Search

Background and purpose — When children with irregular body proportions or asymmetric limbs present, it may be unclear where the pathology is located. An improved understanding of the clinical ratio between upper extremity, lower extremity, and spine length may help elucidate whether there is disproportion between the trunk and limbs, and whether there is a reduction deficit of the shorter limb rather than hypertrophy of the longer limb. Patients and methods — We used the Brush Foundation study of child growth and development, which was a prospective, longitudinal study of healthy children between the 1930s and the 1950s, and we collected serial clinical measurements for 290 children at 3,326 visits. Children ranged from 2 to 20 years of age during the study period. Linear and quadratic regression were used to construct nomographs and 95% prediction intervals for anthropometric body proportions. Results — The maximum anterior superior iliac spine height to sitting height ratio occurred at 12.4 years in females and at 14.17 years in males. Overall, the ratio of arm length to sitting height was 0.76 (SD 0.06), the ratio of arm length to anterior superior iliac spine height was 0.76 (SD 0.03), and the ratio of anterior superior iliac spine height to sitting height was 0.98 (SD 0.13). When comparing ratios between arm length, anterior superior iliac spine height, and sitting height, the smallest variance between appendicular proportions was found in the arm length to anterior superior iliac spine height ratio. Interpretation — We recommend comparisons between total arm length and anterior superior iliac spine height to distinguish limb reduction deficits from hemi-hypertrophy, with sitting height being used only if combined upper and lower extremity discrepancy is noted.

STUDY DESIGN Retrospective review of a prospectively collected pediatric orthopedic spine database. OBJECTIVE To investigate whether pelvic incidence (PI) changes during growing rod treatment and to report the effects of PI, if any, on complications during treatment. SUMMARY OF BACKGROUND DATA Growing rods have been demonstrated to correct spinal deformity in early onset scoliosis while allowing for spinal growth. There has been little investigation into the potential effects, if any, of abnormal PI on complications, especially proximal junctional kyphosis (PJK). METHODS We retrospectively reviewed clinical and surgical data from our prospectively collected pediatric orthopedic spine database. Our final cohort of 48 patients had at least one lateral radiograph throughout the course of treatment containing the femoral heads and sacral endplate, and a minimum follow-up of 2 years. Defined failures were identified prospectively. Radiographs were measured for PI and development of PJK. RESULTS Mean age at initial treatment was 6.9 years (range 2.8-10.8 yr), with 35 females and 13 males. The mean length of follow-up was 8.1 years (range 2.0-22.1 yr). No statistical change in PI was observed throughout this study (P = 0.655). Development of any failure as well as total number of failures was associated with younger age at initial treatment (P

The accurate assessment of skeletal maturity is essential in the management of orthopaedic conditions in the growing child. In order to identify the time of peak height velocity (PHV) in adolescents, two systems for assessing skeletal maturity have been described recently; the calcaneal apophyseal ossification method and the Sanders hand scores. The purpose of this study was to compare these methods in assessing skeletal maturity relative to PHV. We studied the radiographs of a historical group of 94 healthy children (49 females and 45 males), who had been followed longitudinally between the ages of three and 18 years with serial radiographs and physical examination. Radiographs of the foot and hand were undertaken in these children at least annually between the ages of ten and 15 years. We reviewed 738 radiographs of the foot and 694 radiographs of the hand. PHV was calculated from measurements of height taken at the time of the radiographs. Prior to PHV we observed four of six stages of calcaneal apophyseal ossification and two of eight Sanders stages. Calcaneal stage 3 and Sanders stage 2 was seen to occur about 0.9 years before PHV, while calcaneal stage 4 and Sanders stage 3 occurred approximately 0.5 years after PHV. The stages of the calcaneal and Sanders systems can be used in combination, offering better assessment of skeletal maturity with respect to PHV than either system alone. Cite this article: Bone Joint J 2015;97-B:1710–17.

Purpose To examine a large osteological collection to assess the relations between the well-described means of quantifying cam deformities of the proximal femur—alpha angle (AA) and anterior femoral neck offset (AFNO)—and osteoarthritis of the lumbar spine. Methods AA and AFNO were measured on paired femurs of 550 well-preserved cadaveric skeletons by use of standardized cephalocaudal digital photographs. Degenerative disease of these specimens' lumbar spines was graded from 0 to 4 with a validated grading system. Proximal femurs showing obvious arthritic changes such as lipping or osteophytes were excluded. Correlations between AA and spine osteoarthritis (SOA), as well as between AFNO and SOA, were evaluated by multiple regression analysis. Results The average age for the skeletons was 47.8 ± 16.2 years. There were 456 male and 94 female specimens. The mean AA and AFNO were 52.4° ± 11.4° and 6.8 ± 1.5 mm, respectively. The average SOA score was 2.1 ± 0.9 (0 in 31 specimens, 1 in 82, 2 in 287, 3 in 106, and 4 in 44). There was a significant correlation between increasing AA and SOA (standardized β = 0.061, P = .041). There was also a significant correlation between decreasing AFNO and SOA (standardized β = −0.067, P = .025). There was a strong correlation between age and SOA (standardized β = 0.582, P Conclusions This study provides important insight into the understanding of the hip-spine connection. Although it has no way of showing a causative or clinically significant relation, this study did show that the cam-type deformity markers of increasing AA and decreasing AFNO were significantly associated with SOA in a large osteological collection. Clinical Relevance Clinical and biomechanical studies to assess whether cam deformity in the younger individual may contribute to the accelerated development of SOA in later life are warranted.

