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BACKGROUND Perthes disease most commonly affects children 5 to 7 years old, and nonoperative management, such as weightbearing and activity restrictions, is generally recommended. In earlier research in children aged 8 to 14 years who had Perthes disease, we found that the restrictions were associated with worse mobility, but mental health or social health measures were not linked. However, Perthes disease most commonly affects children 5 to 7 years old who are more emotionally and cognitively immature. Children in this age group are beginning school and organized sports experiences while developing meaningful social relationships for the first time. Because of such different life experiences, it is important to understand the psychosocial consequences of weightbearing and activity restrictions on this specific age group, as they may help guide choices about weightbearing restrictions and mental health support. QUESTIONS/PURPOSES In patients aged 5 to 7 years with Perthes disease, we asked: (1) Are weightbearing and activity restrictions associated with worse mental health, evaluated with the Patient-reported Outcome Measurement Information System (PROMIS) depressive symptoms, anxiety, and anger questionnaires? (2) Are weightbearing and activity restrictions associated with worse social health (PROMIS peer relationships measure)? (3) Are weightbearing and activity restrictions associated with worse physical health measures (PROMIS mobility, pain interference, and fatigue measures)? (4) What other factors are associated with mental, social, and physical health measures in these patients? METHODS Data were collected from 97 patients with a diagnosis of Perthes disease. Inclusion criteria were age 5 to 7 years at the time the PROMIS was completed, English-speaking patients and parents, in the active stage of Perthes disease (Waldenstrom Stages I, II, or III) who were recommended weightbearing and activity restrictions because of worsening hip pain, poor hip ROM, femoral head deformity, as a postoperative regimen, or if there was substantial femoral head involvement on MRI [23]. Based on their weightbearing and activity restriction regimen, patients were categorized into one of four activity restriction groups (no, mild, moderate, and severe restriction). The following pediatric parent-proxy PROMIS measures were obtained: depressive symptoms, anxiety, anger, peer relationships, mobility, pain interference, and fatigue. We excluded five patients who did not meet the inclusion criteria. Of the remaining 92 patients, 21 were in the no restriction group, 21 were in the mild restriction group, 28 were in the moderate restriction group, and 22 were in the severe restriction group at the time of PROMIS administration. ANOVA was used to compare differences between the mean PROMIS T-scores of these four groups. T-scores are computed from PROMIS survey responses, and a T-score of 50 represents the age-appropriate mean of the US population with an SD of 10. A higher T-score means more of that measure is being experienced and a lower score means less of that measure is being experienced. To address the possibility of confounding variables such as Waldenstrom stage, gender, age at diagnosis, and history of major surgery, we performed a multivariable analysis to compare the association of different weightbearing regimens and the seven PROMIS measures. This allowed us to answer the question of whether weightbearing and activity restrictions are associated with worse physical, mental, and social health measures in Perthes patients aged 5 to 7 years, while minimizing the possible confounding of the variables listed above. RESULTS After controlling for confounding variables such as Waldenstrom stage, gender, age at diagnosis, and history of major surgery, we found that moderate activity restriction was associated with worse depressive symptoms (β regression coefficient = 6 [95% CI 0.3 to 12]; p = 0.04) and anxiety (β = 8 [95% CI 1 to 15]; p = 0.02) T-scores than no restrictions. The mild (β = -7 [95% CI -12 to -1]; p = 0.02), moderate (β = -15 [95% CI -20 to -10]; p < 0.001), and severe (β = -23 [95% CI -28 to -18]; p < 0.001), restriction groups had worse mobility T-scores than the no restriction group. Weightbearing and activity restrictions were not associated with anger, peer relationships, pain interference, and fatigue measures. Waldenstrom Stage II disease was associated with worse pain interference than Waldenstrom Stage III (β = 7 [95% CI 0.4 to 13]; p = 0.04). A history of major surgery was associated with worse anger scores (β = 18 [95% CI 3 to 33]; p = 0.02). The child's gender and age at diagnosis had no association with any of the seven PROMIS measures. CONCLUSION Moderate weightbearing and activity restrictions are associated with worse depressive symptoms and anxiety in patients with Perthes disease aged 5 to 7 years, after controlling for Waldenstrom stage, gender, age at the time of diagnosis, and history of surgery. Considering the discoveries in this study and in our previous study, for patients 5 to 7 years old, we recommend that providers discuss the potential for mental health changes with moderate weightbearing restrictions with patients and their families. Furthermore, providers should monitor for worsening mental health symptoms at each follow-up visit and refer patients to a clinical child psychologist for support when appropriate. Future studies are needed to assess the effects of these restrictions on mental health over time and after patients are allowed to return to normal activities. LEVEL OF EVIDENCE Level III, therapeutic study.

IFN-γ licensing to mesenchymal stem cells (MSCs) is applied to enhance the therapeutic potential of MSCs. However, although the features of MSCs are affected by several stimuli, little information is available on changes to the therapeutic potential of IFN-γ-licensed differentiated MSCs during xenogeneic applications. Therefore, the present study is aimed at clarifying the effects of adipogenic/osteogenic differentiation and IFN-γ licensing on the in vitro immunomodulatory and migratory properties of porcine bone marrow-derived MSCs in xenogeneic applications using human peripheral blood mononuclear cells (PBMCs). IFN-γ licensing in differentiated MSCs lowered lineage-specific gene expression but did not affect MSC-specific cell surface molecules. Although indoleamine 2,3 deoxygenase (IDO) activity and expression were increased after IFN-γ licensing in undifferentiated MSCs, they were reduced after differentiation. IFN-γ licensing to differentiated MSCs elevated the reduced IDO expression in differentiated MSCs; however, the increase was not sufficient to reach to the level achieved by undifferentiated MSCs. During a mixed lymphocyte reaction with quantification of TNF-α concentration, proliferation and activation of xenogeneic PBMCs were suppressed by undifferentiated MSCs but inhibited to a lesser extent by differentiated MSCs. IFN-γ licensing increasingly suppressed proliferation of PBMCs in undifferentiated MSCs but it was incapable of elevating the reduced immunosuppressive ability of differentiated MSCs. Migratory ability through a scratch assay and gene expression study was reduced in differentiated MSCs than their undifferentiated counterparts; IFN-γ licensing was unable to enhance the reduced migratory ability in differentiated MSCs. Similar results were found in a Transwell system with differentiated MSCs in the upper chamber toward xenogeneic PBMCs in the lower chamber, despite IFN-γ licensing increased the migratory ability of undifferentiated MSCs. Overall, IFN-γ licensing did not enhance the reduced immunomodulatory and migratory properties of differentiated MSCs in a xenogeneic application. This study provides a better understanding of the ways in which MSC therapy can be applied.

Variation exists in the Pavlik harness (PH) treatment regimen for infantile developmental dysplasia of the hip (DDH). The purpose of this study was to determine if the daily PH wear duration (23 vs. 24 h) and frequency of follow-up visits affect the clinical and radiographic outcomes of infants with dislocated but reducible (Ortolani+) hips.This study reviewed prospectively enrolled patients with DDH in a single center who presented at age6 months with Ortolani+ hips and were treated with PH. Recommended daily PH wear duration (23 vs. 24 h) and the frequency of clinic visits in first 4 weeks after the initiation of PH treatment were analyzed. The clinical success (stable hip that did not require closed or open reduction or the use of an abduction orthosis) and radiographic success based on the acetabular index at 2-year follow-up were compared between different PH regimen groups.Sixty-two patients (74 hips, 53 females) with Ortolani+ hips had a mean age of presentation of 23±28 days (range, 4 to 128 d) and mean follow-up of 33.2±18.4 months (range, 8 to 85 mo). Overall clinical success rate of PH for Ortolani+ hips was 93% (69/74 hips) and radiographic success rate at 2 years was 84% (48/57 hips). There was no difference in clinical or radiographic success rate between the 23- and 24-hour wear groups (P0.99, 0.73) or between hips assessed almost weekly compared with once or twice during the first 4 weeks of PH treatment (P0.99 for both).The 23- versus 24-hour PH regimen and frequency of clinic visits in the first 4 weeks of PH treatment did not affect the clinical or radiographic success rate of Ortolani+ hips in infantile DDH. A strict weekly clinic visit and 24-hour PH regimen may not be necessary to obtain stable reduced hips in infants presenting6 months of age with Ortolani+ hips.Level III-therapeutic.

Study Design Retrospective review. Objectives To evaluate the incidence of adolescent idiopathic scoliosis (AIS) curve progression and brace prescription in skeletally immature patients (Risser 0 to Risser 1) with curves 15°–24°. Summary of Background Data Many skeletally immature patients with mild AIS ask about the likelihood of curve progression. No studies have answered these questions. Methods The charts and radiographs of 302 consecutive patients with curves 15°–24° at initial visit, Risser 0 to Risser 1, were reviewed until skeletal maturity (≥Risser 4) or surgery. Curves averaged 19.1° ± 2.9° at initial visit. The Risser grade was 0 in 247 patients (82%) and 1 in 55 patients (18%). Patients who were Risser 0 were compared with those who were Risser 1, curves 15°–19° were compared with curves 20°–24°. Results The majority of patients demonstrated curve progression ≥5° (65%). Patients who were Risser 0 did not progress significantly more than patients who were Risser 1 (10° vs. 8°) (p = .22). Patients with curves 20°–24° did not progress significantly more than patients with curves 15°–19° (10° vs. 9°) (p = .65). Conclusions Curve progression for small curves (15°–19°) is similar to curves between 20° and 24°. Close observation or perhaps early intervention for these patients is necessary. These data may suggest a paradigm shift to earlier brace initiation and call for early treatment in small curves. Level of Evidence Level II.

