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Background: Current trends in the treatment of idiopathic clubfoot have shifted from extensive surgical release to more conservative techniques. The purpose of the present study was to prospectively compare the results of the Ponseti method with those of surgical releases for the correction of clubfoot deformity.Methods: We prospectively compared patients who had idiopathic clubfoot deformities that were treated at a single institution either with the Ponseti method or with below-the-knee casting followed by surgical release. The clinical records of the patients with a minimum duration of follow-up of two years were reviewed. All scheduled and completed operative interventions and associated complications were recorded.Results: Fifty-five patients with eighty-six clubfeet were treated; forty feet were included in the group that was treated with the Ponseti method, and forty-six feet were included in the group that was treated with below-the-knee casts followed by surgery (with three of these feet requiring casting only). There was no difference between the groups in terms of sex, ethnicity, age at the time of first casting, pretreatment Pirani score (average, 5.2 in both groups), or family history. The average number of casts was six in the Ponseti group and thirteen in the surgical group. Of the feet that were treated with below-the-knee casts, forty-three underwent surgery, with forty-two undergoing major surgery (posterior release [eleven] or posteromedial release [thirty-one]). In the Ponseti group, fourteen feet required fifteen operative interventions for recurrences, with only one foot requiring revision surgery. Four of these fifteen were major (necessitating posterior [one] or posteromedial release [three]) while eleven were minor. Thirteen feet in the surgical group required fourteen surgical revisions. Two postoperative complications were seen in each group.Conclusions: While both cohorts had a relatively high recurrence rate, the Ponseti cohort was managed with significantly less operative intervention and required less revision surgery. The Ponseti method has now been adopted as the primary treatment for clubfoot at our institution. [ABSTRACT FROM AUTHOR]

Introduction: Cast saw injury is a notable source of medicolegal risk. Previous work with plaster casts demonstrated that cast saw injury was minimized by waiting 12 minutes before removal. In this study, we evaluate the safety parameters of fiberglass casting materials., Methods: Eight-ply plaster and fiberglass casts were applied to a pediatric forearm model at variable dip-water temperatures, and the mean time to reach their exothermic peak was determined. Fiberglass casts were then maintained at the manufacturer's recommended dip-water temperature and removed at intervals of 2 (before exothermic peak), 6 (approximately fiberglass's exothermic peak), or 12 (after exothermic peak) minutes. All casts were removed by a pediatric orthopaedic surgeon blinded to the cast set time. Cast/blade temperature, saw force, blade-to-skin contact, bivalve time, cast spreading force, and cut completeness were assessed individually and as short (<6-minutes) or long (≥6-minutes) set times., Results: Fiberglass casts exothermically peaked markedly earlier (5.2 [IQR = 5-5.4] minutes) than plaster (14.8 [IQR = 13.7-15.3] minutes), P < 0.0001, at maximum temperatures, which did not markedly differ. Downward force applied during fiberglass cast removal was markedly lower in the short versus long set time groups [average forces of 8.3 (IQR = 6.4-10.4) versus 12.9 (IQR = 11.1-14.5) Newtons, P < 0.0001, as were maximum forces: 23.2 (IQR = 18.9-26.6) versus 43.8 (IQR = 38.6-48.5) Newtons, P < 0.0001]. Bivalve time and maximum cast spreading force were decreased in short set times with 40.5 (IQR = 39.2-44.7) versus 44.4 (IQR = 40.6-47.3) seconds (P = 0.06) and 15.5 (IQR = 14-18.5) versus 21.5 (IQR = 18-26.5) N (P = 0.07), respectively. Maximum saw blade temperature was markedly lower in the short (99.6°C [IQR = 98.2-105.6°C]) versus long (130.6°C [IQR = 121.9-141°C]) set times (P = 0.04). No notable differences in blade-to-skin touches or touch duration were detected., Discussion: Unlike plaster, fiberglass casts cut before exothermically peaking were associated with less downward force, faster bivalve times, and decreased spread force without increased blade temperature or skin contacts. This suggests that fiberglass casts can be bivalved markedly earlier without increased risk of injury., (Copyright © 2024 by the American Academy of Orthopaedic Surgeons.)

The ability to locally deliver bioactive molecules to distinct regions of the skeleton may provide a novel means by which to improve fracture healing, treat neoplasms or infections, or modulate growth. In this study, we constructed single-sided mineral-coated poly-ε-caprolactone membranes capable of binding and releasing transforming growth factor beta 1 (TGF-β1) and human growth hormone (hGH). After demonstrating biological activity in vitro and characterization of their release, these thin bioabsorbable membranes were surgically implanted using an immature rabbit model. Membranes were circumferentially wrapped under the periosteum, thus placed in direct contact with the proximal metaphysis to assess its bioactivity in vivo. The direct effects on the metaphyseal bone, bone marrow, and overlying periosteum were assessed using radiography and histology. Effects of membrane placement at the tibial growth plate were assessed via physeal heights, tibial growth rates (pulsed fluorochrome labeling), and tibial lengths. Subperiosteal placement of the mineralized membranes induced greater local chondrogenesis in the plain mineral and TGF-β1 samples than the hGH. More exuberant and circumferential ossification was seen in the TGF-β1 treated tibiae. The TGF-β1 membranes also induced hypocellularity of the bone marrow with characteristics of gelatinous degeneration not seen in the other groups. While the proximal tibial growth plates were taller in the hGH treated than TGF-β1, no differences in growth rates or overall tibial lengths were found. In conclusion, these data demonstrate the feasibility of using bioabsorbable mineral coated membranes to deliver biologically active compounds subperiosteally in a sustained fashion to affect cells at the insertion site, bone marrow, and even growth plate., (© 2024 Wiley Periodicals LLC.)

The purpose of the present study was to define the prevalence of hip pain in nonambulatory children with spinal muscular atrophy (SMA) (type I or II) treated with aggressive medical management, prior to widespread use of disease-modifying therapies (DMTs)., Methods: A retrospective chart review (1993 to 2017) was performed on children diagnosed with SMA to identify subjective reports of hip pain and associated interventions, while radiographs were evaluated to assess hip instability and spinal deformity., Results: Seventy-two patients (33 with type I and 39 with type II) met the inclusion criteria. Hip pain was more frequent in type-II SMA (49% versus 12%; p = 0.001). Seventeen percent of the patients with 2 copies of the SMN2 (survival motor neuron 2) gene, 53% of patients with 3 copies, and 1 of the 2 patients with 4 copies reported hip pain. Nearly all patients had abnormal findings on hip radiographs made at the onset of pain or at the latest follow-up; however, no patient with type-I and 18% of those with type-II SMA had pain that was severe enough to undergo invasive intervention (p = 0.01). The intervention reduced the pain in most of those patients but completely eliminated it in only 1 patient. No significant differences were found with respect to the mean age at the onset of scoliosis, the mean age at the time of scoliosis surgery, or whether insertion of growing rods or posterior spine fusion was performed between those with and without hip pain requiring invasive treatment., Conclusions: This study is, to our knowledge, the largest investigation to date to assess hip pain among nonambulatory children with type-I or type-II SMA and suggests that symptoms rather than radiographs be utilized to direct care. These data will be crucial in assessing any effects that the new DMTs have on the natural history of hip pathology and pain in nonambulatory patients with SMA., Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSOA/A411)., (Copyright © 2022 The Authors. Published by The Journal of Bone and Joint Surgery, Incorporated. All rights reserved.)

