BACKGROUND:Talocalcaneal (TC) coalitions are a common cause of hindfoot pain in adolescents. Resection is effective when the posterior facet is preserved but can be technically demanding, with risk of incomplete resection and prolonged operative time. This study describes a simplified technique for TC coalition excision and compares its outcomes with traditional methods. METHODS:A retrospective review was performed of patients undergoing isolated TC coalition excision with autogenous fat graft interposition at a single pediatric institution (2001 to 2025). Patients with prior surgery, neuromuscular or syndromic conditions, or concomitant procedures were excluded. Forty-eight patients (54 feet) met the inclusion criteria: 39 feet underwent traditional excision, and 15 feet underwent a simplified technique using converging Kirschner wires to guide resection. Outcomes included tourniquet time, anesthesia time, procedural cost, and perioperative complications. Costs were estimated using institutional per-minute operating room rates. Statistical significance was set at P<0.05. RESULTS:There were no differences between groups in age, sex, body mass index, or prevalence of flatfoot deformity. The traditional group had a higher proportion of osseous coalitions (51.3% vs. 13.3%, P=0.04). Tourniquet time (93.4± 20.5 vs. 47.5± 9.9 min, P<0.0001), total anesthesia time (118.6±30.9 vs. 58.9±14.2, P<0.0001), direct cost ($1987 vs. $986, P<0.0001), and total cost ($5819 vs. $2887, P<0.0001) were all significantly lower in the simplified method group. No perioperative complications occurred in either group. At a mean follow-up of 2.1 years (range: 0.10 to 8.2 y), there were no differences in complications or secondary procedures. CONCLUSION:The simplified technique for TC coalition excision using converging Kirschner wires is associated with reduced operative time and cost without increased complications. This method provides a reproducible and efficient alternative to traditional resection techniques. LEVEL OF EVIDENCE:Level III-therapeutic.
Background: Vertebral body tethering (VBT) is a fusionless surgical technique used to treat adolescent idiopathic scoliosis (AIS). It is unclear what the optimal window is for surgical intervention using VBT. The purpose of this study is to report the rate of success following VBT in patients with open triradiate cartilage (OTC) and to report the rate of reoperation. Methods: A retrospective review was performed for patients with early-onset scoliosis (EOS) or AIS with OTC who underwent VBT from 2012 to 2020 with a minimum 2-year follow-up. Success was defined as curves <35 degrees at the last follow-up. Failure was subdivided into undercorrection (curves ≥35 degrees at follow-up or reoperation for tether replacement or conversion to fusion) or overcorrection (curves ≥35 degrees in the contralateral direction or reoperation for tether release, or conversion to fusion). The major coronal curve was measured at preoperative, first erect, and annual visits thereafter. Binary logistic regression models were created to correlate demographic and radiographic variables with failed curve correction. Results: A total of 115 patients with OTC (60 EOS, 55 AIS) underwent thoracic VBT. Of these, 87% were female, and 91% of the female patients were premenarchal. The median preoperative Sanders score for all groups was 3. Surgery was successful in 64 patients (56%). Fifty-one patients were classified as treatment failures, 34 (29%) were the result of undercorrection, and 17 (15%) were the result of overcorrection. There was a significant difference in the initial thoracic major curve between success and undercorrection groups (53±10 degrees vs. 60± 8 degrees, P <0.05). There was also a significant difference in the first erect thoracic major curve between success and undercorrection (28±11 degrees and 36±9 degrees, P <0.01). There was a significant difference in the first erect percent correction between success and overcorrection (48±17% and 40±13%, P <0.04). Conclusion: VBT with OTC was successful in 56% of the cases. Undercorrection was associated with a thoracic bend of >51 degrees, percent thoracic correction <54%, and upright preoperative thoracic major curve >79 degrees. Overcorrection was associated with an upright preoperative thoracic major curve <46 degrees. Level of Evidence: Level IV.
