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Background: In light of increasing productivity demands and modern changes to work/life balance, physician wellness has become a more pertinent topic among physicians. We investigated whether modern pediatric orthopaedic surgeons are at higher risk for early mortality than their historic cohorts. Methods: Data was collected from the Pediatric Orthopaedic Society of North America (POSNA), which records the passing of its members. The members were sorted into the decennial nearest their birth year. Using publicly available data from the US Social Security Administration, we determined life expectancy from age 45 for all deceased members (LE45), and compared this to their actual age at death. Results: There was a total of 45 deceased POSNA members included. POSNA members born nearest the deciles of 1930 and 1940 had only one instance of a member dying more than 15 years prior to their expected age at death, compared to eight instances from the 1950 and 1960 deciles. There was one member each from the 1950 and 1960 deciles dying more than 30 years prior to their expected age at death, compared to three from the 1970 decile. Conclusions: Although this data is difficult to analyze due to limitations in the denominator, the results are concerning and highlight the importance of more understanding of how to improve physician wellness. Additional study is necessary to further investigate if younger surgeons are at risk for early mortality.

An AP knee radiograph is considered adequate if the patella is centred between the femoral condyles. Our previous studies demonstrated a tendency for lateral patellar deviation on an AP view orthogonal to the posterior femoral condyles. However, findings were based on cadaveric samples limited by the lack of soft tissue effects on patellar positioning.After excluding those with deformity or damage to osseous or ligamentous structures, 106 knee MRI scans were randomly selected. Patellar centring was calculated as a percentage of total distal femoral intercondylar width and represented how lateral the centre of the patella is located with respect to the midpoint of the femoral condyles. Multiple regression analysis was performed to determine the relationship between patellar centring and age, gender, anatomic lateral distal femoral angle (aLDFA), medial proximal tibial angle (MPTA) and tibial tuberosity to trochlear groove (TT-TG) distance.There were 35 males and 71 females included in the study with a mean age of 29 ± 14 years. Mean patellar centring was 8 ± 4%. There was a statistically significant correlation between TT-TG distance and positive (lateral) patellar centring (standardisedThis study demonstrates that the patella is rarely perfectly centred and is usually positioned slightly laterally within the femoral condyles in an AP view orthogonal to the posterior aspect of the femoral condyles. The use of supine MRI scans makes this data relevant to a patient on the operating room table.Shah NS, Kyriakedes JC, Liu RW. An MRI-based Study to Investigate If the Patella is Truly Centred between the Femoral Condyles in the Coronal Plane. Strategies Trauma Limb Reconstr 2022;17(2):63-67.

Although skeletal maturity is most relevant during adolescence, it has utility in treatment of younger patients in some circumstances, such as scoliosis, limb length discrepancy, or endocrinopathies. Currently, a quick, accurate, and reproducible method of estimating skeletal maturity in preadolescents using wrist radiographs is lacking.Serial anteroposterior wrist radiographs taken at historical growth study visits leading up to the chronological age (CA) associated with 90% of the final height (an enhanced skeletal maturity standard as compared with peak height velocity) were analyzed in 102 children. Epiphyseal and metaphyseal widths of 5 physes were evaluated: distal radius, distal ulna, first metacarpal, third metacarpal, and fifth metacarpal. Ulnar styloid height and radial styloid height were also measured, for a total of 7 epiphyseal:metaphyseal radiographic parameters. Greulich and Pyle (GP) bone age was also measured. A combination of stepwise linear regression and generalized estimating equation analyses was used to produce a skeletal maturity estimation model incorporating demographics (CA and sex) and the epiphyseal:metaphyseal ratios significantly correlated with skeletal maturity.A total of 273 left anteroposterior hand-wrist radiographs from 56 girls (163 radiographs, range 4 to 13 y) and 46 boys (112 radiographs, range 3.8 to 15 y) were included. The demographics+ratios model had better prediction accuracy than GP only and GP with demographics (0.44, 0.87, and 0.47 y mean discrepancy from actual skeletal age, P0.05 for both comparisons). There was no significant difference in the rate of outlier skeletal age estimates, defined as an estimate1 year off from the true skeletal age, between the demographics+ratios model and the demographics+GP model (5.9% vs. 8.4%, P =0.12).When combined with CA and sex data, measurement of the epiphyseal:metaphyseal ratios of the left first and third metacarpals allows for improved skeletal maturity estimation compared with the GP technique.Our modified wrist skeletal maturity system offers a relatively quick and reproducible method for estimating skeletal maturity extending into the juvenile age range. This study is a level III retrospective study of longitudinal human growth data obtained from the Bolton Brush Collection in Cleveland, Ohio.

Background: Little data exist regarding the association of slipped capital femoral epiphysis (SCFE) and sporting activities. Hypothesis: There is no association between SCFE and sporting activities. Study Design: Retrospective review of all SCFE cases at our institution from 2010 through March 2021. Level of Evidence: Level 3. Methods: All patients with idiopathic SCFE were reviewed looking for the presence/absence of sporting activities and symptom onset. Also collected were the age, symptom duration, and weight/height of the patient, sex, race, and stable/unstable nature of the SCFE. The severity of the SCFE was measured using the lateral epiphyseal-shaft angle. Results: There were 193 children (110 boys, 83 girls) with idiopathic SCFEs. The SCFE was stable in 147, unstable in 45, and unknown in 1. The average age was 12.1 ± 1.8 years, average SCFE angle 38° ± 20° and symptom duration 4.0 ± 5.1 months. An association with a sporting activity was present in 64 (33%). The sporting activity was basketball (18), football (11), baseball/softball (10), and others (23). Football, basketball, and soccer predominated in boys, baseball and running sports were equal between boys and girls, and cheerleading/gymnastics/dancing predominated in girls. Differences showed that those involved in sports had a slightly lower body mass index (BMI) (88th percentile vs 95th percentile, P = 0.00). There were no differences between those involved and those not those involved in sporting activities for symptom duration, SCFE severity, sex, race, or stable/unstable SCFE type. Conclusion: Sporting activities are associated with the onset of symptoms in 1 of 3 of patients with SCFE, refuting the null hypothesis. Clinical Relevance: A high level of suspicion for SCFE should be given when any peripubertal athlete presents with hip or knee pain regardless of BMI/obesity status, and appropriate imaging performed.

Predicting ultimate lower extremity length is important in the treatment of lower limb length discrepancy (LLD), congenital limb deficiency, and other etiologies. Utilizing skeletal age over chronological age improves the prediction of ultimate lower extremity length. The recently described modified Fels knee skeletal maturity system allows for skeletal age estimation via imaging always available in LLD patients. We sought to compare the accuracy of the modified Fels knee skeletal maturity system versus chronological age in ultimate limb length prediction of a modern adolescent clinical population.The medical records of all patients treated at our institution over a 20-year period with unilateral lower extremity pathology and available lower extremity imaging before and after reaching skeletal maturity were reviewed. Skeletal maturity was defined radiographically by closed distal femoral, proximal tibial, and proximal fibular physes. The femoral, tibial, and lower extremity length was measured in all radiographs. The modified Fels knee skeletal maturity system was applied to all radiographs obtained before maturity to estimate skeletal age. The accuracy of 3 widely utilized lower extremity length prediction systems was compared when utilizing estimated Fels skeletal age versus chronological age inputs.A total of 245 radiographs (109 before maturity) from 43 patients were eligible for inclusion. On cross-sectional analysis, linear modeling using Fels skeletal ages was uniformly associated with higher (improved) R2 values than chronological age-based models. On longitudinal analysis, skeletal age mixed-effects models had significantly lower (improved) Akaike information criterion and Bayesian information criterion values than chronological age models in all cases. Cohen d values were also significantly different (P0.05) for the skeletal age models compared with chronological age models in all cases.In the treatment of LLD, the modified Fels knee skeletal maturity system can be readily applied to available imaging to improve the prediction of ultimate femoral, tibial, and lower extremity length. This skeletal maturity system may have significant utility in the estimation of ultimate LLD and determination of appropriate timing of epiphysiodesis.Level III.