Purpose: To determine the effectiveness of a novel cast-saw alarm system in minimizing the number and duration of cast-saw blade-to-skin contacts., Methods: Twenty orthopaedic residents removed a pair of long-arm casts applied to instrumented pediatric upper extremity models. The model and cast-saw were instrumented to detect blade to "skin" contact at a rate of 600 Hz. Each resident performed cast removal with and without the use of a cast-saw alarm, the order of which was randomized. Eleven additional "new" cast-saw users then removed pairs of casts, without and then with the cast alarm, to evaluate what effect the alarm would have on preventing blade-to-skin contact in users with no previous cast-saw experience. The number and duration of cast-saw touches were then evaluated. Statistical significance was determined paired 1-sided students t tests (number of touches)., Results: For the residents (n=20), the total number of blade-to-skin contacts was 233. One hundred eighty-one blade-to-skin contacts without the alarm and 52 with the alarm (71% reduction) (t(19)=-3.42, P=0.001), averaging 6.45 more blade-to-skin contacts per cast without the alarm. The median blade-to-skin contact duration was 0.166 seconds without the alarm and 0.087 seconds with the alarm. This was a 48% reduction in contact time (P=0.073). For the inexperienced users (n=11), the total number of blade-to-skin contacts was 356, 324 blade-to-skin contacts without the alarm and 32 with the alarm (90% reduction) (t(10)=-2.78, P=0.009), averaging 26.5 more blade-to-skin contacts without the alarm. The median blade-to-skin contact duration for the novice was 0.313 seconds without the alarm and 0.1 seconds with the alarm (68% reduction). Contact time was reduced in both groups but failed to reach statistical significance. However, alarm use significantly reduced the number of touches of >0.5 seconds duration (62 vs. 3) in the novice group, P=0.0176. Blade-to-skin contact of >0.5 seconds were felt to represent touches that were more likely to result in thermal injury to a living patient., Conclusion: Blade-to-skin contact can be reduced with the use of a cast-saw alarm. These effects appear most amplified in users with little prior cast-saw experience., Level of Evidence: Not applicable., Competing Interests: S.S.: Receives royalties from Wolters Kluver. Committee member for AAP, AOA, POSNA, & OTA. M.A.H.: Patent pending for cast saw protective system. Grant support from the Hartwell Foundation and CHRI. Co-editor for Elsevier. Consultant for Alcyone. The remaining authors declare no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: In 2010, 2 authors of this current study reported the results of Ponseti treatment compared with primary posteromedial release (PMR) for congenital talipes equinovarus in a cohort of 51 prospective patients. This current study shows outcomes recorded at a median of 15 years after the original treatment., Methods: Patient health records were available for all 51 patients at a median of 15 years (range, 13 to 17 years) following treatment of congenital talipes equinovarus with either the Ponseti method (25 patients [38 feet]) or PMR (26 patients [42 feet]). Thirty-eight of 51 patients could be contacted, and 33 patients (65%) participated in the clinical review, comprising patient-reported outcomes, clinical examination, 3-dimensional gait analysis, and plantar pressures., Results: Sixteen (42%) of 38 Ponseti-treated feet and 20 (48%) of 42 PMR-treated feet had undergone a further surgical procedure. The PMR-treated feet were more likely to undergo osteotomies and intra-articular surgical procedures (15 feet) than the Ponseti-treated feet (5 feet) (p < 0.05). Of the 33 patients reviewed with multimodal assessment, the Ponseti group, compared with the PMR group, demonstrated better Dimeglio scores (5.8 compared with 7.0 points; p < 0.05), Disease Specific Instrument (80.7 compared with 65.6 points; p < 0.05), Functional Disability Inventory (1.1 compared with 5.1; p < 0.05), and American Academy of Orthopaedic Surgeons (AAOS) Foot and Ankle Outcomes Questionnaire scores (52.2 compared with 46.6 points; p < 0.05), as well as improved total sagittal ankle range of motion in gait and ankle plantar flexion range at toe-off. The PMR group with clinical hindfoot varus displayed higher pressures in the lateral midfoot and the forefoot., Conclusions: Although the numbers of repeat surgical interventions following Ponseti treatment and primary PMR were similar, the PMR-treated feet had greater numbers of osteotomies and intra-articular surgical procedures. Functional outcomes were improved at a median of 15 years for feet treated with the Ponseti method compared with feet treated with PMR, with advantages seen in the Ponseti group over several domains. This study provides the most comprehensive evaluation of outcomes close to skeletal maturity in prospective cohorts, reinforcing the Ponseti method as the initial treatment of choice for idiopathic clubfeet., Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/G705)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

Purpose: To compare the histological healing and radiographic effects of tendons transferred to ossified or unossified bone using different tendon fixation techniques., Methods: Nine new-born piglets underwent bilateral tendon transfers to either the ossified boney calcaneal body or unossified apophysis. The tendons were fixed using metallic suture anchors, sutures alone or a bone tunnel. At six weeks of age, calcanei were harvested, radiologically imaged and then prepared for histology. A semi-quantitative aggregated scoring system with values ranging from 0 (poor) to 15 (excellent), was used to grade healing at the surgical enthesis and the apophyseal ossification was graded by five independent reviewers in triplicate using a modified (1 to 4) validated scoring system., Results: Histologically, the cartilaginous transfers utilizing the tunnel and suture techniques also demonstrated the best average aggregated scores of entheses healing rivalling that measured in transfers using the classic bone tunnel technique (clinical benchmark), whereas suture anchor fixation demonstrated the worst healing in both the ossified and unossified samples. All three transfer techniques caused at least minor alterations in apophyseal ossification, with the most significant changes observed in the metallic suture anchor cohort. The tunnel and suture techniques demonstrated similar and more mild abnormalities in ossification., Conclusion: Tendon transfers to unossified bone heal histologically as well as transfers classically performed through tunnels in bone. Suture fixation or tunnel techniques appear radiographically and histologically superior to suture anchors in our newborn porcine model., (Copyright © 2021, The author(s).)

This is a retrospective radiographic review to assess post-operative sagittal plane deformities in patients with Spinal Muscular Atrophy type 2 that had been treated with posterior spinal instrumentation. Thirty-two patients with a history of either spinal fusion (N = 20) or growing rods (N = 12) were identified with an average of 7.6 (2.1-16.6) years post-operative follow-up. Forty percent (13/32) of the patients were identified as having obvious "tucked chin" (N = 4), "tipped trunk" (N = 9), or both (N = 3). Sacral incidence was the only parameter that was statistically significant change between pre-operative or immediate post-operative measurements (66.9° vs. 55.2° p = 0.03). However, at final follow-up, the post-operative thoracic kyphosis had decreased over time in those that developed a subsequent sagittal deformity (24.2°) whereas it increased in those that did not (44.7°, p = 0.008). This decrease in thoracic kyphosis throughout the instrumented levels, resulted in a greater lordotic imbalance (30.4° vs. 5.6°, p = 0.001) throughout the instrumented levels in the group that developed the subsequent cervical or pelvic sagittal deformities. In conclusion, sagittal plane deformities commonly develop outside the instrumented levels in children with SMA type 2 following posterior spinal instrumentation and may be the result of lordotic imbalance that occurs through continued anterior growth following posterior instrumentation.

Background: Upper extremity fractures requiring cast immobilization are exceedingly common, especially in the pediatric population. Studies have shown improved outcomes when patients can participate in water-based activities while casted. However, waterproof cast material is not feasible in all clinical settings and wet cast complications remain a source of morbidity and expense. External cast protectors play an important role in preventing wet casts, but the efficacy of various commercially available brands during relevant water-based activity remains unknown., Purposes: To determine if there are differences in the rate and extent of moisture exposure for four commercially available cast protectors using a mechanized cast arm model and human volunteers., Methods: A mechanized arm model was developed with four implanted humidity sensors. Cast protectors were applied over the arm, the model was submerged in water, and moved back and forth, simulating cast-wearers' motion. Data regarding humidity was recorded for successive 10-minute trials. Trials were analyzed using a mixed effects linear model to determine change in humidity over time. The top and bottom performing cast protectors were then applied to four adult volunteers prior to thirty minutes of swimming. Questionnaires regarding comfort and a qualitative assessment of cast wetness using a chemical color indicator were completed., Results: 372 instances of sensor data from 96 10-minute trials was collected. The CVS, SealTight and Walgreens brands showed significant increases in humidity beginning at 10, 20 and 20 minutes, respectively. DryPro showed no significant increase in moisture level up to 50 minutes. In successive trials up to 120 minutes, DryPro showed only a 2% increase in moisture. In human subjects testing, 3/4 casts underneath CVS protectors had some degree of wetness-related color change that would require cast change as compared to 0/4 casts underneath DryPro protectors., Conclusions: Significant differences exist between commercially available cast protectors. Vacuum-sealed protectors performed best in both mechanical and human subject portions of this study and allowed minimal change in humidity for extended periods of sequential water immersion. Their cost is notably less than management of a wet cast. Lower-performing products may expose cast-wearers to an increased risk of wet cast complications., Competing Interests: Declarations of Competing Interest None., (Copyright © 2021. Published by Elsevier Ltd.)

The purpose of this study was to explore early changes in patient and family caregiver report of quality of life and family impact during the transitional period of nusinersen use. Communication; family relationships; physical, emotional, social, and cognitive functioning; and daily activities were measured using Pediatric Quality of Life modules (Family Impact Modules and both Patient and Proxy Neuromuscular-Specific Reports) pre- and post-nusinersen exposure. A total of 35 patients with SMA (15 Type 1, 14 Type 2, and 6 Type 3) were grouped according to nusinersen exposure. When analyzed as a whole cross-sectional clinical population, no significant differences were found between the initial and final surveys. Nusinersen therapy was associated with improved communication and emotional functioning in subsets of the population, particularly for patients on maintenance therapy for longer duration. Several unexpected potentially negative findings including increases in family resources and trends towards increases in worry warrant further consideration. Further research is warranted to explore the impact of novel pharmaceuticals on quality of life for children with SMA longitudinally to optimize clinical and psychosocial outcomes.

Recently, our group used exosomes from mesenchymal stromal/stem cells (MSCs) to simulate an M2 macrophage phenotype, that is, exosome-educated macrophages (EEMs). These EEMs, when delivered in vivo, accelerated healing in a mouse Achilles tendon injury model. For the current study, we first tested the ability of EEMs to reproduce the beneficial healing effects in a different rodent model, that is, a rat medial collateral ligament (MCL) injury model. We hypothesized that treatment with EEMs would reduce inflammation and accelerate ligament healing, similar to our previous tendon results. Second, because of the translational advantages of a cell-free therapy, exosomes alone were also examined to promote MCL healing. We hypothesized that MSC-derived exosomes could also alter ligament healing to reduce scar formation. Similar to our previous Achilles tendon results, EEMs improved mechanical properties in the healing ligament and reduced inflammation, as indicated via a decreased endogenous M1/M2 macrophage ratio. We also showed that exosomes improved ligament remodeling as indicated by changes in collagen production and organization, and reduced scar formation but without improved mechanical behavior in healing tissue. Overall, our findings suggest EEMs and MSC-derived exosomes improve healing but via different mechanisms. EEMs and exosomes each have attractive characteristics as therapeutics. EEMs as a cell therapy are terminally differentiated and will not proliferate or differentiate. Alternatively, exosome therapy can be used as a cell free, shelf-stable therapeutic to deliver biologically active components. Results herein further support using EEMs and/or exosomes to improve ligament healing by modulating inflammation and promoting more advantageous tissue remodeling., (© 2020 The Authors. STEM CELLS published by Wiley Periodicals LLC on behalf of AlphaMed Press.)