BACKGROUND:Acetabular dysplasia is an important risk factor for hip complaints and osteoarthritis in (young) adults. Early identification during childhood is important, as timely intervention may prevent irreversible joint damage. Although traditionally considered an infant-onset condition, more recent evidence indicates that acetabular dysplasia can also develop later in childhood, yet its occurrence rate remains unknown. Existing prevalence estimates derive mainly from infants, adults, or selected clinical samples.This study aims to determine the prevalence and distribution of acetabular dysplasia in a large, multiethnic cohort of early adolescents, including key subgroup analyses. METHODS:This study was part of the Generation R study, an ongoing prospective population-based cohort study in Rotterdam (NL). In early adolescence, DXA imaging of the right hip was done, and the lateral center-edge angle (LCEA), as an indicator for acetabular roof coverage, was determined. Acetabular dysplasia was defined as LCEA <20.0 degrees. Prevalence was estimated and reported as a percentage with 95% CI in the overall population and subgroups. RESULTS:A total of 3896 participants were included with a mean age of 13.6 years (SD: 0.3 y) and 46.8% males. Overall prevalence of acetabular dysplasia was 6.4% (95% CI: 5.6-7.1). In multivariate analysis, sex assigned at birth and ethnicity had no statistical significant association with acetabular dysplasia, but prevalence was higher in skeletally immature compared with skeletally mature participants (OR=2.94). CONCLUSION:The prevalence of acetabular dysplasia was 6.4%. Skeletal immaturity was strongly associated with acetabular dysplasia. This prevalence is higher than in infants and comparable to adults, which suggests that acetabular dysplasia can develop later during childhood growth. LEVEL OF EVIDENCE:Level II.
STUDY DESIGN:Retrospective cohort study. INTRODUCTION:Cell saver (CS) is widely used in spinal fusion to reduce exposure to allogeneic transfusion, which carries risks such as infection and prolonged hospitalization. Pediatric spinal fusion is frequently associated with significant intraoperative blood loss. Concerns persist that reinfused blood could increase morbidity. We therefore evaluated the association between CS exposure and postoperative outcomes after pediatric spinal fusion using the American College of Surgeons National Surgical Quality Improvement Program Pediatric database. METHODS:Among patients who underwent spinal fusion surgery for pediatric spinal deformity between 2021 and 2023, CS exposure was categorized as none, low (<3.5 mL/kg), or high (≥3.5 mL/kg). Inverse probability of treatment weighting (IPTW) was used to balance demographics, comorbidities, and surgical complexity across groups. Logistic regression assessed outcomes, with global tests followed by Tukey-adjusted pairwise contrasts. The primary outcome was all-cause morbidity; secondary outcomes included reoperation rates, discharge to home, allogeneic transfusion, and other system-based complications. RESULTS:There were 20,376 patients included in this study (no CS: 6967; low CS: 6811; high CS: 6598). High CS patients had more complex baseline profiles, including higher ASA III-IV status (42.4% vs. 28.6% no CS, 26.3% low CS), neuromuscular scoliosis (27.4% vs. 15.9% and 11.6%), and ≥13 levels fused (52.8% vs. 26.3% and 33.6%; all P<0.001). After IPTW, all-cause morbidity did not differ significantly between groups (P=0.75). Respiratory, renal, and infectious complications, discharge to home, and reoperation were also not significantly different (all P>0.05). Neurological complications varied significantly (P=0.013), but only the high CS versus no CS comparison was significant (OR=1.60; P=0.015). Intraoperative allogeneic transfusion rates differed (P<0.001), with low CS associated with reduced rates (OR=0.62; P<0.001) and high CS with increased rates (OR=1.83; P<0.001). CONCLUSIONS:CS use was not associated with increased overall morbidity within 30 days. High CS volume identified a subgroup with higher odds of neurological complications and greater transfusion rates, likely reflecting residual confounding or bleeding severity rather than a direct CS effect. Low CS exposure was associated with reduced allogeneic transfusions. LEVEL OF EVIDENCE:Level III.
BACKGROUND:Developmental dysplasia of the hip (DDH) is increasingly recognized as a dynamic condition that may evolve after birth. This study aims to evaluate the natural history of hips with normal or borderline findings on early ultrasound and to identify imaging features associated with late-presenting acetabular dysplasia. METHODS:We retrospectively reviewed the medical records of children who underwent hip ultrasonographic screening between March 2020 and February 2023. Children with Graf type I hips who had pelvic radiographs after 2 years of age were included. Graf type I hips were further subdivided into 4 subgroups according to the β angle (≤55 or >55 degrees) and the bony rim morphology (blunt or sharp). Acetabular index was measured and evaluated on the final follow-up pelvic radiographs, and acetabular dysplasia was defined as an AI >2 SDs above the mean. RESULTS:A total of 87 children (174 hips) met the inclusion criteria. The mean age at the final ultrasound was 17.2±5.7 weeks, the mean α angle was 66.4±2.5 degrees, and the mean β angle was 52.9±4.0 degrees (range: 41.0 to 63.4 degrees). The mean age at the final radiographic follow-up was 2.9±0.6 years. Twenty-two hips were classified as acetabular dysplastic. There was a significant association between sex and acetabular dysplasia (χ2=7.19; P=0.007; OR=6.17; 95% CI: 1.39-27.38). A blunt bony rim on the final ultrasound examination was identified in 29 hips and was strongly associated with acetabular dysplasia (χ2=26.02; P<0.001; OR=9.53; 95% CI: 3.58-25.37). CONCLUSIONS:Graf type I hips with a blunt bony rim may not be entirely equivalent to mature, normal hips and may represent a subgroup susceptible to developing acetabular dysplasia during growth. Careful surveillance of hips with subtle morphologic abnormalities, particularly in female children, may therefore be warranted to facilitate early detection of acetabular dysplasia. LEVEL OF EVIDENCE:Retrospective level III.