This article provides researchers with the background and guidance necessary to practically incorporate skeletal maturity estimation into any study of adolescents with imaging of the shoulder, elbow, hand, hip, knee, or foot. It also provides clinicians with a comprehensive, concise synopsis of systems that can be used to estimate skeletal maturity in clinical practice. In the article, we provide a relatively brief overview of each currently available skeletal maturity system that has been validated on a longitudinal dataset. The supplementary files include 2 PowerPoint files for each skeletal maturity system. The first PowerPoint file offers examples and instructions for using each radiographic system. The second PowerPoint file includes 20 graded radiographs that can be used for reliability analyses in the research setting. We have also developed a free mobile application available on the iOS and Android platforms named "What's the Skeletal Maturity?" that allows clinicians to rapidly estimate skeletal maturity on any patient using any commonly obtained orthopaedic radiograph.

The recently described optimized Oxford skeletal maturity system utilizes anteroposterior (AP) hip radiographs to accurately, rapidly, and reliably estimate skeletal maturity. However, in the real-world setting, significant positional variation in AP hip radiographs may influence the accuracy of optimized Oxford skeletal age estimates. We sought to evaluate the consistency of skeletal age estimations using the optimized Oxford system between differently rotated radiographs.Thirty normal computerized tomography scans of males (15 children, 9 to 15 y) and females (15 children, 8 to 14 y) were obtained retrospectively, converted into 3D reconstructions, and then used to produce simulated hip radiographs in five different rotational positions. The optimized Oxford system was applied to the 150 simulated AP hip radiographs (5 differently rotated views of 30 hips) to produce a skeletal age estimate for each.Rotational position did not have a statistically significant effect on the skeletal age (P=0.84) using 1-way repeated measures analysis of variance. Of the 5 radiographic parameters in the optimized Oxford system, only greater trochanter height showed significant rotational variation after Greenhouse-Geisser correction (F2.58, 74.68=5.98, P0.001). However, post hoc analyses showed that the greater trochanter height obtained at the most centered position was not different from the other 4 rotational positions (P0.05 for all).The optimized Oxford skeletal maturity system is resilient to rotational variation. Mildly to moderately rotated radiographs obtained in the modern clinical setting can be used for skeletal age estimation by this method, broadening the clinical usage of this system.Level III-diagnostic study.

The recently described Modified Fels knee system allows for accurate skeletal maturity estimation using a single anteroposterior knee radiograph but requires evaluation of 7 parameters. A faster method may have clinical utility in the outpatient setting.Seven anteroposterior knee radiographic parameters associated with 90% of the final height (an enhanced skeletal maturity standard compared with peak height velocity) were analyzed in 78 children. Segmented linear regression and generalized estimating equation analyses were used to identify the subsets of parameters most important for accurate skeletal maturity estimation for different patient demographics and parameter scores. This process produced abbreviated skeletal maturity systems, which include fewer parameters and are quicker to use. The accuracy of the resulting abbreviated skeletal maturity systems was evaluated and compared with the full 7-parameter Modified Fels knee system and with the Greulich and Pyle (GP) left-hand bone age.A total of 326 left knee radiographs from 41 girls (range, 7 to 15 y) and 37 boys (range, 9 to 17 y) were included. Models generated by segmented regression and generalized estimating equation analysis required fewer parameters (range, 1 to 5 parameters) than the full Modified Fels knee system (7 parameters). Skeletal age estimates produced by segmented regression models were more accurate than GP (P0.05) and not significantly different from the full Modified Fels system (P0.05). The percentage of outlier estimations (estimations1 y off from actual skeletal age) made by segmented regression models was not significantly different from GP (P0.05) or the Modified Fels knee system (P0.05).An abbreviated version of the Modified Fels knee system estimates skeletal maturity more accurately than the GP system with just 2 to 3 radiographic knee parameters.The abbreviated Modified Fels knee system may allow for rapid skeletal age estimation (~30 s) appropriate for routine outpatient practice.

Introduction COVID-19 has resulted in decreases in absolute imaging volumes, however imaging utilization on a per-patient basis has not been reported. Here we compare per-patient imaging utilization, characterized by imaging studies and work relative value units (wRVUs), in an emergency department (ED) during a COVID-19 surge to the same period in 2019. Methods This retrospective study included patients presenting to the ED from April 1–May 1, 2020 and 2019. Patients were stratified into three primary subgroups: all patients (n = 9580, n = 5686), patients presenting with respiratory complaints (n = 1373, n = 2193), and patients presenting without respiratory complaints (n = 8207, n = 3493). The primary outcome was imaging studies/patient and wRVU/patient. Secondary analysis was by disposition and COVID status. Comparisons were via the Wilcoxon rank-sum or Chi-squared tests. Results The total patients, imaging exams, and wRVUs during the 2020 and 2019 periods were 5686 and 9580 (−41%), 6624 and 8765 (−24%), and 4988 and 7818 (−36%), respectively, and the percentage patients receiving any imaging was 67% and 51%, respectively (p

Percutaneous iliosacral screw fixation and transsacral fixation are challenging procedures requiring extensive knowledge of sacral anatomy to avoid damaging nearby neurovascular structures. Greater knowledge of anatomical screw trajectory and size allowances would be helpful to guide surgical placement. An anatomical study of 40 cadaveric sacra in specimens ages 18-65 was performed. Three-dimensional surface scans were obtained, and computer modeling software was used to simulate a 7.3 mm diameter screw with 1 mm buffer inserted orthogonal to the sacroiliac joint in the pelvic inlet and outlet views. Transsacral screws were also inserted into S1 and S2 vertebrae. For screws orthogonal to the sacroiliac joint, the overall mean screw insertion angle was 4.1° ± 7.5° (range, -18.3° to 22.0°) in the inlet view in the posterior to anterior direction, and 21.7° ± 5.1° (range, 8.2°-36.3°) in the outlet view in the caudal to cranial direction. Before breaching the sacrum, the range of sacral tunnel lengths was between 31.1 and 70.1 mm with a range of diameters between 9.3 and 13.3 mm. Transsacral screws inserted into either the S1 or S2 vertebrae did not breach the sacrum in 40% (16/40) at each level. 30% (12/40) of sacra could not safely accommodate both S1 and S2 transsacral screws. There is an initial screw insertion angle range of -4° to 12° in the inlet view and 16°-27° in the outlet view. There was always adequate size to accept a 7.3 mm or larger screw.

PURPOSE Pelvic incidence (PI) is a position independent parameter used to quantify spinopelvic sagittal balance. PI is generally measured on lateral radiographs, but more recent studies have suggested better accuracy with standard CT scans versus three-dimensional (3D) CT scans. This study compares PI obtained from lateral XR, standard CT scan and CT scan with 3D reconstruction. METHODS A total of 77 subjects with lateral XRs of the pelvis or lumbosacral spine and CT scans of the pelvis were randomly selected. Pelvic incidence on lateral XRs, standard CT scans and CT scans utilizing multiplanar reconstruction were measured and compared using intraclass correlation coefficients (ICC). PI was also measured on serial images in 28 individuals using the same imaging modality within 3 years and evaluated using ICC. RESULTS Mean ± SD of PI measurements on XR, standard CT and CT with 3D reconstruction were 56° ± 13°, 53° ± 12° and 53° ± 12°, respectively, demonstrating a small but significant elevation of PI measurement on XR (P