BACKGROUND Lumbar herniated nucleus pulposis (HNP) occurs infrequently in the pediatric/adolescent population. A minority of patients with radicular symptoms fail to improve with conservative management and require discectomy. The authors hypothesize that children who ultimately require surgical intervention have an underlying lumbar stenosis predisposing them to continued symptoms. METHODS Pediatric patients with a lumbar HNP on advanced imaging were retrospectively identified at a tertiary pediatric orthopaedic institution. Patients with spondylolisthesis, fractures, previous spine surgery, or structural thoracolumbar scoliosis were excluded. On sagittal magnetic resonance imagings, measurements were taken of the L4 and L5 vertebral body diameters (VBD) and canal diameters (CD) by 2 independent reviewers. Statistical analysis was performed using 2 sample T tests followed by logistic regression analysis. This was utilized to identify significant associations between CD and need for surgical decompression. RESULTS A total of 76 patients (37 males/39 females) were identified with a lumbar HNP from 2001 to 2016. Eleven patients underwent discectomy. Sixty-five patients were managed conservatively. Age at magnetic resonance imaging was not different between groups (15.1±1.7 vs. 14.9±2.2 y, P=0.82). VBD at L4 and L5 were not different between groups (P=0.2 and 0.36, respectively). The reviewers had fair to good (0.584-0.854) interrater reliability correlation coefficients. CD was decreased in the surgically treated cohort at L4 (11.6±1.6 vs. 14.2±2.1 mm, P=0.0002) and at L5 (10.1±1.3 vs. 14.2±2.2 mm, P

Introduction Electronic medical record (EMR) use among pediatric orthopaedic surgeons has evolved substantially within the past decade. In response to the Patient Protection and Affordable Care Act, large hospitals and tertiary pediatric medical centers rapidly acquired and implemented EMRs with uncertainty as to the potential impact on patient care and operational efficiency of subspecialists. This study reviews the background and regulatory framework for Meaningful Use of EMR and assesses the current landscape of EMR utilization by pediatric orthopaedic surgeons. Methods In 2015, the Practice Management Committee distributed a survey regarding EMR use and satisfaction to members of the Pediatric Orthopaedic Society of North America. Survey responses from 324 members were used to analyze levels of satisfaction by EMR platform and practice type and to consider drivers of satisfaction or dissatisfaction of end users. Results Although there were no differences in overall satisfaction based on vendor or practice type, significant differences were noted for 5 specific parameters of satisfaction, including: usefulness of templates, efficiency of practice workflow, information services support, number of logon events, and speed of the system. A user/vendor map is provided to facilitate networking among providers and groups utilizing common EMR platforms to help bring about rational improvements in EMR functionality for the future. Conclusions Substantial effort needs to be made to improve subspecialty-specific EMR documentation, order entry, research tools, and clinical workflows to enhance the processes of care for children with orthopaedic conditions in the era of EMR. Level of evidence Level IV.

Background The prognosis of Legg-Calve-Perthes disease (LCPD) is dependent upon several factors, with the length and severity of the fragmentation stage among the most important. Previous retrospectively collected data from a single center have suggested that early proximal femoral varus osteotomy (PFO) may shorten the length of fragmentation and allow 34% of patients to bypass fragmentation altogether resulting in less femoral head deformity. The purpose of this study was to validate these findings in a prospectively collected multicenter cohort. Methods Patients with LCPD treated with early PFO (during Waldenstrom stage I) were prospectively followed with serial radiographs at 3-month intervals until a minimum of 2-year follow-up. Waldenstrom stages and lateral pillar class were determined by mode assessments from 3 pediatric orthopaedic surgeons. The duration of fragmentation was defined as the interval between the first radiographs demonstrating features of stage IIa and stage IIIa. "Complete" bypass was defined as the absence of stage IIa or IIb findings on sequential radiographs with no development of femoral head deformity or collapse. "Partial" bypass was defined as the absence of advanced features of fragmentation and femoral head collapse (stage IIb). Results Forty-six patients (80% male individuals) with initial stage LCPD and a mean age of 8.2±1.2 years were identified. The weighted kappa statistics for Waldenstrom staging and lateral pillar classifications showed excellent (0.833) and substantial (0.707) agreement, respectively. Ninety-eight percent of patients (45/46) underwent some period of fragmentation lasting between 91 and 518 days; the median duration was 206 days (interquartile range, 181 to 280). One patient (2%) bypassed fragmentation completely; 8 patients (17%) demonstrated partial bypass. Patients who completely or partially bypassed fragmentation experienced significantly less severe lateral pillar collapse (P=0.016) and shorter fragmentation duration (P=0.001). Conclusions In this prospective multicenter cohort, we found a lower rate of fragmentation bypass than previously reported. Nonetheless, our data support the previous contention that early PFO may shorten fragmentation and minimize collapse in LCPD compared with historical controls. Further study with larger cohorts and a more rigorous definition of what constitutes bypass is warranted to clarify the effect of early PFO on the reparative biology of LCPD. Level of evidence Level IV-therapeutic study.

Purpose To evaluate the curve magnitude in participants with mild adolescent idiopathic scoliosis (AIS) at high risk of progression who received outpatient physical therapy scoliosis-specific exercises (PSSEs). Methods Participants with AIS curves 12° to 20° and Risser grade 0 chose either the PSSE or the control group. The PSSE group was instructed in the Barcelona Scoliosis Physical Therapy School. The control group was observed. Cobb angles were measured by one observer masked to group type at baseline, 6-month follow-up, and 1-year follow-up. Results Forty-nine participants were enrolled (26 exercise vs 23 controls). Thirty-three participants (19 exercise vs 14 controls) were seen at 1-year follow-up. At 1-year follow-up, the exercise group had smaller curves than controls (16.3° vs 21.6°, P = .04) and less curve progression (0° vs 5.6°, P = .02). Bracing was performed similarly between groups at 1-year follow-up (37% vs 43%). Conclusions In this small prospective series, PSSE resulted in significantly less curve progression compared with controls.

Background It has been shown that retrograde titanium flexible intramedullary nails (Ti FIN) provide superior resistance to bending compared to antegrade Ti FIN in distal femur fractures. The purpose of this study was to compare resistance to torsional and bending forces of stainless steel (SS) FIN, with or without a locking screw, and Ti FIN in distal third femoral shaft fractures. We hypothesize that locked retrograde SS FIN will demonstrate greater resistance to both bending and torsional forces. Methods Thirty adolescent synthetic femur models were used to simulate transverse distal femoral fractures at either 60 mm or 90 mm proximal to the distal femoral physis. The femurs were instrumented with antegrade Ti FIN, antegrade SS FIN, retrograde Ti FIN, retrograde SS FIN, or retrograde locked SS FIN. Three models for each construct at both osteotomy levels were tested. Models were analyzed to determine maximum resistance to bending and torsion. Results In fractures 60 mm from the physis, retrograde SS FIN demonstrated statistically superior resistance to bending when compared with both antegrade and retrograde Ti FIN (P=0.001 and 0.008, respectively) and antegrade SS FIN (P=0.0001). Locked SS constructs showed a trend towards greater resistance to bending forces when compared with unlocked constructs (P>0.05). No significant difference was seen in resistance to bending when fractures were 90 mm proximal to the distal femoral physis between the five groups. No significant differences were observed in resistance to torsion in either the proximal or distal fracture models, regardless of construct type. Conclusions Retrograde SS FIN confer significantly greater resistance to bending forces for fractures 60 mm proximal to the distal femoral physis compared with Ti FIN or antegrade entry SS FIN. In fractures 90 mm from the physis, no differences were noted in our model. Our results support the use of retrograde SS nails in the pediatric patient with distal femoral shaft fractures. Level of evidence Level II-comparative biomechanical study.

Health care in America continues to place more importance on providing value-based medicine. Medicare reimbursements are increasingly being tied to this and future policy changes are expected to reinforce these trends. Recent literature has shown pediatric femur fractures in preschool-age children have equivalent clinical and radiographic outcomes when treated with spica casting or flexible intramedullary nails (IMN). We compared hospital care statistics including charges for nonoperative versus operative treatment for closed femur fractures in 3- to 6-year-olds.An IRB-approved retrospective chart review was performed of 73 consecutive 3- to 6-year-olds treated at a regional level 1 pediatric hospital from January 1, 2009 to December 31, 2013 with an isolated, closed femoral shaft fracture. Exclusion criteria included open fractures, bilateral injury, and polytrauma. Immediate spica casting was performed in the Emergency Department or Anesthesia Procedure Unit versus IMN in the operating room.A total of 41 patients were treated with spica casting and 32 patients were treated operatively with flexible IMNs; 3 patients failed nonoperative care. After analysis of final treatment groups, significant differences included age at injury: 3.7 years for cast versus 5.3 years for IMN (P0.001), time to discharge 21 versus 41 hours (P0.001), 3.2 versus 4.4 clinic visits (P0.001), follow-up 3.5 versus 9.4 months (P0.001). Orthopedic surgeon charges were $1500 for casted patients versus $5500 for IMN (P0.001). Total hospital charges were $19,200 for cast versus $59,700 for IMN (P0.001). No difference was found between clinic charges or number of radiographs between groups. In total, 76% of cast group were discharged24 hours from admission versus 8.6% in operative group. In the operative group, 83% had implant removal with no statistically significant charge difference between those who had implant removal versus retention.Treatment of pediatric femur fractures in 3- to 6-year-olds with IMN is associated with longer hospital stays, significantly greater hospital charges, longer follow-up and more clinic visits compared with spica casting. These findings are at odds with previous literature showing shorter hospital stays and decreased cost with nailing compared to traction and casting. This shows a clear difference between 2 treatments that yield similar clinical and radiographic outcomes.Level III-retrospective comparative study.

