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Brachial plexus birth palsy (BPBP) is a neurologic injury that can result in mild to full paralysis of the affected upper extremity. In severe cases, nerve surgery is often performed before age 1 year. Several studies report gains in elbow flexion with onabotulinum toxin type A (OBTT-A) injections to the triceps; however, its use in infants is not widely reported. The purpose of this study is to present our experience using these injections before 6 months of age to therapeutically unmask elbow flexion and diagnostically guide surgical decision making. This is a retrospective observational cohort study. The cohort included infants with BPBP who received OBTT-A injection to the triceps before age 6 months. Indications for the injections include trace elbow flexion and palpable co-contraction of the biceps and triceps. Elbow flexion was evaluated using the Toronto Test score. Therapeutic success was defined as an increase in post-injection scores. These scores were then used diagnostically as an indication for surgery if the infant did not achieve full elbow flexion by 8 months. A treatment algorithm for OBTT-A triceps injection was developed based on all treatment options offered to infants with elbow flexion deficits seen in the clinic. Of the 12 infants that received OBTT-A triceps injections, 10 (83%) had improved Toronto test elbow flexion scores post-injection. Gains in elbow flexion once attained were maintained. Of the 9 OBTT-A infants with at least 2 years follow-up, 4 achieved full elbow flexion without surgery; the remainder after surgery. No complications with OBTT-A injections were noted and patients were followed on average 6 years. The average age at time of injection was 4 months (range: 2–5 months). Compared to other treatments given, OBTT-A infants tended to present with more elbow flexion than the 4 infants requiring immediate surgical intervention and less elbow flexion than the 16 infants treated conservatively. OBTT-A injection to the triceps in infants with BPBP before 6 months of age therapeutically improved elbow flexion and diagnostically guided surgical decisions when full elbow flexion was not achieved by 8 months of age with no known complications.

Background: The etiology for recurrent patellar dislocations in children with patellofemoral instability (PFI) is not always apparent. Radiographic and other imaging measures help guide the clinician. However, the imaging parameters for pathologic pediatric PFI and the significance of these measures based on severity are not clearly defined. This study compares common imaging measures for PFI in a non-pathologic and known patellar dislocation pediatric population and determines the likelihood of symptoms based on the severity of each individual measure. Methods: An IRB-approved retrospective review of knee MRIs and radiographs at a single pediatric institution identified 108 limbs (102 patients) meeting inclusion criteria. Sixty-nine limbs had no known patellar pathology (control group) and 39 had surgery for recurrent patellar dislocations (surgical group). MRI measures included tibial tuberosity-trochlear groove distance (TT-TG), tibial tuberosity-posterior cruciate ligament distance (TT-PCL), and lateral trochlear inclination (LTI). Radiographic measures included the Caton-Deschamps Index (CDI) and Insall-Salvati Index (ISI). These measures are representative of PFI risk factors, specifically patellar tendon malalignment, trochlear dysplasia, and patella alta. Binomial logistic regression was used to relate the anatomical parameters to the probability of PFI. Results: The surgical and control groups were similar in terms of age, height and weight. The logistic regression analysis indicated that the TT-TG (p=0.001) and LTI (pConclusion/Significance: Comparing pediatric patients with recurrent patellar dislocations to controls, logistic regression analysis suggests the likelihood of PFI correlates with the severity of specific radiographic measures, specifically those representing the degree of patellar tendon alignment (TT-TG) and trochlear dysplasia (LTI). Knowing this correlation can help guide the treatment of PFI in pediatric patients by providing physicians and families with a continuum on which to base their decisions.

Current surgical options for treating genu varum in achondroplasia include tibial and fibular osteotomy and growth modulation using plates and screws. However, a single surgeon consistently treated genu varum using a planned fibular nonunion (PFN). The purpose of this study is to describe his surgical technique and report radiographic and clinical outcomes for the cohort studied.This is an observational retrospective review. The cohort studied included patients with achondroplasia who had PFN surgery for the treatment of genu varum at a young age (

Control tissue in studies of various orthopedic pathologies is difficult to obtain and presumably equivalent biopsies from other anatomic sites have been utilized in its place. However, for growth plates, different anatomic regions are subject to dissimilar mechanical forces and produce disproportionate longitudinal growth. The purpose of this study was to compare gene expression and structure in normal physes from different anatomic regions within a single animal species to determine whether such physes were equivalent. Thirteen female New Zealand white rabbits (five 15-week-old and eight 19-week-old animals) were euthanized and physes harvested from their proximal and distal femurs and proximal tibiae. Harvested physes were divided into groups for histological, immunohistochemical (IHC), and reverse transcription-quantitative polymerase chain reaction analyses. All physes analyzed demonstrated no apparent differences in morphology or proteoglycan staining intensity on histological examination or in type II collagen presence determined by IHC study. Histomorphometric measures of physeal height as well as gene expression of type II collagen and aggrecan were found to be statistically significantly equivalent (p

Purpose In situ fixation for mild to moderate slipped capital femoral epiphysis (SCFE) remains an acceptable treatment methodology in most centers. Satisfactory fixation results have been reported with the procedure using either the fracture table or radiolucent table, both of which allow the hip to be imaged during the procedure. The position of the pin within the center of the femoral head is important to secure adequate fixation of the capital femoral epiphysis and prevent further slippage with minimal risk for articular penetration and avascular necrosis (AVN) or chondrolysis. Methods We describe a pre-operative planning technique to determine the pin-entry point for percutaneous pinning of SCFE on a radiolucent operating table. A retrospective review of patients who underwent in situ screw fixation with the usage of a cannulated screw on a radiolucent table or fracture table over a 6-year period was conducted. Results The pin-entry point with this technique was reliable in 92% of procedures and comparable in both accuracy and complications to in situ screw fixation on a fracture table. In situ screw fixation on a regular radiolucent table was straightforward and required significantly less surgical time than on the fracture table ( P = 0.01). It was also more efficient during a bilateral procedure, as it required only a single preparation and draping of the patient. Conclusion This pre-operative planning technique for deciding the starting point on the proximal femur is helpful in executing an accurate in situ screw fixation of hips with SCFE.