The recently developed modified Fels knee and optimized Oxford hip skeletal maturity systems (SMS) have demonstrated impressive performance compared with the Greulich and Pyle skeletal age atlas when applied to the same historical, mostly white, pediatric population. We sought to determine whether these 2 systems require modification before being used in modern children.We collected knee and hip radiographs between January 2015 and September 2020 from our electronic medical record from 4 groups of children: (1) white males, (2) black males, (3) white females, and (4) black females. Males between 9 and 17 years and females between 7 and 15 years were included. After reliability analyses, 5 nonpathologic radiographs for each age and joint were randomly selected from each group and evaluated with the appropriate SMS. The mean discrepancy between each group's chronological age at the time of radiograph and estimated skeletal age was compared between our modern cohort and the historical Bolton-Brush children. After normality testing, paired t tests or Wilcoxon signed-rank tests were performed, as appropriate. A Bonferroni correction was applied to address multiple testing.Three hundred sixty modern radiographs were evaluated (180 knees and 180 hips). All 7 modified Fels knee parameters and all 5 optimized Oxford hip parameters had inter and intrarater reliability coefficients ≥0.7, indicating good to very good reliability. For the modified Fels knee SMS, white males (Δ0.74 y, P0.001), black males (Δ0.69 y, P0.001), and black females (Δ0.4 y, P=0.04) had advanced skeletal age compared with their historical counterparts of the same sex. No differences were found between historical and modern patients for the optimized Oxford hip SMS. No differences were found for either SMS comparing modern patients along racial lines (P0.05 for all).Discrepancies in skeletal age estimates made by the modified Fels knee SMS exist between modern pediatric white males, black males, and black females and their historic counterparts. No differences were found when using optimized Oxford hip SMS. Future studies should evaluate how these translate to clinical decision-making.Level III; retrospective chart review.

Previous investigations have demonstrated that up to 7% of the distal femoral physis can be violated using a rigid, retrograde nail without growth inhibition or arrest. The purpose of this investigation was to evaluate the behavior of the distal femoral physis after retrograde femoral nail removal in a sheep model, with and without placement of an interpositional fat graft.Retrograde femoral nails were placed in 8 skeletally immature sheep. Implants were removed at 8 weeks, with the residual defects left open (n=4) or filled with autologous fat graft (n=4). Differences in femoral length between surgical versus contralateral control femurs were measured after an additional 3 (n=4) or 5 months (n=4) before sacrifice, and the physis was evaluated histologically.When compared with control limbs, femoral length was significantly shorter in limbs sacrificed at 3 months (mean: 3.9±1.3 mm; range: 2.7 to 5.7 mm) compared with limbs at 5 months (mean: 1.0±0.4 mm; range: 0.4 to 1.2 mm) ( P =0.005). No significant difference in mean shortening was appreciated in limbs without (2.4±1.6 mm) versus with fat grafting (2.5±2.3 mm) ( P =0.94). Histologic analysis revealed no osteoid formation across the physis in sheep sacrificed at 3 months, whereas there was evidence of early osteoid formation across the physis in sheep at 5 months. All specimens demonstrated evidence of an active physes.Femurs undergoing retrograde implant placement were significantly shorter when compared with control limbs in sheep sacrificed at 3 months, whereas differences were nominal in sheep sacrificed at 5 months after retrograde implant removal, suggesting growth inhibition with nail removal improved with time. Fat grafting across the distal femoral physis did not result in a significant difference in femoral lengths. Histologic evidence at 5 months revealed early development of a bone bridge, emphasizing the importance of follow-up to skeletal maturity in patients treated with retrograde nailing across an open physis.Level IV.

Skeletal maturity estimation is central in the management of scoliosis and lower-limb deformity. Utilizing demographic characteristics and modern computing, we sought to create a reliable, rapid, and accurate method for measuring skeletal maturity on an elbow radiograph.Utilizing the Bolton-Brush Collection, 4 parameters from the modified Sauvegrain method and 7 novel parameters were screened. Ten parameters were evaluated on serial peripubertal elbow radiographs, using Greulich and Pyle (GP) skeletal age from corresponding hand radiographs as a comparison. Stepwise linear regression and generalized estimating equations were used to identify radiographic and demographic parameters for estimating skeletal maturity based on 90% of final height. The elbow system was compared with GP only; olecranon apophysis only; age, sex, and GP; age, sex, and olecranon apophysis; age, sex, and elbow system with anteroposterior and lateral parameters; age, sex, and elbow system with anteroposterior parameters; and age, sex, and elbow system with lateral parameters.In this study, 367 radiographs from 77 patients (40 girls and 37 boys) were included. Following stepwise linear regression, 4 radiographic parameters were included in the anteroposterior and lateral elbow system; 3 were included in the anteroposterior elbow system; and 4 were included in the lateral elbow system. The lateral elbow system predicted skeletal maturity with a mean discrepancy of 0.41 year and produced similar mean discrepancies to GP with age and sex (0.42; p = 0.93), and it trended toward better performance than the olecranon apophysis system with age and sex (0.43; p = 0.06). The lateral elbow system had the lowest percent of outlier predictions1 year discrepant from the skeletal maturity reference (4.6%), although it was only significantly better than the GP-only group (29.4%) and the olecranon apophysis-only group (21.0%) (p0.001 for both).We systematically developed a lateral elbow system that performed equivalently to GP using 4 simple parameters and trended toward outperforming the olecranon apophysis systems in skeletal maturity estimation. Future clinical validation will be necessary to understand the utility of this system.The lateral elbow system may be a more accurate prediction of skeletal maturity compared with the previously described olecranon apophysis system and can be used to guide the management of many pediatric orthopaedic conditions.

The etiology of patellofemoral disorders is multifactorial. Preoperative patellofemoral anatomy evaluation is of great importance in patients undergoing surgery for patellofemoral disorders. Although anatomical risk factors of patellofemoral disorders have been thoroughly investigated in clinical and radiological studies, there are sparse data regarding the association between trochlear dysplasia with other anatomical parameters. This study sought to explore those associations using a large osteological collection. Five-hundred and seventy-nine cadaveric skeletons were obtained from the Hamann–Todd osteological collection. Mechanical lateral distal femoral angle (mLDFA), medial proximal tibial angle (MPTA), femoral version, tibial torsion, lateral position of the tibial tubercle, and femoral length were modeled as predictors of medial and lateral flange height of the distal femur trochlea at various degrees of knee flexion. The average age and standard deviation for the 1158 lower extremities analyzed was 55.9 ± 10.2 years. There were 500 males (86%) and 79 females. Increasing MPTA or tibial valgus predicted increasing lateral femoral flange height at 0, 30, and 50 degrees of knee flexion [(standardized beta 0.111, p = 0.01), (standardized beta 0.129, p

Background The onset of peak height velocity (PHV) guides the timing of interventions in the growing child. The purpose of the present study was to validate the Dimeglio olecranon grading system and to compare these scores with the Risser/triradiate closure (TRC), proximal humerus, and Sanders hand scores. Methods Eighty children with annual serial radiographs were selected from the Bolton-Brush collection. The olecranon apophysis was graded with use of lateral radiographs of the elbow. The mean age to PHV was determined for each stage, and reliability was calculated with use of an intraclass correlation coefficient (ICC). Olecranon stage was combined with age, sex, and height in a generalized estimating equation (GEE) model to predict PHV. Predictive performance of this model was evaluated with use of tenfold cross-validation such that the model was trained on 90% of the radiographs and was asked to predict the PHV of the remaining 10%. Results PHV is closely associated with olecranon stage, with stage 1 occurring 3.0 years before PHV and stage 7 occurring 3.4 years after PHV. Stage 5 was found to occur at PHV. Scoring system reliability was high across an array of observers (ICC = 0.85 ± 0.07). The GEE model showed that this olecranon system outperforms the Risser/TRC system in predicting PHV and is comparable with the humerus and Sanders hand systems. When combined with age and sex, the olecranon system successfully predicted PHV such that 62% of PHV predictions were accurate within 6 months and 90% of PHV predictions were accurate within a year. Conclusions Our data show that stage 5 occurs at PHV, contrary to previously published data. When combined with age and sex, the olecranon system successfully predicts PHV within a year in 90% of cases, establishing a single lateral view of the olecranon as a simple alternative to more complex grading systems. Last, we describe novel 3 variations in olecranon morphology and provide a guide for accurate olecranon staging. Clinical relevance Understanding PHV is critical in the treatment of many pediatric orthopaedic disorders. The revised olecranon staging system will allow for more accurate determination of this variable.