In the operating room, after first obtaining a proper lateral radiograph with the condyles superimposed, a 90-degree rotation of the intraoperative fluoroscopy unit does not always produce an anteroposterior (AP) image with the patella centered. The orthogonality of these 2 views has not been well determined in children.This study was comprised of a radiographic group (35 knees) and a cadaveric group (59 knees). Both cadaveric and clinical images were obtained by resting or positioning the femur with the posterior condyles overlapped, and then taking an orthogonal AP image. Centering of the patella was calculated and multiple regression analysis was performed to determine the relationship between patellar centering and age, sex, ethnicity, mechanical lateral distal femoral angle (mLDFA), medial proximal tibial angle (MPTA), and contralateral centering.Mean patellar centering, expressed as the lateral position of the patella with respect to the total condylar width, was 0.08±0.10 in the radiographic group and 0.06±0.03 in the cadaveric group. Positive (lateral) patellar centering in 1 knee had a statistically significant correlation with positive patellar centering in the contralateral knee in both the radiographs and the cadavers. In the radiographic group, there was a statistically significant correlation between femoral varus and valgus deformities and positive patellar centering. In the cadaveric group, there was a statistically significant correlation between tibial valgus and negative (medial) patellar centering.The patella in an immature knee is rarely perfectly centered on a true AP image, and is usually seated slightly laterally within the femoral condyles.Obtaining a true AP intraoperative radiograph is critical to analyzing and correcting valgus and varus deformities, and in the proper placement of implants. When addressing knee deformity one should consider obtaining an AP view orthogonal either to a perfect lateral of the knee or orthogonal to the flexion axis of the knee, particularly when evaluating distal femoral deformity.

Purpose Interventional radiology (IR) has historically failed to fully capture the value of evaluation and management services in the inpatient setting. Understanding financial benefits of a formally incorporated billing discipline may yield meaningful insights for interventional practices. Materials and Methods A revenue modeling tool was created deploying standard financial modeling techniques, including sensitivity and scenario analyses. Sensitivity analysis calculates revenue fluctuation related to dynamic adjustment of discrete variables. In scenario analysis, possible future scenarios as well as revenue potential of different-size clinical practices are modeled. Results Assuming a hypothetical inpatient IR consultation service with a daily patient census of 35 patients and two new consults per day, the model estimates annual charges of $2.3 million and collected revenue of $390,000. Revenues are most sensitive to provider billing documentation rates and patient volume. A range of realistic scenarios—from cautious to optimistic—results in a range of annual charges of $1.8 million to $2.7 million and a collected revenue range of $241,000 to $601,000. Even a small practice with a daily patient census of 5 and 0.20 new consults per day may expect annual charges of $320,000 and collected revenue of $55,000. Conclusions A financial revenue modeling tool is a powerful adjunct in understanding economics of an inpatient IR consultation service. Sensitivity and scenario analyses demonstrate a wide range of revenue potential and uncover levers for financial optimization.

Tibial torsion and femoral anteversion are common rotational abnormalities in children, and their courses are most often benign and self-resolving. Although neither usually requires surgical treatment, the decision to perform a derotational osteotomy is usually based on the degree of functional impairment. Neither condition is thought to influence the development of osteoarthritis of the hip or knee; however, to date there have been no large scale studies confirming this.Tibial torsion and femoral version in 1158 cadaveric tibiae and femora were measured using a camera setup based on previously described radiographic landmarks. Any specimens with obvious traumatic, rheumatic, or metabolic abnormalities were excluded. Degenerative joint disease of the hip and knee were each graded from 0 to 6. Correlations between tibial torsion, femoral version, age, race, and sex with osteoarthritis of the hip and knee joints were evaluated with multiple regression analysis.The mean and SDs of tibial torsion and femoral anteversion were 7.9±8.8 and 11.4±12.0 degrees, respectively. African Americans had significantly increased tibial torsion (5.1±8.7 vs. 9.2±8.5 degrees, P0.0005) and greater femoral anteversion (14.1±11.9 vs. 10.2±11.8 degrees, P0.0005) compared with whites. The average grades for hip and knee osteoarthritis were 3.1±1.4 and 2.7±1.4. Using multiple regression analysis neither tibial torsion nor femoral version were independent predictors of hip or knee arthritis (P0.05 for all).This study confirmed previously reported differences in the rotational profiles between races and sexes. However, neither tibial torsion nor femoral anteversion had a significant influence on the development of arthritis of the hip or knee.These results support the practice of treating tibial torsion and femoral anteversion based on the symptomatology of the patient. Parents of asymptomatic children can be reassured that long-term consequences are unlikely.