BACKGROUND:Assessment of idiopathic scoliosis (IS) relies on radiographs and measurement of coronal curve magnitude, but repeated radiation exposure raises safety concerns in children. Noninvasive surface topography (ST) combined with machine learning (ML) has emerged as a potential radiation-free alternative for estimating curve severity, predicting coronal curve magnitude (Cobb angle), and monitoring longitudinally. This review aims to systematically review current evidence on the application of ML techniques to ST-based assessment of IS. METHODS:This systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, Embase, Scopus, Cochrane Library, and Web of Science were searched from database inception through August 2025 for studies applying ML algorithms to noninvasive ST methods in IS. Extracted data included study design, patient characteristics, surface acquisition techniques, ML model architecture, validation strategies, and performance metrics. Methodological quality and risk of bias were assessed using the QUADAS-2 tool. RESULTS:Twelve studies met the inclusion criteria, encompassing 5015 patients and more than 6000 trunk surface scans. ST techniques included laser scanning, Moiré topography, raster stereography, depth sensors, and markerless 3D imaging. ML models demonstrated high accuracy in estimating curve severity and predicting coronal curve magnitude, with mean absolute errors of ∼3 to 6 degrees and sensitivities exceeding 0.9, approaching the variability of radiographic measurements. Curve-type classification showed lower and more heterogeneous performance, whereas binary classification models demonstrated strong potential for radiation-free screening and follow-up. CONCLUSIONS:ML applied to ST represents a promising noninvasive and radiation-free approach for IS assessment. Current evidence supports clinically meaningful performance in estimating curve severity and coronal curve magnitude, although limitations persist in classifying curve type. Larger prospective and multicenter studies are needed to validate these methods and define their role in clinical practice. LEVEL OF EVIDENCE:Level III.
BACKGROUND:The Silent Messenger is a widely recognized sculpture displayed at Shriners Hospitals for Children and Shriners temples across North America. Inspired by Randy Dieter's 1970 photograph of Shriner Al Hortman carrying young Bobbi Jo Wright and her crutches, the image evolved into a symbol of compassion, service, and pediatric orthopaedic care. This study examines the sculpture's historical development, visual composition, and relevance to pediatric orthopaedics. METHODS:A historical and visual analysis was conducted using archival accounts, organizational records, and contemporary installations, including the original bronze sculpture by Fred Guentert, its 1993 placement at Shriners International Headquarters in Tampa, Florida, and the 2018 red cedar wood interpretation created for the Alaska Shriners. RESULTS:The sculpture's naturalistic depiction of a caregiver carrying a child with crutches conveys themes central to pediatric orthopaedics: mobility challenges, vulnerability, trust, and the collaborative journey toward recovery. For observers, the work provides an immediate message of safety and hope. For Shriners, it embodies the fraternity's core belief: to lift up children, no matter the weight, distance, or journey, and serves as a lasting emblem of compassion in action, brotherhood in service, and hope in every step. CONCLUSION:The Silent Messenger functions as both a narrative of pediatric disability and a visual mission statement for Shriners International. By portraying support, resilience, and the promise of healing, the sculpture reflects the foundational goals of pediatric orthopaedics: restoring function through compassionate, coordinated care. LEVEL OF EVIDENCE:Level V (expert opinion/historical analysis).
