Faculty Bibliography

Eponyms, while inherently flawed, remain a constant in medical vernacular, especially in orthopaedic surgery. It is essential to understand how these eponyms came to be named and for whom they were named after in order to know the correct usage and definition of these eponyms. In this first part, we describe the history of eponym usage in paediatric hip radiography; who, when, what, where, and how. We hope to provide a historical perspective of interest, resolve any controversies in semantic definitions, and create a comprehensive library of eponymous terms related to paediatric hip radiography.

BACKGROUND:Children with suspected fractures are typically evaluated with multiple x-rays. This approach can add time, discomfort, and radiation exposure without clinical benefit. The purpose of this study was to determine whether a focused radiographic protocol could reduce the number of x-rays performed without missing any fractures. METHODS:Pediatric patients presenting at 2 sites within an academic medical center [urgent care (UC) and the emergency department(ED)] for a suspected fracture were identified. There were 495 patients (UC, 409; ED, 86) over a 3-month period. A retrospective chart review was performed to characterize the standard x-rays performed. Using this data, a simplified protocol was developed and distributed. Subsequently, 333 patients (UC, 259; ED, 74) were evaluated over the same period 1-year later. The main outcome measures included the final diagnosis, the total number of x-rays, the number of anatomic areas imaged, visit length, and the time for additional trips to radiology. Charts were reviewed to identify any missed injuries. Welch 2-sample t tests and Fisher exact tests were used for statistical analysis. RESULTS:After implementing the radiographic protocol, there was a significant reduction in the number of x-ray views, 3.4 versus 5.1 (P<0.001). There was a decrease in imaging of multiple anatomic areas with the largest reduction occurring in patients presenting with elbow injuries (9% vs. 44%, P<0.001). No difference was found in the rate of patients sent back to radiology (6% vs. 7%, P=0.67). However, among patients presenting with outside imaging, significantly fewer were sent to radiology for additional x-rays (29% vs. 50%, P<0.01). CONCLUSION/CONCLUSIONS:A simple radiographic protocol for evaluating pediatric patients with suspected fractures safely led to a decrease in the overall number of x-rays without missing any injuries. LEVEL OF EVIDENCE/METHODS:Level III, retrospective comparative study.

OBJECTIVES/OBJECTIVE:The cast index is the most commonly used measurement of cast quality in pediatric forearm fractures, with low values representing a good quality cast and higher values suggesting poor technique. However, in some instances the cast index may not accurately reflect cast quality. The purpose of this study was to critically evaluate the quality of casts deemed "good" or "bad" based on the cast index against other measurements in order to identify these examples. METHODS:Pediatric patients casted for a distal or midshaft forearm fracture were identified from a prospectively gathered database. There were 121 casts on 97 forearms. Measurements were made on forearm or wrist x-rays to calculate the cast index, gap index, and the anatomic dimensions of the forearm at the level of the fracture. Fisher's exact test was used to assess the likelihood of a good cast index (< 0.75) to also have an acceptable gap index (< 0.15). Pearson's correlation compared the anatomic measurements of the forearm and the cast index. RESULTS:There were 65 casts with a good cast index, and 58% also had an acceptable gap index (< 0.15). Among the 56 casts with a bad cast index, 20% had an acceptable gap index (p < 0.001). The anatomic measurements of the forearm and the cast index were strongly correlated (r = 0.96). CONCLUSION/CONCLUSIONS:Many casts with a good cast index have an unacceptable gap index. Forearm measurements and cast index are highly correlated, suggesting that a well-molded cast may have a higher cast index due to the shape of the forearm. While the cast index is a useful tool, "good" or "bad" casts are not uniformly captured by this measurement.

