Faculty Bibliography

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.

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

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

Congenital tibial deficiency is a rare condition characterized by partial to complete absence of the tibia, an intact but frequently overgrown fibula, variable degrees of knee deformity and function, and an abnormal equinovarus foot. It can occur in isolation but also presents concurrently with other orthopaedic anomalies and syndromic conditions. Among these, congenital abnormalities of the hand and femur are most commonly observed. Many theories exist regarding its etiology and some genetic mutations have been identified; however, the underlying mechanism remains unknown. The prognosis and treatment differ based on the clinical severity. The goal of treatment is always to create a stable, functional limb, most commonly with amputation and use of prosthetics. Controversy exists over the level of amputation and the usefulness of reconstructive procedures to preserve the foot and limb length. Current investigation on this complex disorder is focused on identifying its origins and further developing a classification-based treatment algorithm to improve patient outcomes.

BACKGROUND:The success of hip arthroscopy has led to increased application in younger populations. However, hip arthroscopy remains a challenging procedure, and its safety and efficacy in the adolescent population have been controversial. Most existing literature on outcomes in such patients contains only short-term follow-up, and a paucity of evidence is available regarding long-term outcomes in adolescents. PURPOSE:To report on clinical outcomes at a minimum 5-year follow-up in patients younger than 18 years who underwent arthroscopic treatment of labral tears. STUDY DESIGN:Case series; Level of evidence, 4. METHODS:Data were prospectively collected and retrospectively reviewed on all patients younger than 18 years who underwent hip arthroscopy in a tertiary hip preservation setting at a single institution. Patients were excluded if they had previous ipsilateral hip conditions or surgery. All patients underwent either labral repair or debridement for treatment of a labral tear. Patient-reported outcome measures were recorded at 3 months and at 1, 2, or a minimum of 5 years. These included the modified Harris Hip Score (mHHS), Nonarthritic Hip Score, Hip Outcome Score-Sports Specific Subscale (HOS-SSS), visual analog scale, and patient satisfaction. Additionally, the abbreviated International Hip Outcome Tool and Short Form Health Survey were collected at latest follow-up. RESULTS:The study included 44 hips in 32 patients that underwent arthroscopic labral repair (86.4%) or labral debridement (13.6%) between April 2008 and April 2011, with latest follow-up at a mean of 69.2 months (range, 60.0-89.9 months) postoperatively. The average age at surgery was 16.3 years (range, 14.2-17.9 years), and 39 hips from female patients. Statistically significant improvements were seen in all patient-reported outcome measures from preoperative to minimum 5-year follow-up. Improvements were noted at 1-year follow-up and maintained at minimum 5-year follow-up. At the latest follow-up, the Patient Acceptable Symptomatic State was achieved in 95.5% of patients for the mHHS and 72.7% for the HOS-SSS. Two patients subsequently underwent secondary arthroscopy on the ipsilateral hip; however, the survivorship of all hips was 100%. CONCLUSION:Hip arthroscopy for the treatment of labral tears in adolescents remains a technically challenging procedure that should be approached with appropriate caution. The results of the present study on a population treated in a specialized hip preservation center demonstrate that hip arthroscopy is a safe procedure with stable improvement in patient-reported outcome measures at 5 years.

Femoral version is reported to vary in relation to age, gender and other patient-specific factors. Differences in femoral version are suspected to contribute to the development of hip pathology. However, normative data on pathologic hips has never been reported. To evaluate the femoral version in a large population of patients with symptomatic hip pathology treated with arthroscopy and report differences within this group based on age, gender, bony morphology and other hip-related factors. A prospectively gathered database of 1449 hips was reviewed. All patients underwent pre-operative MRI with measure of femoral version. The average femoral version of the entire population was 8.4+ 9.2°, range -23 to 63. There no statistically significant differences encountered based on age, gender, bony morphology or other hip-related factors. Across all groups, there was wide variation in the femoral version present. Among younger patients, there was trend to have a greater proportion of retroversion. Significant variation in femoral version exists in patients with symptomatic hip pathology. Although the geometry of the proximal femur is commonly described as anteverted, relative retroversion is also frequently encountered.

INTRODUCTION/BACKGROUND:There is a paucity in the literature regarding mid-term results of microfracture in hip arthroscopy. We aim to assess 5-year outcomes of patients who underwent acetabular microfracture for full-thickness chondral lesions as a part of hip arthroscopy. METHODS:Between August 2008 and September 2011, data were prospectively gathered for patients undergoing acetabular microfracture during hip arthroscopy with minimum 5-year follow-up. All patients were assessed pre- and postoperatively, with modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score - Sports Specific Subscale (HOS-SSS), and visual analog scale (VAS). International Hip Outcome Tool (iHOT-12) and satisfaction were collected postoperatively. Exclusion criteria included previous hip conditions, or preoperative Tönnis grade ≥2. RESULTS:Fifty three hips were eligible for this study. Of these, 43 (81.1%) hips in 42 patients had follow-up. The study group had a male majority (65.1%) and an average age of 44.4 ± 9.5 years. There was statistically significant improvement in all patient-reported outcomes (PROs) and VAS at follow-up. Patient satisfaction was 7.6 ± 2.6. A comparison of 2-year to minimum 5-year follow-up results identified no statistically significant deterioration in PROs, VAS, and patient satisfaction. Survivorship was 72.1% with 12 patients converted to total hip arthroplasty (THA). Four patients (10.8%) underwent secondary arthroscopy. CONCLUSIONS:In the mid-term, microfracture as a part of hip arthroscopy demonstrated favourable outcomes and 72% survivorship. Careful patient selection is warranted to limit the risk of conversion to THA.