BACKGROUND:Management of pediatric fractures continually evolves, with a documented shift toward removable devices, such as splints, braces, or boots, for stable injuries. However, there is a need to evaluate current practice patterns. METHODS:A self-administered, 22-question online survey was open to all practicing orthopaedic surgeon members of Pediatric Orthopaedic Surgeons of North America (POSNA) between June and September 2025. Questions were consistent with a previous 2015 survey. Demographic information, immobilization practices, comfort with removable devices, complications, and barriers were analyzed and compared with 2015 data. RESULTS:A total of 323/865 (37.3%) invitees responded, with well-distributed experience levels, and 165 (56.9%) belonged to a university-affiliated practice. A total of 293 (95.1%) completed their pediatric fellowship, and 132 (45.4%) reported that their practice has an accepted standard of treatment for these fractures. A total of 256 respondents (87.7%) would treat distal radius buckle fractures with a removable device, which is significantly different than 2015, when 29.1% of respondents would treat these injuries with a removable device (P<0.001). Removable devices were not commonly used for greenstick [40 (13.7%)] or transverse [5 (1.7%)] fractures. Cast utilization decreased in both radius and fibula fractures, with the most pronounced reduction observed in distal fibula avulsion fractures, declining over 9-fold. Respondents were likely to prescribe a cast in 5.9% of fibula avulsion fractures, followed by 17.0% in Salter-Harris I and 38.5% in Salter-Harris II fractures. Concerns regarding patient family preference 170 (58.0%), patient compliance 158 (53.9%), and complications 91 (31.1%) are the most common reported barriers to using a removable form of immobilization. Although patient complications were listed as a potential barrier for 91 (31.1%) respondents, the perceived risk of complications was reported as "very low" for distal radius buckle [280 (96.2%)] and greenstick [91 (31.4%)] fractures. Transverse fractures were considered to have a moderate risk for complications [130 (44.8%)]. CONCLUSIONS:Compared with 2015, an increased utilization of removable devices for minimally displaced common pediatric fractures was seen. Barriers were patient or family compliance and preference, and concern for potential complications, highlighting the importance of education and shared decision-making. CLINICAL RELEVANCE:It is important to evaluate the current state of evidence-based practice regarding the use of removable devices for pediatric fractures. Addressing barriers such as patient and family compliance, preferences, and concerns about complications through targeted education may improve adherence and optimize clinical outcomes.
BACKGROUND:Web creep following syndactyly release is a well-documented problem, yet studies focusing on simple syndactyly are limited. While numerous approaches, including local flaps and skin grafts, have been proposed for skin coverage, existing research lacks sufficient power or follow-up duration to accurately assess web creep rates. This study aimed to compare web creep outcomes between skin graft-sparing local flaps and full-thickness skin grafts after simple syndactyly release. METHODS:This is a single-institution, retrospective review encompassing patients identified using CPT codes 26560 and 26561 from 2006 to 2024. Inclusion criteria were patients with simple syndactyly with at least 2 years of follow-up and younger than 18 years of age at initial surgery. We collected patient demographics, age at surgery, reoperation timing, web space location, and length of follow-up from the medical record. RESULTS:A total of 42 patients contributing to 66 web commissures (n=32 skin-graft sparing, n=34 full-thickness skin graft) were included in our analysis with an average follow-up length of 7.20±3.77 years. There were no significant differences in age at initial surgery, sex, race, hand, location of web spaces, or length of follow-up between groups. There was a significant difference in complete versus incomplete syndactyly, with 7/34 (20.6%) incomplete webs in the skin-graft group versus 27/34 (79.4%) with complete (P=0.02). Reoperation rates for web creep between the skin graft-sparing local flaps versus full-thickness skin grafts were found to be 34.4% (11/32) and 29.4% (10/34), respectively, having no significant difference (P=0.793), with an average of 31.8% reoperation across both groups. CONCLUSION:Our findings revealed no difference in reoperation rates between skin graft-sparing local flaps and full-thickness grafts, suggesting that both treatments effectively cover simple syndactyly release without added web creep risk. This may guide decisions on the necessity of the additional morbidity associated with skin graft harvesting. LEVEL OF EVIDENCE:Level III, retrospective cohort study.