Medial proximal tibial angle (MPTA) and posterior proximal tibial angle (PPTA) are commonly used to characterize the geometry of proximal tibia and are important considerations in lower extremity realignment procedures and total knee arthroplasty. This study utilized a large cadaveric collection to explore relationships between tibial slope and coronal plane deformity of the tibia. We utilized 462 well-preserved skeletons (924 tibiae), excluding any with fracture or obvious rheumatologic or infectious findings. Custom cards were made with different sized arcs on the bottom surface, so that they could rest on the anterior and posterior aspects of the medial and lateral tibial plateaus of each bone to measure PPTA. Previously measured MPTA values for the same bones were also utilized. Multiple regression analysis was used to determine relationship between MPTA and medial and lateral PPTAs. The mean age was 56 ± 10 years, with 13% female and 31% African American (remainder Caucasian). The mean MPTA was 87.2 ± 2.4 degrees. The mean medial plateau PPTA was 81.5 ± 3.8 degrees and mean lateral plateau PPTA was 81.3 ± 3.7 degrees. Regression analysis found that MPTA was significantly associated with both medial and lateral PPTAs (standardized betas 0.197 and 0.146, respectively, p

Background Benign bone tumors are common incidental findings in the pediatric population during radiographic evaluation. Counseling these patients requires reassurance and raises questions about the natural history of these tumors over time. The purpose of this study was to estimate the prevalence and observe the behavior of benign childhood bone tumors in an asymptomatic population. Methods A historical, longitudinal radiographic collection of healthy children was reviewed, which included comprehensive left-sided radiographs of the extremities at yearly intervals. In this study, 262 subjects with 25,555 radiographs were screened for benign bone tumors at a median age of 8 years (range, 0 to 18 years). All potential tumors were reviewed by a multidisciplinary panel, which confirmed the radiographic diagnosis of each lesion, the age at which the lesion first appeared, and the age at which it had resolved. Prevalence rates were calculated using the number of distinct subjects available for each radiographic location and age. Results Thirty-five tumors were identified in 33 subjects, including 19 nonossifying fibromas, 8 enostoses, 6 osteochondromas, and 2 enchondromas. The prevalence rate for all tumors combined increased with age and was 18.9% overall. The overall prevalence rates for specific tumor types were 7.5% for nonossifying fibromas, 5.2% for enostoses, 4.5% for osteochondromas, and 1.8% for enchondromas. Nonossifying fibromas demonstrated a bimodal distribution of prevalence, with a peak at 5 years (10.8%) and another after skeletal maturity (13.3%). The median age at the first appearance for all tumors combined was 9 years (range, 2 to 15 years), but varied by tumor type. Nonossifying fibromas often resolved (7 [37%] of 19), with further resolution possible beyond the last available radiograph. Enostoses, osteochondromas, and enchondromas persisted until the last available radiographs in all subjects. Conclusions The prevalence of benign childhood bone tumors of the extremities was 18.9% in a historical asymptomatic population. Longitudinal radiographs allowed observation of the timing of the first appearance and the potential for resolution for each tumor type. These findings provide unique evidence to answer many commonly encountered questions when counseling patients and their families on benign bone tumors. Level of evidence Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The standard treatment of stable slipped capital femoral epiphysis (SCFE) is generally accepted to be in situ pinning. Controversy exists regarding the treatment of unstable SCFE, including the role of a purposeful closed reduction or open reduction. The objective of this study was to investigate the rate of avascular necrosis (AVN) with purposeful closed reduction and in situ pinning of unstable SCFE. The authors retrospectively reviewed 221 patients with 302 SCFE hips treated with in situ pinning between 2000 and 2014. Forty-eight patients (50 hips) presented with an unstable SCFE. All unstable SCFEs were treated by a gentle reduction method with traction and hip internal rotation followed by pinning. Southwick angles were measured prior to reduction and at the first postoperative visit. No stable SCFEs developed AVN. Thirteen (26%) unstable SCFEs developed AVN. Avascular necrosis developed in 7 of 17 (41%) hips screened with magnetic resonance imaging vs 6 of 33 (18%) hips screened with plain radiographs alone. Mean change in Southwick angle was 28°±8° in the AVN group vs 18°±18° in the no AVN group ( P =.18). Despite potentially inflating the rate with the use of early detection magnetic resonance imaging, the authors found an AVN rate comparable to that in the published literature with the use of gentle purposeful reduction on a fracture table, and no statistical differences in reduction amount between patients with and without AVN. Gentle purposeful reduction appears to be a reasonable low morbidity option in the treatment of unstable SCFE without a clear increase in risk of AVN. [ Orthopedics . 2021;44(2):92–97.]

Background The ability to estimate skeletal maturity using a knee radiograph would be useful in anterior cruciate ligament (ACL) injuries and limb-length discrepancy in immature patients. Currently, a quick, accurate, and reproducible method is lacking. Methods Serial knee radiographs made 3 years before to 2 years following the chronologic age associated with 90% of final height (an enhanced skeletal maturity gold standard compared with peak height velocity) were analyzed in 78 children. The Pyle and Hoerr (PH) knee method was simplified by developing discrete stages for the distal part of the femur, the proximal part of the tibia, the proximal part of the fibula, and the patella. The Roche-Wainer-Thissen (RWT) knee method was simplified from the 36 original parameters to 14 parameters by removing parameters that were poorly defined, were not relevant to the peripubertal age range, were poorly correlated with 90% final height, or were poorly reliable on a 20-radiograph pilot analysis. We also compared the recently described central peak value (CPV) of the distal part of the femur. The Greulich and Pyle (GP) left-hand bone age was included for comparison. Results In this study, 326 left knee radiographs from 41 girls (age range, 7 to 15 years) and 37 boys (age range, 9 to 17 years) were included. Stepwise linear regression showed higher correlation in predicting years from 90% final height using the modified RWT and demographic characteristics (R2 = 0.921) compared with demographic characteristics alone (R2 = 0.840), CPV and demographic characteristics (R2 = 0.866), GP and demographic characteristics (R2 = 0.899), and PH and demographic characteristics (R2 = 0.902). Seven parameters were excluded from the RWT and demographic characteristics model using stepwise linear regression and generalized estimating equations analysis, leaving 7 parameters (2 femoral, 4 tibial, and 1 fibular) in the final model. Compared with RWT and demographic characteristics (R2 = 0.921), there were minimal incremental increases by adding CPV (R2 = 0.921), GP (R2 = 0.925), or PH (R2 = 0.931). Conclusions This large analysis of knee skeletal maturity systems isolated 7 discrete radiographic knee parameters that theoretically outperform the GP bone age in estimating skeletal maturity. Clinical relevance We present a modified knee skeletal maturity system that can potentially preclude the need for additional imaging of the hand and wrist in reliably estimating skeletal maturity.

INTRODUCTION Adolescent total hip arthroplasty (THA) is guarded partially due unclarity as to when pediatric hip joints reach full development. This study sought to identify when maximum acetabular and femoral head diameters are achieved with relation to chronological and skeletal age. MATERIALS AND METHODS Consecutive femoral head and acetabular diameters were measured in a random sample of 54 female and 78 male subjects, which were queried from a historical collection of annual radiographs of children. Femoral head and triradiate physeal plates were scored according to Oxford bone parameters. RESULTS At 14 years females had femoral diameters of 4.16 +/- 0.23 cm and acetabular diameters of 5.15 +/- 0.30 cm. At 16 years males had femoral diameters of 4.85 +/- 0.30 cm and acetabular diameters of 5.90 +/- 0.35 cm. In the year following maximal femoral Oxford scores, no significant change was seen in femur and acetabulum diameters in females and in femur diameters in males. In the year following maximal acetabular Oxford scores, there was a significant increase in both femur and acetabulum diameters in both females and males. CONCLUSIONS Females on average reach maximum pelvis maturity at 14 years and males reach maximum pelvis maturity at 16 years. A closed femoral head was found to be a good marker of full hip growth, while a closed triradiate was not. This study provides anatomical data for surgeons to consider in assessing risk factors of THA failure in adolescents.