Klippel-Feil syndrome (KFS), or congenital fusion of the cervical vertebrae, has been thought to be an extremely rare diagnosis. However, recent literature suggests an increased prevalence, with a high proportion of asymptomatic individuals. Occurring as a sporadic mutation or associated with several genes, the pathogenesis involves failure of cervical somite segmentation and differentiation during embryogenesis. Most commonly, the C2-C3 and C5-C6 levels are involved. KFS is associated with other orthopaedic conditions including Sprengel deformity, congenital scoliosis, and cervical spine abnormalities, as well as several visceral pathologies. There are several classification systems, some based on the anatomic levels of fusion and others on its genetic inheritance. Management of patients with KFS primarily involves observation for asymptomatic individuals. Surgical treatment may be for neurologic complaints, correction of deformity, concomitant spinal anomalies, or for associated conditions and varies significantly. Participation in sports is an important consideration. Recommendations for contact sports or activities depend on both the level and the number of vertebrae involved in the fusion. A multidisciplinary team should be involved in the treatment plan and recommendations for complex presentations.

Methods of diagnosing and monitoring pediatric musculoskeletal infections are rapidly evolving. Key serologic tests are typically used in screening patients with suspected infections, and remain an integral part of the initial work-up. Synovial studies from arthrocentesis in possible septic arthritis, and source-specific cultures have been the foundation of our treatment algorithm. Given the prevalence of soft tissue abscesses and osteoarticular infections, advanced imaging is an advantageous tool. More affordable use and expanded access to MRI has made it a valuable adjunct to clinical picture and existing tests in order to comprehensively visualize the extent of musculoskeletal infections in children. Ongoing validation for criteria to help determine the patients that stand to benefit the most from MRI, even when surgical intervention may be delayed, remains of significant clinical interest. Given the rates of culture-negative infections, and the need for timely diagnosis, new diagnostic techniques are always being considered. The search for more accurate biomarkers, and technology such as Whole genome sequencing (WGS) and next-generation sequencing (NGS) that can rapidly identify pathogens of all types of phyla based on a small sample of DNA, has promising clinical implications. While once novel and prohibitively expensive, these tests are now being applied in university and tertiary care centers in certain scenarios. Applying these techniques to pediatric musculoskeletal will require a large change in lab workflow and training. However, the benefits of acquiring diagnostic information along with will make them a superior tool in our arsenal of diagnostic tests.

Ultrasonography is a valuable tool that can be used in many capacities to evaluate and treat pediatric orthopaedic patient. It has the capability to depict bone, cartilaginous and soft-tissue structures, and provide dynamic information. This technique can be readily applied to a wide range of pediatric conditions, including developmental dysplasia of the hip, congenital limb deficiencies, fracture management, joint effusions, and many other musculoskeletal pathologies. There are many benefits of implementing ultrasonography as a regular tool. It is readily accessible at most centers, and information can be quickly obtained in a minimally invasive way, which limits the need for radiation exposure. Ultrasonography is a safe and reliable tool that pediatric orthopaedic surgeons can incorporate into the diagnosis and management of a broad spectrum of pathology.

BACKGROUND:There is evidence that femoroacetabular impingement (FAI) is increasingly prevalent among adolescent athletes. Abnormal contact forces across the hip and alterations in bony morphology characteristic of FAI may be especially detrimental in this group, given their young age and active lifestyle. PURPOSE/OBJECTIVE:The purpose of this study was to report the findings, outcomes, and return to sport percentage among adolescent athletes with FAI treated with hip arthroscopy. METHODS:A retrospective review of all patients younger than 18 years who underwent hip arthroscopy for FAI at a single institution was performed. All athletes who were attempting to return to sport and underwent hip arthroscopy were included. Patients with previous hip surgery and/or hip conditions were excluded. Arthroscopic procedures and an assessment of intra-articular findings were recorded. Patient-reported outcome measures were recorded at 3 months, 1 year, and 2 years postoperatively, and included the modified Harris hip score, the nonarthritic hip score, hip outcome score-sports subscale, visual analogue scale for pain, and patient satisfaction. Return to sport percentage and ability levels were also noted. RESULTS:There were 96 eligible cases of adolescent athletes treated with hip arthroscopy; 81 (84.4%) hips in 69 patients had 2-year follow-up. Running/track and field was the most common sport (25), followed by soccer (12), dance (10), baseball/softball (9), and basketball (6). There were 61 females and 20 males, whose average age was 15.9±1.2 y (range: 13.1 to 18.0 y). The most common procedures were labral repair (81.5%), iliopsoas fractional lengthening (72.8%), femoroplasty (69.1%), and acetabuloplasty (66.7%). Capsular repair or plication was performed in most patients (81.5%). Cartilage damage was more common on the acetabulum than the femur, with Outerbridge grade 2 or higher occurring in 23.5% and 4.9% of hips, respectively. Statistically significant improvements were seen in all patient-reported outcomes from preoperative to minimum 2-year follow-up. A total of 84.0% of patients had returned to their sport at latest follow-up. There were 6 (7.4%) patients who underwent revision arthroscopy at a mean of 37.3 months postoperatively. CONCLUSION/CONCLUSIONS:Symptomatic FAI in adolescent athletes can be successfully treated with hip arthroscopy, with a higher return to sport rate and low complications and reoperation rate at minimum 2-year follow-up.