Background and Aims: Current multi-disciplinary management of children with spinal muscular atrophy (SMA) often requires the surgical management of spinal deformities. We present the outcomes of our peri-operative experience around the time of their spinal surgery and share our neuromuscular perioperative protocol., Methods: A single-centre retrospective chart review was performed to evaluate all children with SMA types I and II that underwent thoracolumbar spinal deformity correction (posterior spinal fusion or growing rod insertion) from 1990 to 2015. Electronic medical records were reviewed to assess pre-operative, intraoperative, and postoperative variables. T-tests, Wilcoxon Rank Sum, Fisher's Exact tests were performed as appropriate., Results: Twelve SMA I and twenty-two SMA II patients were included. Type I patients tended to be smaller and had a higher percentage (36.4% vs 4.5%) of American Society of Anesthesiologists (ASA) class 4 patients. Preoperative total parenteral nutrition (TPN) was utilised in 75.0% of type I and 18.2% type II patients. A difficult intubation was experienced in around 25% of the patients (20.0% SMA I, 27.3% SMA II). Approximately two hours of anaesthetic time was required in addition to the actual surgical time in both types. The intensive care unit (ICU) length of stay averaged 6 (4.0-7.5) days for type I and 3 (3-5) days for type II (p = 0.144). Average post-operative length of stay was (8 (7-9) vs. 7 (6-8)) P = 1.0., Conclusion: Children with type I and II SMA have similar hospital courses. The surgical and anaesthesia team should consider perioperative TPN and NIPPV (non-invasive positive-pressure ventilation), anticipate difficult intubations, longer than usual anaesthetic times, and potentially longer ICU stays in both SMA type I and II., Competing Interests: There are no conflicts of interest., (Copyright: © 2020 Indian Journal of Anaesthesia.)

Study Design: Single center, retrospective chart review., Objectives: To determine if routine posterior spinal fusion (PSF) is unnecessary in non-ambulatory growing rod graduates with SMA. Most non-ambulatory children with SMA develop early-onset scoliosis (EOS). Posterior growing rods (GR) have been shown safe and effective in managing spinal deformities in these children. The best management of these children, once graduated from their GR, is currently unknown. In this study, we report the clinical results of managing these children without routine definitive fusion following a course of GR treatment., Methods: A single-center, retrospective chart and radiographic review was performed on children with SMA treated with posterior distraction GR, with a two-year minimum follow-up since final lengthening. Electronic medical records and radiographs were reviewed for demographic variables, Cobb measurements, implant revisions, occult radiographic implant failure, symptomatic failure, and/or conversion to PSF., Result: 12 patients (2 type 1, 9 type 2, 1 type 1/2) met inclusion criteria. Mean age at growing rod insertion was 6.2 years of age (range 4.1-8.2) and age at final lengthening 10.3 years of age (range 9.3-11.9). The mean time between last lengthening and latest clinical or radiographic review was 5.5 (range 2.1-9.0) years. Average mean pre, post, final Cobb angles were 71°, 27° (p < 0.001), 25°. Following final lengthening, only one patient required hardware revision and conversion to definitive fusion in attempts to alleviate chronic hip pain, which was unsuccessful. One additional patient was found to have an occult rod failure that has not required treatment., Conclusion: While limited by sample size, this single-center cohort of non-ambulatory SMA patients with EOS treated with similar constructs suggests that routine, definitive fusion in SMA GR graduates may be unnecessary., Level of Evidence: Level IV.

Background: Spinal muscular atrophy is an autosomal-recessive, progressive neuromuscular disease associated with extensive morbidity. Children with spinal muscular atrophy have potentially increased life spans due to improved nutrition, respiratory support, and novel pharmaceuticals., Objectives: To report on the quality of life and family experience for children with spinal muscular atrophy with attentiveness to patient- and proxy-concordance and to stratify quality of life reports by spinal muscular atrophy type and medical interventions., Methods: A prospective, crossover survey study inclusive of 58 children (26 spinal muscular atrophy type I, 23 type II, 9 type III) and their family caregivers at a free-standing Midwestern children's hospital. Twenty-eight families completed the 25-item PedsQL 3.0 Neuromuscular Module. Forty-four participants completed the 36-item PedsQL Family Impact Module and 47 completed the Caregiver Priorities and Child Health Index of Life with Disabilities (CPCHILD) questionnaire., Results: The PedsQL Family Impact Module demonstrated significant differences between spinal muscular atrophy types I and II in functioning domains including physical, emotional, social, and family relations ( P < .03). Child self-report and proxy report surveys demonstrated significant differences between spinal muscular atrophy types in the communication domains ( P < .003). Children self-reported their quality of life higher than proxy report of child quality of life. Gastrostomy tube ( P = .001) and ventilation support ( P = .029) impacted proxy-reported quality of life perspectives, whereas nusinersen use did not. Spinal surgery was associated with improved parental quality of life and family impact ( P < .03)., Conclusions: The measurement and monitoring of quality of life for children with spinal muscular atrophy and their families represents an implementable priority for care teams.

Case: A 12-year-old boy with spinal muscular atrophy (SMA) Type II presented 5 years after undergoing spinal growing rod placement with cervical kyphosis at C2-3. He underwent anterior cervical discectomy and fusion but 6 years later developed significant kyphosis at the adjacent C3-4 level., Conclusion: We describe a rare adjacent segment kyphotic condition in a young man with SMA Type II. Clinicians should be cognizant of the risk of cervical kyphosis in adolescent patients with SMA.

INFIX instrumentation has provided an alternative treatment option for anteriorly unstable pelvic injuries. In this study, we explore the biomechanical feasibility of using an INFIX construct in an unstable longbone model and present a unique clinical case of its use. The external fixation, locked plate and spinal implant constructs (n = 5 each) were applied to lengthunstable fracture models and tested under various loads. Analysis of variance and pairwise Ttests were performed with levels of significance adjusted by Bonferroni correction to account for multiple comparisons. The biomechanical stiffness of the INFIX was found to be intermediate between the other two constructs in axial loading and torsion and was equivalent to one of the other constructs in sagittal and lateral bending. It was never the most compliant construct in any testing mode. This study and case report demonstrate the biomechanical feasibility of using INFIX to treat limb injuries. (Journal of Surgical Orthopaedic Advances 29(1):1825, 2020).

Study Design: Retrospective comparative study., Objectives: In patients with cerebral palsy (CP), we determine the impact of intrathecal baclofen pumps (ITBPs) on scoliosis curve progression before posterior spine fusion (PSF) and its effects on surgical outcome., Background: Children with CP can have rapid scoliosis progression, and high rates of surgical complications can be encountered. It is unknown whether the presence of pre-existing ITBP results in more difficult surgery and higher complication rates in similarly affected children., Methods: This is a single-center retrospective study of CP patients undergoing PSF over a 15-year period. Demographics, comorbidities, curve magnitudes, and surgical methods were compared between patients with ITBP and those without. Postoperative complications, length of intensive care unit/hospital stay, drain use and output volume, and need for further surgery were also compared. Curve progression analysis after ITBP placement was performed on a subgroup of patients with high-quality consistent radiographs., Results: Nineteen patients with ITBP and 49 patients without ITBP met inclusion criteria. Age, comorbidities, number of levels fused, and fixation techniques during PSF were not significantly different between cohorts. ITBP patients were more likely to have PSF with osteotomy (p = 0.022). Increased intraoperative neurosurgical consultations were found for patients with ITBP (42.1% vs. 4.0%; p < 0.001). Median surgical time was 1.2 h greater in patients with ITBP (6.7 vs. 5.5 h, p = 0.039). There was no difference in hospital course and complications in patients with ITBP and those without ITBP. Thirty-one patients without ITB were compared with 15 ITBP patients for curve progression before PSF, demonstrating a mean rate of scoliosis progression of 9.6° ± 6.7°/year and 14.8° ± 9.1°/year (p = 0.0346), respectively., Conclusion: The presence of an ITBP appears to be associated with the increase in scoliosis progression; and these patients will likely have a more challenging spine fusion. Fortunately, the final outcome is not affected by ITBP., Level of Evidence: Level III.