Background Children with osteomyelitis demonstrate a wide spectrum of illness. Objective measurement of severity is important to guide resource allocation and treatment decisions, particularly for children with advanced illness. The purpose of this study is to validate and improve a previously published severity of illness scoring system for children with acute hematogenous osteomyelitis (AHO). Methods Children with AHO were prospectively studied during evaluation and treatment by a multidisciplinary team who provided care according to evidence-based guidelines to reduce variation. A severity of illness score was calculated for each child and correlated with surrogate measures of severity. Univariate analysis was used to assess the significance of each parameter within the scoring model along with new parameters, which were evaluated to improve the model. The scoring system was then modified by the addition of band count to replace respiratory rate. The modified score was calculated and applied to the prospective cohort followed by correlation with the surrogate measures of severity. Results One hundred forty-eight children with AHO were consecutively studied. The original severity of illness score correlated well with length of stay and other established measures of severity. Band percent of the white blood cell differential ≥1.5% was found to be significantly associated with severity and chosen to replace respiratory rate in the model. The modified calculated severity scores correlated well with the chosen surrogate measures and significantly differentiated children with osteomyelitis on the basis of causative organism, length of stay, intensive care, surgeries, bacteremia, and disseminated or multifocal disease. Conclusions The findings of this study validate the previously published severity of illness scoring tool in large cohort of children who were prospectively evaluated. The replacement of respiratory rate with band count improved the scoring system.

The purpose of this investigation was to evaluate the risk for long-term, adverse outcomes among children with osteomyelitis.Children with osteomyelitis were prospectively enrolled from 2012 to 2014. Care was accomplished by a multidisciplinary team according to an institutional algorithm. Data were collected to define the severity of illness during the initial hospitalization and assess short, intermediate and long-term outcomes. Clinical examination, radiographic assessment and functional outcome survey administration were performed at a minimum of 2 year follow-up. A comparison cohort analysis was performed according to initial severity of illness score of mild (0-2), moderate (3-6) and severe (7-10).Of 195 children enrolled, 139 (71.3%) returned for follow-up at an average of 2.4 years (range, 2.0-5.0 years). Children with severe illness were less likely to have normal radiographs (severe, 4.0%; moderate, 38.2%; mild, 53.2%, P0.0001), and more likely to have osteonecrosis, chondrolysis, or deformity (severe, 32.0%; moderate, 5.9%; mild, 1.3%, P0.0001). Functional outcome measures did not significantly differ between severity categories. By regression analysis severity of illness score, plus age less than 3 years and Methicillin-resistant Staphylococcus aureus predicted severe sequelae with an area under the curve of 0.8617 and an increasing odds ratio of 1.34 per point of increase in severity score.Long-term severe adverse outcomes among children with osteomyelitis occurred in 11 of 139 (7.9%) children and were predicted by initial severity of illness. Other risks that diminished the likelihood of complete resolution or increased the risk of severe sequelae included Methicillin-resistant Staphylcoccus aureus etiology and young age. The majority of children with osteomyelitis do not require long-term follow-up beyond the initial treatment period.

Purpose One method of predicting leg-length discrepancy at maturity is the Moseley straight-line graph. Beumer et al developed an alternative graph, using a more modern Dutch population. The purpose of this study was to compare the prediction accuracy of these two graphs in a cohort of patients treated at our institution using epiphysiodesis. Methods We identified 76 patients treated using epiphysiodesis for leg-length discrepancy who were followed to maturity and had adequate preoperative radiographic assessment for straight-line graph construction. We compared predicted long leg length (after epiphysiodesis), short leg length, and residual leg-length discrepancy to actual outcome for both methods, using both chronological and skeletal ages. Results Both methods were more accurate using skeletal age rather than chronological age. The Rotterdam graph showed modest improved accuracy compared to the Moseley graph in developmental aetiologies and in Hispanic patients. Using a difference of one centimetre in prediction error as clinically relevant (long leg [after epiphysiodesis], short leg, and leg-length discrepancy in each of the 76 patients, 228 predictions), we found comparable predictions in 171, more accurate prediction using the Rotterdam in 32, and using the Moseley in 25 predictions. Conclusions Straight-line graphs provide a generally more accurate prediction of leg lengths at maturity by virtue of multiple preoperative evaluations. The Rotterdam straight-line graph was equal to or superior to the Moseley graph in most patients in this cohort. Use of skeletal age resulted in more accurate predictions than chronological age. Clinicians should remain familiar with the concept and use of the straight-line graph. Level of evidence III, case-control study.

Purpose: The purpose of this study is to examine pediatric patients (under the age of 18) with a radial neck fracture, and determine the factors associated with a failed closed reduction (CR) in the Emergency Department (ED). We aim to use these factors to recommend a protocol that guides the treatment management of these fractures. Methods: 70 patients who presented to our ED with acute radial neck fractures were retrospectively reviewed. Inclusion criteria were: age 18 years or younger at time of injury, diagnosis of radial neck fracture without other …

There is significant controversy in the literature over rates of late-developing dysplasia following normal screening ultrasound in breech babies, with reported rates varying from 7% to 29%. The purpose of this study is to investigate the rates of radiographic dysplasia in breech babies after a normal ultrasound with a minimum of 1 year of radiographic follow-up.This study was an institutional review board-approved prospective study of all patients referred by their pediatrician for concern for developmental dysplasia of the hip between July 2008 and August 2014. We identified all subjects with breech presentation and excluded those with an abnormal initial examination/ultrasound or with12 months of radiographic follow-up. Anterior-posterior pelvis films were obtained after12 months and acetabular indices (AIs) were measured and compared with contemporary normative data. Dysplasia was diagnosed as2 SDs above the mean.A total of 654 patients were referred with a history of a breech presentation, and 150 (22.9%) were found to have clinical instability or sonographic evidence of dysplasia on initial presentation and were observed with serial imaging or treated. Of the remaining 504 subjects with a normal clinical examination and screening ultrasound, 133 (26.4%; 74.4% females, 25.6% males) were followed until at least 12 months of age. Of those presenting at age 12 to 14 months, the mean AI was 0.42±0.83 SD above the mean with a skew towards elevated AIs. At the final follow-up (mean: 20.7±6.7 mo), the mean AI was 0.05±0.92 SD above the mean, and only 3/133 (2.2%) patients had a dysplastic hip. No patients underwent treatment other than an observation during the study period.One in 5 breech babies have dysplasia at presentation, but late dysplasia following normal screening ultrasound may be less common than previously reported and may be due to our prolonged follow-up period. We recommend surveillance of breech babies with follow-up visits after 12 months of age since earlier visits may offer limited benefits.Level II-prospective prognostic study.

BACKGROUND The Classification of Early-Onset Scoliosis (C-EOS) allows providers to differentiate patients, for clinical and research purposes, on the basis of the etiology of their disease as well as radiographic parameters. The Early Onset Scoliosis Questionnaire (EOSQ) is the first disease-specific, parent-reported HRQOL (health-related quality-of-life) outcome measure for this condition. We sought to determine the influence of the C-EOS etiology designation, radiographic parameters, and medical comorbidities on EOSQ scores to differentiate quality of life in this heterogeneous patient population. We hypothesized that baseline EOSQ scores for patients with EOS would be strongly affected by the C-EOS etiology designation. METHODS The analysis included prospectively enrolled patients with EOSQ scores recorded in a multicenter EOS database prior to intervention for the EOS. EOSQ scores were compared across C-EOS etiologies, severity of disease based on radiographic measurements, and patient comorbidities prior to scoliosis intervention. RESULTS Six hundred and ten patients with EOS were available for analysis; 119 had congenital, 201 had idiopathic, 156 had neuromuscular, and 134 had syndromic EOS. In multivariate analysis, neuromuscular and syndromic etiologies were associated with lower scores than congenital and idiopathic etiologies in many EOSQ domains including general health, transfer, daily living, fatigue/energy level, and emotion. Patients with neuromuscular EOS had the lowest EOSQ scores in general. Congenital and idiopathic EOS did not differ from each other in any EOSQ domain. Coronal Cobb and kyphosis angles had significant inverse but generally weak correlations with EOSQ domains. Individual medical comorbidities had a minor effect on certain domains while American Society of Anesthesiologists (ASA) class and total number of comorbidities had inverse correlations with most domains. CONCLUSIONS The underlying etiology of EOS appears to have a significant influence on the parent-reported HRQOL outcomes of the disease. Specifically, syndromic and neuromuscular C-EOS diagnoses are associated with lower EOSQ scores before treatment compared with congenital and idiopathic diagnoses. Radiographic measurements of severity have a relatively small influence on EOSQ scores. These baseline differences in C-EOS-designated etiology should be accounted for in studies comparing outcomes of treatment for this heterogeneous patient population. LEVEL OF EVIDENCE Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Mesenchymal stem cells (MSCs) are valuable candidates in tissue engineering and stem cell-based therapy. Traditionally, MSCs derived from various tissues have been successfully expanded in vitro using adherent culture plates commonly called as monolayer two-dimensional (2D) cultures. Recently, many studies demonstrated that stemness and multilineage differentiation potential could be enhanced to greater extent when MSCs are cultured as suspended aggregates by means of three-dimensional (3D) culturing techniques. However, there are limited reports on changed mitochondrial metabolism on 3D spheroid formation of MSCs. Therefore, the present study was aimed at investigating the stemness, differentiation potential, and mitochondrial metabolism capacity of 3D dental pulp-derived MSC (DPSC) spheroids in comparison to monolayer cultured DPSCs. We isolated dental pulp-derived MSCs (DPSCs) and successfully developed a 3D culture system which facilitated the formation of MSC spheroids. The cell aggregation was observed after 2 hours, and spheroids were formed after 24 hours and remained in shape for 72 hours. After spheroid formation, the levels of pluripotent markers increased along with enhancement in adipogenic and osteogenic potential compared to 2D cultured control cells. However, decreased proliferative capacity, cell cycle arrest, and elevated apoptosis rate were observed with the time course of the 3D culture except for the initial 24-hour aggregation. Furthermore, oxygen consumption rates of living cells decreased with the time course of the aggregation except for the initial 24 hours. Overall, our study indicated that the short-term 3D culture of MSCs could be a suitable alternative to culture the cells.

