Faculty Bibliography

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.

PURPOSE/OBJECTIVE:The American Academy of Orthopaedic Surgeons (AAOS) and the American Academy of Pediatrics (AAP) both advocate for childhood injury prevention by publishing recommendations to orthopaedic surgeons, pediatricians, and the public. Popular topics of advocacy campaigns have included trampolines, all-terrain vehicles (ATVs), and lawnmowers. The purpose of this study was to investigate the temporal relationship between AAOS/AAP advocacy and pediatric orthopaedic injury rates, using these topics as examples. We hypothesized that pediatric orthopaedic injury rates decline in years, following related AAOS/AAP recommendations. METHODS:A retrospective review of fractures associated with trampolines, lawnmowers, and ATVs among patients aged 2 to 18 years from 1991 to 2014 was performed using the National Electronic Injury Surveillance System (NEISS). Fracture rates and percent changes year-to-year were calculated. A timeline of AAOS and AAP advocacy statements published on the products was created. RESULTS:Trampoline-related fractures rose 14% yearly from 1991 to 1999, reached a plateau from 1999 to 2003, corresponding with a 1999 AAP statement. Injury rates dropped 4.3% from 2006 to 2010 after 2005 and 2006 statements, and reached another plateau thereafter, as 2010 and 2012 statements were published. ATV-related fractures rose 14% yearly between 1997 and 2002, then dropped 15% from 2007 to 2010 following yearly AAP or AAOS statements from 2004 to 2007. From 2010 to 2014, the injury rate held constant during which time 2010, 2013, and 2014 statements were published. Lawnmower injury rates did not fall despite statements in 1998 and 2001 and a poster campaign in 2001. A 25% drop from 2007 to 2008 coincided with an AAOS statement in 2008. Fracture rates further dropped 31% from 2009 to 2011 and 21% from 2012 to 2014, amidst 2012 and 2014 statements. For ATV-related and lawnmower-related injuries, more male individuals were affected than female individuals, and for ATVs alone, injury rates increased with age. CONCLUSIONS:Although AAOS/AAP statements did not universally coincide with dropping fracture rates, statements often were associated with substantial decreases in following years. This is likely because injury prevention messages are dispersed from providers to the public over time and outcomes depend on highly variable patient behaviors. LEVEL OF EVIDENCE/METHODS:Level V-systematic review of descriptive data.

Bone abnormalities on pediatric radiographs are not uncommon findings for both the general orthopedist as well as the specialist. Although the majority of lesions encountered are benign, the treating physician should also be aware of more concerning diagnoses. General orthopedists and pediatric orthopedists should exhibit a basic level of comfort with working up and diagnosing these benign lesions. When evaluating the pediatric patient with a bone lesion it is crucial to keep in mind important aspects of the clinical history, physical exam, and radiographic findings. Here we provide a review of important findings for the orthopedic surgeon in each of these areas. Many times diagnoses can be made with these alone. With better understanding of clinical and radiographic features of these lesions the orthopedist should be comfortable knowing which lesions he or she can reasonably treat and which should be referred to an oncologic specialist.

Purpose: Abnormal vasculature has been observed in as much as 85% of children with clubfoot. The purpose of this study was to compare foot perfusion between clubfeet and unaffected feet. Methods: A Masimo Radical 7 Pulse Oximeter (Masimo Corporation, Irvine, CA) was used to measure the foot perfusion index (PI) of children five years of age and younger. Patients with clubfoot undergoing nonoperative treatment, and control patients undergoing treatment for orthopedic concerns not involving the foot, were tested. Exclusion criteria for patients with clubfoot were previous clubfoot surgery and non-idiopathic etiology. The PI of the affected clubfeet was compared to the PI of the unaffected feet of the controls. Results: Sixty-six patients were enrolled, 34 with clubfoot (16 bilateral and 18 unilateral), and 32 controls. No significant difference in PI was found between the affected feet and the unaffected feet (3.1 vs. 2.5; P = 0.200). Conclusion: This analysis showed no difference in PI between clubfeet and unaffected feet of controls. Significance: Although abnormal vasculature in clubfoot has been reported, the perfusion to a non-operative treated clubfoot is similar to an unaffected foot

