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Background: Assessment of long leg radiographs (LLRs) in pediatric orthopedic patients is an important but time-consuming routine task for clinicians. The goal of this study was to evaluate the performance of artificial intelligence (AI)-based leg angle measurement assistant software (LAMA) in measuring LLRs in pediatric patients, compared to traditional manual measurements. Methods: Eligible patients, aged 11 to 18 years old, referred for LLR between January and March 2022 were included. The study comprised 29 patients (58 legs, 377 measurements). The femur length, tibia length, full leg length (FLL), leg length discrepancy (LLD), hip–knee–ankle angle (HKA), mechanical lateral distal femoral angle (mLDFA), and mechanical medial proximal tibial angle (mMPTA) were measured automatically using LAMA and compared to manual measurements of a senior pediatric orthopedic surgeon and an advanced practitioner in radiography. Results: Correct landmark placement with AI was achieved in 76% of the cases for LLD measurements, 88% for FLL and femur length, 91% for mLDFA, 97% for HKA, 98% for mMPTA, and 100% for tibia length. Intraclass correlation coefficients (ICCs) indicated moderate to excellent agreement between AI and manual measurements, ranging from 0.73 (95% confidence interval (CI): 0.54 to 0.84) to 1.00 (95%CI: 1.00 to 1.00). Conclusion: In cases of correct landmark placement, AI-based algorithm measurements on LLRs of pediatric patients showed high agreement with manual measurements. [ABSTRACT FROM AUTHOR]

This study aimed to evaluate the prevalence of and risk factors for coxa vara deformity in patients with fibrous dysplasia/McCune- Albright syndrome (FD/MAS). This study was conducted at the National Institutes of Health and Leiden University Medical Center. All patients with any subtype of FD/MAS, FD involving the proximal femur, one or more X-rays available and age <30 years were included. X-rays were scored for the neck-shaft angle (NSA). Varus deformity was defined as NSA <110 degrees or >10 degrees below age-specific values. Risk factors for deformity were assessed by nested case--control analysis, comparing patients and femurs with and without deformity, and by linear mixed effects model, modeling temporal NSA decrease (the natural course of the NSA) in non-operated femurs with two or more X-rays. Assessed variables included growth hormone excess, hyperthyroidism, hypophosphatemia, >25% of the femur affected, calcar destruction, radiolucency, and bilateral involvement. In total 180 patients were studied, 57% female. Mean ± SD baseline age was 13.6 ± 7.5 years; median follow-up 5.4 (interquartile range [IQR], 11.1) years. Sixty-three percent (63%) were diagnosed with MAS. A total of 94 patients were affected bilaterally; 274 FD femurs were analyzed; 99 femurs had a varus deformity (36%). In the nested case--control analysis, risk factors were as follows: presence of MAS (p < 0.001), hyperthyroidism (p < 0.001), hypophosphatemia (p < 0.001), high percentage of femur affected (p < 0.001), and calcar destruction (p < 0.001). The linear mixed effects model included 114 femurs, identified risk factors were: growth hormone excess (β = 7.2, p = 0.013), hyperthyroidism (β = 11.3, p < 0.001), >25% of the femur affected (β = 13.2, p = 0.046), calcar destruction (β = 8.3, p = 0.004), radiolucency (β = 3.9, p = 0.009), and bilateral involvement (β = 9.8, p = 0.010). Visual inspection of the graph of the model demonstrated most progression of deformity if NSA <120 degrees with age < 15 years. In conclusion, in tertiary care centers, the prevalence of FD/MAS coxa vara deformity was 36%. Risk factors included presence of MAS, high percentage of femur affected, calcar destruction, radiolucency, NSA <120 degrees and age < 15 years. © 2023 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR). [ABSTRACT FROM AUTHOR]