BACKGROUND: Gait indices were developed to represent the magnitude of impairment extracted from a gait analysis with a single value. The Gillette Gait Index (GGI), and the Gait Deviation Index (GDI) are 2 widely used indices that represent gait impairment differently based on their statistical properties. Our purpose was to (1) report on the results of gait analysis for a broad spectrum of pediatric conditions using the GGI and GDI, and (2) identify the parameters that dominate impairment. METHODS: A total of 1439 children with 13 different diagnoses with a complete, baseline gait analysis were identified. The GGI and its 16 parameters were calculated in all cases, and the GDI was calculated from a smaller subset. T tests, and z-scores were used to compare each of these values to typically developing children for each diagnosis. A separate linear regression controlling for age, sex, and use of an orthosis, or assistive device was performed for the GGI. RESULTS: In our series, there were 71 typically developing children with a GGI of 31. We qualify relative gait impairment as severe, mild, or moderate as based on the GGI, and propose that values <100 represent mild, 100 to 200 represent moderate, and >200 represents severe impairment. On the basis of strong correlation between the GGI and GDI, we suggest that GDI values >80 represent mild, and values <70 represent severe impairment. T tests and z-scores demonstrated that both the number and magnitude of abnormal parameters increase the GGI. These tests also identified the most clinically relevant parameters contributing to functional impairment for each diagnosis. Multivariate linear regression showed that all diagnoses except flatfoot and scoliosis demonstrated statistically significant differences in GGI scores. CONCLUSIONS: This is the first study to apply these gait indices to a large population of diverse pediatric conditions. We propose GGI and GDI values to qualify gait impairment among these conditions as severe, moderate, or mild. Furthermore, impairment in gait reflects both the number and magnitude of abnormal parameters within each condition. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

BACKGROUND:Hip arthroscopy is an established surgical treatment for pathologic hip conditions in athletes. There is a paucity in the literature regarding outcomes and return to sport for athletes in the midterm. PURPOSE:To report minimum 5-year outcomes, return to sport, and level of sport among athletic patients who underwent hip arthroscopy. In addition, we compared 2- and 5-year outcomes to evaluate whether there is a deterioration in functional status. STUDY DESIGN:Case series; Level of evidence, 4. METHODS:Data were prospectively collected on all patients who underwent hip arthroscopy between February 2009 and November 2011 at 1 institution. Athletes at the high school, collegiate, or professional level who underwent hip arthroscopy and had preoperative patient-reported outcome (PRO) scores were considered for inclusion. Exclusion criteria were preoperative Tönnis grade >1 or prior ipsilateral hip conditions or surgery. Data on sports participation, competition level, and ability were collected. At a minimum of 5 years postoperatively, PROs, visual analog scale (VAS), iHOT-12 (short version of International Hip Outcome Tool), satisfaction, and postoperative complication data were collected. RESULTS:Seventy-seven hips met all criteria, among which 66 (85.7%) had a minimum 5-year follow-up and were included. There were 37 high school, 20 collegiate, and 9 professional athletes. Mean ± SD improvements at a minimum of 5 years were as follows: modified Harris Hip Score, 66.8 ± 16.3 to 87.0 ± 14.8 ( P < .001); nonarthritic hip score, 66.2 ± 19.9 to 87.2 ± 15.2 ( P < .001); Hip Outcome Score-Sports Specific Subscale, 47.0 ± 22.4 to 79.1 ± 23.0 ( P < .001); and VAS, 5.4 ± 2.5 to 1.8 ± 2.1 ( P < .001). At latest follow-up, mean iHOT-12 was 78.8 ± 22.7, and satisfaction was 8.2. A total of 50 athletes (53 hips, 80.3%) reported that they returned to sports; 71.2% reported "same" or "higher" sport ability as compared with a year before surgery. Postoperative complications included 3 cases (4.5%) of numbness and 1 case (1.5%) of pulmonary embolism. Ten hips (15.2%) required secondary arthroscopies, and no hips were converted to total hip arthroplasty. There were no significant differences between 2- and 5-year PROs, VAS, or satisfaction. CONCLUSION:Midterm results of hip arthroscopy in athletes are shown to be safe and favorable. Most athletes return to sports and continue to play after 5 years with the same or higher ability.

Radiographic Union Score for Tibia (RUST) and modified RUST (mRUST) are radiographic tools for quantitatively evaluating fracture healing using a cortical scoring system. This tool has high intra-class correlation coefficients (ICCs); however, little evidence has evaluated the scores against the physical properties of bone healing. Closed, stabilized fractures were made in the femora of C3H/HeJ male mice (8-12 week-old) of two dietary groups: A control and a phosphate restricted diet group. Micro-computed tomography (µCT) and torsion testing were carried out at post-operative days (POD) 14, 21, 35, and 42 (n = 10-16) per group time-point. Anteroposterior and lateral radiographic views were constructed from the µCT scans and scored by five raters. The raters also indicated if the fracture were healed. ICCs were 0.71 (mRUST) and 0.63 (RUST). Both RUST scores were positively correlated with callus bone mineral density (BMD) (r = 0.85 and 0.80, p < 0.001) and bone volume fraction (BV/TV) (r = 0.86 and 0.80, p < 0.001). Both RUST scores positively correlated with callus strength (r = 0.35 and 0.26, p < 0.012) and rigidity (r = 0.50 and 0.39, p < 0.001). Radiographically healed calluses had a mRUST ≥13 and a RUST ≥10 and had excellent relationship to structural and biomechanical metrics. Effect of delayed healing due to phosphate dietary restrictions was found at later time points with all mechanical properties (p < 0.011), however no differences found in the RUST scores (p > 0.318). Clinical relevance of this study is both RUST scores showed high correlation to physical properties of healing and generally distinguished healed vs. non-healed fractures. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:945-953, 2018.