Tendon healing follows a complex series of coordinated events, which ultimately produces a mechanically inferior tissue more scar-like than native tendon. More regenerative healing occurs when anti-inflammatory M2 macrophages play a more dominant role. Mesenchymal stromal/stem cells (MSCs) are able to polarize macrophages to an M2 immunophenotype via paracrine mechanisms. We previously reported that coculture of CD14+ macrophages (MQs) with MSCs resulted in a unique M2-like macrophage. More recently, we generated M2-like macrophages using only extracellular vesicles (EVs) isolated from MSCs creating "EV-educated macrophages" (also called exosome-educated macrophages [EEMs]), thereby foregoing direct use of MSCs. For the current study, we hypothesized that cell therapy with EEMs would improve in vivo tendon healing by modulating tissue inflammation and endogenous macrophage immunophenotypes. We evaluated effects of EEMs using a mouse Achilles tendon rupture model and compared results to normal tendon healing (without any biologic intervention), MSCs, MQs, or EVs. We found that exogenous administration of EEMs directly into the wound promoted a healing response that was significantly more functional and more regenerative. Injured tendons treated with exogenous EEMs exhibited (a) improved mechanical properties, (b) reduced inflammation, and (c) earlier angiogenesis. Treatment with MSC-derived EVs alone were less effective functionally but stimulated a biological response as evidenced by an increased number of endothelial cells and decreased M1/M2 ratio. Because of their regenerative and immunomodulatory effects, EEM treament could provide a novel strategy to promote wound healing in this and various other musculoskeletal injuries or pathologies where inflammation and inadequate healing is problematic. Stem Cells 2019;37:652-662., (© 2019 The Authors. Stem Cells published by Wiley Periodicals, Inc. on behalf of AlphaMed Press 2019.)

Background: Lateral condyle fractures are associated with high morbidity due to their risk of nonunion and avascular necrosis (AVN). This study aims to assess the outcomes between closed reduction and the more traditional open techniques for operative fractures., Methods: All lateral condyle fractures that required operative fixation (pins or screws) over a ten-year period were included. We compared open versus closed reduction for OR time, infection rate, AVN, nonunion, premature physeal closure, ulnohumeral angle, and interepicondylar width (IEW)., Results: 28 patients were identified in the closed reduction group while 41 were identified in the open reduction group. Average displacement at surgery for these two groups was significantly different at 3.95mm for the closed group and 9.47mm for the open group (p<0.0001). Operating room time was significantly greater for the open reduction group by an average of 45 minutes (p <0.0001). Additionally, the closed reduction group was significantly less likely to require postoperative admission compared to the open reduction group (p=0.0004). There were no significant differences between the two groups with regard to abnormal ulnohumeral angles, infection rates, avascular necrosis, nonunion, lateral spur formation, premature physeal closure, or reoperation rate., Conclusions: The significant differences in OR time and post-operative admission make closed reduction the preferred approach from a hospital system quality improvement standpoint. Level of Evidence: IV., Competing Interests: Disclosures: Kenneth Noonan, MD receives Royalties for Spine Implants, Zimmer-Biomet. The authors related to this work received nothing of value.

Background: The act of applying, univalving, and spreading a plaster cast to accommodate swelling is commonly performed; however, cast saws can cause thermal and/or abrasive injury to the patient. This study aims to identify the optimal time to valve a plaster cast so as to reduce the risk of cast-saw injury and increase spreading efficiency., Methods: Plaster casts were applied to life-sized pediatric models and were univalved at set-times of 5, 8, 12, or 25 minutes. Outcome measures included average and maximum force applied during univalving, blade-to-skin touches, cut time, force needed to spread, number of spread attempts, spread completeness, spread distance, saw blade temperature, and skin surface temperature., Results: Casts allowed to set for ≥12 minutes had significantly fewer blade-to-skin touches compared with casts that set for <12 minutes (p < 0.001). For average and maximum saw blade force, no significant difference was observed between individual set-times. However, in a comparison of the shorter group (<12 minutes) and the longer group (≥12 minutes), the longer group had a higher average force (p = 0.009) but a lower maximum force (p = 0.036). The average temperature of the saw blade did not vary between groups. The maximum force needed to "pop," or spread, the cast was greater for the 5-minute and 8-minute set-times. Despite requiring more force to spread the cast, 0% of attempts at 5 minutes and 54% of attempts at 8 minutes were successful in completely spreading the cast, whereas 100% of attempts at 12 and 25 minutes were successful. The spread distance was greatest for the 12-minute set-time at 5.7 mm., Conclusions: Allowing casts to set for 12 minutes is associated with decreased blade-to-skin contact, less maximum force used with the saw blade, and a more effective spread., Clinical Relevance: Adherence to the 12-minute interval could allow for fewer cast-saw injuries and more effective spreading.

Background: The purpose of this study was to explore the role of perinatal vitamin-D intake on the development and characterization of hyperkyphosis in a porcine model., Methods: The spines of 16 pigs were assessed at 9, 13, and 17 weeks of age with radiography and at 17 weeks with computed tomography (CT), magnetic resonance imaging (MRI), histology, and bone-density testing. An additional 169 pigs exposed to 1 of 3 maternal dietary vitamin-D levels from conception through the entire lactation period were fed 1 of 4 nursery diets supplying different levels of vitamin D, calcium, and phosphorus. When the animals were 13 weeks of age, upright lateral spinal radiography was performed with use of a custom porcine lift and sagittal Cobb angles were measured in triplicate to determine the degree of kyphosis in each pig., Results: The experimental animals had significantly greater kyphotic sagittal Cobb angles at all time points when compared with the control animals. These hyperkyphotic deformities demonstrated no significant differences in Hounsfield units, contained a slightly lower ash content (46.7% ± 1.1% compared with 50.9% ± 1.6%; p < 0.001), and demonstrated more physeal irregularities. Linear mixed model analysis of the measured kyphosis demonstrated that maternal diet had a greater effect on sagittal Cobb angle than did nursery diet and that postnatal supplementation did not completely eliminate the risk of hyperkyphosis., Conclusions: Maternal diets deficient in vitamin D increased the development of hyperkyphosis in offspring in this model., Clinical Relevance: This study demonstrates that decreased maternal dietary vitamin-D intake during pregnancy increases the risk of spinal deformity in offspring. In addition, these data show the feasibility of generating a large-animal spinal-deformity model through dietary manipulation alone.

Background: Early-onset scoliosis (EOS) affects roughly 1 to 2 out of 10,000 live births per year. Because this subset of patients has a yet to achieve a majority of their skeletal growth, a number of treatment challenges need to be addressed before surgical intervention. If left untreated, EOS can cause a number of problems throughout the patient's lifespan, particularly in regards to the growth of the thorax and pulmonary development. A wide variety of surgical systems and techniques are available to the treating surgeon., Methods: A review of the orthopaedic literature from 2010 to 2015 relating to pediatric spine growth modulation was performed. Ninety-eight papers were identified and, following exclusion criteria, a total of 31 papers were selected for further review., Results: This paper summarizes the recently published literature regarding growth-friendly spinal implants, the status of their Food and Drug Administration approval labeling as well as the indications, applications, and complications associated with their implementation., Conclusions: There are a growing number of options at the surgeon's disposal when treating patients with EOS. As surgeons, we must continue to be vigilant in our demand for sound clinical evidence as we strive to provide optimal care for our patients. The rapidly advancing field of spinal growth modulation is exciting. More work must be done to further enhance our ability to predictably modulate growth in the pediatric spine.

Background: Respiratory weakness and spinal deformity are common in patients with spinal muscular atrophy (SMA). Posterior (distraction type) growing rods have recently gained favor as a treatment option in this population, due to their ability to prevent spinal deformity progression and their potential to allow lung volumes to increase over time. The objective of this study was to determine the impact of posterior growing rods on the spinal alignment and respiratory function in children with SMA with intermediate term follow-up., Methods: A single center, retrospective review was performed on SMA patients treated with growing rods, inserted between 2004 and 2010, with a minimum of 2-year follow-up. SMA type, changes in the route of bi-level positive airway pressure respiratory support and the amount of time receiving respiratory support are reported. Pulmonary function tests (PFTs) and radiographs were reviewed and data evaluated preinsertion, postinsertion, and at latest follow-up., Results: Sixteen children with SMA (5 type I, 11 type II) met inclusion criteria. The average age of insertion was 5.8 (±1.5) years, the median number of lengthenings was 4 (range, 3 to 5), and the median time between insertion and last clinical review was 4.7 (range, 2.7 to 9.5) years. Radiographic review demonstrated significant (P<0.05) improvements in the following: Spinal curve magnitude, pelvic obliquity, space available for the lung, rib vertebral angle difference, and thoracic kyphosis following growing rod implantation. Thoracic and lumbar height and chest width and depth increased significantly (P<0.05) over the lengthening process. None of the patients initially required more than noninvasive positive pressure ventilation support. Fifteen of the 16 experienced no changes in their noninvasive positive pressure ventilation support needs throughout the study duration, requiring support only at night and naps. Serial PFTs were available for 6 children with SMA type II. PFTs demonstrated significant improvements in absolute forced vital capacity (FVC), minimal changes in the maximal inspiratory and expiratory pressures, and a gradual worsening of percent predicted FVC., Conclusions: Clinical respiratory support requirements appear to stabilize following the insertion and lengthening of posterior based growing rods in the SMA population. Similar to previous studies, increased spinal height and thoracic cavity size were noted throughout the process. Despite an increasing absolute FVC, the percent predicted FVC diminished over time., Level of Evidence: Level IV-therapeutic.