Background Outcomes studies following successful closed reduction of late-detected developmental dysplasia of the hip (DDH) reveal high rates of secondary reconstructive surgery with limited comparative data demonstrating lower rates of residual dysplasia with open reduction. The purpose of this study was to compare long-term outcomes, with regard to radiographic evidence of residual dysplasia and secondary reconstructive procedures, between late closed and late open reduction for DDH in patients 6 to 24 months of age at reduction. Methods We identified all patients between 6 and 24 months of age who underwent closed or open reduction for DDH between 1980 and 2008 and were followed until at least 10 years of age. Outcomes included radiographic measurement of acetabular dysplasia after triradiate cartilage closure, development of osteonecrosis, and the need for secondary procedures for residual dysplasia. Results One hundred and four hips underwent index closed reduction and 54 hips underwent index open reduction. There was no significant difference in the age at reduction (p = 0.07). Among the 116 hips for which initial anteroposterior pelvic radiographs were available, most closed reductions (55%) were performed in International Hip Dysplasia Institute (IHDI) grade-III hips whereas most open reductions (71%) were performed in IHDI grade-IV hips. Analysis of the hips that did not undergo a secondary procedure showed that those with an index open reduction had a greater lateral center-edge angle (mean and standard deviation, 27.2° ± 10.0° versus 22.4° ± 6.8° in the closed reduction cohort; p = 0.02), lower femoral head extrusion index (22.2% ± 8.9% versus 26.0% ± 6.2%; p = 0.04), and lower Sharp angle (43.3° ± 6.0° versus 46.6° ± 3.1°; p = 0.002) at triradiate closure. There was no difference in the prevalence of osteonecrosis (Bucholz-Ogden grades II, III, and IV) between the closed and open reduction cohorts (22% versus 19%, respectively; p = 0.60). Secondary procedures were performed more frequently after closed reduction than after open reduction (47% versus 30%, respectively; p = 0.03). Conclusions In patients with late reduction of DDH, closed reduction was associated with increased residual dysplasia and it was associated with a higher rate of secondary surgery in those >12 months old despite a decreased severity of displacement based on the IHDI classification. Additional, prospective studies with assessment of functional outcomes are needed to validate these findings. Level of evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Intraoperative neuromonitoring (IONM) has historically been difficult to obtain in patients with Charcot-Marie-Tooth (CMT) disease. Transcranial motor-evoked potentials (TcMEPs) have been found to be safe and effective for other spinal deformity patients. Our objective was to determine the effectiveness of TcMEP monitoring in patients with CMT.An IRB-approved, retrospective review of CMT patients undergoing spinal deformity surgery assessing TcMEP, somatosensory-evoked potential (SSEP), and neurogenic motor evoked potential (NMEP) IONM was performed. A 2:1 matched cohort control group of idiopathic spinal deformity patients was used. A waveform grading system was applied to review baseline TcMEP reliability and quality, which was validated via intraclass correlation coefficient amongst five raters.Twenty-three CMT patients (26 surgical cases) were identified. The use of TcMEP improved the ability to obtain baseline IONM when compared to SSEP (83% vs. 20%; p 0.001) and NMEP (83% vs. 18%; p = 0.003). Baseline monitoring was obtained less often for CMT patients using SSEP (20% vs. 100%; p 0.001) and TcMEP (83% vs. 100%; p = 0.111) compared to idiopathic patients. Sweep length (time from stimulation waveform evaluation) and maximum stimulation voltage were higher in the CMT group (289 ms vs. 111 ms p = 0.007 and 740 V vs. 345 V p = 0.089, respectively).TcMEP monitoring significantly improves the ability to provide IONM for CMT patients undergoing spinal deformity surgery. Utilizing longer sweep lengths enhances the ability to attain baseline TcMEP readings, allowing surgeons to more safely proceed with surgery for these complex patients.Therapeutic-Level III.

Background The purpose of this study is to examine pediatric patients with a radial neck fracture and determine the factors associated with a failed closed reduction (CR) in the emergency department (ED). Methods A total of 70 patients with acute radial neck fractures were retrospectively reviewed. Inclusion criteria were: age 18 years or younger at time of injury, diagnosis of radial neck fracture without other associated elbow fractures, an attempt at CR with manipulation in the ED or immediate surgery, open proximal radial physis, and appropriate imaging to categorize the injury. Charts were reviewed and demographic data was obtained. Initial injury films were reviewed and the Judet classification was used to define fracture types/categories. Results CR was attempted on 41 patients. Twenty-nine patients went straight to surgery without a CR attempt. Compared with patients that had an attempted CR in the ED, patients that went straight to surgery had longer mean time from injury to ED presentation (5.6 d; P=0.0001), greater mean fracture angulation (55.0 degrees; P=0.001), and greater fracture translation (46.2%; P=0.001). When analyzing the patients that had a CR attempted in the ED, univariate statistical analysis demonstrated that ≥Judet 4 classification (P=0.03), greater amounts of fracture angulation (P=0.003), and a treatment delayed >24 hours from injury (P=0.007) were significant risk factors for failure of CR in the ED. Zero (0/10) patients with fracture angulation ≥60 degrees had a successful CR. Only 1/14 patients presenting >24 hours after injury had a successful CR in the ED. Conclusions Circumventing sedation in the ED, and instead splinting for a planned surgical intervention may be a more efficient treatment method for pediatric radial neck fractures that present to the ED>24 hours after injury and/or have angulations ≥60 degrees. Adopting this new strategy may save time, reduce costs, and avoid possible harm/complications associated with sedation in the ED. Level of evidence Level III-prognostic.

BACKGROUND Controversy exists regarding the need for proximal fibular epiphysiodesis in conjunction with proximal tibial epiphysiodesis to prevent relative overgrowth of the fibula. The purpose of this study was to determine the incidence of relative fibular overgrowth in patients who had undergone proximal tibial epiphysiodesis with or without proximal fibular epiphysiodesis to manage leg-length discrepancy. METHODS We identified patients who had undergone proximal tibial epiphysiodesis, with or without concomitant fibular epiphysiodesis, followed to skeletal maturity, and with adequate scanograms to measure tibial and fibular lengths. We assessed tibial and fibular lengths, ratios, and distances between the tibia and fibula proximally and distally preoperatively and at skeletal maturity, and obvious radiographic proximal migration of the fibular head. RESULTS A total of 234 patients met inclusion criteria, including 112 girls and 122 boys. In total, 179 patients had undergone concomitant fibular epiphysiodesis, and 55 had not. The fibular epiphysiodesis group was significantly younger preoperatively than the nonfibular epiphysiodesis group (average: 12.3 vs. 13.6 y), which accounted for most of the preoperative differences noted between the groups. Within the subset of younger patients (≥2 y of growth remaining at the time of epiphysiodesis), there were statistically significant differences between those with or without fibular epiphysiodesis at skeletal maturity in the proximal tibial-fibular distance (P

Selective thoracic fusion (STF) for double curve patterns in idiopathic scoliosis is an attractive treatment option. However, short-term coronal decompensation and truncal imbalance are known findings. Previous studies with hook constructs showed that eventually balance is achieved via an increase in lumbar curve magnitude, as the lumbosacral obliquity did not change following surgery. Our aim is to investigate patients with idiopathic curves who underwent STF using all-pedicle screw constructs to determine if the uninstrumented lumbar curve and lumbosacral obliquity responded in the same manner as was previously reported with all-hook constructs.102 consecutive patients with Lenke 1B, 1C or 3C curves who underwent STF using all-screw constructs at a single institution were included in this study. Radiographic assessment was performed, and patient reported outcomes were obtained. Subgroup analyses were performed based on preoperative thoracic: lumbar curve ratio as well as lumbar curve magnitude.Overall, the patients showed statistically significant improvement in both trunk shift and L4-pelvis obliquity at final follow-up. The uninstrumented lumbar curves trended toward improvement over time, but did not reach statistical significance (p = 0.107). SRS-30 scores were statistically significantly improved in multiple domains.Selective thoracic fusion is an excellent treatment option in most double curve patterns. Balance in the coronal plane is predictably achieved at 2-year follow-up. The lumbosacral obliquity improves more with screw technology than was previously found with hook constructs; therefore, the improvement in balance over time does not depend upon an increase in the uninstrumented lumbar curve.IV.