BACKGROUND The purpose of this investigation was to develop a quantitative and reproductible method for estimating skeletal maturity based on measurements of the height of the bony greater trochanter (GT) using timing to 90% of final height as a gold standard. METHODS Bony GT height was measured using serial anteroposterior pelvic radiographs in 76 healthy pediatric patients obtained from the Bolton-Brush (BB) Study with corresponding Greulich-Pyle (GP) bone ages. Chronologic age at 90% of final height was calculated. GT height was then measured in 300 contemporary patients aged 4 to 18 years, evenly divided based on sex and race. Bony GT height was compared between BB and contemporary patients, while linear mixed-effects models were used to examine for potential predictors of years to 90% final height using patient sex, GP bone age and bony GT height measurements. RESULTS Bony GT height was measured in 303 radiographs from the BB Collection (n=37 males; n=39 females) with corresponding GP bone ages, chronological ages, and heights to represent skeletal maturity. Mean age at 90% final height was 13.3±0.6 years for males and 11.4±0.8 years for females. When controlling for patient age and sex, multiple regression analysis revealed that contemporary patients possessed significantly greater bony GT height (mean difference: 1.15 mm; P=0.001) when compared with BB patients. Multivariate analysis showed that combining bony GT height, GP bone age, and sex significantly predicted years to 90% total growth (P

Background The long-term consequences of tibial torsion remain unclear. This study evaluated whether syndesmotic injuries are associated with tibial torsion. Methods A collection of over 3000 cadaveric skeletons was screened for irregular bony prominence along the lateral distal tibia, consistent with previous syndesmosis injury. Tibial torsion was measured and compared to 1034 control cadaveric tibiae. Results Mean torsion of 236 specimens with syndesmotic injury was 6.2 ± 8.9 degrees, while that of control specimens was 7.9 ± 8.8 degrees (P = 0.008). Multiple regression analysis showed a non-statistically significant trend toward internal torsion and syndesmotic injury (standardized beta = −0.051, P = 0.059). Syndesmosis injury was present in 48/200 specimens (24.0%) with internal torsion and 31/199 specimens (15.6%) with external torsion (P = 0.035). Conclusion This association between internal tibial torsion and syndesmotic injury suggests that internal tibial torsion might not be an entirely benign condition and merits further study.

Highlights • Developed two simple-to use nomograms for identifying COVID-19 positive patients. • Probabilities are provided to allow healthcare leaders to decide suitable cut-offs. • Variables are age, white cell count, chest x-ray appearances and contact history. • Model variables are easily available in the general hospital setting., Objectives To develop:(1) two validated risk prediction models for COVID-19 positivity using readily available parameters in a general hospital setting; (2) nomograms and probabilities to allow clinical utilisation. Methods Patients with and without COVID-19 were included from 4 Hong Kong hospitals. Database was randomly split 2:1 for model development database (n = 895) and validation database (n = 435). Multivariable logistic regression was utilised for model creation and validated with the Hosmer-Lemeshow (H-L) test and calibration plot. Nomograms and probabilities set at 0.1, 0.2, 0.4, 0.6 were calculated to determine sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). Results 1330 patients (mean age 58.2 ± 24.5 years; 50.7% males; 296 COVID-19 positive) were recruited. First prediction model developed had age, total white blood cell count, chest x-ray appearances and contact history as significant predictors (AUC = 0.911 [CI = 0.880-0.941]). Second model developed has same variables except contact history (AUC = 0.880 [CI = 0.844-0.916]). Both were externally validated on H-L test (p = 0.781 and 0.155 respectively) and calibration plot. Models were converted to nomograms. Lower probabilities give higher sensitivity and NPV; higher probabilities give higher specificity and PPV. Conclusion Two simple-to-use validated nomograms were developed with excellent AUCs based on readily available parameters and can be considered for clinical utilisation.

Aim To promote a discussion on the ethics and justifications of stature lengthening in patients without skeletal deformity. Background Stature lengthening for height gain in patients without skeletal deformity has stirred controversy within the orthopedic community. However, current literature does not delineate the ethical issues surrounding this procedure. Improvements in the techniques, technology, and safety profile of stature lengthening warrant an ethical discussion to challenge, justify, and guide the use of this surgical procedure. Review results Examination of ethical issues leads to the distinction between the dual roles of stature lengthening as a treatment vs an enhancement. The primary focus on stature lengthening as treatment allows for exploration of “height dysphoria”—a psychological burden caused by a dissatisfaction with one's height—as the primary pathology that may justify surgical intervention. Conclusion In our opinion, additional work is required to establish “height dysphoria” as a true pathology in order to ethically justify stature lengthening as a legitimate form of treatment. Further discussion is needed to address the ethics of stature lengthening as an enhancement. Clinical significance This paper addresses salient ethical issues of stature lengthening in patients without skeletal deformity by exploring historical, contemporary, and comparative contexts. How to cite this article Lee RC, Aulisio M, Liu RW. Exploring the Ethics of Stature Lengthening as Treatment for Height Dysphoria. Strategies Trauma Limb Reconstr 2020;15(3):163–168.

BackgroundThe operating room can be a frightening environment for paediatric patients. This study investigated whether music medicine can mitigate preoperative anxiety in children.Materials and methodsOne hundred and fifty children undergoing general anaesthesia were randomised to listen to music of the child’s choice, lullaby music or no music before induction. Heart rates were measured in the waiting room, upon first entry into the operating room and just prior to induction.ResultsThere was no significant difference in average heart rate change from the waiting room to induction in the patient choice, lullaby and control groups. Older age was associated with higher heart rate changes between baseline and entering the operating room. Pharmacologic sedation showed a significant beneficial effect on heart rate change at induction.ConclusionUse of music medicine in the operating room does not show efficacy to reduce anxiety in children based on heart rate changes.

BACKGROUND Because of the complex nature and relatively rare prevalence of triplane fractures, ideal imaging and optimal treatment remain controversial. The purpose of this investigation was to systematically review and compare clinical outcomes in skeletally immature patients with triplane fractures on the basis of imaging modalities [radiography alone vs. radiography+computed tomography (CT)] and fracture management (operative vs. nonoperative). METHODS A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement using a PRISMA checklist. All the literature related to skeletally immature patients with triplane fractures published from January 1988 to March 2020 were identified. Inclusion criteria consisted of skeletally immature patients with triplane fractures with reported imaging modality performed during diagnosis, fracture management, and postoperative outcomes on the basis of functional scores and the incidence of any complications. RESULTS A total of 11 articles met inclusion criteria, comprising a total of 203 skeletally immature patients with 203 documented triplane fractures. Male individuals were significantly older at the time of injury (14.2±0.6 y) when compared with female individuals (12.6±0.9 y) (P=0.006). Fracture diagnosis and management were evaluated using radiography+CT in 63% (128/203) of patients, whereas 37% (75/203) underwent radiography only. No significant differences in good/excellent Modified Weber Protocol scores were reported in patients treated nonoperatively versus those undergoing operative treatment (P=0.78), whereas Modified Weber Protocol scores were significantly higher in patients using radiography alone (P=0.02). No significant difference in complication incidence was reported on the basis of management type (nonoperative, 16%; operative, 15%; P=0.47). CONCLUSIONS Patients undergoing operative management of triplane fractures achieved comparable functional outcomes scores without an increased incidence of complications when compared with patients undergoing nonoperative treatment. Further investigations analyzing outcomes at middle and long-term follow-up are necessary to determine the clinical utility of CT and various treatment modalities for the management of triplane fractures. LEVEL OF EVIDENCE Level IV-Systematic review.