BACKGROUND There is a dearth of literature examining the causes of cam-type femoroacetabular impingement (FAI) and when such morphology appears. The purpose of the current study was to analyze how the ossific portion of the proximal femur develops over time with respect to standard cam-type FAI parameters. METHODS A collection of 193 femurs from cadavers aged 4 to 21 years were evaluated. The age, sex, ethnicity, and status of the proximal femoral physes (open or closed) of each were recorded. Each specimen was digitally photographed in standardized anteroposterior and modified axial positions. From these photographs, the anterior offset, anterior offset ratio (AOR), and α-angle were determined. A cam lesion was defined as an α-angle >55 degrees on the lateral view. RESULTS The mean age of the specimens was 17.5±4.2 years. The majority were male (69%) and African American (79%) with closed physes (78%). There were significant differences among discrete age groups with respect to α-angle (P=0.01), anterior offset (P

Background Trochanteric entry femoral nails have been increasing in popularity in the pediatric population for stabilization in fractures and osteotomies. The proper position for entry point in the coronal plane has been well studied; however, the sagittal plane in the pediatric population has not yet been well characterized. Methods Eighty-eight cadaveric femora aged 8 to 20 years were studied in an apparent neck-shaft angle (ANSA) position, with distal condyles flat on the surface, and a true neck-shaft angle (TNSA) position, with internal rotation to neutralize femoral anteversion. Anterior and lateral offset were measured on lateral and anteroposterior photographs, respectively, as the perpendicular distance from the greater trochanter apex to the center of the intramedullary canal. The effect of rotational position (ANSA vs. TNSA) of the proximal femur was compared using the intraclass correlation coefficient for anterior and lateral offset. Correlations between age, demographics, anteversion, and greater trochanter morphology with anterior and lateral offset were evaluated with multiple regression analysis. Results The mean age was 15.8±3.8 years. The mean anterior displacement of the trochanteric apex was 4.8±3.0 and 4.6±3.2 mm in the ANSA and TNSA positions, respectively. The mean lateral displacement was 10.6±4.2 and 9.7±4.0 mm in the ANSA and TNSA positions, respectively. The intraclass coefficient for anterior offset in the ANSA versus TNSA position was 0.704 and 0.900 for lateral offset. Change was minimal for anterior offset in the ANSA and TNSA positions versus age (standardized beta values 0.240, 0.241, respectively). There was a significant correlation with increasing lateral offset in the ANSA and TNSA positions with increasing age (standardized beta values 0.500, 0.385 respectively). Conclusions In the pediatric population, the tip of the greater trochanter is consistently anterior by approximately 5 mm. The mean lateral displacement was approximately 10 mm and increased with increasing age. Clinical relevance Nail entry at the pediatric greater trochanter apex would likely result in anterior placement. We recommend inserting the guidewire 5 mm posterior to the apex of the trochanter and confirming coronal and sagittal position with fluoroscopy.

Pelvic incidence is a position- and posture-independent parameter used to quantify sagittal balance of the spine, sacrum, pelvis and hips. Its functional consequences have been associated with a number of different pathologies of the spine. However, there exists considerable controversy over which demographic features contribute to the development of pelvic incidence. 880 cadaveric skeletons from the Hamann-Todd Osteological Collection were obtained. The innominate bones and sacrum were reconstructed, and pelvic incidence was measured using a previously validated technique. Specimens with obvious fracture, infection, or rheumatologic conditions were excluded from study. Descriptive data of age at the time of death, gender, race and height were collected. The average pelvic incidence was 46.0° ± 11.0°. Pelvic incidence did not change with age (r = 0.026, p = 0.288). There was no difference in pelvic incidence measurements between females and males (47.2° ± 13.8° vs. 45.8° ± 10.4°, respectively; p = 0.257), although this analysis was under-powered. Pelvic incidence was higher in African-Americans compared to Caucasians (48.9° ± 11.0° vs. 44.9° ± 10.8°; p = 0.001). There was no association between height and pelvic incidence (r = −0.042, p = 0.164). This study represents the largest single cohort of pelvic incidence measurements reported in the literature. Our data suggest that pelvic incidence does not change with age or height, although racial differences do exist. As spine care providers increasingly rely on pelvic incidence as an important means to quantify sagittal balance, the normative data provided herein will provide an essential reference.

BACKGROUND Recent anatomic data supports a mechanism for slipped capital femoral epiphysis (SCFE) where the metaphysis rotates on the epiphysis through the eccentrically located epiphyseal tubercle as a pivot. The validity of such a mechanism and its clinical consequences have not been well investigated. METHODS This cadaveric study defined the normal location of the calcar ridge line in 100 paired femora and compared them with 11 SCFE specimens, and with 25 immature femora where the metaphysis was rotated 30, 60, and 90 degrees on the epiphysis to model progressive SCFE. Coronal, sagittal, and axial plane deformity were measured on the rotational model to define the characteristic deformity caused by rotation, and lateral epiphyseal foramina stretch was measured to quantify the protective effect of an eccentric pivot. RESULTS The posterior displacement of the fovea with respect to the calcar ridge line was 1±5 mm for the controls, versus 23±10 mm for the SCFE specimens (P

Purpose To investigate the relation between cam, acetabular version, and pelvic incidence. Methods This was a retrospective analysis of 65 patients with symptomatic hip pain and radiographic signs of femoroacetabular impingement (FAI). Twenty-seven patients were used as a control. All patients received a CT scan of the pelvis that included the sacral endplate. Alpha angle, acetabular version, and pelvic incidence (PI) were measured on 2D CT. Patients were then assigned to 1 of 4 groups: control, cam (alpha angle > 55°, version > 15°), retroverted (alpha angle 55°, version Results The PI in mixed-type FAI was 46.7° ± 3.7°, which showed a statistically significant decrease from the PI of the control group, 56.1° ± 4.4° ( P = .01). The PI for cam-only deformity was 50.8° ± 4.6°, and the PI for retroverted-only deformity was 51.0° ± 4.6°. Neither was statistically different from the control. Conclusions This study suggests that mixed-type FAI may develop as a response to decreased PI. This result is consistent with previous reports showing decreased PI associated with cam and retroversion deformities. Although the cause of FAI remains controversial, the potential impact of sagittal balance of the pelvis, and specifically, decreased PI, should not be ignored. Level of Evidence Level IV, therapeutic case series.