Legg-Calvé-Perthes disease (LCPD) is a childhood form of ischemic osteonecrosis of the femoral head which can produce a permanent femoral head deformity and early osteoarthritis. The femoral head deformity results from increased bone resorption and decreased bone formation during repair and remodeling of the necrotic femoral head. A recent study showed that a pro-inflammatory cytokine, interleukin-6 (IL-6), is significantly elevated in the synovial fluid of patients with LCPD. We hypothesized that IL-6 elevation decreases bone formation during the repair process following ischemic osteonecrosis and that IL-6 depletion will increase new bone formation. To test this hypothesis, we surgically induced ischemic osteonecrosis in the wild-type (n = 29) and IL-6 knockout (KO) mice (n = 25). The animals were assessed at 48 h, 2 weeks and 4 weeks following the induction of ischemic osteonecrosis using histologic, histomorphometric and micro-CT methods. IL-6 immunohistochemistry showed high expression of IL-6 in the osteonecrotic side of the wild-type mice at 48 h and 4 weeks following ischemic osteonecrosis, but not in the IL-6 KO mice. We also confirmed an undetectable level of IL-6 expression in the primary osteoblasts of the IL-6 KO mice compared to the readily detectable level in the wild-type mice. Furthermore, we confirmed that IL-6 deletion did not affect the extent of bone necrosis in the IL-6 KO mice compared to the wild-type mice by performing histologic and terminal deoxynucleotidyl transferase mediated dUTP nick-end labeling (TUNEL) assessments at 2 weeks following the induction of ischemia. Both groups had the same extent of ischemic osteonecrosis and absence of repair at 2 weeks. At 4 weeks, the necrotic epiphyses showed a significant increase in the extent of revascularization in the IL-6 KO mice compared to the wild-type mice (p = 0.001). In addition, a significantly greater recovery of the hematopoietic bone marrow was observed in the osteonecrotic side of the IL-6 KO mice compared to the wild-type mice (p 0.01). Vascular endothelial growth factor (VEGF) immunohistochemistry showed regionally increased staining in the areas of repair in the osteonecrosis side of IL-6 KO mice compared to the wild-type mice at 4 weeks following ischemic osteonecrosis. Micro-CT assessment of the wild-type mice at 4 weeks showed a significant decrease in the percent bone volume (p 0.01) in the osteonecrotic side compared to the control side. In contrast, IL-6 KO mice showed significantly increased bone volume in the osteonecrotic side compared to the osteonecrotic side of WT mice (p 0.001). No significant difference in the bone volume percentage was found between the control side of the wild-type and the IL-6 KO mice. Histomorphometric analysis at 4 weeks revealed increased osteoblast number/bone surface (p 0.001), bone formation rate (BFR) (p = 0.0001), and mineral apposition rate (MAR) (p 0.0001) in the osteonecrotic side of the IL-6 KO mice compared to the wild-type mice. The number of osteoclast/bone surface was also increased in the IL-6 KO mice compared to the wild-type mice (p 0.0001). No significant difference was observed between the control side of the wild-type and IL-6 KO mice with regards to the number of osteoblast or osteoclast/bone surface, BFR, and MAR. We next obtained primary osteoblasts from IL-6 KO mice and showed they expressed a significantly higher level of RANKL/OPG than wild-type mice (p = 0.001) in hypoxia culture condition. Taken together, the findings indicate that IL-6 deletion stimulates revascularization and new bone formation following ischemic osteonecrosis. This study provides new evidence that therapeutic strategies to block IL-6 may be beneficial for bone healing following ischemic osteonecrosis.

Purpose The Ponseti method of treatment is the standard of care for idiopathic clubfoot. Following serial casting, percutaneous tendo-Achilles tenotomy (TAT) is performed to correct residual equinus. This procedure can be performed in either the outpatient clinic or the operating room. The purpose of this study was to evaluate the expense of this procedure by examining hospital charges in both settings. Methods We retrospectively reviewed charts of 382 idiopathic clubfoot patients with a mean age of 2.4 months (0.6 to 26.6) treated with the Ponseti method at three institutions. Patients were divided into three groups depending on the setting for the TAT procedure: 140 patients in the outpatient clinic (CL), 219 in the operating room with discharge following the procedure (OR) and 23 in the operating room with admission to hospital for observation (OR+). Medical records were reviewed to analyze age, deformity, perioperative complications and specific time spent in each setting. Hospital charges for all three groups were standardized to one institution's charge structure. Results Charges among the three groups undergoing TAT (CL, OR, OR+) were found to be significantly different ($3840.60 versus $7962.30 versus $9110.00, respectively; p ≤ 0.001), and remained significant when separating unilateral and bilateral deformities (p < 0.001). There were nine total perioperative complications (six returns to the ER and three unexpected admissions to the hospital): five (2.3%) in the OR group, four (17.4%) in the OR+ group and none in the CL group. The OR+ group statistically had a higher rate of complications compared with the other two groups (p = 0.006). The total event time of the CL group was significantly shorter compared with the OR and OR+ groups (129.1, 171.7 and 1571.6 minutes respectively; p < 0.001). Conclusion Hospital charges and total event time were significantly less when percutaneous TAT was performed in the outpatient clinic compared with the operating room. In addition, performing the procedure in clinic was associated with the lowest rate of complications. Level of Evidence Therapeutic, Level III

PURPOSE To evaluate the gross motor development of 5-year-olds using the Peabody Developmental Motor Scales, 2nd Edition (PDMS-2), test after initial nonoperative management of clubfoot as infants. METHODS The PDMS-2 Stationary, Locomotion, and Object Manipulation subtests were assessed on 128 children with idiopathic clubfeet at the age of 5 years. Children were categorized by their initial clubfoot severity as greater than 13, unilateral or bilateral involvement, and required surgery. RESULTS Children with treated clubfeet had average gross motor scores (99 Gross Motor Quotient) compared with age-matched normative scores. Children with more severe clubfeet required surgery significantly more than children with less severe scores (P < .01). Peabody scores were not significantly different according to initial clubfoot severity, unilateral versus bilateral involvement, and surgical versus nonsurgical outcomes. CONCLUSIONS Clubfoot does not significantly impair gross motor development in 5-year-olds.

Background: Curve magnitude and skeletal maturity are important factors in determining the efficacy of bracing for the treatment of adolescent idiopathic scoliosis, but curve morphology may also affect brace success. The purpose of this study was to determine the influence of curve morphology on the response to bracing with a thoracolumbosacral orthosis (TLSO). Methods: A retrospective review of patients managed with an orthosis for the treatment of adolescent idiopathic scoliosis who were prospectively enrolled at the initiation of brace wear and followed through completion of bracing or surgery was performed. Inclusion criteria were main curves of 25° to 45° and a Risser stage of 0, 1, or 2 at the time of brace prescription. Compliance with bracing was measured with Maxim Integrated Thermochrons. Radiographs made at brace initiation, brace cessation, and final follow-up were used to retrospectively categorize curves with use of the modified Lenke (mLenke) classification system and more broadly to categorize them as main thoracic or main lumbar. The effect of morphology on outcome was evaluated using chi-square and Fisher exact tests. Results: One hundred and sixty-eight patients were included. There was no difference in curve magnitude at the time of brace initiation (p = 0.798) or in average hours of daily brace wear (p = 0.146) between groups. The rate of surgery or progression of the curve to ≥50° was 34.5% (29 of 84) in mLenke-I curves, 54.5% (6 of 11) in mLenke-II curves, 29.4% (10 of 34) in mLenke-III curves, 17.6% (3 of 17) in mLenke-V curves, and 13.6% (3 of 22) in mLenke-VI curves. There were no mLenke-IV curves at the time of brace initiation. The rate of surgery or progression to ≥50° was 34.1% (44 of 129) in the combined thoracic group and 15.4% (6 of 39) in the combined lumbar group (p = 0.0277). In brace-compliant patients (>12.9 hours/day), the rate of surgery or progression to ≥50° was 30.3% (20 of 66) in main thoracic curves and 5.3% (1 of 19) in main lumbar curves (p = 0.0239). One-tenth of curves changed morphology during bracing. The rate of surgery or progression to ≥50° was 35.8% (43 of 120) in persistent main thoracic curves, 20.0% (6 of 30) in persistent main lumbar curves, 12.5% (1 of 8) in main thoracic curves that became main lumbar curves, and 0% (0 of 9) in main lumbar curves that became main thoracic curves (p = 0.0383). Conclusions: Thoracic curves are at greater risk for brace failure than lumbar curves are despite similar initial curve magnitudes and average amount of daily brace wear. A change in curve pattern may imply flexibility and is associated with brace success. Patients with thoracic curves should be counseled accordingly. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND Few studies have prospectively assessed functional outcomes after the surgical management of supracondylar humerus fractures (SCHFXs) and the relationship between fracture pattern and ultimate patient outcome has never been prospectively evaluated. The purpose of this study was to prospectively evaluate fracture classification and functional outcome in children with extension SCHFXs using validated outcome measures. METHODS An Institutional Review Board-approved prospective enrollment of consecutive patients with operative SCHFX was performed over a 3-year period. Fractures were classified by the treating surgeon using the modified Gartland classification. Functional outcome was assessed at final follow-up using the Pediatric Outcomes Data Collection Instruments (PODCI) and the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) outcome measure. Patients with flexion-type fractures, multidirectionally unstable fractures and those with