BACKGROUND:Cast saw burns (CSBs) are a preventable, iatrogenic complication that may occur during bivalving or removal of fiberglass casts. Children undergoing fracture reduction with the use of procedural sedation, typically in the emergency department (ED), are at heightened risk for CSBs because they cannot provide real-time pain feedback during cast saw use. While prior investigations have examined the effects of cast material, cast thickness, and water dip temperature, the comparative thermal performance of commercially available cast padding products during cast bivalving has not been systematically evaluated. This study used thermal probes to compare measured temperatures beneath 2 widely used cast padding products, Webril (Kendall/Cardinal Health) and Specialist (BSN Medical), during a standardized cast application, molding, and bivalving protocol. METHODS:A custom upper-extremity model was instrumented with 2 calibrated thermocouples (labeled "near" and "far"). Twenty experimental runs were performed, 10 each per padding product, with bivalving performed separately for near and far probes (N=40 total). Temperatures were recorded at 3 time points: baseline (before the application of any materials), prebivalve (immediately after fiberglass application ), and at maximum temperature during bivalving with an oscillating cast saw. The primary outcome was the change in temperature from prebivalve to maximum bivalve temperature (ΔT) measured by near and far probes. Secondary outcome included maximum temperatures relative to established burn injury thresholds. RESULTS:The mean ΔT during bivalving was 13.2±13.0°C for Specialist padding and 13.0±6.9°C for Webril padding (P=0.95). The mean absolute maximum temperature was 40.8±13.2°C for Specialist and 39.5±6.8°C for Webril. In the Specialist group, 6/10 runs exceeded the 44°C adult burn threshold on at least one probe, compared with 4/10 runs in the Webril group. Linear mixed-effects analysis with Kenward-Roger degrees of freedom revealed a significant material×probe interaction during bivalving (P=0.020): at the near probe, Specialist peak temperatures averaged 8.5°C higher than Webril (P=0.041), whereas the 2 materials did not differ significantly at the far probe (P=0.146). CONCLUSION:Maximum temperatures exceeded clinically relevant burn thresholds in both cast padding groups, supporting the high-risk thermal environment at cast mold sites during bivalving. While Webril had some protective effect, neither commercially available cast-padding product provided consistently sufficient or statistically superior thermal protection. LEVELS OF EVIDENCE:Not applicable (biomechanical study).
BACKGROUND:The association between congenital talipes equinovarus (CTEV) and developmental dysplasia of the hip (DDH) remains contested. Some guidelines consider idiopathic clubfoot a DDH risk factor warranting routine hip ultrasonography, while others do not. This study aimed to determine the prevalence of DDH in a large cohort of infants with idiopathic CTEV and assess whether routine screening is justified. METHODS:A retrospective review of prospectively collected data was conducted at a single tertiary pediatric orthopaedic center. Children treated for idiopathic CTEV between July 2000 and November 2023 with a minimum 2-year follow-up were included. Teratologic and syndromic cases were excluded. All patients underwent routine hip ultrasonography at 6 weeks of age, classified by the Graf method. Hips graded Graf type 2B or higher received treatment. RESULTS:A total of 515 patients (766 feet; 72% male) were included. Mean age at initiation of Ponseti casting was 14 days (SD: 14.2); mean follow-up was 7.3 years (SD: 4.1). DDH was identified in 4 patients (0.78%): 1 male (0.27%) and 3 females (2.05%). All 4 were classified as Graf type 2B or 2C; no frank dislocations were observed. DDH was successfully managed concurrently with CTEV treatment in all cases, with no recurrence. CONCLUSIONS:In this largest single-center series to date, the prevalence of DDH in idiopathic CTEV was comparable to population norms, indicating that idiopathic clubfoot is not an independent risk factor for DDH. These findings do not support routine hip ultrasound screening based on a clubfoot diagnosis alone in selective screening systems, though no change is warranted in universal screening systems. This may not apply to syndromic clubfoot, which was not evaluated here. LEVELS OF EVIDENCE:Level III-retrospective review of a prospective cohort.
