Faculty Bibliography

With the increasing popularity of hoverboards in recent years, multiple centers have noted associated orthopaedic injuries of riders. We report the results of a multi-center study regarding hoverboard injuries in children and adolescents. who presented with extremity fractures while riding hoverboards to 12 paediatric orthopaedic centers during a 2-month period were included in the study. Circumstances of the injury, location, severity, associated injuries, and the required treatment were recorded and analysed using descriptive analysis to report the most common injuries. Between-group differences in injury location were examined using chi-squared statistics among (1) children versus adolescents and (2) males versus females. Seventy-eight patients (M/F ratio: 1.8) with average age of 11 ± 2.4 years were included in the study. Of the 78 documented injuries, upper extremity fractures were the most common (84.6%) and the most frequent fracture location overall was at the distal radius and ulna (52.6%), while ankle fractures comprised most of the lower extremity fractures (66.6%). Majority of the distal radius fractures (58.3%) and ankle fractures (62.5%) were treated with immobilization only. Seventeen displaced distal radius fractures and three displaced ankle fractures were treated with closed reduction in the majority of cases (94.1% versus 66.7%, respectively). The distal radius and ulna are the most common fracture location. Use of appropriate protective gear such as wrist guards, as well as adult supervision, may help mitigate the injuries associated with the use of this device; however, further studies are necessary to demonstrate the real effectiveness of these preventions.

The brachial plexus is a complex network of peripheral nerves that enables sensing from and control of the movements of the arms and hand. Nowadays, the coordination between the muscles to generate simple movements is still not well understood, hindering the knowledge of how to best treat patients with this type of peripheral nerve injury. To acquire enough information for medical data analysis, physicians conduct motion analysis assessments with patients to produce a rich dataset of electromyographic signals from multiple muscles recorded with joint movements during real-world tasks. However, tools for the analysis and visualization of the data in a succinct and interpretable manner are currently not available. Without the ability to integrate, compare, and compute multiple data sources in one platform, physicians can only compute simple statistical values to describe patient's behavior vaguely, which limits the possibility to answer clinical questions and generate hypotheses for research. To address this challenge, we have developed MOTION BROWSER, an interactive visual analytics system which provides an efficient framework to extract and compare muscle activity patterns from the patient's limbs and coordinated views to help users analyze muscle signals, motion data, and video information to address different tasks. The system was developed as a result of a collaborative endeavor between computer scientists and orthopedic surgery and rehabilitation physicians. We present case studies showing physicians can utilize the information displayed to understand how individuals coordinate their muscles to initiate appropriate treatment and generate new hypotheses for future research.

The Patient-Reported Outcomes Measurement Information System (PROMIS) was developed to examine the quality of life across various medical conditions. No studies have evaluated the use of the PROMIS in children with idiopathic talipes equinovarus (ITEV). The construct validity of the PROMIS Parent Proxy Profile short forms version was assessed by comparing its domains of Mobility, Fatigue and Pain Interference to the Function domain of the Disease Specific Instrument (DSI) for ITEV. The two questionnaires were mailed out to the parents of 93 patients, aged 5-17 years, with ITEV. We received a total of 21 complete responses (22.6% response rate). The patients' current mean age was 8.0 years (SD, 3.0 years). Seventeen were males and 4 were females. Nine had unilateral ITEV and 12 had bilateral ITEV. Bivariate correlation analysis, using Pearson correlation coefficients, demonstrated a moderate positive correlation between the DSI Function domain and the PROMIS Mobility domain (r=0.67) as well as a moderate negative correlation between the DSI Function domain and the PROMIS Pain Interference domain (r=-0.64). A fair negative correlation was found between the DSI Function domain and the PROMIS Fatigue domain (r=-0.35). These results provide support for the validity of the PROMIS Mobility Item in this population, however further studies are needed to assess the feasibility and reliability of these instrument items as well as other items within PROMIS