Background: Guided growth is often used to correct limb deformity and yet implant screw failure in modular systems has been reported. There have been no reports of plate failure and we do not know the exact mode of failure when screws do break., Methods: We report the first published case of a fractured plate in a modular plate and screw construct that was used to correct Blount disease in a child through guided growth. The implants were removed and analyzed for method of failure using scanning electron microscopy., Results: Scanning electron microscopy of the explant confirms that the mode of failure was not a result of static tension from growth. Rather, analysis confirms cyclic fatigue that led to crack propagation across the anterior side of the plate until overload caused complete plate failure., Conclusions: This analysis confirms an in vivo cyclic compression-relaxation of the growth plate presumably to weight-bearing, and that when excessive may lead to implant failure as seen here in this case., Level of Evidence: Level V.

Purpose: Tibialis anterior tendon transfers (TATT) are commonly performed in young children following Ponseti casting for clubfeet. The classic TATT involves advancing the tendon through a hole drilled in the ossified cuneiform. The aim of this study was to determine if tendons transferred through unossified bones have untoward effects on subsequent bone development., Method: Twenty-five piglets underwent one of five surgical procedures. An 18-gauge needle was then used to place a tunnel through the bony or cartilaginous portion of the calcaneus (through direct visualization) and isolated slips of the flexor digitorum superficialis (FDS) were placed through the tunnels, as determined by surgical procedure. Radiographic and/or histologic evaluations of the calcaneal apophyses were then performed. A discrete (1-4) and dichotomous "Normal" or "Abnormal" scoring system was developed and its reliability assessed to grade the appearance of the calcanei. Calcaneal appearances following the surgical procedures were then compared with controls. The average load to failure of a subset of transferred tendons was then compared using an MTS machine., Results: The proposed apophyseal grading system (1-4) demonstrated an intraclass correlational coefficient (ICC) for consistency of 0.92 [95% confidence interval (CI) 0.88 < ICC < 0.95] and ICC for agreement of 0.91 (95% CI 0.86 < ICC < 0.95), indicating strong agreement and consistency. Similarly, Fleiss' kappa for the 1-4 scoring system was found to be 0.67, indicating substantial agreement between reviewers. When the 1-4 system was translated into the dichotomous scheme "Normal" and "Abnormal", the kappa value increased to 0.94, indicating strong agreement. Forty-six apophyses (13 control and 33 operative) were assessed using this scoring scheme. Apophyseal transfers were significantly more abnormal than controls (p < 0.0001), while no difference in abnormalities was found following tunnel placement alone (p = 1). Mechanical testing of the tendons transferred to bone or through the cartilaginous apophysis demonstrated no significant differences (p = 0.2)., Conclusion: Tendon transfers through unossified bones altered subsequent bone development., Significance: While the long-term consequence of these structural changes is unknown, these findings suggest that tendon transfers through unossified bones should be avoided and alternative methods of tendon fixation explored., Competing Interests: The Authors have no potential conflicts of interest pertaining to this manuscript. Funding This study was funded by an Orthopaedic Research and Education Foundation (OREF) Resident Research Grant (MSN158875). The principal investigator (PI) was Sam Abrams, M.D. Ethical approval All applicable international, national, and/or institutional guidelines for the care and use of animals were followed. Animal use was approved through our Institutional Animal Care and Use Committee (IACUC).

Purpose: The accepted mechanism explaining the accelerated growth following periosteal resection is that the periosteum serves as a mechanical restraint to restrict physeal growth. To test the veracity of this mechanism we first utilized Second Harmonic Generation (SHG) imaging to measure differences of periosteal fiber alignment at various strains. Additionally, we measured changes in periosteal growth factor transcription. Next we utilized SHG imaging to assess the alignment of the periosteal fibers on the bone both before and after periosteal resection. Based on the currently accepted mechanism, we hypothesized that the periosteal fibers adjacent to the physis should be more aligned (under tension) during growth and become less aligned (more relaxed) following metaphyseal periosteal resection. In addition, we measured the changes in periosteal micro- and macro-scale mechanics., Methods: 30 seven-week old New Zealand White rabbits were sacrificed. The periosteum was imaged on the bone at five regions using SHG imaging. One centimeter periosteal resections were then performed at the proximal tibial metaphyses. The resected periosteal strips were stretched to different strains in a materials testing system (MTS), fixed, and imaged using SHG microscopy. Collagen fiber alignment at each strain was then determined computationally using CurveAlign. In addition, periosteal strips underwent biomechanical testing in both circumferential and axial directions to determine modulus, failure stress, and failure strain. Relative mRNA expression of growth factors: TGFβ-1, -2, -3, Ihh, PTHrP, Gli, and Patched were measured following loading of the periosteal strips at physiological strains in a bioreactor. The periosteum adjacent to the physis of six tibiae was imaged on the bone, before and after, metaphyseal periosteal resection, and fiber alignment was computed. One-way ANOVA statistics were performed on all data., Results: Imaging of the periosteum at different regions of the bone demonstrated complex regional differences in fiber orientation. Increasing periosteal strain on the resected strips increased periosteal fiber alignment (p<0.0001). The only exception to this pattern was the 10% strain on the tibial periosteum, which may indicate fiber rupture at this non-physiologic strain. Periosteal fiber alignment adjacent to the resection became less aligned while those adjacent to the physes remained relatively unchanged before and after periosteal resection. Increasing periosteal strain on the resected strips increased periosteal fiber alignment (p<0.0001). The only exception to this pattern was the 10% strain on the tibial periosteum, which may indicate fiber rupture (and consequent retraction) at this non-physiologic strain. Increasing periosteal strain revealed a significant increase in relative mRNA expression for Ihh, PTHrP, Gli, and Patched, respectively., Conclusion: Periosteal fibers adjacent to the growth plate do not appear under tension in the growing limb, and the alignments of these fibers remain unchanged following periosteal resection., Significance: The results of this study call into question the long-accepted role of the periosteum acting as a simple mechanical tether restricting growth at the physis., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Placement and removal of fiberglass casts are among the more-common interventions performed in pediatric orthopaedic surgery offices. However, cast removal is associated with abrasive injuries and burns from the oscillating cast saw, and these injuries can occur even when the cast is removed by experienced personnel. It is unknown whether an added barrier, such as a safety strip, can mitigate injuries from blade-to-skin contact during cast removal with the oscillating saw., Questions/purposes: We asked: (1) Can a safety strip provide a physical barrier during cast removal, decreasing blade-to-skin contact? (2) Does the safety strip lessen heat transfer? (3) Will the use of the safety strip prevent cast pressure from being released when the cast is split?, Methods: Standard long-arm fiberglass casts were removed by experienced and inexperienced healthcare personnel (n = 35) from life-sized pediatric models. A commercially available woven cast saw safety strip, commonly incorporated in waterproof cast constructs, was chosen as the protective strip. Each participant removed a cast with and without the safety strip present. All participants were blinded to the presence or absence of the safety strip at the time of cast removal. The number of touches was compared between cast removal with and without protective strips. A separate model was designed to assess prevention of heat transfer. Temperatures were recorded, using thermocouples, for three designated temperatures. Five to six trials were conducted at each designated temperature for each of two conditions, with and without the safety strip. Finally, to assess if the safety strip would prevent cast pressure from being released, a third model was used. Thirty standard short-arm casts were applied and removed from the arm models by one of the authors. Pressure data were collected from between the padding layers, in casts with and without the safety strip present, after application, univalving and bivalving each cast., Results: Use of the safety strip reduced the number of simulated skin touches compared with casts removed without the safety strip, among experienced users (mean, 9.0 [range, 1-28] versus 0.1 [range, 0-1], mean ratio, 0.0012; 95% CI, 0.002-0.063; p < 0.001) and inexperienced users (mean, 8.5 [range, 0-31] versus 0.6 [range, 0-3], mean ratio, 0.07; 95% CI, 0.03-0.15; p < 0.001). The safety strips decreased heat transfer, preventing temperatures at the cast-skin interface from reaching 50 °C. Finally, after splitting the cast, with the numbers available, there was no increase in the pressure beneath the casts in those with the safety strip present (mean without, 0.23 [SD, 0.070] versus safety strip in the padding 0.20 [SD, 0.091] and safety strip on top padding, 0.21 [SD, 0.090]; p = 0.446 and p = 0.65 respectively)., Conclusions: Our study showed the effectiveness of a safety strip in reducing simulated touches with the oscillating cast saw during cast splitting. Additional studies are warranted to investigate the clinical use and utility of the safety strip in practice., Clinical Relevance: The findings of this study suggest that using safety strips in clinical practice could decrease blade-to-skin contact and therefore minimize cast saw injuries. However, validation of these findings in the clinical setting is necessary before drawing a definitive conclusion.

Background: As casts are routinely used in pediatric orthopaedics, casts saws are commonly used to remove such casts. Despite being a viewed as the "conservative" and therefore often assumed safest treatment modality, complications associated with the use of casts and cast saws occur., Methods: In this manuscript, we review the risk factors associated with cast saw injuries., Results: Cast saw injuries are thermal or abrasive (or both) in nature. Thermal risk factors include: cast saw specifications (including a lack of attached vacuum), use of a dull blade, cutting in a concavity, too thin padding, and overly thick casting materials. Risk factors associated with abrasive injuries include: sharp blades, thin padding, and cutting over boney prominences. Because nearly all clinicians contact the skin with the blade during cast removal, appropriate "in-out technique" is critical. Such technique prevents a hot blade from remaining in contact with the skin for any significant time, diminishing the risk of burn. Similarly, using such technique prevents "dragging the blade" that may pull the skin taught, cutting it. It may be useful to teach proper technique as perforating a cast rather than cutting a cast.