BACKGROUND:Preaxial polydactyly is a common congenital hand anomaly with substantial anatomic variability. Although several classification systems exist, the relationship between anatomic subclassification and postoperative outcomes remains incompletely defined. This study evaluated clinical and radiographic outcomes after surgical reconstruction, compared associations of the Wassel-Flatt (WF) and JK classifications with outcomes, and assessed the Japanese Society for Surgery of the Hand (JSSH) and Rotterdam scoring systems. METHODS:We retrospectively reviewed 58 patients (59 thumbs) treated surgically between 2012 and 2024. Thumbs were classified using the WF and JK systems. Final outcomes included range of motion, alignment, stability, JSSH and Rotterdam scores, and reoperation. Associations with classification subtype, surgical procedures, and temporary transarticular K-wire fixation were analyzed at the thumb level. RESULTS:WF type IV and JK type IV were the most common categories. Total range of motion exceeded 70 degrees in 39 thumbs, and joint stability was preserved in 52. Fifty-three thumbs had good or excellent outcomes acoording to JSSH criteria; the mean Rotterdam score was 27.1±2.5. Eleven thumbs were classified differently by the 2 systems. Of 29 WF type IV thumbs, 26 remained JK type IV and 3 were reclassified as JK type VIIB; the latter had lower JSSH total and functional scores. Overall, the JK classification was associated with postoperative alignment and JSSH total score, although the small type VIIB subgroup limits interpretation. Temporary K-wire fixation was associated with lower interphalangeal joint and total range of motion and lower functional scores; however, confounding by deformity severity and reconstruction complexity cannot be excluded. No reoperations were required during the available follow-up period. CONCLUSIONS:Surgical reconstruction yielded favorable outcomes in most patients. The JK classification provided additional anatomic granularity, particularly by identifying a small type VIIB subgroup within heterogeneous WF categories, but its prognostic value requires validation in larger cohorts. Temporary K-wire fixation was associated with reduced postoperative motion without establishing causation. The JSSH and Rotterdam instruments provided complementary outcome assessment. LEVELS OF EVIDENCE:Level III-retrospective comparative study.
PURPOSE:Rigo Chêneau-style orthoses (RCSOs) have gained popularity for treating adolescent idiopathic scoliosis (AIS) due to their emphasis on 3-dimensional correction. However, previous studies lack objective measures of brace wear compliance and have not described in-brace correction (IBC) thresholds associated with treatment success. This study evaluated the relationship between IBC, brace wear, and treatment outcomes in AIS patients treated with RCSOs. METHODS:A retrospective review at a single academic institution included skeletally immature patients aged 10 to 18 years with AIS and a major curve of 20 to 40 degrees, who underwent full-time RCSO treatment with thermal wear-time sensors. Patients were followed until skeletal maturity or progression to surgery. Treatment success was defined as a change of ≤5 degrees in the major curve at the latest follow-up. Multivariable logistic regression identified predictors of treatment success. RESULTS:Fifty patients (45 females, 90%) were included, with 36 (72%) classified as Sanders stage 3 and a mean age at brace initiation of 12.4±1.2 years (range: 10.1 to 15.5). The mean baseline major curve was 31±5 degrees with an IBC of 55±20%. The mean brace wear was 11.7±3.6 hours per day. At a mean follow-up of 3.0±0.9 years (range: 1.1 to 5.3), 43 patients (86%) avoided surgery and 36 (72%) met criteria for treatment success, with a mean major curve of 32±12 degrees. Greater IBC (60% vs. 40%, P<0.001) and brace wear (12.4 vs. 10.0 h, P=0.034) were associated with treatment success in univariate analysis, with IBC remaining an independent predictor in multivariable analysis (P=0.013). An IBC ≥45% was associated with treatment success (AUC=0.79). Patients achieving ≥45% IBC (n=33) demonstrated significantly higher success rates (88% vs. 41%, P<0.001) and lower rates of progression to surgery (6% vs. 29%, P=0.037). CONCLUSIONS:In this study, which included objective compliance data, 3-dimensional RCSO bracing in AIS was associated with high rates of treatment success. Greater IBC and brace wear were associated with improved outcomes, with IBC emerging as the primary independent predictor of success. An IBC of 45% was associated with improved outcomes and may represent a clinically meaningful target in modern 3-dimensional bracing. LEVEL OF EVIDENCE:Level IV.