Objectives: Knowledge on the epidemiology and long-term course of rotator cuff calcific tendinitis (RCCT) is scarce. We assessed demographics, radiological characteristics, and their association with long-term outcomes in a large patient group.Methods: Baseline demographics, radiological characteristics and treatment were recorded in 342 patients. Interobserver agreement of radiological measures was analyzed. Long-term outcome was evaluated with questionnaires (WORC, DASH). The association of baseline characteristics with outcome was assessed.Results: Mean age was 49.0 (SD = 10.0), and 59.5 % were female. The dominant arm was affected in 66.0 %, and 21.3 % had bilateral disease. Calcifications were on average 18.7 mm (SD = 10.1, ICC = 0.84 (p < 0.001)) and located 10.1 mm (SD = 11.8) medially to the acromion (ICC = 0.77 (p < 0.001)). Gärtner type I calcifications were found in 32.1 % (Kappa = 0.47 (p < 0.001)). After 14 years (SD = 7.1) of follow-up, median WORC was 72.5 (range, 3.0-100.0; WORC < 60 in 42 %) and median DASH 17.0 (range, 0.0-82.0). Female gender, dominant arm involvement, bilateral disease, longer duration of symptoms, and multiple calcifications were associated with inferior WORC. DASH results were similar.Conclusions: Many subjects have persisting shoulder complaints years after diagnosis, regardless of treatment. Female gender, dominant arm involvement, bilateral disease, longer duration of symptoms, and multiple calcifications were associated with inferior outcome. Radiological measures had moderate-to-good reliability and no prognostic value.Key Points: • Most RCCT studies report on short-term outcome and/or small patients groups. • In this large, long-term observational study, RCCT appeared to not be self-limiting in many subjects. • Negative prognostic factors included female gender, more calcifications, dominant arm affected, and longer duration of symptoms. • Interobserver agreement of general radiological RCCT measures is moderate to good. • More rigorous diagnostics and treatment might be needed in specific RCCT cases. [ABSTRACT FROM AUTHOR]

Purpose: Diagnostics and treatment pathways for developmental dysplasia of the hip are highly variable in clinical practice. Recently, two national guidelines were developed in the Netherlands, providing a uniform protocol for the diagnosis and treatment of developmental dysplasia of the hip in children under the age of 1 year. The aim of this survey study was to assess whether diagnostic and treatment strategies have changed amongst paediatric orthopaedic surgeons in the Netherlands compared to a similar survey study in 2011, after the introduction of the guidelines., Methods: A web-based online questionnaire was developed and shared amongst the members of the Dutch Paediatric Orthopaedic Society. The questions concerned the diagnosis and treatment of developmental dysplasia of the hip, ranging from mildly dysplastic to dislocated hips, in children under the age of 1 year. We used a questionnaire similar to the previous study and evaluated the results., Results: Thirty-four participants completed the survey. Regarding diagnosis and follow-up, ultrasonography was generally applied for children younger than 6 months, while radiography was more frequently used for children aged 6-12 months. In 2011, radiography was more widely applied in all age groups. Initial treatment for dysplastic, stable hips was mostly active monitoring, while this was generally a rigid splint in 2011. For dislocated unstable hips, the first step in treatment was generally the Pavlik harness, as in 2011., Conclusion: The diagnostic and treatment pathways of developmental dysplasia of the hip in children under the age of 1 year seem to have partially changed amongst Dutch paediatric orthopaedic surgeons compared to 2011, after the publication of new guidelines., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article., (© The Author(s) 2024.)

Background and Purpose:  Developmental dysplasia (DDH) and Legg-Calvé-Perthes disease (LCPD) are common indications for total hip arthroplasty (THA) at a young age, and may be associated with increased revision risk. We aimed to investigate the 10-year cumulative aseptic cup revision and overall revision risk of THA, and investigated whether these are increased compared with THA for primary osteoarthritis (OA) in patients below 55 years., Methods:  All THAs (2007-2019) in patients under the age of 55 for the indications OA, DDH, and LCPD were extracted from the Dutch Arthroplasty register. The 10-year cumulative incidences of aseptic cup failure and overall revision were assessed for the 3 groups, with death as a competing risk. Cox regression analysis was used., Results:  24,263 THAs were identified: 20,645 (85%) for OA, 3,032 (13%) for DDH, and 586 (2%) for LCPD. The 10-year cumulative revision risk for aseptic cup failure was 3.4% (95% confidence interval [CI] 3.0-3.8) for OA, 3.4% (CI 2.4-3.4) for DDH, and 1.7% (CI 0.2-3.1) for LCPD. The 10-year cumulative overall revision risk was 6.0% (CI 5.6-6.5) for OA, 6.0% (CI 4.9-7.2) for DDH, and 5.1% (2.7-7.5) for LCPD. The multivariable Cox regression analysis for aseptic cup failure yielded hazard ratios of 0.7 (0.5-1.2) for DDH, and 0.8 (0.3-2.1) for LCPD compared with OA. No statistically significant differences for overall revision were found., Conclusion:  THA performed for DDH or LCDP in patients under the age of 55 was not associated with a statistically significant increased risk of aseptic cup revision or overall revision, compared with THA performed for primary OA in the same age group.