The Ponseti method for the correction of idiopathic talipes equinovarus (ITEV) produces excellent results, however recurrence is common, ranging from 11-37%. Recurrences require repeat manipulation and casting, frequently followed by surgical procedures. We hypothesized that at a minimum 4-year follow-up, the rate of invasive surgical interventions such as posteromedial release (PMR) or osteotomy, is low. A retrospective chart review of patients with ITEV treated by the Ponseti method from January 1999 to June 2017 was conducted. An invasive procedure was defined as a PMR or osteotomy, whereas minimally invasive procedures involved tendon lengthening and transfers. Inclusion criteria were patients with ITEV, less than 90 days old at initial visit, no previous series of casts, and potential of being 4 years old at last visit. A total of 150 feet (102 patients) were studied. Mean age at initial visit and last follow-up were 19.5 days and 7.6 years, respectively. For the initial series of casts, mean number of casts was 5.4 and 67.3% of feet had percutaneous Achilles tenotomies. Fifty-eight percent did not undergo any form of surgical procedure, while 33% underwent a tibialis anterior tendon transfer alone or in combination with a gastrocnemius recession, tendo-Achilles lengthening, or plantar fascia release. Early in the series, three feet in two patients underwent a PMR. The mean age at time of surgery was 55.3 months. In contrast to those treated for recurrence after PMR, the vast majority (98%) of feet with recurrence after Ponseti-treated ITEV had either no surgery or minimally invasive surgery

BACKGROUND AND IMPORTANCE/BACKGROUND:The use of nerve transfers to restore nerve function following traumatic avulsion injuries has been described, though there is still a paucity in the literature documenting technique and long-term outcomes for these procedures. The double Oberlin nerve transfer involves transferring fascicles from the median and ulnar nerves to the musculocutaneous nerve to restore elbow flexion in patients with a C5-C6 avulsion injury. The purpose of this case report is to present our indications and technique for a double Oberlin transfer in addition to exhibiting video footage at follow-up time points documenting the incremental improvement in elbow flexion following the injury. CLINICAL PRESENTATION/METHODS:The patient is a 25-yr old, left-hand dominant male who presented 5 mo following a motor vehicle accident. He had 0/5 biceps muscle strength on the left with a computed tomography myelogram that demonstrated pseudomeningoceles from C2-C3 to C7-T1 with root avulsions of C5 and C6. He was subsequently indicated for a double Oberlin nerve transfer to restore elbow flexion. CONCLUSION/CONCLUSIONS:In this case report, we present our technique and outcomes for a double Oberlin transfer with restoration of elbow flexion at 1-yr follow-up for a patient with traumatic brachial plexus injury. We believe that the double Oberlin transfer serves as a safe and effective method to restore elbow flexion in this patient population.

Accelerated discharge protocols for scoliosis surgery have recently been described in the literature. There are limited data describing the association of length of stay (LOS) during the index admission with postoperative outcomes. We sought to define the economic and clinical implications of an additional 1 day in the hospital for scoliosis surgery. The Statewide Planning and Research Cooperative System database was used to identify patients with adolescent idiopathic scoliosis who underwent spinal fusion from 1 October 2007 to 30 September 2012 at high-volume institutions (>20 cases/year) in the state of New York. Regression models were adjusted for age, sex, race, insurance, comorbidity score, and perioperative complications during the index admission. Among the 1286 patients with AIS who underwent spinal fusion, the mean LOS was 4.90 days [95% confidence interval (CI)=4.84-4.97; SD=1.19]. In the perioperative period, 605 (47.05%) underwent transfusion and 202 (15.71%) had problems with pain control. An additional 1 day in the hospital was associated with $11 033 (95% CI=7162-14 904; P<0.001) in insurance charges, $5198 (95% CI=4144-6252; P<0.001) in hospital costs, 28% increased risk (odds ratio=1.28; 95% CI=1.01-1.63; P=0.041) of all-cause 90-day readmission, and a 57% increased risk (odds ratio=1.57; 95% CI=1.13-2.17; P=0.007) of returning to the operating room within 90 days. Increased LOS during the index admission scoliosis surgery is associated with higher costs and an increased risk of 90-day postoperative complications. Protocols to decrease LOS for this surgery have potential benefits to patients, hospitals, and insurers.