Background: Nonoperative treatment of idiopathic clubfoot is standard. The purpose of this study was to determine if measurements made on standing lateral radiographs of successfully treated clubfeet made at 18 to 24 months of age were predictive of late recurrence. Methods: Inclusion criteria were idiopathic clubfoot with an age at presentation of ≤3 months, nonoperative treatment resulting in a clinically plantigrade foot at 2 years of age, standing lateral radiograph of the involved foot made at 18 to 24 months of age, and a minimum age of 4 years at the time of follow-up. The radiographs were assessed for the talocalcaneal angle and the tibiocalcaneal angle, with measurements made by 2 trained practitioners. The average values of the 2 raters were used. The interobserver reliability was calculated using intraclass correlation coefficients (ICCs). A total of 211 patients with 312 clubfeet were evaluated. The average age at the time of follow-up was 8.0 years (range, 4.0 to 13.3 years). Results at the time of follow-up were rated as good (maintained plantigrade foot), fair (required limited surgery to maintain, or return to, a plantigrade position), or poor (required posteromedial release). Results: Over time, 75% of the feet had a good result, 19% had a fair result, and 6% had a poor result. With regard to radiographic assessment, the ICCs were 0.97 (talocalcaneal angle) and 0.98 (tibiocalcaneal angle), demonstrating excellent agreement between the raters. The mean talocalcaneal angle differed significantly between the feet with a good clinical outcome and those with a fair outcome (28° versus 24°; p < 0.02), but did not differ significantly between those with a good versus poor outcome (28° versus 26°), or a fair versus poor outcome (24° versus 26°). There were no significant differences in the mean tibiocalcaneal angle among the groups (86°, 90°, and 84°, respectively) (p = 0.17). Conclusions: Most clubfeet that were clinically plantigrade at 2 years of age remained so, while one-fourth subsequently required some surgery for late recurrence, primarily limited procedures. The tibiocalcaneal angle and talocalcaneal angle from standing lateral radiographs made at 18 to 24 months of age were not helpful in predicting future relapse. Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Category: Bunion Introduction/Purpose: The orthopaedic literature is rife with reports of high failure rates following the surgical correction of juvenile bunion deformities. We contend that the reason for these poor outcomes is that although juvenile and adult bunion deformities have similar clinical appearances, the pathophysiology of the two is distinct. As such, successful surgical management of juvenile bunions requires greater understanding of this unique deformity in order to plan appropriate surgical correction. The first step in this process is to redefine the parameters that constitute the juvenile bunion. We propose that the distal metatarsal articular angle (DMAA) is the central defining characteristic of the juvenile bunion and that a higher DMAA may correlate with greater symptomatology in this population. Methods: An IRB approved retrospective analysis of prospectively enrolled patients between 10 and 18 years of age with bunion deformities was performed at a single pediatric institution over a two-year period. Patients with metabolic bone disease, neurologic disorders, and inflammatory arthritis were excluded. Demographic data was recorded and standardized weight-bearing radiographs were used to determine the hallux valgus angle (HVA), intermetatarsal angle (IMA), distal metatarsal articular angle (DMAA), hallux interphalangeus angle, metatarsal cuneiform angle (MCA), cuneiform obliquity, sesamoid position (SP), and joint congruency. Patient reported outcome measures (PROs) including the Oxford Foot and Ankle Questionnaire (OxAFQ-C), Foot and Ankle Ability Measure (FAAM), Foot and Ankle Outcome Score (FAOS), Pain Numeric Rating Scale Score (PNRS), and Functional Disability Inventory Score (FDI) were administered at initial presentation. Bivariate analysis using Spearman’s correlation was used to determine the association between individual deformity parameters and the relationship of those parameters to PRO’s. Results: 32 patients (57 feet) met inclusion criteria (average age of 14 years; range 11-17 years). 48/57 feet (84%) had an elevated DMAA (average 23.1° ± 7.8°). The DMAA correlated positively with the HVA (r= 0.734, pConclusion: In contrast to the average adult bunion, the vast majority of juvenile bunions demonstrate elevation of the DMAA. Furthermore, the DMAA correlates significantly with deformity parameters more familiar to a general or pediatric orthopaedic surgeon such as the HVA, IMA, and sesamoid position. While a higher DMAA and more lateral SP seem to be associated with greater functional disability, elevations in the IMA seem to correlate with complaints of pain. These findings corroborate the need for a more detailed understanding of this unique deformity to perhaps improve upon the historically poorer results following operative management of this condition.

BACKGROUND Magnetic resonance imaging (MRI) is a heavily utilized resource to evaluate children suspected to have a musculoskeletal infection. Complex interdisciplinary workflows are involved with decision-making with regard to indications, anesthesia, contrast use, and procedural timing relative to the scan. This study assesses the impact of a quality improvement endeavor on MRI workflows at a tertiary pediatric medical center. METHODS A registry of consecutively enrolled children for a multidisciplinary musculoskeletal infection program identified those evaluated with MRI from 2012 to 2018. Annual MRI process improvement feedback was provided to the key stakeholders. Demographic characteristics, laboratory parameters, MRI indications, anesthesia use, MRI findings, final diagnoses, scan duration, imaging protocol, surgical intervention following MRI, and length of stay were retrospectively compared between the 3 cohorts (initial, middle, and final) representing 2-year increments to assess the impact of the initiative. RESULTS There were 526 original MRI scans performed to evaluate 1,845 children with suspected musculoskeletal infection. Anesthesia was used in 401 children (76.2%). When comparing the initial, middle, and final study period cohorts, significant improvement was demonstrated for the number of sequences per scan (7.5 sequences for the initial cohort, 5.8 sequences for the middle cohort, and 4.6 sequences for the final cohort; p < 0.00001), scan duration (73.6 minutes for the initial cohort, 52.1 minutes for the middle cohort, and 34.9 minutes for the final cohort; p < 0.00001), anesthesia duration (94.1 minutes for the initial cohort, 68.9 minutes for the middle cohort, and 53.2 minutes for the final cohort; p < 0.00001), and the rate of contrast use (87.6% for the initial cohort, 67.7% for the middle cohort, and 26.3% for the final cohort; p < 0.00001). There was also a trend toward a higher rate of procedures under continued anesthesia immediately following the MRI (70.2% in the initial cohort, 77.8% in the middle cohort, and 84.6% in the final cohort). During the final 6-month period, the mean scan duration was 24.4 minutes, anesthesia duration was 40.9 minutes, and the rate of contrast administration was 8.5%. CONCLUSIONS Progressive quality improvement through collaborative interdisciplinary communication and workflow redesign led to improved utilization of MRI and minimized contrast use for suspected musculoskeletal infection. There was a high rate of procedural intervention under continued anesthesia for children with confirmed musculoskeletal infection. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background The Trendelenburg test has been used to assess hip abductor muscle function. A standardized evaluation of the test requires an assessment of both pelvis and trunk coronal plane alignment as the patient stands on one leg for 30 s. Coronal plane biomechanics using motion analysis allows for development of objective criteria to grade the test response. The aim of this study was to develop biomechanical criteria of the pelvis and trunk coronal plane kinematics. Methods The video of 39 subjects with acetabular hip dysplasia performing the test while instrumented with a full-body modified Plug-In-Gait marker set for three-dimensional kinematic analysis, were evaluated by two orthopedic surgeons and one senior level biomechanist. Reviewers as a group assessed whether the subject had a positive test and noted the reason using guidelines outlined in the literature. Coronal plane trunk and pelvic angles of all subjects were analyzed and Receiver Operating Characteristic curves were used to determine optimal kinematic cutoff values for each positive Trendelenburg test reason. Findings There were 26/39 patients who reviewers identified as having a positive test. Area under the curve of the receiver operating characteristic curve for trunk and pelvis mean/minimum were greater than 0.75. The curve was used to identify the optimal cut-offs of trunk lean and pelvic obliquity mean/minimum. Interpretation The biomechanical criteria developed includes clinically derived coronal plane kinematic cut-offs of the pelvic and trunk angles. The criteria can be used within a motion capture setting for the standardization of the grading of the test response.

OBJECTIVE: Although the Pavlik Harness (PH) is the most utilized treatment for developmental dysplasia of the hip (DDH), the ideal treatment protocol (frequency of clinic visits in the first month and daily wear duration) for Barlow ​+ ​hips (reduced but dislocatable) has yet to be defined. METHODS: This study compared DDH patients with Barlow hips who were treated with 23 vs 24 h per day PH wear and weekly vs every other week visits. Clinical success was defined as a stable hip that did not require closed or open reduction, or the use of an abduction orthosis prior to achieving clinical stability. Radiographic success was based on the acetabular index at 2-year follow up. RESULTS: Sixty-five patients (75 hips/58 females) with Barlow hips had a mean age of presentation of 15 ± 12 days (range 4–70) and mean follow-up of 33 ± 17 months (range 6–90). There was no difference in clinical or radiographic success rate between 23 h vs 24 h wear groups (p > 0.99 both) or the Frequently vs Infrequent visit groups (p = 0.49 both). Overall clinical success rate was 97% (73/75 hips) and radiographic success rate at 2 years was 97% (58/60 hips). CONCLUSION: A strict, weekly clinic visit and 24-h PH regimen may not be necessary to obtain good clinical and radiographic outcomes in infants presenting

Background Epiphysiodesis of the distal femoral and/or proximal tibial physes is commonly performed in children and adolescents to treat lower-limb length discrepancy. It is important to determine the amount of growth remaining in the physes of these patients. Two main methods are used to make this determination: the White-Menelaus arithmetic method, which assumes a consistent amount of growth per year until skeletal maturity, and the Anderson-Green growth-remaining charts, which diagram average growth per year ± 2 standard deviations. The purpose of the present study was to evaluate these apparently disparate predictions of growth remaining in a cohort of patients managed with epiphysiodesis. Methods From a database of patients managed with epiphysiodesis for lower-limb length discrepancy, we identified all healthy, unoperated leg segments with follow-up to skeletal maturity. We compared the amount of observed growth with the growth predicted by the White-Menelaus method and the Anderson-Green growth-remaining graphs, for both skeletal and chronological ages. Results A total of 441 healthy segments (201 femora and 240 tibiae) in 221 patients (105 boys and 116 girls) with an age range of 9.0 to 16.5 years at the time of epiphysiodesis were analyzed. We observed no relationship between the length percentile of the leg segments at the time of epiphysiodesis and the amount of growth that actually occurred. Growth in the distal femoral and proximal tibial physes was relatively constant (9 and 6 mm per year of skeletal growth, respectively). Skeletal age was a better predictor of growth remaining than chronological age for both methods of estimation. Although the distribution of growth remaining in the present study resembled the Anderson-Green growth-remaining charts, that distribution was not associated with the initial length of leg segments. Conclusions The White-Menelaus method predicted the amount of growth remaining more accurately than the Anderson-Green growth-remaining charts. The distribution of growth remaining observed in the present study resembled that of the Anderson-Green growth-remaining graphs but was not predicted by the initial bone segment length. Clinical relevance The present study found no positive association between the length percentile of leg segments and the amount of growth that occurred in an epiphysiodesis-age group. This finding can explain the comparative accuracy of the White-Menelaus method and the possible source of prediction errors in the straight-line graph and multiplier methods.