Background. Axial dynamization has been shown in previous studies to promote callus formation, improve bone healing at fracture sites, and enhance bone remodeling. However, the possibility of non-axial movements or uniform fracture site compression during dynamization, and the appropriate relaxation of fixator joints to achieve such function, have not been investigated. Methods. This study used previously developed computational models based on two commercially available unilateral external fixators (Dynafix and Orthofix) to analyze the fixator joint adjustments used and the fracture site movements generated during dynamization. Findings. When none of the fixator’s sliding joints were parallel to the long bone axis, significant non-axial movements occurred during dynamization. The dual sliding joint design of the Dynafix fixator was beneficial in reducing these non-axial movements. When all of the fixator joints were allowed to adjust simultaneously during dynamization, exact axial movement or uniform compression at a complicated fracture site was achievable. Interpretation. This study revealed that significant non-axial movements may occur during dynamization, and that such a deficiency can be corrected by relaxing certain fixator joints in addition to the sliding mechanism. The same modeling technique can also be applied in bone lengthening application to assure desirable limb alignment during the distraction process. These analysis results can aid the performance assessment of an external fixator and facilitate appropriate application of such a device to achieve either active or controlled axial movement.

BACKGROUND The calcaneal apophysis ossification staging system is a novel method for assessing skeletal maturity. However, it was created using the same historic patient population that was used to create the Greulich and Pyle atlas of the hand and wrist, predominantly white children. It is unclear if the calcaneal apophysis ossification staging system is still applicable to the modern pediatric population and to children of other races. METHODS We retrospectively studied 1327 benign lateral foot x-rays from modern white and black children. Calcaneal stage was determined and age, race, and sex were collected for each patient. A 2-tailed Student t test was used to compare between cohorts the differences in age for each calcaneal stage. RESULTS Mean age was 11.55±4.39 years. Modern white females graded as stage 3 and 4 were significantly delayed in their bone age (stage 3 P

Purpose: In pediatric patients with congenital or acquired limb-length inequalities, estimating the amount of remaining skeletal growth is essential to determine the timing and method of treatment. Current methods for estimating skeletal maturity show wide variability and involve significant complexity, limiting practical use and leading some to favor chronological age. It has been shown that 90% of final adult height is a more accurate predictor of skeletal growth compared to peak height velocity. Using 90% of ultimate height as a gold standard and …

Background: Accessory ossicles off the talus (“os trigonum”) are a common radiographic finding seen within the foot with variable symptomatology in adult and pediatric patients. While most studies have examined the incidence of these anatomic variants in a retrospective fashion, few have longitudinally followed the behavior of os trigonum over time. The aim of this study was to investigate the incidence, mean age of …

Purpose: Pelvic incidence (PI) is an important spinopelvic parameter that is a major determinant in spine and hip pathology. PI is ideally measured using a lateral radiograph, and the midpoint of the two femoral heads is commonly used as an approximation when the view is slightly rotated. The accuracy of using this approximation has not been rigorously studied and is important to better understand as the understanding of PI continues to grow. Methods: This was a descriptive laboratory study utilizing the Haman-Todd cadaveric research collection. Fluoroscopic …

Background Authors have recently proposed the concept of “hip-spine syndrome,” however there exists limited evidence available to differentiate whether these concomitant arthritides are due to anatomic/structural causes or systemic/metabolic effects. Exploring this relationship has important implications during the evaluation and treatment of both spine and hip disorders – a common clinical presentation of many patients. The purpose of this experiment was to investigate the individual contribution of hip arthritis towards the development of spine arthritis, with knee arthritis also being analyzed as a negative (systemic) control. Hypothesis Hip and spine arthritis are caused by both metabolic and independent causes. Methods A large, well-organized osteological database was queried and osteoarthritis of the spine, hip and knee joints was quantified using a validated scoring criteria. Six hundred and twenty-five specimens were chosen for analysis. Multivariate linear regression models were created to quantify the independent contributions of age, gender, race, height and arthritis of the spine and hip joints. Results Age was the strongest predictor of arthritis at each site (standardized betas > 0.281, P Conclusions Anatomic/structural influences about the lumbo-sacral-pelvic junction contribute towards the development of arthritis that is separate from any systemic/metabolic effects. Surgeons performing total hip arthroplasty should remain aware of these relationships, although future research is necessary regarding optimal surgical treatment of these patients. Level of evidence N/A (cadaveric study).