BACKGROUND:Fixation with a single screw is the recommended treatment for slipped capital femoral epiphysis (SCFE). Achieving optimal implant positioning can be difficult owing to the complex geometry of the proximal femur in SCFE. We assessed a novel navigation technology incorporating an inertial measurement unit to facilitate implant placement in a SCFE model. METHODS:Guidewires were placed into 30 SCFE models, using a navigation system that displayed the surgeon's projected implant trajectory simultaneously in multiple planes. The accuracy and the precision of the system were assessed as was the time to perform the procedure. RESULTS:Implants were placed an average of 5.3mm from the femoral head center, with a system precision of 0.94mm. The actual trajectory of the implant deviated from the planned trajectory by an average of 4.9° ± 2.2°. The total average procedure time was 97 seconds. CONCLUSION/CONCLUSIONS:The use of computer-based navigation in a SCFE model demonstrated good accuracy and precision both in terms of implant trajectory and placement in the center of the femoral head. This article is protected by copyright. All rights reserved.

BACKGROUND:Idiopathic talipes equinovarus (ITEV) is a prevalent structural deformity of the foot and ankle in children. The disease-specific instrument (DSI) has commonly been used as an outcomes metric in these patients. The Patient-Reported Outcomes Measurement Information System (PROMIS) was developed to examine the quality of life across various medical conditions. PROMIS has been validated for multiple conditions; however, no studies have evaluated the use of the PROMIS in children with ITEV. METHODS:A prospective analysis was performed whereby the 2 questionnaires were mailed out to the parents of 91 patients, aged 5 to 17 years, with ITEV. Construct validity of the PROMIS Parent Proxy Profile short forms version was assessed by comparing its domains of Mobility, Fatigue, Pain Interference, and Pain Intensity to the DSI Function domain and PROMIS domains of Anxiety, Depressive Symptoms, Peer Relationships, and Pain Intensity to DSI Satisfaction domain. RESULTS:Thirty-one complete responses (34% response rate) were returned. The patients' current mean age was 8.8 years, 7 were female individuals, and 12 had unilateral ITEV. Bivariate correlation analysis, using Spearman correlation coefficients, demonstrated a moderate positive correlation between the DSI Function domain and the PROMIS Mobility domain (rs=0.52) and a moderate negative correlation between the DSI Function domain and the PROMIS Pain Interference domain (rs=-0.56), as well as the PROMIS Pain Intensity domain (rs=-0.75). A fair negative correlation (rs=-0.38) with PROMIS Fatigue domain was found. Correlations between the DSI Satisfaction domain and the PROMIS domains were fair or had little relationship. CONCLUSIONS:These results provide support for the validity of the PROMIS Mobility, Pain Interference, and Pain Intensity domains in this population, however there are no items in PROMIS that can assess overall satisfaction, as with the DSI. LEVEL OF EVIDENCE/METHODS:Level II-prospective comparative study.