Contractures of the shoulder joint and glenohumeral joint dysplasia are well known complications to obstetrical brachial plexus palsy. Despite extensive description of these sequelae, the exact pathogenesis remains unknown. The prevailing theory to explain the contractures and glenohumeral joint dysplasia states that upper trunk injury leads to nonuniform muscle recovery and thus imbalance between internal and external rotators of the shoulder. More recently, another explanation has been proposed, hypothesizing that denervation leads to reduced growth of developing muscles and that reinnervation might suppress contracture formation. An understanding of the pathogenesis is desirable for development of effective prophylactic treatment. This article aims to describe the current state of knowledge regarding these important complications.

BACKGROUND:Vascular aberration has been accepted as a potential etiology of clubfoot, and abnormal vasculature has been observed in as high as 85% of children with severe clubfoot. The perfusion index (PI) corresponds to the ratio of pulsatile to nonpulsatile blood flow at a monitoring site and can be used to quantify perfusion of the extremities. The purpose of this study was to use PI to compare the perfusion of clubfeet to controls in order to further assess the role of abnormal vasculature in clubfoot. METHODS:A Masimo Radical 7 Pulse Oximeter (Masimo Corporation, Irvine, California) was used to measure the PI and oxygen saturation (SpO2) of the feet of children 5 years of age and younger with and without clubfoot. The sensor was placed on the great toe. Patients with clubfoot undergoing non-operative treatment and control patients undergoing treatment in a clinic for orthopedic concerns not involving the foot and with no known vascular issues were assessed. The PI and SpO2 for the following three groups were compared: 1. affected feet of patients with bilateral or unilateral clubfoot, 2. unaffected feet of patients with unilateral clubfoot, and 3. control feet. RESULTS:One hundred and twenty-eight patients were enrolled, 64 with clubfoot (31 bilateral and 33 unilateral) and 64 controls. No significant differences in PI or SpO2 were found between: 64 clubfeet and 64 feet of controls (PI of 2.9 vs. 2.9, p = 0.984; SpO2 of 97.1 vs. 98.1, p = 0.192); unaffected feet of 30 patients with unilateral clubfoot and 64 controls (PI of 3.0 vs.2.9, p = 0.907; SpO2 of 96.9 vs. 98.1, p = 0.224); and affected and unaffected feet of 30 patients with unilateral clubfoot (PI of 3.3 vs.3.0, p = 0.500; SpO2 of 97.4 vs. 96.9, p = 0.527). CONCLUSIONS:No difference was observed in the PI or SpO2 when comparing affected clubfoot limbs with unaffected limbs, suggesting that vascular anomalies cannot fully explain the development of clubfoot.

Purpose/UNASSIGNED:The morphology of the proximal femur has been extensively studied in the adult population. However, no literature providing a comprehensive evaluation of the anatomy in paediatric patients exists. The current study aims to characterize such anatomy in skeletally-immature patients, examine potential differences between genders, and analyze how these anatomical parameters change with age. Methods/UNASSIGNED:Cadaveric femurs from the Hamann-Todd Osteological Collection were examined. Specimens with open physes and no skeletal disease or deformity were included for analysis. Age and gender were recorded for each specimen. Each femur was photographed in standardized modified axial and anteroposterior views. In all, 14 proximal femoral anatomical parameters were measured from these photographs. Comparisons between genders and age were calculated. Results/UNASSIGNED:A total of 43 femurs from ages four to 17 years met inclusion criteria. The majority were female (56%); no difference existed in age between genders (p = 0.62). The specimens had a neutral mean neck-shaft angle (130.7º) and anteversion (12.8º), and the sphericity of the ossified femoral heads was symmetrical. Male specimens had significantly higher alpha angles (p = 0.01), posterior offset (p = 0.02), neck width (p = 0.04) and head-neck length ratio (p = 0.02) values than female specimens. Strong positive correlations exist between length/size parameters and age, while negligible correlations were noted for angular measurements. Conclusions/UNASSIGNED:This study establishes reference values for a comprehensive list of anatomical parameters for the skeletally-immature ossified proximal femur. It highlights gender differences in morphology and demonstrates that angular characteristics remain relatively stable while length parameters generally increase with age. Level of Evidence/UNASSIGNED:Level III Diagnostic.