysiodesis, 15 had temporary pain (18%), five had temporary effusion (6.1%), four had broken implants (4.9%), four developed mild angulation (4.9%), and three had failed epiphysiodesis requiring revision (3.7%). Thirty-one underwent screw removal ( n  = 31, 38%). Mean LLD at maturity was 17.3 mm (SD = 5.8 mm). Mean efficacy at the distal femur was 97% (SD = 46%), at the proximal tibia was 108% (SD = 66%) and was 103% (SD = 57%) overall. Increased screw threads across the lateral proximal tibial physis (Spearman's correlation coefficient = 0.67; 95% CI = 0.40-0.94) and higher BMI (Spearman's correlation coefficient = 0.55; 95% CI = 0.34-0.77) were positively associated with increased efficacy., Conclusions: The efficacy of PETS may be more favorable than previously reported. Only 3.7% had serious complications requiring revision epiphysiodesis, lower than previous reports. Attention to sufficient screw threads across the physis may be important in optimizing PETS results.

Background: EOS low-dose biplanar X-ray used with tantalum bead implantation is an appealing imaging modality to evaluate limb length and physeal growth due its relatively low radiation exposure, excellent inter- and intra-observer reliability, and minimal magnification/shrinkage error., Questions/purposes: The purpose of this study was to establish the error in total length and inter-bead distances using EOS and tantalum beads due to variable positioning in the EOS gantry, by assessing variation in measurements made on the same subject repeatedly positioning by one positioner (intra-positioner measurement error) and variation in measurements made on the same subject with positioning by multiple positioners (inter-positioner measurement error)., Methods: Tantalum bead markers were placed about the distal femoral physis of a cadaveric lamb femur. Three investigators positioned the femur in the EOS gantry 10 times, totaling 30 EOS scans. Total limb length and inter-bead distances were measured on AP and lateral views; mean and standard error were calculated. A random effects analysis of variance for nested data was used to determine the proportion of variation due to differences between positioners and differences between positioning by the same positioner., Results: Intra-positioner measurement error ranged from 0.01 to 0.06 mm. Inter-positioner measurement error ranged from 0.00 to 0.09 mm., Conclusions: EOS has relatively low radiation and allows standing assessment of limb length and alignment. In this study, length measurements and inter-bead distances demonstrated minimal error due to positioning in the EOS gantry, documenting that there is minimal error from positioning, minimal magnification/shrinkage error, and exceptional inter and intra-rater reliability. EOS is the preferred method for length and angular measurements, and with tantalum beads, is ideal for measuring growth about the physis.

Differentiating septic arthritis of the pediatric hip from other causes of hip pain and effusion continues to present a diagnostic challenge for the clinician. Although septic arthritis traditionally has been reported to have a synovial white blood cell count of 75,000 cells/mm3 or greater, lower counts can be seen in this condition. In cases where a synovial sample has been obtained and the cell count falls in the intermediate range between 25,000 and 75,000 cells/mm(3), it is unclear what proportion of these cases may be truly septic hips. In this evidence-based review, we examine Heyworth et al's study focusing on the predictive value of this intermediate white cell count range in a Lyme-endemic region.