Background: Rotator cuff calcific tendinitis (RCCT) is a commonly occurring disease, with a prevalence of up to 42.5% in patients with shoulder pain 1,2 . RCCT is characterized by hydroxyapatite deposits in the tendons of the rotator cuff and is considered a self-limiting disease that can be treated nonoperatively 3 . However, in a substantial group of patients, RCCT can have a very disabling and long-lasting course 1,4 , requiring additional treatment. Ultrasound-guided percutaneous needling and lavage (i.e., barbotage) is a safe and effective treatment option for RCCT 5 . In the present article, we focus on the 1-needle barbotage technique utilized in combination with an injection of corticosteroids in the subacromial bursa., Description: It must be emphasized that symptomatic RCCT should be confirmed before barbotage is performed. Therefore, we recommend a diagnostic ultrasound and/or physical examination prior to the barbotage. Barbotage is performed under ultrasound guidance with the patient in the supine position. After sterile preparation and localization of the calcified deposit(s), local anesthesia in the soft tissue (10 mL lidocaine 1%) is administered. Next, the subacromial bursa is injected with 4 mL bupivacaine (5 mg/mL) and 1 mL methylprednisolone (40 mg/mL) with use of a 21G needle. The deposit(s) are then punctured with use of an 18G needle. When the tip of the needle is in the center of the deposit(s), they are flushed with a 0.9% saline solution and the dissolved calcium re-enters the syringe passively. This process is repeated several times until no more calcium enters the syringe. In the case of solid deposits, it may not be possible to aspirate calcium; if so, an attempt to fragment the deposits by repeated perforations, and thus promote resorption, can be made. Postoperatively, patients are instructed to take analgesics and to cool the shoulder., Alternatives: RCTT can initially be treated nonoperatively with rest, nonsteroidal anti-inflammatory drugs, and/or physiotherapy 3 . If the initial nonoperative treatment fails, extracorporeal shockwave therapy (ESWT), corticosteroid injections, and/or barbotage can be considered 8 . In severe chronic recalcitrant cases, arthroscopic debridement and/or removal can be performed as a last resort., Rationale: Both barbotage and ESWT result in a reduction of calcific deposits, as well as significant pain reduction and improvement of function 8 . No standard of care has been established until now; however, several prior meta-analyses concluded that barbotage is the most effective treatment option, with superior clinical outcomes after 1 to 2 years of follow-up 9-11 . No difference in complication rates has been reported between the various minimally invasive techniques. The purpose of barbotage is to stimulate the resorption process, which is promoted by the perforation of the deposits. Clinical outcomes are not associated with the success of the aspiration 7,12 . Patients with ≥1 larger deposit show greater improvement following barbotage than patients with small deposits 12 , in contrast with ESWT, in which larger deposits have been associated with worse outcomes. The inferior outcome of barbotage in patients with small deposits remains the subject of debate, but outcomes may be confounded by the fact that patients with smaller deposits might be less symptomatic at baseline and are therefore less likely to demonstrate improvement 4 ., Expected Outcomes: In the first weeks after barbotage, there is generally a substantial reduction in symptoms. Symptoms can recur at around 3 months, presumably because the effect of the corticosteroids is temporary 5 . After 6 months and 1 year, patients show substantial improvement in pain, shoulder function, and quality of life, with results superior to those shown for subacromial injections and ESWT 9,10,13,14 . At 5 years postoperatively, there are no significant differences in outcomes between barbotage and subacromial injections 15 . This may demonstrate a self-limiting course in the long term., Important Tips: Good candidates for barbotage are those with RCCT who have ≥1 large calcific deposit.If a patient has a solid deposit, the physician can gently rotate and repeatedly puncture the deposit to promote disaggregation and fragmentation.Barbotage generally results in adequate pain relief and functional improvement even in patients in whom calcium deposits cannot be aspirated 12 ., Acronyms and Abbreviations: SAI = injection in the subacromial bursaNSAIDs = nonsteroidal anti-inflammatory drugs., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSEST/A433)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Osteomyelitis is uncommon in childrenandthe diagnosis is oftendelayedduetononspecificsymptoms. However, early diagnosis and treatment is necessarytopreventcomplicationsfromoccurring. We hereindescribethe case of a 13-year-old boy with a delayed diagnosis of osteomyelitis of his distal radius.