Shoulder dislocation is relatively uncommon in the younger pediatric population. Because of the relative strength of the surrounding soft tissue structures of the shoulder compared with the proximal humeral physis, subluxation or dislocation resulting from a traumatic event or application of force is rare and instead a proximal humeral physeal injury occurs. Case presentation - We present a 5-year-old male who presented to the office with post-traumatic left shoulder pain for about 1 week. Radiographs of the left shoulder indicated inferior subluxation of the humeral head. He was ultimately diagnosed and treated for a septic shoulder. Septic arthritis of the glenohumeral joint accounts for about 3% of all septic arthritis cases. About half of the pediatric patients with a septic arthritis will present with a concomitant osteomyelitis about the joint involved. Widening of the glenohumeral joint and subluxation clinically as well as radiographically have been described in cases of large joint effusions because of an increase in intra-articular fluid in adults. This inferior subluxation is often noted without a frank dislocation. The case described in this report is unique in that this is the first to describe a pediatric septic shoulder presenting as a shoulder subluxation. Given the rarity of pediatric shoulder dislocations and subluxations, the pediatric orthopaedist and pediatrician should maintain a suspicion for a septic joint.

BACKGROUND: Postoperative wound complications after posterior spinal fusion are difficult to manage. The incidence in the nonidiopathic patient population is significantly higher than the adolescent idiopathic population. A comparison of wound complications after posterior spinal fusion for nonidiopathic scoliosis between the utilization of the orthopaedic surgical team at the time of closure performing a nonstandardized wound closure versus a plastic surgeon with a plastic multilayered closure technique and rotational flap coverage when needed had not previously been evaluated. The purpose of this study was to compare the complication rate between nonstandardized and plastic multilayered closure of the surgical incision in patients undergoing posterior spinal fusion for nonidiopathic scoliosis. METHODS: The charts of 76 patients with a primary diagnosis of scoliosis associated with a syndrome or neuromuscular disease and who underwent a posterior spinal fusion were reviewed. Forty-two patients had their incisions closed using the nonstandardized technique and 34 using the plastic multilayered technique. These 2 groups were compared for age, sex, primary diagnosis, number of levels fused, estimated blood loss, number of units transfused, operating room time, wound complication, and return to operating room. RESULTS: The wound complication rate in the nonstandardized closure group was 19% (8/42) compared with 0% (0/34) in the plastic multilayered closure group (P=0.007). The unanticipated return to the operating room rate was 11.9% (5/42) for the nonstandardized closure patients versus 0% (0/34) for the plastic multilayered closure patients (P=0.061). CONCLUSIONS: The use of the plastic multilayered closure technique in this patient population is important in an effort to decrease postoperative wound complications. The ability of the surgical team to decrease the infection rate of nonidiopathic scoliosis cannot be overstated. The method of wound closure plays a major role in lowering this incidence. LEVEL OF EVIDENCE: Level III-therapeutic.

BACKGROUND: There is a dearth of literature examining the causes of cam-type femoroacetabular impingement (FAI) and when such morphology appears. The purpose of the current study was to analyze how the ossific portion of the proximal femur develops over time with respect to standard cam-type FAI parameters. METHODS: A collection of 193 femurs from cadavers aged 4 to 21 years were evaluated. The age, sex, ethnicity, and status of the proximal femoral physes (open or closed) of each were recorded. Each specimen was digitally photographed in standardized anteroposterior and modified axial positions. From these photographs, the anterior offset, anterior offset ratio (AOR), and alpha-angle were determined. A cam lesion was defined as an alpha-angle >55 degrees on the lateral view. RESULTS: The mean age of the specimens was 17.5+/-4.2 years. The majority were male (69%) and African American (79%) with closed physes (78%). There were significant differences among discrete age groups with respect to alpha-angle (P=0.01), anterior offset (P<0.01), and AOR (P<0.01). In addition, younger femurs with open physes had a significantly higher mean alpha-angle (P<0.01), lower mean anterior offset (P<0.01), and higher mean AOR (P<0.01) compared with older ones with closed physes. Specimens defined as having a cam deformity had a statistically higher alpha-angle (P<0.01) and lower anterior offset (P<0.01), but there was no difference in AOR values compared with specimens without a cam lesion (P=0.1). CONCLUSIONS: The apparent decline in alpha-angles as age increases indicates that the traditional alpha-angle in younger patients measures a different anatomic parameter (ossified femur excluding the cartilaginous portion) than in older patients (completely ossified femur). This suggests that the bony alpha-angle is inappropriate in the evaluation of cam lesions in the immature physis. The AOR, rather than the anterior offset, may be more accurate in the evaluation of the growing proximal femur. CLINICAL RELEVANCE: This study provides novel insight into, and enhances the understanding of, the development of cam-type FAI.