Background: Guided growth corrects pediatric limb deformity by inhibiting growth on the convexity of the bone. Both modular and rigid implants have been used; we endeavor to determine whether a clear advantage of one implant exists. We further hypothesize that improved correction could be realized by accelerating growth with resection of the periosteum., Methods: Sixteen lambs underwent guided growth of the medial proximal tibia (the opposite limb served as a control). Group 1 used a rigid staple (n=5); group 2 a modular plate and screw construct (n=5), and group 3 had a similar device plus periosteal resection (n=6). Radiographs tracked the progression of deformity in the coronal plane. Before sacrifice, pulsed fluorochrome labels allowed for temporal and spatial growth rate analysis. At sacrifice, True Deformity was calculated (and compared with control tibia) from standardized radiographs in the coronal and sagittal planes. Device Efficiencies were normalized by dividing True Deformity produced (degrees) by the Expected Growth gain (mm) from the control limb., Results: Group 3 produced greater coronal plane deformity than group 1 by an average of 2.2 degrees per month (P=0.001) and group 2 by an average of 2.4 degrees per month (P=0.0007). At sacrifice, groups 1 and 2 were equally effective at limiting growth to 75% of control; no differences in growth retardation were noted. No differences in Device Efficiency were noted between groups 1 and 2. The Device Efficiency was significantly different between groups 1 and 2 with comparison with group 3 (P=0.05 and P=0.022); with a 2.5 degree/mm faster deformation in the stripped cohort., Conclusions: Rigid implants initially produced deformity quicker than modular constructs; yet ultimately, both implants were equally effective at guiding growth. Device Efficiency for the modular group improved significantly with the addition of periosteal stripping as method to accelerate growth.

Background: Disruption of the periosteum has been used to explain overgrowth after long bone fractures. Clinically, various periosteal procedures have been reported to accelerate growth with varied results. Differences between procedures and study populations, in these prior studies, make drawing conclusions regarding their effectiveness difficult., Questions/purposes: The purpose of this study was to (1) determine if all reported periosteal procedures accelerate growth and increase the length of bones; (2) study the relative duration of these growth-accelerating effects at two time points; and (3) identify the periosteal procedure that results in the most growth., Methods: Periosteal stripping (N = 8), periosteal transection (N = 8), periosteal resection (N = 8), (and) full periosteal release (N = 8) were performed on the tibiae of skeletally immature rabbits. Tibiae were collected 2 weeks postoperatively. The tibiae of additional cohorts of periosteal transection (N = 8), periosteal resection (N = 8), full periosteal release (N = 8), and repetitive periosteal transection (N = 8) were collected 8 weeks postoperatively. The contralateral tibiae served as an operative sham control in all cohorts. Fluorochrome bone labeling was used to measure growth rates, whereas high-resolution Faxitron imaging was performed to measure tibial lengths. Comparisons were then made between (1) experimental and sham controls; and (2) different procedures. Eight additional nonsurgical animals were included as age-matched controls., Results: Growth (in microns) was accelerated at the proximal tibial physis on the tibia undergoing the periosteal surgical procedures versus the contralateral control limb after the transection (411 ± 27 versus 347 ± 18, p < 0.001 [mean ± SD]), resection (401 ± 33 versus 337 ± 31, p < 0.001), and full periosteal release (362 ± 45 versus 307 ± 33, p < 0.001), 2 weeks after the index procedure. Conversely, the periosteal stripping cohort trended toward less growth (344 ± 35) than the controls (356 ± 25; p = 0.08). No differences were found between limbs in the nonoperative controls. Tibial lengths for the experimental tibiae were longer at 2 weeks in the transection (1.6 ± 0.4 mm, p < 0.001), resection (1.6 ± 0.9 mm, p = 0.03), and full periosteal release (1.7 ± 0.5 mm, p < 0.001), whereas negligible differences were found between the tibiae of the nonoperative controls (0.13 ± 0.7 mm, p = 0.8) and stripping cohorts (0.10 ± 0.6 mm, p = 0.7). At 8 weeks, growth acceleration ceased at the proximal tibial physes in the transection cohort (174 ± 11 versus 176 ± 21, p = 0.8), and the control limbs actually grew faster than the experimental limbs after resection (194 ± 24 versus 178 ± 23, p = 0.02) and full periosteal release (193 ± 16 versus 175 ± 19, p < 0.01) cohorts. Growth rates were increased over control limbs, only in the repetitive transection cohort (190 ± 30 versus 169 ± 19, p = 0.01) at 8 weeks. Tibial lengths for the experimental tibiae remained longer at 8 weeks in the transection (1.4 ± 0.70 mm, p < 0.001), resection (2.2 ± 0.82 mm, p < 0.001), full periosteal release (1.6 ± 0.42 mm, p < 0.001), and repetitive periosteal transection (3.3 ± 1.1 mm, p < 0.001), whereas negligible differences were found between the tibiae of the nonoperative controls (-0.08 ± 0.58 mm, p = 0.8). Comparing the procedures at 2 weeks postoperatively, no differences were found in tibial lengths among the transection (2.1% ± 0.5% increase), resection (2.1% ± 1.1% increase), and full periosteal release (2.1% ± 0.6 %); however, all three demonstrated greater increased growth when compared with the stripping cohort (-0.10% ± 0.7%; p < 0.05). At 8 weeks no differences could be found between increased tibial lengths among the transection (1.5% ± 0.7%), resection (2.3% ± 0.9%), and full periosteal release (1.7% ± 0.4%). The repetitive transection produced the greatest over length increase (3.5% ± 1%), and this was greater than the acceleration generated by the single resection (p < 0.001) or the full periosteal release (p = 0.001). All four demonstrated an increase greater than the nonoperative control (0.09% ± 0.6%; p < 0.05)., Conclusions: Transection of the longitudinally oriented periosteal fibers appears critical to accelerate growth in a rabbit model., Clinical Relevance: These findings in an animal model support previous claims that limb overgrowth occurs as the result of periosteal disruption. Based on these findings in rabbits, we believe that less invasive procedures like periosteal transection are a promising avenue to explore in humans; clinical studies should seek to determine whether it is equally effective as more invasive procedures and its role as an adjunct to guided growth or distraction osteogenesis.

Background: The aim of this study was to determine if radiographic measurements, taken before tenotomy, can predict outcome in children with idiopathic clubfoot treated by the Ponseti method., Methods: A retrospective chart and radiographic review was performed on children with idiopathic clubfoot treated with the Ponseti method over a 10-year period with minimum 2-year follow-up that had a forced dorsiflexion lateral foot radiograph before tenotomy. All angles were measured in duplicate on the pretenotomy radiographs, including: foot dorsiflexion (defined as the 90 minus the angle between the tibial shaft and a plastic plate used to dorsiflex the foot), tibio-calcaneal, talo-calcaneal, and talo-first metatarsal angles. Clinical review of patient records identified different patient outcomes: no additional treatment required, relapse (additional casting and/or surgery required), recurrence (any additional surgery required), or reconstruction (surgery not including repeat tenotomy)., Results: Forty-five patients (71 feet) were included in the study. The median age at follow-up was 4.6 years. The intrareader reliability was acceptable for all measures. Thirteen of the 71 (18%) feet required additional surgery, occurring at a median age of 3.6 years. Of the 4 radiographic measures, only pretenotomy foot dorsiflexion predicted recurrence (hazard ratio=0.96, P=0.03). Youden's method identified 16.6 degrees of dorsiflexion as the optimal cutoff. Feet with at least that amount of dorsiflexion pretenotomy (n=21) experienced no recurrences; feet with less than that amount of dorsiflexion (n=50) experienced 13 recurrences (P=0.007)., Conclusions: Reduced foot dorsiflexion on lateral forced dorsiflexion pretenotomy radiograph was associated with an increased risk of recurrence. Radiographic dorsiflexion to 15 degrees past neutral before tenotomy appears to predict successful treatment via the Ponseti method.

Introduction: Children with cerebral palsy undergoing soft tissue and bony procedures often experience pain and spasticity postoperatively. Differentiation of pain from spasticity complicates management, so controlling spasticity with a continuous infusion of baclofen, an antispasmodic, through an already present indwelling epidural catheter holds interest., Methods: A retrospective chart review was performed of patients with cerebral palsy undergoing single event, multilevel lower extremity surgery at a single institution who received epidural analgesia with or without continuous baclofen infusion. Primary outcomes included need for supplemental narcotic analgesics and benzodiazepines postoperatively. Duration of hospitalization, pain scores, and complications were also evaluated., Results: Forty-four patients were identified, ranging in age from 3 to 17 years, 19 of whom received epidural baclofen. No differences were found in use of supplemental narcotic analgesia, benzodiazepines, or duration of hospitalization. Differences in pain scores were not statistically significant (0.82±0.95 for baclofen vs. 1.48±0.99 for controls) (P=0.391). Mean arterial pressure was lower in patients receiving baclofen (P=0.004). No potential side effects attributable to baclofen were noted., Conclusions: Continuous epidural baclofen infusion seems unlikely to alter the pain-spasm cycle experienced by patients with cerebral palsy following orthopaedic surgery to a clinically significant degree. More effective, and cost-effective, measures at assessing and controlling pain and muscle spasm should be explored to benefit cerebral palsy patients postoperatively., Level of Evidence: Level III-therapeutic study.