Treatment for a child with limb length discrepancy is generally based on weighing the benefits of lower morbidity with epiphyseodesis versus avoiding surgery on the healthy leg, the ability to correct associated deformities, and greater ultimate height with limb lengthening. Although commonly ignored when balancing risks and benefits, mature height can affect patients socioeconomically. Though studies have noted an association between increased height and increased income as an adult, this relationship has not been rigorously investigated. Data from the …

91 Background: Patient-provider communication is essential to delivering high quality cancer care, including post-treatment when survivors have many complex care needs. In this study, we used data collected for quality improvement from a small, feasibility sample to examine patient perceptions of provider communication and inform the development of a new Oncology Survivorship Clinic model. Methods: As part of a pilot project conducted at Kaiser Permanente Northern California (KPNC), we surveyed 51 breast cancer patients post-treatment. The survey included a communication measure from the 2011 Medical Expenditure Panel Survey (MEPS) Experiences with Cancer survey evaluating provider discussions of: surveillance for recurrence; late or long-term treatment effects; healthy lifestyle behaviors; and emotional or social needs. We also examined reports of the six core functions of patient-centered communication (i.e. managing uncertainty, responding to emotions, making decisions, fostering healing relationships, enabling self-management, and exchanging information) using a measure from the Health Information Trends Survey (HINTS) survey. Part of the purpose was to evaluate acceptability of a new Oncology Survivorship Clinic utilizing non-physician providers. Results: The sample included 51 breast cancer patients surveyed in 2016 within six months of treatment completion. Overall, sizable proportions received detailed communication about surveillance (65%), treatment side effects (46%), emotional needs (41%), and healthy lifestyles (71%) and the majority received patient-centered communication (range: 60-73% based on core function). Particular gaps were noted related to provider communication about treatment side effects (54%), emotional/social needs (59%), managing uncertainty (35%), and responding to emotions (40%). Conclusions: Our very preliminary findings suggest that the majority of women had positive communication experiences, including with non-physician providers. However, clear communications gaps existed underscoring future avenues for research and care delivery interventions to address the comprehensive needs of breast cancer patients.

BACKGROUND Femoral anteversion can be difficult to determine intraoperatively, particularly in cases with complicated deformity. Although biplanar methodology exists for measuring femoral anteversion, the measurements are generally based on the proximal femur, without consideration for the femoral bow. METHODS We directly measured femoral version in 70 mature cadaveric femora. Using the standard Ogata-Goldsand approach, femoral version was geometrically calculated after measuring apparent neck-shaft angle and the β-angle, which is the angle between the femoral neck and proximal femoral shaft on a direct lateral view. We then used a modified β-angle, measured between the femoral neck and a line representing the entire femur. RESULTS Mean anatomic femoral anteversion was 20±11 degrees. Mean calculated femoral version using the standard Ogata-Goldsand technique was 32±13 degrees, whereas mean calculated femoral version using the modified Ogata-Goldsand technique was 22±12 degrees. Repeated measures ANOVA analysis found an overall statistically significant difference between the 3 groups (P

Background: Based on the complexity of proximal femoral geometry, osteotomies in the coronal plane may change femoral version, while osteotomies in the plane of the femoral neck should not. Theoretically, this relationship can lead to a systematic error when measuring rotational correction in the proximal part of the femur. Methods: We developed a mathematical model to predict the error with three different techniques for rotational measurement: (1) a pin along the axis of the femoral neck and a lateral pin across the femoral condyles, (2) a proximal lateral pin perpendicular to the femur and a lateral pin across the femoral condyles, and (3) two anterior pins representing a score mark on the proximal part of the femur. Varus derotational osteotomies were performed on twenty-four Sawbone femora, and femoral anteversion and the angles between each set of pins were measured. Results: Our mathematical model predicted no error with the neck-pin technique regardless of the type of osteotomy performed. With the lateral pin technique, there was no predicted error with the neck plane osteotomy but a large error with the coronal plane osteotomy. The score-mark technique had a small amount of error with the neck plane osteotomy and a large error with the coronal plane osteotomy. Our Sawbones model measurements correlated well with the mathematical model, with intraclass correlation coefficients of 0.96, 0.89, and 0.91 for the neck-pin, lateral pin, and score-mark techniques, respectively. Conclusions: This study describes and validates a model for predicting the error of three different techniques for measuring femoral rotation. It demonstrates that inadvertent systematic error can occur with lateral pin and score-mark techniques, particularly when the osteotomy is out of plane with the femoral neck. Clinical Relevance: Although the mathematics of this study are complex, the conclusions are clinically straightforward: rotational error is minimized by performing an osteotomy in the plane of the femoral neck or by using a pin in the femoral neck to judge rotation. If neither of these techniques is employed, then systematic error can be introduced and can be substantial.

The optimal route (oral versus intravenous) of antibiotic administration for pediatric acute osteomyelitis is not well established. Seventy-eight children from our university hospital and 17 children at our county hospital were treated for acute osteomyelitis. The rates of intravenous antibiotics upon discharge were 95% versus 65% (P=0.002), respectively. The recurrence rate and line complication rates were 10% and 24% at the university hospital, compared to 0% (P=0.34) and 6% (P=0.29) at the county hospital. Based on this data, a prospective comparison between intravenous and early oral antibiotic therapy for pediatric acute osteomyelitis is recommended.