BACKGROUND: The orthopaedic treatment of the patient with cerebral palsy (CP) is complex and must take into account the heterogeneity and natural history of the condition. Although the goals of management are for the most part universal, the specific interventions and outcome measures used to reach these goals are wide ranging. This update serves to summarize some of the recent publications in the field of pediatric orthopaedics that have made important contributions to our understanding and care of the patient with CP. METHODS: We searched the PubMed database using the following terms: "cerebral palsy" AND "orthopedic." The results were then filtered to include only review papers or clinical trials published in English from 2010 to 2014. The obtained list of references was then reviewed for publications in the fields of lower extremity muscle imbalance, foot and ankle deformities, hip and acetabular dysplasia, and advances in orthopaedic-related technology. RESULTS: Updates in the field of pediatric orthopaedics are constant and the current level of evidence for the effectiveness of specific treatment modalities in patients with CP was reviewed. The search method yielded 153 publications, of which 31 papers were identified as having contributed important new findings. CONCLUSIONS: Our understanding of orthopaedic treatments for children with CP continues to grow and expand. The studies reviewed illustrate just some of the strides we have taken in utilizing evidence-based surgical decision making in practice. Nevertheless, there remains a paucity of randomized controlled trials and higher evidence research, which may contribute to the variability in current practices among providers. By elucidating these gaps we can more purposefully delegate our time and resources into targeted areas of research. LEVEL OF EVIDENCE: Level 4-literature review.

INTRODUCTION: Legg-Calve-Perthes disease is a pediatric condition that occurs when blood supply is temporarily interrupted to the femoral head of the hip joint. Most animal models in the literature induce necrosis by surgical techniques, but our aim was to test whether non- surgical methods could be utilized, particularly as that would be a closer match to the true pathophysiology of LCPD. Avascular necrosis has been observed in the epiphyseal nuclei of the femoral head in 33 per cent of Wistar-Kyoto rats housed in high feeding cages, due to the repetitive mechanical stress on the femoral heads at 5 to 9 weeks (1). This is comparable to the rate of induction of the radiological and histological characteristics of LCPD in New Zealand rabbits using microtrauma with a vibratory motor (2). METHODS: We induced osteonecrosis in Wistar Kyoto rats (WKYs) as described by Masatsugu Suehiro et al (1). In the treatment group, six 5 week old male Wistar Kyoto rats (WKYs) from Charles River Labs were housed in high cages for 10 weeks. The high cages were High temperature Polysulfone Type 2000 static rat cages (Allentown) in which the feed-box and the drinking aperture were placed at a height (27 cm height), such that the rats were forced to stand erect on the hind limbs while drinking and feeding. In the control group, two similarly aged male WKYs were housed in regular low cages (height 10 cm) for the same time period, and allowed to drink and feed without standing. Subsequently, the femoral heads were assessed in both groups by radiological and pathological methods. RESULTS: Radiological evaluation was used to make specific femoral head measurements and calculations for medial neck length (MNL), lateral neck length (LNL), width of femoral head (WH), and curvature radius (CR), as mentioned in Suehiro et al (3). Table 1 shows the radiological measurements for LNL, MNL, WH and CR in the control and osteonecrosis groups. The t-test was done to measure the significance of the differences between the mean of both groups. In the osteonecrosis group, the shape of the femoral head had a flatter appearance with an increased CR and decreased WH (Fig. 1). Histopathological evaluation, using Hematoxylin and Eosin (H&E) stain, revealed a diffuse presence of empty lacunae accompanied by bone marrow cell necrosis in the bone trabeculae of the osteonecrosis group. (Fig.2) DISSCUSSION: Histopathological evaluation revealed cartilage thinning in the femoral head along with discontinuity and clusters of chondrocytes of the osteonecrosis (standing) group. Also, there was necrosis of osteocytes in the bone marrow and bone trabeculae. Empty lacunae were also observed in sections of the reparative bone. These pathological changes indicated osteonecrosis similar to those of early-stage Perthes' disease in the standing group. Our findings agree with current literature that overload or excessive mechanical stress on the femoral head seems to contribute to the etiology of osteonecrosis in WKYs. (Table Presented)