Background: This study addressed risk factors for surgical site infection in patients who had undergone orthopaedic oncology surgical procedures., Methods: We retrospectively reviewed data on 1521 orthopaedic oncologic surgical procedures in 1304 patients. We assessed patient demographics, updated Charlson comorbidity index, surgery-specific data, and treatment-related data and attempted to identify predictors of surgical site infection with bivariate and multivariable analysis., Results: Eight factors independently predicted surgical site infection: body mass index (odds ratio [OR]:, 1.03, 95% confidence interval [CI]: 1.00 to 1.07), age (OR: 1.18, 95% CI: 1.05 to 1.33), total number of preceding procedures (OR: 1.19, 95% CI: 1.07 to 1.34), preexisting implants (OR: 1.94, 95% CI: 1.17 to 3.21), infection at another site on the date of the surgery (OR: 4.13, 95% CI: 1.57 to 10.85), malignant disease (OR: 1.46, 95% CI: 0.94 to 2.26), hip region affected (OR: 1.96, 95% CI: 1.35 to 2.84), and duration of the procedure (OR: 1.16, 95% CI: 1.07 to 1.25)., Conclusions: These factors can inform patients and surgeons of the probability of surgical site infection after orthopaedic oncologic surgery. While most risk factors are unmodifiable or related to the complexity of the case, infection at another site on the date of the surgery is one factor amenable to intervention.

Over a 6-year-period, 15 women and 11 men with a mean age of 53 years (range, 24 to 80 years) had resection of the distal part of the ulna (Darrach's procedure) to address stiffness, instability, non-union, or substantial radioulnar length discrepancy after trauma. At an average follow-up of 21 months (range, 4 to 60 months), the improvement in total arc of forearm rotation averaged 87 degrees (range, 0 degrees to 160 degrees), from an average of 49 degrees to an average of 136 degrees (p < 0.001). The proportion of patients with occasional or continuous pain after the Darrach procedure (7 after vs. 16 prior ; p = 0.04) was significantly reduced. Only two patients had reoperation related to the residual ulna. In this study, the Darrach procedure improved forearm rotation and pain in patients with posttraumatic stiffness, instability, nonunion, or substantial radioulnar length discrepancy with a low complication and re-operation rate.

Objectives: To highlight the potential for vascular injury with fracture of the distal radius., Design: Retrospective case series., Setting: The practices of several orthopaedic hand surgeons., Patients/participants: Six patients with arterial injury as a consequence of fracture of the distal radius: 2 partial lacerations of the radial artery, 2 complete arterial lacerations (1 radial and 1 ulnar), 1 thrombosed radial artery, and 1 thrombosed ulnar artery. There were 4 men and 2 women with an average age of 42 years (range 26-70 years). Three of the fractures were open, and 3 had an associated distal ulnar fracture., Intervention: Volar open reduction and internal fixation of the distal radius fracture. Ligation or no treatment for 3 arterial injuries and repair or vein graft reconstruction (1 patient) for 3 injuries., Main Outcome Measurements: Vascular status of the hand., Results: At an average follow-up of 9 months (range 5-16 months), all patients had a well-vascularized hand, normal capillary refill, and no complaints of vascular dysfunction., Conclusions: Vascular complications, once thought rare in association with fracture of the distal radius, may be more frequently recognized as volar exposures are increasingly used. Because most single artery injuries in the wrist and forearm are not associated with ischemia, identification of these injuries is unlikely to affect the functional result or outcome. In the unusual patient with a dysvascular hand after distal radius fracture, arterial reconstruction may be necessary.