Segmental arterial mediolysis (SAM) is an uncommon, nonatherosclerotic, noninflammatory, large- to medium-sized arteriopathy first described in 1976. It is characterized histologically by vacuolization and lysis of the outer arterial media leading to dissecting aneurysms and vessel rupture presenting clinically with self-limiting abdominal pain or catastrophic hemorrhages in the abdomen. Patients of all ages are affected with a greater incidence at the fifth and sixth decades. There is a slight male predominance. Imaging findings overlap with inflammatory vasculitis, collagen vascular disease, and fibromuscular dysplasia. The presence of segmental dissections involving the celiac, mesenteric, and/or renal arteries is the key distinguishing features of SAM. Inflammatory markers, genetic tests for collagen vascular disorders, and hypercoagulable studies are negative. Anti-inflammatory agents and immunosuppressants are not effective. A mortality rate of 50 % has been attributed to the acute presentation with aneurysmal rupture necessitating urgent surgical or endovascular treatments; in the absence of the acute presentation, SAM is a self-limiting disease and is treated conservatively. There are no established guidelines on medical therapy, although optimal control of blood pressure is considered the main cornerstone of medical therapy. The long-term prognosis is not known.

Federal healthcare spending has been a subject of intense concern as the US Congress continues to search for ways to reduce the budget deficit. The Congressional Budget Office (CBO) estimated that, even though it is growing more slowly than previously projected, federal spending on Medicare, Medicaid and the State Children's Health Insurance Program (SCHIP) will reach nearly $900 billion in 2013. In 2011 the Medicare program paid $68 billion for physicians and other health professional services, 12% of total Medicare spending. Since 2002 the sustainable growth rate (SGR) correction has called for reductions to physician reimbursements; however, Congress has typically staved off these reductions, although the situation remains precarious for physicians who accept Medicare. The fiscal cliff agreement that came into focus at the end of 2012 averted a 26.5% reduction to physician reimbursements related to the SGR correction. Nonetheless, the threat of these devastating cuts continues to loom. The Administration, Congress and others have devised many options to fix this unsustainable situation. This review explores the historical development of the SGR, touches on elements of the formula itself and outlines current proposals for fixing the SGR problem. A recent CBO estimate reduces the potential cost of a 10-year fix of SGR system to $138 billion. This has provided new hope for resolution of this long-standing issue.

Background: It has been proposed that the epiphyseal tubercle on the inferior surface of the capital femoral epiphysis may be responsible for the clinical distinction between a stable and an unstable slipped capital femoral epiphysis (SCFE). The anatomy of the tubercle and its relationship to the lateral epiphyseal vessels have not previously been rigorously defined. Methods: Twenty-two cadaveric capital femoral epiphyses from donors who had been three to seventeen years of age were analyzed and then digitized with use of a high-resolution laser scanner. The height, location, and approximate surface area of the epiphyseal tubercle were measured and were normalized to the size of the entire capital femoral epiphysis. Results: In all specimens except that from the youngest donor, the foramina for the lateral epiphyseal vessels were visible and were located directly superior to the epiphyseal tubercle. The height of the epiphyseal tubercle was 4.4 ± 1.1 mm. When normalized to the overall size of the capital femoral epiphysis, the relative height (r = 0.71) and relative area (r = 0.56) of the epiphyseal tubercle decreased with increasing age. The epiphyseal tubercle was consistently located in the posterosuperior quadrant, with its position being more posterior and less superior in specimens from younger donors. Conclusions: The epiphyseal tubercle appears to be a major stabilizer, or keystone, of the capital femoral epiphysis and the lateral epiphyseal vessels. Its relative decrease in height and surface area with increasing age may help explain the susceptibility of individuals to SCFE in adolescence: in a stable SCFE, the physis rotates on the tubercle; however, in an unstable SCFE, the tubercle dislodges, leading to more substantial displacement of the capital femoral epiphysis and the lateral epiphyseal vessels, risking osteonecrosis. Clinical Relevance: These anatomic data offer a possible insight into the pathogenesis of SCFE and the potential complication of osteonecrosis. When fixation of an SCFE is performed with a single screw, the posterosuperior quadrant should be avoided to maximize any possible derotational effect of the epiphyseal tubercle.

Avascular necrosis (AVN) of the capital femoral epiphysis (CFE) after an unstable slipped capital femoral epiphysis (SCFE), femoral neck fracture or traumatic hip dislocation can result in severe morbidity. Treatment options for immature patients with AVN are limited, including a closed bone graft epiphysiodesis (CBGE). However, it is unclear whether this procedure prevents AVN progression.We investigated whether early MRI screening and CBGE prevented the development of advanced AVN changes in the CFE and the rates of complications with this approach.We prospectively followed all 13 patients (seven boys, six girls) with unstable SCFEs (six patients), femoral neck fractures (five patients), and traumatic hip dislocations (two patients) and evidence of early AVN treated between 1984 and 2012. Mean age at initial injury was 12 years (range, 10-16 years). Nine of the 13 patients had followup of at least 2 years or until conversion to THA (mean, 4.5 years; range, 0.8-8.5 years), including two with unstable SCFEs, the five with femoral neck fractures, and the two with traumatic hip dislocations. All patients had technetium scans and/or MRI within 1 to 2 months of their initial injury (before CBGE) and all had evidence of early (Ficat 0) AVN. Patients were followed clinically and radiographically for AVN progression.Six of the nine hips did not develop typical clinical or radiographic evidence of AVN. These six patients have been followed 6.3 years (range, 4.3-9.1 years) from initial injury and 5.9 years (range, 3.8-8.5 years) from CBGE. The remaining three patients were diagnosed with AVN at periods ranging from 3 to 6 months after CBGE.Early recognition and treatment of AVN with a CBGE may alter the natural history of this complication.Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