The epiphyseal tubercle, a posterosuperior projection of the epiphysis into the metaphysis, serves as the axis of rotation in slipped capital femoral epiphysis (SCFE) and a source of physeal stability. We hypothesized that in a biomechanical model of single screw fixation of stable SCFE, a screw passing through the epiphyseal tubercle (the axis of rotation) would confer less rotational stability than a centrally placed screw. Three femurs were selected from a sample population of 8- to 15-year-old healthy hips to represent three stages of maturation: a "young" femur with a prominent epiphyseal tubercle and decreased epiphyseal cupping around the metaphysis, a "median" femur with a subsiding tubercle, and a "mature" femur with a subsided epiphyseal tubercle and increased peripheral epiphyseal cupping. Specimens were three-dimensional printed with one of two screw trajectories: passing centrally in the epiphysis or directly through the epiphyseal tubercle. Resistance to rotational displacement was measured through stiffness and maximum torque over 30° degrees of displacement. In the "young" model, epiphyseal tubercle screw position conferred less rotational stiffness and required less maximum torque during rotational displacement when compared to a centrally placed screw (P < .001). In the "median" and "mature" models where the tubercle has subsided and is replaced by peripheral epiphyseal cupping, screw position through the tubercle was associated with equal or greater rotational stiffness and maximum torque during displacement as a centrally placed screw.

BACKGROUND Most cancer centers prefer preoperative radiation therapy (preRT) over postoperative therapy to treat soft-tissue sarcoma (STS) to limit long-term fibrosis, joint stiffness, and edema. Surgery is often delayed after preRT to allow for tissue recovery and to reduce wound complications. However, the association between the time interval between preRT and surgery and survival is unknown. QUESTIONS/PURPOSES (1) What factors are associated with the preRT-surgery interval in patients with STS? (2) Is the preRT-surgery interval associated with overall survival? METHODS The National Cancer Database, a nationwide registry that includes 70% of all new cancers in the United States with 90% follow-up, was reviewed to identify 6378 patients who underwent preRT and surgical resection for a localized extremity or pelvic STS from 2004 to 2014. Patients were excluded if they had lymphatic or metastatic disease at diagnosis (23%; n = 1438), underwent neoadjuvant chemotherapy (24%; 1531), were missing vital status (8%; 487), had chemosensitive histologies (9%; 603), underwent radiation other than external beam (1%; 92), were missing preRT-surgery interval (1%; 45), or had a preRT-surgery interval greater than 120 days (< 1%; 6). A total of 2176 patients were included for analysis, with a mean preRT-surgery interval of 35 ± 16 days. A multiple linear regression model was generated to assess demographic, clinicopathologic, and treatment characteristics associated with the preRT-surgery interval. A Kaplan-Meier survival analysis was then conducted, stratified by the preRT-surgery interval, to assess survival over 10 years. Finally, a multivariate Cox regression analysis model was constructed to further evaluate the association between the preRT-surgery interval and overall survival, adjusted for demographic, clinicopathologic, and treatment characteristics. RESULTS A longer preRT-surgery interval was associated with higher age (β = 0.002 per year [95% CI 0.0 to 0.004]; p = 0.026), tumor location in the pelvis (compared with the lower extremity; β = 0.15 [95% CI 0.082 to 0.22]; p < 0.001), and malignant peripheral nerve sheath tumor subtype (compared with undifferentiated pleomorphic sarcoma; β = 0.17 [95% CI 0.044 to 0.29]; p = 0.008). A shorter preRT-surgery interval was associated with higher facility volume (β = -0.002 per case [95% CI -0.003 to -0.002]; p = 0.026) and higher tumor stage (compared with Stage I; β = -0.066 [95% CI -0.13 to -0.006]; p = 0.03 for Stage II; β = -0.12 [95% CI -0.17 to -0.065]; p < 0.001 for Stage III). The 5-year overall survival rates were similar across all preRT-surgery interval groups: less than 3 weeks (66% [95% CI 60 to 72]), 3 to 4 weeks (65% [95% CI 60 to 71]), 4 to 5 weeks (65% [95% CI 60 to 71]), 5 to 6 weeks (66% [95% CI 60 to 72]), 6 to 7 weeks (63% [95% CI 54 to 72]), 7 to 9 weeks (66% [95% CI 58 to 74]), and more than 9 weeks (59% [95% CI 48 to 69]). Over 10 years, no difference in overall survival was observed when stratified by the preRT-surgery interval (p = 0.74). After controlling for potentially confounding variables, including age, sex, Charlson/Deyo comorbidity score, histology, tumor size, stage and surgery type, the preRT-surgery interval was not associated with survival (hazard ratio = 1 per day [95% CI 1 to 1]; p = 0.88). CONCLUSION With the numbers available, this study demonstrates that a delay in surgery up to 120 days after radiation is not associated with poorer survival. Therefore, clinicians may be able to delay surgery to minimize the risks of wound complications and modifiable comorbidities without affecting overall survival.Level of Evidence Level III, therapeutic study.

Background This study provides a comprehensive, full-length assessment of radial and ulnar bowing in anteroposterior (AP) and sagittal planes. Methods Radial and ulnar AP and lateral bowing were assessed using orthogonal digital photographs of 211 randomly selected cadaveric bilateral forearms (422 radius, 422 ulna bones) from a well-preserved osteologic collection. Results In the radial AP plane, an apex-radial bow was present at a mean of 58% of bone length (slightly distal to midpoint), with a mean depth of 1.3 cm. In the radial lateral plane, an apex-dorsal bow occurred at a mean of 45% of bone length, with a mean depth of 0.8 cm. In the ulnar AP plane, apex-radial bow occurred at a mean of 32% of bone length with a mean depth of 1.0 cm. In the ulnar lateral plane, the majority of specimens (81%) had an apex-dorsal bow, whereas 19% had a reverse (apex-volar) bow. Lateral ulnar bow was located at a mean of 33% of bone length with a mean depth of 2.0 cm, with 36% of specimens possessing a lateral bow located at 35% or more distal along the ulna. Side-to-side differences for bow location and depth were less than 2% of bone length. Conclusions Ulnar lateral bow was found to be more distal than in previously published works, which analyzed only the proximal ulna, and this study describes a reverse ulnar bow in 19% of specimens. This demonstrates lateral ulnar morphology to be more variable than previously defined with minimal side-to-side variability, which are important considerations for fracture fixation and elbow arthroplasty.

Lower limb deformities have a wide range of presentations and require significant preparation and planning from the surgeon to correct. It is important to provide a clear and systematic approach to preoperative planning for these cases and to detail three well-established correction techniques: external fixation, plate fixation, and intramedullary nail fixation. In using a simple mnemonic that lays out the systematic analysis of various axis lines and joint angles from proximal to distal in the lower extremity, deformities can be readily identified, and correction strategies can be effectively used to produce a successful deformity correction that restores colinear alignment to the lower limb. Additional pearls and pitfalls for these techniques are also provided to assist with some of the nuances that exist in the field.