Purpose: The aim of this study was two-fold: (1) to determine if radiographic measures can be reliably made in infants being treated with the Ponseti method and (2) to document radiographic changes before and after Achilles tenotomy., Methods: A retrospective radiographic and chart review was performed on children with clubfoot treated by the Ponseti method at a single institution over a 10-year period. Five independent reviewers measured a series of angles from a lateral forced dorsiflexion radiograph taken prior to and following Achilles tenotomy. These measures were taken in triplicate to determine the intra- and inter-reader reliability of dorsiflexion, tibio-calcaneal, talo-calcaneal, and talo-first metatarsal angles., Results: Thirty-six subjects (56 feet) were treated with the Ponseti method and met the inclusion criteria. The median (range) age of patients at the time of tenotomy was 52 (34-147) days. The intra-reader reliability [intra-rater correlation coefficient (ICC)] for each of the measured angles pre- and post-tenotomy ranged from 0.933 to 0.995 and 0.864 to 0.995, respectively. Similarly, the inter-reader reliabilities (ICC) ranged from 0.727 for the pre-tenotomy (talo-calcaneal) to 0.950 for the post-tenotomy (talo-first metatarsal) angles. The mean differences between pre- and post-tenotomy radiographs were: dorsiflexion increase of 17°, tibio-calcaneal angle increase of 19°, talo-calcaneal angle increase of 9°, and talo-first metatarsal angle increase of 10° (p-value ≤0.001 for all measurements except the talo-first metatarsal angle, with a p-value of 0.001)., Conclusions: Reliable radiographic measures can be made from lateral dorsiflexion radiographs of clubfeet treated with the Ponseti method before and after Achilles tenotomy.

Introduction: We describe the correct technique for measuring compartment pressure with a handheld device to diagnose compartment syndrome., Step 1 Device Preparation: Proper preparation of the handheld pressure monitoring device (Stryker Surgical, Kalamazoo, Michigan) is critical to ensure that the device performs appropriately., Step 2 Identification of the Compartment of Interest: The needle must be placed in the proper location to appropriately measure a compartment's pressure., Step 3 Injection: Inject saline solution from the pressure monitoring device to clear any soft tissue from the side port on the needle that could result in inaccurate pressure measurements., Step 4 Stabilization and Pressure Reading: The pressure must reach a stable state before it is recorded; different pressure thresholds for decompression have been recommended in the literature., Step 5 Repeat Measurements: As mistakes can be made with any single measurement, accuracy may be improved by repeating steps 1 through 4 and averaging the results., Step 6 Additional Compartments: After the reading is obtained, move on to any additional compartment(s) that need to be evaluated, repeating the steps listed above., Results: The handheld intracompartmental monitoring device with a side-ported needle has been shown to be extremely accurate in the laboratory.IndicationsContraindicationsPitfalls & Challenges.

Tissue development is orchestrated by the coordinated activities of both chemical and physical regulators. While much attention has been given to the role that chemical regulators play in driving development, researchers have recently begun to elucidate the important role that the mechanical properties of the extracellular environment play. For instance, the stiffness of the extracellular environment has a role in orienting cell division, maintaining tissue boundaries, directing cell migration, and driving differentiation. In addition, extracellular matrix stiffness is important for maintaining normal tissue homeostasis, and when matrix mechanics become imbalanced, disease progression may ensue. In this article, we will review the important role that matrix stiffness plays in dictating cell behavior during development, tissue homeostasis, and disease progression.

Study Design: Single-center, prospective, randomized, double-blinded trial., Objectives: To compare blood loss, allogenic transfusion requirements, and coagulation parameters between pediatric spinal deformity patients receiving aminocaproic acid (Amicar) or tranexamic acid (TXA) during posterior spinal fusion., Summary of Background Data: Amicar and TXA have been shown to decrease blood loss in pediatric spinal deformity cases compared with controls. The difference in efficacy between these medications in this population has not been reported., Methods: Enrolled patients were randomized to receive either Amicar or TXA during scoliosis surgery. Baseline demographic and deformity comparisons were collected. Intraoperative comparisons included estimated and calculated blood loss, number of levels instrumented, number of osteotomies, operative time, and allogenic transfusion requirements. Preoperative and postoperative hemoglobin, platelets, prothrombin time, partial prothrombin time (PTT), international normalized ratio (INR), and fibrinogen were recorded., Results: A total of 47 patients were enrolled with data available for review (N = 25, Amicar; N = 22, TXA). No difference in cohorts was found in demographics, preoperative hemoglobin, platelets, prothrombin time, PTT, INR, initial Cobb angle, average number of: levels fused, patients with osteotomies and osteotomies, operative time, and final Cobb angles. Estimated blood loss was significantly less (about 221 mL) than the calculated blood loss in both groups (p = .003). Estimated blood loss (1,088 vs. 726 mL; p = .055) and calculated blood loss (1,366 vs. 903 mL; p = .13) trended higher in the Amicar group. Although no difference in allogenic transfusion rates (20% vs. 14%) was observed, average volumes transfused were significantly higher in the Amicar cohort (1,014 vs. 461 mL; p = .03). The TXA cohort demonstrated a statistically significant smaller change in INR, a lower PTT, and greater fibrinogen levels postoperatively., Conclusions: Compared with Amicar, TXA use was associated with a lower allogenic transfusion requirement, less alteration in postoperative clotting studies, and a trend toward lower blood loss in pediatric posterior spinal fusion patients., (Copyright © 2014 Scoliosis Research Society. Published by Elsevier Inc. All rights reserved.)

Displaced radial neck fractures in the pediatric population can be treated with retrograde intramedullary nailing of the radius (the Métaizeau technique). This method allows early movement, which may improve functional outcome. Unfortunately, repeated intraoperative attempts with this treatment in challenging fractures can result in compartment syndrome. In this article, we report the cases of 2 patients who underwent the Métaizeau technique for displaced radial neck fractures. In each case, optimal fixation of the radius was impossible because of concurrent elbow instability. Multiple attempts to reduce and stabilize these fractures may cause development or exacerbation of forearm compartment syndrome. The Métaizeau technique has been shown to be an effective method of minimally invasive surgical management of pediatric radial neck fractures. Its success may hinge on the ability of the elbow joint to hold the radial head in position while the implant is driven into the proximal radius in a retrograde fashion. Care should be used when dealing with radial neck fractures associated with elbow dislocation, as they may be difficult to reduce and stabilize. The increased operative time and soft-tissue injury associated with repeated attempts with this method may lead to or worsen compartment syndrome.

Background: Cast-saw injuries are sustained during cast removal or splitting of a cast when a hot cast-saw blade touches the patient's skin inadvertently during cast removal. Other studies have evaluated risk factors associated with saw-blade temperature, however, none have documented the number and duration of blade-to-skin contacts during cast removal., Methods: Using a pediatric long-arm model capable of detecting cast-saw blade contact, we tested the ability of health care providers to apply and remove casts before and after a brief education module. The total number and duration of "touches" between the saw and the model's "skin" were recorded. Correlations between user "touches," and experience and comparisons between pre- and post-education "touches" were performed., Results: Of the 18 study participants, 16 touched the model surface with the cast saw; 7 of the 18 participants maintained blade contact with the skin for > 1 second 22 times during the testing process. Participants with less experience averaged 20 (± 16) touches, whereas more experienced participants averaged 24 (± 19) touches (P = 0.7). Average number of touches was similar-before 22 (± 20) and after 25 (± 22); P = 0.5-participants completed an education module. No correlation between experience or participation in the education program was found with decreased number of blade-to-skin touches., Conclusion: Nearly all clinicians inadvertently contacted the underlying skin with the cast-saw blade. In our limited sample size, experience and education did not prevent this; therefore, minimizing time of contact and blade temperature may be more important factors in minimizing cast-saw injuries.

Appropriate pressure during the application of a cast is critical to provide adequate stabilization of fractures. Force-sensing resistors (FSR) were used to measure pressure during cast placement and removal. The data demonstrated a signature pattern of skin pressure during the different steps of cast placement and removal. This reproducible signal provides validity evidence for our model.

Study Design: Retrospective case report of 2 cases., Objective: To describe 2 cases of cervical spinal cord injury/vascular insult after posterior instrumentation of thoracic/thoracolumbar scoliosis., Summary of Background Data: Spinal cord injury is an uncommon but well-documented complication associated with spinal deformity surgery. The midthoracic spinal cord is most vulnerable to these presumed vascular insults. Injuries above the level of instrumentation are rare., Methods: In this report, we review the clinical histories of 2 adolescent females undergoing posterior spinal fusion with subsequent cervical spinal cord injuries., Results: In both cases, intraoperative cervical alignment appeared neutral and all hardware appeared appropriately positioned. Spinal cord monitoring demonstrated changes in 1 patient but not in the other. With time, both patients improved clinically., Conclusion: Cervical spinal cord injuries may occur after distal deformity correction.