The purpose of this article is to determine normative values for the length of the acetabular rim and detect differences between gender, age, ethnicity, height and leg length. Six measurements were taken on the acetabular rim of 143 cadaveric skeleton specimens (286 acetabula) using a coordinate-measuring device: circumferential (excluding acetabular notch), anterior inferior iliac spine (AIIS)-anterior, AIIS-posterior, 12–3 o’clock, 12–9 o’clock and 11–5 o’clock. Museum specimen height data and leg length data from a previous study were recorded for 109 of 143 specimens. Intraclass correlation coefficients were calculated. Student t-tests compared mean values. Multiple regression analysis was used to determine the relationship between acetabular rim length and gender, age, ethnicity, height and leg length. The average acetabular rim length in males for circumferential, AIIS-anterior, AIIS-posterior, 12–3, 12–9 and 11–5 o’clock were 15.8, 4.2, 11.7, 4.9, 4.7 and 9.5 cm, respectively; and for females: 13.7, 3.7, 10.0, 4.3, 4.1 and 8.3 cm, respectively. Intraclass correlation coefficients were 0.953, 0.930, 0.958, 0.857, 0.913 and 0.951, respectively, for each measurement. All six measurements were significantly larger for males (P

MLN4924 is an investigational small-molecule inhibitor of the NEDD8-activating enzyme (NAE) in phase I clinical trials. NAE inhibition prevents the ubiquitination and proteasomal degradation of substrates for cullin-RING ubiquitin E3 ligases that support cancer pathophysiology, but the genetic determinants conferring sensitivity to NAE inhibition are unknown. To address this gap in knowledge, we conducted a genome-wide siRNA screen to identify genes and pathways that affect the lethality of MLN4924 in melanoma cells. Of the 154 genes identified, approximately one-half interfered with components of the cell cycle, apoptotic machinery, ubiquitin system, and DNA damage response pathways. In particular, genes involved in DNA replication, p53, BRCA1/BRCA2, transcription-coupled repair, and base excision repair seemed to be important for MLN4924 lethality. In contrast, genes within the G2–M checkpoint affected sensitivity to MLN4924 in colon cancer cells. Cell-cycle analysis in melanoma cells by flow cytometry following RNAi-mediated silencing showed that MLN4924 prevented the transition of cells from S–G2 phase after induction of rereplication stress. Our analysis suggested an important role for the p21-dependent intra-S-phase checkpoint and extensive rereplication, whereas the ATR-dependent intra-S-phase checkpoint seemed to play a less dominant role. Unexpectedly, induction of the p21-dependent intra-S-phase checkpoint seemed to be independent of both Cdt1 stabilization and ATR signaling. Collectively, these data enhance our understanding of the mechanisms by which inhibition of NEDD8-dependent ubiquitination causes cell death, informing clinical development of MLN4924. Cancer Res; 73(1); 225–34. ©2012 AACR.

Diffuse large B-cell lymphoma (DLBCL) is the most common of the non–Hodgkin lymphomas, accounting for up to 30% of all newly diagnosed lymphoma cases. Current treatment options for this disease are effective, but not always curative; therefore, experimental therapies continue to be investigated. We have discovered an experimental, potent, and selective small-molecule inhibitor of PLK1, MLN0905, which inhibits cell proliferation in a broad range of human tumor cells including DLBCL cell lines. In our report, we explored the pharmacokinetic, pharmacodynamic, and antitumor properties of MLN0905 in DLBCL xenograft models grown in mice. These studies indicate that MLN0905 modulates the pharmacodynamic biomarker phosphorylated histone H3 (pHisH3) in tumor tissue. The antitumor activity of MLN0905 was evaluated in three human subcutaneous DLBCL xenograft models, OCI LY-10, OCI LY-19, and PHTX-22L (primary lymphoma). In each model, MLN0905 yielded significant antitumor activity on both a continuous (daily) and intermittent dosing schedule, underscoring dosing flexibility. The antitumor activity of MLN0905 was also evaluated in a disseminated xenograft (OCI LY-19) model to better mimic human DLBCL disease. In the disseminated model, MLN0905 induced a highly significant survival advantage. Finally, MLN0905 was combined with a standard-of-care agent, rituximab, in the disseminated OCI LY-19 xenograft model. Combining rituximab and MLN0905 provided both a synergistic antitumor effect and a synergistic survival advantage. Our findings indicate that PLK1 inhibition leads to pharmacodynamic pHisH3 modulation and significant antitumor activity in multiple DLBCL models. These data strongly suggest evaluating PLK1 inhibitors as DLBCL anticancer agents in the clinic. Mol Cancer Ther; 11(9); 2045–53. ©2012 AACR.