Identifying ideal candidates for orthopaedic surgery residency is difficult. Data available for applicant selection are evolving; preclinical grades and the Alpha Omega Alpha (AOA) honors society are being phased out at some medical schools. Similarly, three-digit United States Medical Licensing Examination (USMLE) Step 1 scores have been eliminated. There is renewed interest in improving resident selection to provide a diverse, comprehensive educational opportunity that produces orthopaedic surgeons who are prepared for practice.We sought to identify whether (1) academic achievements, (2) letters of recommendation, (3) research activity, and (4) miscellaneous factors available on Electronic Residency Application Service (ERAS) applications were associated with outstanding residency performance.Ten faculty members (22% of all full-time faculty) with extensive educational involvement for at least 7 years, whose expertise covered all subspecialty departments at an urban, academic orthopaedic surgery residency program's were given an anonymous survey on the performance of the four most recent classes of residency graduates (24 residents). This survey was developed due to the lack of a validated residency outcomes tool or objective metrics for residency performance. The evaluated criteria were decided upon after discussion by a relatively large group of academic orthopaedic surgeons considering the factors most important for graduating orthopaedic residents. The faculty were selected based on their long-term knowledge of the residency, along with their diversity of specialty and backgrounds; there were no nonresponders. Faculty graded each resident on a scale from 1 to 10 (higher is better) on six criteria: surgical technical skills, research productivity, clinical knowledge, professionalism, personality, and fellowship match. The mean of the faculty ratings made by all faculty for all six criteria was calculated, producing the overall residency performance score. Factors available on each resident's ERAS application were then correlated with their overall residency performance score. Categorical ERAS factors, including AOA status, five or more honors in core clerkships, at least three exceptional letters of recommendation, collegiate athletics participation, expertise with a musical instrument, and research (6-year) track residents, were correlated with overall residency performance score via point biserial analysis. Continuous ERAS factors including USMLE Step 1 and Step 2 scores, number of publications before residency, number of research years before residency, medical school ranking, and number of volunteer experiences were correlated with overall residency performance score via Pearson correlation. USMLE Step 1 three-digit scores were evaluated despite their recent elimination because of their historic importance as a screening tool for residency interviews and for comparison to USMLE Step 2, which retains a three-digit score. Application factors with a p0.2 on univariate analysis (five or more honors in core clerkships, at least three exceptional letters of recommendation, research track residents) were included in a stepwise linear regression model with "overall residency performance score" as the outcome variable. All p values0.05 were considered significant.The mean overall residency performance score was 7.9 ± 1.2. Applicants with at least five honors grades in core clerkships had overall residency performance scores 1.2 points greater than those of their peers (95% confidence interval (CI) 0.3 to 2.0; p = 0.01, Cohen ƒ2 = 0.2, representing a small effect size). ERAS applications including at least three exceptional letters of recommendation were associated with a 0.9-point increase in residency performance (95% CI 0.02 to 1.7; p = 0.046, Cohen ƒ2 = 0.1, representing a small effect size). Participation in the residency research (6-year) track was associated with a 1-point improvement in residency performance (95% CI 0.1 to 1.9; p = 0.03, Cohen ƒ2 = 0.2, again, representing a small effect size). Together, these three factors accounted for 53% of the variance in overall residency performance score observed in this study.Past clinical excellence, measured by core clerkship grades and exceptional letters of recommendation, is associated with slightly improved overall orthopaedic residency performance scores. Applicants meeting both criteria who also complete a research track residency may perform substantially better in residency than their counterparts, as these three factors accounted for half of all the variance observed in the current study. Although minimum requirements are necessary, traditionally used screening factors (such as USMLE scores, AOA status, medical school rank, and number of publications) may be of less utility in identifying successful future residents than previously thought.Level III, therapeutic study.

Pelvic incidence (PI) is an angular measurement linked to spinal pathologies. There is an increasing distance between facet joints moving caudally down the sagittal plane of the spine. We defined pedicle divergence (PD) as the ratio of interfacet distance (IFD) between adjacent levels. This study aimed to evaluate the relationship between PI and PD. Two hundred and thirty specimens were obtained from the Hamann-Todd Osteological Collection. Specimens were catalogued for age, sex, race, PI, PD, and lumbar facet angle. Multivariate linear regression analysis was performed to determine the relationship between variables. IRB approval was not required. Average age at death was 57.0 years ±6.2 years. There were 211 (92%) male specimens and 176 (77%) were white. Average PI was 47.1 ± 10.5°. For PD between L3/L4, there was a relationship with PI (β = -0.18, p = 0.008). For PD between L4/L5, there was an opposite relationship with PI (β = 0.21, p = 0.003). Regression analyses of the interfacet to body ratio at each level found an association with PI only at L4 (p = 0.008). This study demonstrated that PI has a significant association with IFD in the lower lumbar spine. Increasing PI was associated with increased PD between L3/L4 and decreased PD between L4/L5. These results further support the close relationship between pelvic morphology and the lower lumbar spine, and suggest that L4 may have an important role in compensating for aberrant PI.

The ability to make a continuous skeletal maturity estimate from a wrist radiograph would be useful in the treatment of adolescent forearm fractures, scoliosis, and other conditions. We attempted to create a reliable, rapid, and accurate method to do this.Many anteroposterior wrist radiographic parameters from 3 skeletal maturity systems were simplified to 23 based on relevance to the peripubertal age range, univariate correlation with skeletal maturity, and reliability. These 23 parameters were evaluated on serial peripubertal anteroposterior hand-wrist radiographs. We determined the Greulich and Pyle (GP) skeletal age and Sanders hand system (SHS) stage. We used stepwise linear regression and generalized estimating equation (GEE) procedures to identify important radiographic and demographic parameters for estimating skeletal maturity, creating the "Modified Fels wrist skeletal maturity system." Its accuracy predicting skeletal maturity was evaluated and compared with that of 4 other systems: (1) GP system, (2) SHS, (3) GP parameters along with age and sex, and (4) SHS parameters along with age and sex.Three hundred and seventy-two radiographs of 42 girls (age range, 7 to 15 years) and 38 boys (age range, 9 to 16 years) were included. Fifteen radiographic parameters were excluded from the Modified Fels wrist system by stepwise regression and GEE analyses, leaving age, sex, and 8 radiographic parameters in the final model. Use of the Modified Fels wrist system resulted in more accurate skeletal maturity estimations (0.34-year mean discrepancy with actual skeletal maturity) than all other systems (p0.001 for all). The Modified Fels wrist system had a similar rate of outlier skeletal maturity estimations as the age, sex, and SHS model (1.9% versus 3.5%, p = 0.11) and fewer outliers than all other systems (p0.05 for all).A system that included demographic factors and 8 anteroposterior wrist radiographic parameters estimates skeletal maturity more accurately than the 2 most-used skeletal maturity systems in the United States.The Modified Fels wrist skeletal maturity system may allow for more accurate, reliable, and rapid skeletal maturity estimation than current systems, and also may be used when treating adolescent forearm fractures as it does not require imaging past the metacarpals.Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Key Points Question What are the perceptions and experiences of multidisciplinary cancer care clinicians (medical oncologists, radiation oncologists, surgical oncologists, oncology navigators, and cancer survivorship) with regard to telehealth visits and exchanging secure messages with patients during the COVID-19 pandemic? Findings In this survey study of 202 multidisciplinary cancer care clinicians, most were satisfied with telehealth and wished to maintain or increase future use. Despite being thought to promote a weaker patient-clinician connection, telehealth was considered appropriate by most to handle the greater part of patient assessment and care; however, some clinicians preferred in-person visits for certain activities. Meaning Results of this survey study suggest that telehealth is well accepted by various cancer care clinicians, and is likely to remain used to some extent for most aspects of cancer care in the future., Importance Telehealth use including secure messages has rapidly expanded since the COVID-19 pandemic, including for multidisciplinary aspects of cancer care. Recent reports described rapid uptake and various benefits for patients and clinicians, suggesting that telehealth may be in standard use after the pandemic. Objective To examine attitudes and perceptions of multidisciplinary cancer care clinicians toward telehealth and secure messages. Design, Setting, and Participants Cross-sectional specialty-specific survey (ie, some questions appear only for relevant specialties) among multidisciplinary cancer care clinicians, collected from April 29, 2020, to June 5, 2020. Participants were all 285 clinicians in the fields of medical oncology, radiation oncology, surgical oncology, survivorship, and oncology navigation from all 21 community cancer centers of Kaiser Permanente Northern California. Main Outcomes and Measures Clinician satisfaction, perceived benefits and challenges of telehealth, perceived quality of telehealth and secure messaging, preferred visit and communication types for different clinical activities, and preferences regarding postpandemic telehealth use. Results A total of 202 clinicians (71%) responded (104 of 128 medical oncologists, 34 of 37 radiation oncologists, 16 of 62 breast surgeons, 18 of 28 navigators, and 30 of 30 survivorship experts; 57% (116 of 202) were women; 73% [147 of 202] between ages 36-55 years). Seventy-six percent (n = 154) were satisfied with telehealth without statistically significant variations based on clinician characteristics. In-person visits were thought to promote a strong patient-clinician connection by 99% (n = 137) of respondents compared with 77% (n = 106) for video visits, 43% (n = 59) for telephone, and 14% (n = 19) for secure messages. The most commonly cited benefits of telehealth to clinicians included reduced commute (79%; n = 160), working from home (74%; n = 149), and staying on time (65%; n = 132); the most commonly cited negative factors included internet connection (84%; n = 170) or equipment problems (72%; n = 146), or physical examination needed (64%; n = 131). Most respondents (59%; n = 120) thought that video is adequate to manage the greater part of patient care in general; and most deemed various telehealth modalities suitable for any of the queried types of patient-clinician activities. For some specific activities, less than half of respondents thought that only an in-person visit is acceptable (eg, 49%; n = 66 for end-of-life discussion, 35%; n = 58 for new diagnosis). Most clinicians (82%; n = 166) preferred to maintain or increase use of telehealth after the pandemic. Conclusions and Relevance In this survey of multidisciplinary cancer care clinicians in the COVID-19 era, telehealth was well received and often preferred by most cancer care clinicians, who deemed it appropriate to manage most aspects of cancer care. As telehealth use becomes routine in some cancer care settings, video and telephone visits and use of asynchronous secure messaging with patients in cancer care has clear potential to extend beyond the pandemic period., This survey study assesses the attitudes and perceptions of multidisciplinary cancer care clinicians (from the fields of medical oncology, radiation oncology, surgical oncology, survivorship, and oncology navigation) toward telehealth and secure messages.