Background: To compare the routine use of posterior-based (Ponte) osteotomies to complete inferior facetectomies in thoracic idiopathic scoliosis. Hypokyphosis is common in thoracic adolescent idiopathic scoliosis. The use of pedicle screw fixation in deformity correction can exacerbate this hypokyphosis. We hypothesized that by utilizing posterior-based Ponte osteotomies rather than facetectomies, we could improve coronal plane correction and decrease the loss of kyphosis during curve correction., Methods: The radiographs and clinical charts of patients with idiopathic scoliosis (Lenke types I, II) who underwent isolated thoracic posterior spinal fusion utilizing primarily pedicle screw constructs from January 2008 to August 2010 were reviewed. Maximum preoperative Cobb angle, thoracic kyphosis (T5-T12), levels instrumented, number of posterior-based osteotomies, operative time, estimated blood loss, and postoperative residual coronal Cobb angle and kyphosis were recorded. Operative time per level, blood loss per level, percent main curve correction, and change in thoracic kyphosis was calculated. Patients having undergone complete inferior facetectomies and those with multilevel Ponte osteotomies were then compared., Results: Eighteen patients underwent posterior spinal fusion with osteotomies and 19 patients had complete inferior facetectomies during this time period. The osteotomy cohort had a larger preoperative Cobb angle [59±10 vs. 52±8 (mean±SD); P=0.03]. No difference was observed in the preoperative kyphosis (22±15 vs. 25±12) or in levels fused (9±1 vs. 8±1). Patients with routine osteotomies had them performed at 76% of the levels instrumented. No significant difference was found in terms of percentage of coronal plane correction (84% in both groups), average postoperative kyphosis 28±8 versus 25±7, or the change in kyphosis 6±14 versus 0±2 degrees, in the osteotomy and the facetectomy groups, respectively. Estimated blood loss per level was significantly higher in the osteotomy group (97±42 mL vs. 66±25 mL; P=0.01) as was time per level 31±5 versus 23±3 minutes/level (P<0.001)., Conclusions: This study shows a significantly higher blood loss and operative time associated with the use of routine posterior osteotomies in the thoracic spine without a significant improvement in coronal or sagittal correction.

Study Design: This is a technique article discussing 3 alternative frames for casting children with infantile scoliosis., Objective: To provide surgeons with alternatives to expensive specialized casting tables to allow local treatment of these children utilizing readily available materials present at most institutions., Summary of Background: Casting for infantile scoliosis has become more popular as reports have shown promising results with this technique without the morbidity and complications associated with more invasive procedures. However, without a specialized casting table, treating these patients has been limited to a few centers throughout the country often causing patients to travel large distances to receive care., Methods: Three different alternatives to commercially available casting frames are presented. Requirements, setup, and techniques are discussed., Results: Each surgeon has had success with each of these frames. These provide adequate support and traction while allowing enough access to the trunk to apply a well-molded cast., Conclusions: Cotrel/Metha casting for infantile scoliosis can be accomplished without a specialized table using commonly available equipment.

Aims: Spinal deformity surgery is one of the most complicated procedures performed in pediatric orthopedics. These surgeries can account for long operative times and blood losses. Finding ways to limit patient morbidity undergoing these procedures may benefit many. We hypothesized that utilizing two fellowship trained pediatric spinal deformity surgeons would lead to decreased operative time and blood loss when compared with single surgeon. We felt very little difference would be found in terms of curve correction., Methods: A retrospective review of spinal deformity surgeries performed at two institutions was performed. At one institution, the standard of care was to have two fellowship deformity trained surgeons perform all deformity surgeries simultaneously, while at the second institution posterior spinal fusions performed by individual surgeons were performed. The single surgeon cohort was further divided based on instrumentation type (pedicle screw vs hybrid constructs). Cases for this review were limited to posterior spinal fusions without osteotomies in patients with idiopathic or idiopathic like curves. Cohorts were compared pre-operatively for age at surgery, sex, BMI, largest Cobb angle. Intra-operative comparisons included total EBL, instrumentation type screws vs hybrid, levels fused, and operative time. Comparisons between largest remaining Cobb, EBL/level, time/level, lowest recorded Hb, allogenic transfusion requirements, length of PICU stay, and total length of hospital stay were then made. Pair-wise student t-tests was performed between cohorts with significance defined as a p-value of 0.05 or less., Conclusions: Twenty-four patients were found in the (BMP) cohort, where as eighty-two were found in the control group. No significant difference in age, sex, starting hemoglobin, BMI*, or maximum pre-operative Cobb between cohorts was found. A significantly lower number of levels were fused in the BMP cohort than the control (9 ± 2 vs 11 ± 2) p < 0.001, and likewise a significantly shorter operative time (average >2 h) was seen in the BMP cohort. Interestingly, no difference in estimated blood loss, blood loss/level fused, operative time/level fused was observed, yet a significantly greater drop in hemoglobin (average 1 g) p = 0.001 and allogenic transfusion rate was seen in the control group (4% (1/24) vs 29% (24/82)) p = 0.01. A greater improvement in Cobb angle was seen in the BMP group 46 ± 8 vs 35 ± 10° p < 0.001. No differences were seen in nights in the PICU and peri-operative complications, however patients in the BMP averaged nearly 1day less in the hospital than in the control group. Utilizing a blood management program including two surgeons in spinal deformity surgery appears to decrease operative time, blood loss, and improve curve correction. Confounding factors such as differences in number of fusion levels, curve types, instrumentation type, and institutional practices prevents drawing definitive conclusions. This is the first study to show potential benefits of utilizing a blood management program with dual surgeons in spinal deformity cases.

Purpose: The aim of this study is to examine the short-term effects of patellar tendon advancement on the proximal tibial slope in the skeletally immature patient., Methods: A retrospective, non-randomized, comparative cohort design was used. Koshino indices and tibial slopes were assessed pre-operatively and post-operatively and compared with age- and sex-matched controls., Results: Nine children with 17 patellar tendon advancements were analyzed for changes in Koshino indices. Of these 17 tibiae, radiographs on changes in tibial slope were available for 16 tibiae which were also compared with controls. Children aged <11 years had a greater initial posterior tibial slope (69.8° ± 3.5°) than age-matched controls (80.3° ± 2.7°). A decrease in posterior slope was seen in these younger patients (average change 10.3° ± 4.8°) at an average of 1.6 years of follow-up. Of the nine apophyses in children aged <11 years of age, seven had undergone premature closure., Conclusion: Patellar tendon advancement appears to have an unreported effect on the proximal tibial growth in the young patient (<11 years old). These patients appear to be susceptible to apophyseal closure, resulting in subsequent loss of posterior tibial slope. Surgeons should be aware of this effect and monitor younger patients with radiographs if performing this procedure.

Purpose: To better delineate between incomplete clubfoot correction and true clubfoot recurrence based on the time at which the deformity reappears and the treatment necessary to correct the foot., Methods: A chart review of all idiopathic clubfoot at a single institution treated by either the Ponseti method or short leg casting and surgery were reviewed for recurrent deformity involving the tibia, ankle, or foot. Comparisons of treatment required to correct deformities were made between those noticed within six months of initial treatment and those noticed after six months. Similar comparisons were made based on the initial treatment of the deformity., Results: Forty-four of 51 patients showed some clinical deformities after their initial treatment. Over half of these deformities either resolved or did not require operative intervention at a minimum of two years follow-up, while 43% (19/44) were felt to require surgery. Eight patients had deformities re-appear within six months of initial treatment and eleven patients after six months. Six of the eight patients requiring surgery with deformities noticed less than six months after initial treatment required correction of structural deformities (osteotomies and posterior-medial releases), whereas 10/11 patients requiring surgery for deformities noticed after six months required correction for dynamic deformities. These differences were significant (p=0.01). No difference in terms of the number of deformities noticed (22/25 and 22/26) and number requiring surgery (11/22 in the Ponseti group and 8/22 in the surgical group) were found. However, deformities requiring further surgery in the surgical group re-appeared earlier 0.23±0.2 years than those in the Ponstei group 1.7±1 years (p=0.001). These earlier re-appearing deformities required more structural surgery (6/8) than those in the later appearing Ponseti group (1/11; p=0.01)., Conclusions: Nearly half of all re-appearing deformities required surgery. The deformities noticed within six months of initial correction required more structural surgery to correct than those noticed after six months. We propose that the recurrent deformities noticed before six months of age represent incomplete corrections and those after six months true recurrences. Feet initially treated with surgery may be more prone to incomplete correction whereas those treated by the Ponseti method may be more prone to recurrence., Significance: Not all re-appearing clubfoot deformities are the same. The initial treatment and time at which they first appear may have implications as to the surgery required to correct.

Unlabelled: Both private and socialized healthcare systems require treatments to be not only effective, but also cost-efficient. Although the Ponseti method of clubfoot treatment is effective, its cost-effectiveness has not been demonstrated. We compared the difference in resource use between two prospective cohorts treated for clubfoot by either the Ponseti method or below-knee casting followed by primary surgical release in the socialized healthcare system of New Zealand. Using these cohorts and US billing data, costs of treating these cohorts in the US healthcare system were also calculated. Treatment of initial deformity, recurrences, and complications in both cohorts were included in the final assessment. Twenty-six patients (40 feet) were enrolled in the Ponseti cohort and 29 (46 feet) in the primary surgical cohort. For most patients, the Ponseti method was more cost-effective than the primary surgical treatment in both healthcare systems. The cost of treating both cohorts was lower in the socialized system than in the US healthcare system., Level of Evidence: Level II, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.