BACKGROUND:To evaluate D-dimer levels in patients with slipped capital femoral epiphysis (SCFE), to investigate their association with disease severity and the development of contralateral slip, and to assess their contribution to existing predictive models. METHODS:In this single-center retrospective cohort study, 25 patients with unilateral SCFE diagnosed between January 2020 and April 2024 were included. The control group consisted of age- and sex-matched obese individuals and healthy subjects with normal body mass index (BMI). Clinical variables (age, sex, BMI, stability according to the Loder classification, and chronicity); laboratory parameters [complete blood count, neutrophil-to-lymphocyte ratio (NLR), inflammatory markers including C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR), and coagulation parameters including prothrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen, and D-dimer]; and radiographic measurements [Southwick angle, interhip angle difference, posterior sloping angle (PSA), and modified Oxford bone score (MOBS)] were analyzed. Subgroup analyses based on stability and chronicity were performed, and correlations between D-dimer levels and clinical, laboratory, and radiographic parameters were assessed. Multivariable logistic regression models were constructed to predict contralateral slip, and model performance was evaluated using receiver operating characteristic (ROC) curve analysis. RESULTS:D-dimer levels were significantly higher in the SCFE group compared with both obese and healthy control groups (P<0.001). D-dimer showed positive correlations with CRP and NLR and negative correlations with the MOBS and the interhip Southwick angle difference. Higher D-dimer levels were observed in unstable and acute-on-chronic cases (P<0.001). During a mean follow-up of 24 months, patients who developed contralateral slip had significantly higher D-dimer levels (P=0.002). The addition of Southwick angle difference to a baseline model including age and MOBS increased the AUC from 0.73 to 0.80, while further inclusion of D-dimer improved the AUC to 0.87. However, the increase in AUC after addition of D-dimer was not statistically significant according to the paired DeLong test (P=0.18). CONCLUSION:D-dimer levels are associated with disease severity and the risk of contralateral slip in SCFE. Incorporation of D-dimer into established clinical and radiographic parameters improved predictive model performance. These findings support the role of inflammatory and microvascular processes in the pathogenesis of SCFE and suggest that D-dimer may serve as a useful adjunct biomarker for risk stratification. LEVELS OF EVIDENCE:Level III-retrospective cohort study.
Background: Inequalities in the inclusion of male and female athletes have been documented in the sports medicine literature. However, the extent to which this phenomenon exists in studies of pediatric athletes remains poorly defined. The purpose of this study is to characterize the inclusion of male versus female athletes in pediatric sports medicine. Methods: All articles published from 2020 to 2024 in 12 top interdisciplinary sports medicine journals were manually reviewed, and results were reported following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) protocols. Inclusion criteria were: (1) full-text original research study, (2) isolated athletes, and (3) isolated a pediatric patient population. Exclusion criteria were: (1) editorial or review article, (2) case report with only one subject, and (3) cadaveric study. Data were collected to characterize study design, inclusion, and outcomes of interest. Statistical analysis was performed using the asymptotic χ 2 (Pearson) test as the default. To examine absolute inequality in the inclusion of male and female athletes, mean differences (MDs) were calculated from linear regression models for continuous outcomes. Results: Across 409 included studies, 30% enrolled only male athletes, 10% enrolled only female athletes, and 60% included both male and female athletes. The median inclusion was 61% male and 39% female (mean 64% and 36%, respectively). Among 234 studies that focused on a single sport, 48.7% included only males, 15.4% included only females, and 35.9% included both males and females ( P <0.001). Using MDs from linear regression, female athletes were shown to be underrepresented in study designs representing a higher level of evidence that analyzed variables such as patient-reported outcomes, injury, reinjury, or return to play. No difference in inclusion was seen in studies of mental health outcomes. Conclusion: Females are underrepresented in studies of youth athletes, particularly in single-sport studies and study designs with a higher level of evidence. Clinical Relevance: Given that there are known differences in sex-related outcomes, future research should prioritize equity in the inclusion of male and female athletes. Levels of Evidence: Level IV—systematic review.
BACKGROUND:Pelvic reconstruction is commonly performed to manage hip displacement in patients with cerebral palsy (CP), yet population-based outcome data remain limited. Most existing studies are from single centers and have limited generalizability. Here, we present a national descriptive study outlining outcomes of hip reconstruction in patients with CP. METHODS:A retrospective cohort study was conducted using the TriNetX Research Network, a federated database of 163 million patients across 117 US healthcare organizations. Patients aged 1 to 25 years with CP who underwent hip reconstruction between 2015 and 2022 were included. Outcomes assessed included hardware removal, hip dislocation, infection, and mortality, which were analyzed using the Kaplan-Meier method from 6 months to 3 years postoperatively. RESULTS:Among 1037 patients, 3-year cumulative incidence was 38.6% (95% CI: 35.6-41.7) for hardware removal, 38.5% (95% CI: 35.5-41.6) for hip dislocation, 3.6% (95% CI: 2.5-5.3) for infection, and 2.6% (95% CI: 1.8-3.9) for mortality. Temporal analysis revealed that hip dislocation occurred early, with 61% of events in year 1, whereas hardware removal was late-predominant, with 70% of events in years 2 to 3. Notably, 83% of infections presented after the first postoperative year (0.60% at 1 y vs. 3.6% at 3 y). CONCLUSIONS:This large-scale, population-based analysis of hip reconstruction outcomes in CP demonstrates high rates of hardware removal and hip dislocation, and that 83% of hardware-associated infections present after the first postoperative year. These findings suggest that long-term hip surveillance may be warranted after reconstruction. Prospective studies are needed to validate these findings and inform targeted prevention strategies. LEVEL OF EVIDENCE:Level III.