Purpose: The clinical success of the first-in-class proteasome inhibitor bortezomib (VELCADE) has validated the proteasome as a therapeutic target for treating human cancers. MLN9708 is an investigational proteasome inhibitor that, compared with bortezomib, has improved pharmacokinetics, pharmacodynamics, and antitumor activity in preclinical studies. Here, we focused on evaluating the in vivo activity of MLN2238 (the biologically active form of MLN9708) in a variety of mouse models of hematologic malignancies, including tumor xenograft models derived from a human lymphoma cell line and primary human lymphoma tissue, and genetically engineered mouse (GEM) models of plasma cell malignancies (PCM). Experimental Design: Both cell line–derived OCI-Ly10 and primary human lymphoma–derived PHTX22L xenograft models of diffuse large B-cell lymphoma were used to evaluate the pharmacodynamics and antitumor effects of MLN2238 and bortezomib. The iMycCα/Bcl-XL GEM model was used to assess their effects on de novo PCM and overall survival. The newly developed DP54-Luc–disseminated model of iMycCα/Bcl-XL was used to determine antitumor activity and effects on osteolytic bone disease. Results: MLN2238 has an improved pharmacodynamic profile and antitumor activity compared with bortezomib in both OCI-Ly10 and PHTX22L models. Although both MLN2238 and bortezomib prolonged overall survival, reduced splenomegaly, and attenuated IgG2a levels in the iMycCα/Bcl-XL GEM model, only MLN2238 alleviated osteolytic bone disease in the DP54-Luc model. Conclusions: Our results clearly showed the antitumor activity of MLN2238 in a variety of mouse models of B-cell lymphoma and PCM, supporting its clinical development. MLN9708 is being evaluated in multiple phase I and I/II trials. Clin Cancer Res; 17(23); 7313–23. ©2011 AACR.

Treatment methods in Legg-Calve-Perthes disease (LCPD) have varied during the 100-year history of this disorder. This is a review of the present practice of bracing in LCPD.Published articles from the last 35 years were reviewed including primary analyses of bracing, meta-analysis, and summaries of present opinion. The recent literature was also evaluated to determine the present bracing practices.Studies performed regarding specific braces failed to show that they offer any advantage over other methods of management, including no treatment. Similarly, meta-analyses showed that hips treated with nonoperative containment had little difference in outcome based on present methods of analysis. Opinion papers suggested that the use of braces in LCPD should be significantly decreased or discontinued altogether. There is a major controversy regarding weaning and discontinuation of bracing. The use of Petrie casts can be considered in "salvage" techniques of hips with subluxation or hinged abduction.The present literature does not provide evidence sufficient to support the use of bracing in LCPD. On the basis of this review, our recommendation is that the abduction orthosis should rarely be used in the treatment of LCPD. Petrie casts still have a role in short-term treatment in patients with deformed femoral heads before complete reossification.

Background Rib head penetration into the spinal canal in patients with severe kyphoscoliosis secondary to neurofibromatosis type-1 (NF-1) is extremely rare. Double rib head penetration has only been reported once earlier. Methods We are reporting on an adolescent male with NF-1 and severe thoracic kyphoscoliosis with adjacent double rib head penetration into the spinal canal without neurological deficits. Only one was recognized on the initial radiographic imaging. Results A 14-year-old with NF-1 and 74 degrees left thoracic scoliosis and 75 degrees kyphosis was treated at our institution. Preoperative computed tomography (CT) demonstrated protrusion of the left T6 rib head into the spinal canal on the convexity of the curve, compressing the spinal cord. Staged surgical procedures for resection of the rib head and correction of the spinal deformity were planned. After presumed successful resection of the penetrated rib head, a postoperative CT revealed the presence of a second adjacent left T7 rib head in the spinal canal. This was not initially recognized owing to the severe deformity and image obliquity of the CT gantry. Another procedure was performed to remove this rib head. He was then placed in halo traction until anterior and posterior spinal fusion and segmental spinal instrumentation were performed. He achieved good deformity correction and had no neurological deficits throughout his treatment. Conclusions Rib head protrusion into the spinal canal can occur with spine deformity in NF-1. If present, the imaging should be carefully reviewed for the possibility of an adjacent rib head penetration that may have been obscured by the limitations of CT in the context of a dysplastic spinal deformity. Level of evidence Level V. Case study.

Background: Although seldom described, varus and valgus osteotomies of the proximal femur can affect femoral version. The magnitude of the effect can be predicted with an understanding of the distinction between femoral version and femoral neck inclination. The purpose of this study was to elucidate this relationship. Methods: Version, inclination, apparent neck-shaft angle, and true neck-shaft angle were defined and measured in 72 preserved femora. Results: Average values were 19.8 ± 11.8 degrees for version versus 14.5 ± 10.1 degrees for inclination (P=0.004), giving a mean difference of 27% between version and inclination, with greater discrepancy with increasing neck-shaft angle. There were high correlations between measured inclination and inclination calculated using version and apparent neck-shaft angle (r=0.96) and true neck-shaft angle (r=0.97), validating our formulaic relationship between these variables. Conclusions: We present and validate the concept of inclination, and its relationship with version and neck-shaft angle. This explains the mechanism for a varus osteotomy decreasing anteversion, and a valgus osteotomy increasing anteversion. Clinical Relevance: With an understanding of these concepts, a surgeon can incline the femoral neck axis to achieve a desired amount of version, for any given neck-shaft angle. Without this understanding, precise control of the version and neck-shaft angle is difficult.