Case–control study. Evaluate the rate and risk factors for perioperative allogeneic blood transfusion (ABT) in primary idiopathic scoliosis surgery at a single institution. Avoiding perioperative ABT is ideal as transfusions are associated with adverse reactions, increased rates of infection, prolonged hospitalization, additional laboratory testing, and increased cost. Risk factors identified in other studies have differed, and to our knowledge, few studies have identified clinical strategies to predict patients at high risk for ABT. We reviewed 402 idiopathic scoliosis patients who underwent primary posterior spinal fusion and instrumentation (PSFI) at a single institution from 2015 to 2017. Medical records and radiographs were reviewed for all patients. Transfused patients were compared to the remaining cohort to find significant differences and identify predictors of higher ABT risk. ABT occurred in 73 patients (18.2%), with the majority of transfusions occurring intraoperatively (41%) or postoperatively on the day of surgery (25%). The seven surgeons involved varied significantly in incidence of ABT (2.4–35.8%, p = 0.002). Patients who had ABT were younger (13.3 vs. 14.1 years, p

BACKGROUND Either casting or in situ fixation (to prevent displacement) are recommended for minimally displaced pediatric lateral condyle fractures of indeterminate stability with ≤2 mm lateral displacement and narrowed fracture extension to the epiphyseal articular cartilage. This study compares casting only, acute prophylactic in situ pinning, and surgery if casting fails due to displacement. METHODS In total, 738 fractures at a level 1 trauma center between 2008 and 2014 were reviewed. All fractures were assigned a Song classification and Song 2 fractures followed to union were analyzed. Worsening displacement was defined as an increase in Song stage. Patients were grouped per treatment: (1) cast only; (2) in situ pinning; or (3) closed or open reduction percutaneous pinning after displacement during attempted cast treatment. RESULTS In total, 139 fractures were included and 45 (32%) underwent surgery. Among 114 fractures intended for casting, only 20 (18%) displaced and needed surgery. This implies 82% of fractures prophylactically pinned in situ may have remained stable in a cast. On average, displaced fractures were noted 6.5 (2 to 13) days after presentation and required 1 extra clinic visit and week of immobilization without increased complications. Surgeons chose open reduction percutaneous pinning more often for displaced fractures. CONCLUSIONS Our data estimate 82% of Song 2 fractures never meaningfully displace in a cast. Meaningful displacements occur in

Background: Legg-Calve-Perthes disease is a juvenile form of osteonecrosis of the femoral head. The purpose of this study was to use serial perfusion magnetic resonance imaging (MRI) to determine the pattern and rate of revascularization of the femoral heads of patients with the active stage of Legg-Calve-Perthes disease. Methods: We performed a prospective study of 29 patients (30 hips) with a mean age (and standard deviation) of 8.4 ± 1.9 years who were diagnosed with Waldenstrom Stage-1 or 2 Legg-Calve-Perthes disease. All patients had ≥2 perfusion MRIs, and 21 patients (22 hips) had ≥3. Perfusion percentages of the femoral epiphyses were measured by 2 independent observers. Statistical analyses included calculation of the intraclass correlation coefficient, the paired t test, the Mann-Whitney U test, and the Kruskal-Wallis test. Results: Initial perfusion MRIs showed the percent perfusion in the affected femoral heads to range from 5% to 70%. The average percent perfusion (and standard deviation) was 35% ± 16% on the first MRI, which increased to 77% ± 14% on the follow-up MRI acquired at an average of 10.5 ± 2.9 months later (p < 0.01). Serial assessment showed a general pattern of revascularization starting from the periphery of the posterior, lateral, and medial aspects of the femoral epiphysis and converging toward the anterocentral region. The average rate of revascularization was 4.9% ± 2.3% per month with a wide range among the patients (0.6% to 10.4% per month). Conclusions: Revascularization of the necrotic femoral head increased over time in a horseshoe pattern, starting from the posterior, lateral, and medial aspects of the femoral epiphysis. The rate of revascularization was highly variable among patients. Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background: To determine the influence of the Risser sign on the need for surgery in children wearing orthoses for the treatment of adolescent idiopathic scoliosis (AIS), data on compliance with brace wear were collected and analyzed. Methods: One hundred and sixty-eight patients were prospectively enrolled at the time that brace wear had been prescribed and were followed until the cessation of bracing or the need for surgery. Inclusion criteria were a curve magnitude between 25° and 45°; a Risser stage of 0, 1, or 2; and, if female

Flexible intramedullary nailing (IMN) is a valuable tool in the treatment of femoral fractures in school-age children, whereas spica cast immobilization has been the standard of care for younger children. We compared these treatment modalities in a group of preschool-age children (four to five years of age).A retrospective cohort of consecutive patients, four to five years of age, with an isolated, complete femoral shaft or subtrochanteric fracture treated with intramedullary nailing or early spica cast immobilization and followed until fracture-healing were identified from two centers. Radiographic and clinical outcomes were compared between the groups. Statistical methods included chi-square and Fisher exact tests for categorical variables and the Mann-Whitney test for continuous variables.Two hundred and sixty-two patients followed for a mean of thirty-two weeks were identified. One hundred and four patients underwent IMN and 158 patients were treated with immediate spica cast immobilization at the surgeon's discretion. The patients who underwent IMN were older than those who underwent spica cast immobilization (mean, 5.2 versus 4.7 years; p0.001), were heavier (mean, 21.5 versus 18.0 kg; p0.001), and were more likely to have a higher-energy mechanism of injury (p = 0.025). At the time of final follow-up, there was no difference between groups with regard to the percentages of patients who had acceptable coronal angulation (≤15°), sagittal angulation (≤20°), and early fracture shortening (≤20 mm) (96.2% in the spica group versus 99.0% in the IMN group; p = 0.09). While there was no significant difference in the percentages who had an unplanned return to the operating room (3.8% in the IMN group versus 4.4% in the spica group; p0.99), the patients in the IMN group had more clinic visits (mean, 5.8 versus 4.0; p0.001) and longer follow-up (mean, forty-four versus twenty-five weeks; p0.001) than the patients in the spica group and a higher percentage of them underwent repeat procedures (89.4% versus 5.1%; p0.001), primarily for elective implant removal.Preschool-age children (four to five years old) with an isolated femoral fracture have similar clinical and radiographic outcomes regardless of whether they are treated with immediate spica cast immobilization or IMN.

Percutaneous in situ fixation is the gold-standard treatment for stable slipped capital femoral epiphysis (SCFE). While numerous studies have documented good to excellent long-term clinical and radiographic outcomes, few have documented long-term patient-reported outcomes of patients with this condition. This retrospective study was performed to document long-term patient-reported outcomes of a cohort of sixty-four patients with SCFE (ninety-one affected hips) and determine whether the slip angle was associated with poorer health outcomes as measured with the Short Form-12 (SF-12) Physical Component Summary (PCS) and Mental Component Summary (MCS) scores, modified Harris hip score (mHHS), and University of California at Los Angeles (UCLA) Activity Scale. The mean age at presentation was 12.6 years, and the mean duration of follow-up was 19.6 years. At the time of follow-up, the cohort reported higher rates of diabetes, obesity, and hypertension than the general U.S. The mean body mass index (BMI) had increased by 10.2 kg/m(2), with 72% of the subjects meeting the criteria for obesity (BMI > 30 kg/m(2)) at the time of follow-up. The mean age and sex-adjusted PCS and MCS scores were 49.6 and 50.0, respectively, and the mean mHHS was 84.9. Multivariable general linear modeling revealed no association between the initial slip angle and the PCS, MCS, mHHS, or UCLA Activity Scale score. Male sex and a lower BMI were the only predictors of better long-term PCS, mHHS, and UCLA Activity Scale scores. Subjects with a bilateral slip had outcomes similar to those with unilateral disease. The general self-reported health of this cohort was poor compared with that of the general population. The slip angle on presentation did not correlate with any patient-reported outcome measure collected for this study. Higher BMI was one of the only clinical predictors of patient-reported outcomes. Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Introduction No clear practice guideline exists for the management of stable hip with ultrasonic dysplasia (UD). This study assessed the treatment patterns for stable UD and determined the outcomes of Pavlik harness (PH) treatment or observation (OB). Methods This is a prospective study of 80 infants (107 hips) aged ≤12 weeks at presentation diagnosed with stable UD. Results Sixty-five hips were treated with PH, whereas 42 hips were observed. Patients who were older at the time of initial sonogram and those with lower head coverage were more likely to be treated with PH. The mean head coverage was lower in the PH group, indicating more severe UD. At a 2-year follow-up period, 93% of patients in the OB group and 87% in the PH group had a good radiographic outcome. Discussion Head coverage and age at first sonogram had a significant influence on the treatment decision for PH. A milder ultrasonic hip dysplasia can be observed because 93% of the patients who were observed had a good outcome. Level of evidence Level II: prospective cohort study.