BACKGROUND: Splinting is routinely performed in the emergency department (ED), and follow-up visits of improperly placed splints are commonplace in orthopaedic clinics. As open reduction and internal fixation (ORIF) of fractures has become the preferred treatment for many injuries, orthopaedic surgeons and emergency physicians have received less instruction on splinting technique. Limited literature exists regarding error/complication rates of splint application. The purpose of this study is to determine: (1) Is there a difference in splinting complication rates between orthopaedic and non-orthopaedic services, and low versus high volume emergency room and urgent care centers? (2) What are the most common technical errors and complications in splint application? METHODS: Patients presenting to orthopaedic clinic with any extremity splint were enrolled in this IRB approved prospective study. Splint characteristics collected included: type of provider placing the splint, duration of wear, type of splint, and material used (i.e. plaster or fiberglass). Errors included inappropriate length, circumferential placement, and direct contact between the ACE bandage and the skin; while complications included swelling, blistering, ulceration, heat injury, and other issues on a case-by-case basis. RESULTS: 203 patients were enrolled in this study. 98 (48%) were splinted by the Orthopaedics service, 69 (34%) were splinted in the trauma hospital ED, and 36 (18%) were treated at an outside hospital. 123/203 (61%) had an error/ complication related to the splint. Error/complication rates for orthopaedics, the trauma hospital ED, and outside hospitals were 46% (45/98), 65% (45/69), and 92% (33/36) respectively. The most common errors were inappropriate length, present in 58/203 (29%) patients, and direct contact between the ACE bandage and skin, present in 50/203 (25%) patients. CONCLUSION: The appropriateness and complication rates of splints applied in the ED differ based on the type of provider and the institution. Outside hospitals were found to have the highest complication rates, while the lowest rates were associated with splints placed by Orthopaedics. These findings support the importance of education of proper splinting technique in non-trauma hospitals. Level of Evidence: III

INTRODUCTION Preoperative radiographic assessment of curve flexibility in patients with idiopathic scoliosis is important to determine Lenke classification, operative levels, and potential postoperative correction. However, no consensus exists regarding the optimal technique. We compared measurements from supine side bending (SB) and intraoperative traction radiographs under general anesthesia (TUGA) with actual postoperative correction followed for 1 year. METHODS We identified 235 patients with idiopathic scoliosis who underwent posterior spinal fusion with pedicle screw instrumentation between 2010 and 2018 who had preoperative and postoperative radiographs including standing posterior-anterior (PA) and lateral radiographs, preoperative SB radiographs, and TUGA radiographs. Curves were categorized into proximal thoracic, main thoracic/thoracolumbar (MT), and distal thoracolumbar/lumbar (TL/L) curves. Flexibility was calculated from SB and TUGA radiographs. Correction rates were calculated from 1 month and 1 year radiographs postoperatively. Bending radiographs that correlated significantly with postoperative correction with P

Aim and objective In deformity correction around the knee, the mechanical lateral distal femoral angle (mLDFA) and medial proximal tibial angle (MPTA) are used in surgical planning routinely. While plain radiographs are generally adequate, some surgeons utilise intraoperative arthrograms to visualise the articular contours and assess a younger child's true joint alignment, often with findings that these are discrepant from that measured just using bone alignment. The age cutoff for a discrepancy between the two is not defined. Materials and methods We queried our picture archiving and communication systems (PACS) database for MRIs with a radiological read of “normal” for patients between the ages of 4 and 16 years at the time of the study. Anatomic axes were used to determine the anatomic LDFA (aLDFA) and MPTA angles using end-cartilage and end-bone landmarks independently. Results We reviewed 116 MRIs, 56% male, with approximately 9 studies per year of age. There were no significant overall differences between aLDFA and MPTA when measured at the bone vs cartilage surfaces (p = 0.42 and p = 0.53, respectively). In the 4- to 6-year age range, there was a significant difference between bony and cartilaginous aLDFA (p = 0.02) but not MPTA (p = 0.88). Conclusion In children 6 years of age and younger, intraoperative arthrogram should be considered while treating knee deformity, as plain films may not fully represent the true deformity of the distal femur in particular. Clinical significance Supports the need for advanced imaging or intraoperative arthrogram for joint corrective surgery in young patients. Level of evidence Level 3 diagnostic. How to cite this article Bigach SD, Carender CN, Liu RW. Is Bony Knee Alignment Representative of the True Joint Surface in Skeletally Immature Patients? A Magnetic Resonance Imaging Study. Strategies Trauma Limb Reconstr 2020;15(2):79–83.

Background Recent evidence suggests that increasing capital femoral epiphyseal extension may be an adaptive response that underlies the development of most cam morphology, whereas slipped capital femoral epiphysis is associated with its deficiency. However, there is an absence of rigorous data on the normal development of epiphyseal extension in the hip joint in modern adolescents. The aim of this study was to establish normative values for anterior and superior epiphyseal extension in a normal adolescent control population. Methods A total of 210 pediatric subjects (420 hips) between the ages of 8 and 17 years old at the time of presentation who received pelvic radiographs were retrospectively reviewed. Basic demographic data were collected. All subjects with underlying hip pathology were excluded. Epiphyseal extension ratio (EER) was measured, defined as the ratio of extension of the capital femoral epiphysis down the femoral neck relative to the diameter of the femoral head. Superior EER was measured on the anterioposterior view and anterior EER on the frog-leg lateral view bilaterally. Skeletal maturity was graded based on Oxford bone age (OBA) at the proximal femur. Results The superior EER increased from 0.63±0.05 at age 8 to 0.80±0.05 at age 17. The anterior EER similarly increased from 0.56±0.06 at age 8 to 0.74±0.05 at age 17. The superior and anterior EERs increased with age in a linear fashion for males (r=0.80 and 0.75, respectively) and females (r=0.67 and 0.65) through physeal closure. When subjects were standardized by the OBA stage of the femoral head, females and males showed no statistical difference at OBA stages 6, 7 or 8. Conclusions Superior and anterior EER increased throughout adolescent development until physeal closure. When controlling for skeletal maturity, there were no significant differences between sexes. This normative data may help guide future management and research of slipped capital femoral epiphysis and cam morphology. Level of evidence Level II, Diagnostic.