The purpose of this study was to compare the accuracy of different methods used to predict ultimate leg lengths and residual leg-length discrepancy in a group of patients treated with epiphysiodesis at our institution.Seventy-seven patients with adequate preoperative radiographs, no postoperative complications, and follow-up to skeletal maturity composed the study group. We compared the predicted lengths of both legs and residual leg-length discrepancy at maturity with actual outcomes using the White-Menelaus, Anderson-Green, Moseley, and multiplier methods.Skeletal age varied1 year from chronological age in 61 (26%) of 231 observations, including 19 patients (25%) whose average skeletal age from 3 determinations differed by1 year from chronological age. The prediction accuracy of each method was improved by using skeletal, rather than chronological, age. Error in prediction of the length of the short leg varied from a mean (and standard deviation) of 1.8 ± 1.2 cm for the straight-line graph to 2.5 ± 2.0 cm for the multiplier method. Prediction error for the long leg (after epiphysiodesis) varied from a mean of 1.2 ± 1.1 cm for the straight-line graph to 1.7 ± 1.5 cm for the multiplier method. Leg-length-discrepancy prediction error ranged from a mean of 0.7 ± 0.6 cm for the White-Menelaus method incorporating a growth inhibition factor to 1.1 ± 0.9 cm for the multiplier method. The multiplier method was the least accurate of all. All differences were significant.Determination of skeletal age is clinically relevant in patients being considered for epiphysiodesis to manage leg-length inequality. The multiplier method was the least accurate of the prediction methods in this patient population, which may have implications in calculating the appropriate timing of epiphysiodesis.

PURPOSE To evaluate gross motor skills [Bruininks-Oseretsky Test of Motor Proficiency, 2nd ed (BOT-2)] of patients with idiopathic clubfoot initially treated nonoperatively with either the French functional physical therapy (PT) method or the Ponseti technique, at age 10 years. METHODS The BOT-2 was administered by trained physical therapists on patients with idiopathic clubfoot at age 10 years. The cohort was divided by initial treatment method (PT or Ponseti), and compared. Subsequent analyses included comparisons of: initial clubfoot severity (Dimeglio scores: ≤13 vs. >13), laterality (unilateral vs. bilateral), and surgical versus nonoperative outcome. RESULTS Of the 183 patients tested, 172 were included. The Ponseti and PT groups did not significantly differ according to age, height, weight, body mass index, ankle dorsiflexion, sex, average initial Dimeglio score, laterality, or surgical versus nonsurgical outcome. Overall, patients with treated clubfoot had average gross motor BOT-2 scores compared with age-matched peers. Patients in the PT group scored higher on Running Speed/Agility (P=0.019), Body Coordination percentile rank (P=0.038), and Strength and Agility percentile rank (P=0.007) than patients treated by the Ponseti technique. Patients with bilateral clubfoot scored significantly lower on the Balance subtest (P

Toe walking (TW) in children is often idiopathic in origin. Our purpose was to determine the incidence of a neurological etiology for TW in patients seen in the neurology clinic after referral from pediatric orthopaedic surgeons.We performed an Institutional Review Board approved retrospective review of 174 patients referred to the neurology clinic from orthopaedic surgeons at an academic pediatric tertiary care center between January 2010 and September 2015. Medical records were reviewed and data recorded including pertinent family history, birth history, age of initial ambulation, physical examination findings, and workup results including neuroimaging, neurophysiological studies, and findings of genetic testing and tissue biopsy.Sixty-two percent (108/174) of patients were found to have a neurological etiology for TW. Final pathologic diagnoses were: 37% (40/108) previously undiagnosed cerebral palsy (CP), 16.7% (18/108) peripheral neuropathy, 15.7% (17/108) autism spectrum disorder, 13.9% (15/108) hereditary spastic paraparesis, 8.3% (9/108) attention deficit hyperactivity disorder, 5.6% (6/108) syndromic diagnosis, and 2.8% (3/108) spinal cord abnormality. Ankle equinus contractures were noted in idiopathic and neurological patients and did not indicate a pathologic origin. Seventy-one percent of unilateral toe walkers and 32% of bilateral but asymmetric toe walkers were diagnosed with CP (P0.001). Twenty-six percent of 145 brain magnetic resonance imaging studies diagnosed CP. Of the 125 (72%) with spinal imaging, 3 had spinal pathology to account for TW. Fourteen percent of 87 subjects with an electromyography/nerve conduction study had abnormal results indicating a peripheral polyneuropathy.An underlying pathologic diagnosis was found in 62% of patients referred to neurology for TW. A concerning birth history, delayed initial ambulation, unilateral TW, upper or lower motor neuron signs on examination, or behavioral features may suggest a pathologic diagnosis. Ankle contracture is not predictive of an abnormal diagnosis and can be found in idiopathic patients. CP, peripheral neuropathy, autism spectrum disorder, and hereditary spastic paraparesis are the most common pathologic diagnoses identified in our population.Level III-retrospective cohort.

Background There is limited evidence-based guidance for the treatment of children with acute hematogenous osteomyelitis (AHO) and concurrent Staphylococcus aureus bacteremia (SAB). Current guidelines emphasize the need for parenteral antibiotics in the setting of SAB, but optimal duration of parenteral therapy in this setting remains unclear. We examined the utility of a Severity of Illness (SOI) score to provide guidance for antimicrobial use in this setting. Methods We retrospectively studied children with AHO from 2009–2017, employing a clinical practice algorithm and previously validated SOI to assess the incidence and treatment implications of SAB in AHO. Data collected included demographics, antimicrobial therapy, and response to treatment. Cohorts were categorized according to SOI as follows: mild (0–3); moderate (4–7); and severe (8–10), and compared utilizing one-way ANOVA and Kruskal–Wallis tests for continuous variables, and chi-square test for categorical data. Results Among 466 children diagnosed with AHO, 274 (58.5%) were culture positive for Staphylococcus aureus, with SAB noted in 209 (44.8%) individuals. Among children with SAB, 72, 81, and 56 children had SOI scores classified as mild, moderate, and severe, respectively. There were 41 of 72 (57.7%) children with mild illness who were managed with clindamycin alone, clindamycin followed by β-lactam, or β-lactam alone, compared with 36 of 81 (44.4%) with moderate illness, and 3 of 56 (5.4%) with severe illness. Median parenteral antibiotic durations per SOI cohort were 4.7 days, 10.4 days, and 24.7 days, respectively. Greater SOI was associated with longer hospitalization, prolonged bacteremia, more surgeries, increased vancomycin use, greater number of antibiotic combinations, and longer total duration of antibiotics. Conclusion Treatment of AHO with SAB should be tailored to the severity of illness in the affected child. A “one size fits all” approach may expose children to unnecessarily prolonged parenteral antibiotic courses, as well as suboptimal and potentially toxic regimens. Our study demonstrates the utility of an SOI to help guide antibiotic decisions in the setting of AHO with SAB. Additional studies are needed to further delineate optimal parenteral antibiotic durations in AHO with SAB. Disclosures All authors: No reported disclosures.

Background: Magnetic resonance imaging (MRI) with sedation is an important resource used to evaluate children with musculoskeletal infection. This study assesses the impact of multidisciplinary guidelines and continuous process improvement on MRI utilization at a tertiary pediatric medical center. Methods: A multidisciplinary team developed a guideline for MRI with sedation, and it was implemented at our institution. Scan duration, anatomic regions imaged, sequences performed, timing of surgical intervention, length of hospital stay, and readmissions for these children were compared with these measures among a cohort of similar children who had been treated prior to guideline implementation. Comparative data were gathered for the subsequent cohort to determine any impact of the continued process improvement program on MRI utilization. Statistical comparison was performed to determine significant differences between groups. Results: Children evaluated prior to the guideline implementation had 9.0 MRI sequences per scan, an MRI scan duration of 111.6 minutes, and a hospital stay of 7.5 days. In comparison, children in the initial MRI guideline cohort had 7.5 sequences per scan, a scan duration of 76.1 minutes, and a hospital stay of 5.4 days. Children in the subsequent guideline cohort had 6.5 sequences per scan, a scan duration of 56.3 minutes, and a hospital stay of 5.0 days. The rate of immediate surgical procedure under continued anesthesia was 16.7% prior to the guideline, 50.5% among children in the initial guideline cohort, and 64% among children in the subsequent guideline cohort. Differences between cohorts were significant (p < 0.0001). In aggregate, 264 hours of MRI scan time and 809 hospital bed-days were conserved for more than thirty months. Conclusions: This initiative promoted improvement in diagnostic efficiency, therapeutic consistency, and patient safety for children with musculoskeletal infection. Clinical Relevance: The findings of this study illustrate the beneficial impact of interdisciplinary coordination of care on clinical outcomes for children with musculoskeletal infection. Tangible improvements occurred for both length of stay and resource utilization.