BACKGROUND:Serial casting can effectively treat early-onset scoliosis (EOS), thereby preventing or delaying the need for surgery. Reported complications range from pressure sores to cardiac arrest. The modified Clavien-Dindo-Sink (mCDS) system has high reliability for grading complications following EOS surgery, but has not previously been used to classify complications of casting. We aimed to assess the utility of the mCDS system for grading complications of EOS casting and hypothesized that, with modifications, it would be a valid system for assessing these complications. METHODS:This was a multicenter retrospective study. Patients aged 10 years or younger who underwent ≥1 cast application for EOS treatment were included. Demographics, radiographic data, casting details, complications, and unplanned procedures were collected. Two authors (E.S. and M.H.) reviewed complications and assigned a mCDS grade to each. RESULTS:One thousand twenty patients (5605 casts) were included. Two hundred forty-four casting-related complications in 159 patients were analyzed. 15.6% of patients (n=159) had a complication, and 47 patients (4.6%) had >1 complication. Fifteen complications were categorized as mCDS grade I (6.1%), 192 as grade II (78.7%), 5 as grade IIIa (2.0%), 28 as grade IIIb (11.5%), 4 as grade IVa (1.6%), and 0 as grade IVb or grade V (0%). The most common reason for a grade IIIb complication, which is an unplanned procedure, was early cast removal necessitating early cast re-application (25/28 patients). CONCLUSIONS:Most casting complications in our cohort were grades II and IIIb. The mCDS system, in its current state, may not accurately describe the complications of casting. Although a grade IIIb complication after casting results in an additional procedure requiring anesthesia, an unplanned return to the operating room after surgery is likely associated with greater morbidity than an unplanned cast re-application. Using the mCDS system to compare casting with surgery risks overstating the severity of casting complications and may inadequately represent outcomes. We propose modifying the mCDS system for casting. LEVEL OF EVIDENCE:Level III-therapeutic.
BACKGROUND:Nonspecific back pain is increasingly encountered in pediatric orthopaedic clinics. These visits are often complex and time-intensive, yet surgical intervention is rarely indicated. This study describes the characteristics of patients presenting with back pain at a single pediatric institution and examines associated biopsychosocial factors. METHODS:An IRB-approved retrospective review was conducted of patients aged 7 to 22 years presenting with back pain to pediatric orthopaedic and sports medicine clinics in 2021. Demographic, clinical, imaging, and behavioral health data were extracted from the electronic medical record. Patients were categorized based on the presence or absence of structural spine diagnoses. Comparative analyses were performed between groups. Multivariable logistic regression was used to identify independent predictors of persistent symptoms at follow-up. RESULTS:A total of 869 patients were included [mean age: 15.0±2.6 y; 537 (61.8%) female]. Chronic back pain was present in 631 patients (72.6%), and structural diagnoses were identified in 327 patients (37.6%), most commonly spondylolysis (14.6%) and scoliosis (14.3%). Behavioral health diagnoses were documented in 328 patients (37.7%). Pain severity did not differ significantly between patients with and without structural diagnoses (5.6±2.3 vs. 5.5±2.2; P=0.07). However, patients without structural diagnoses demonstrated significantly higher rates of behavioral health conditions (41.2% vs. 32.1%; P<0.001), including depression, ADHD, behavioral concerns, and suicidal ideation. On multivariable analysis, behavioral health diagnoses were independently associated with persistent symptoms (adjusted OR: 1.78, 95% CI: 1.32-2.41; P<0.001), whereas structural diagnosis was not (adjusted OR: 0.89, 95% CI: 0.65-1.23; P=0.48). Higher pain severity was also associated with symptom persistence (adjusted OR: 1.12 per point increase, 95% CI: 1.05-1.20; P=0.001). CONCLUSIONS:In pediatric back pain, structural pathology was not independently associated with symptom persistence. Behavioral health factors demonstrated stronger associations with symptom burden and clinical outcomes, supporting a biopsychosocial model of care. Routine integration of behavioral health assessment may improve management and reduce persistent symptoms in this population. LEVELS OF EVIDENCE:Level III-retrospective cohort study.
Purpose: Some patients with familial Synpolydactyly Type I have severe flexion deformities of the hands and feet at the metacarpophalangeal and the metatarsophalangeal joints, and the resulting deformity has been named “cupping” of the hands and feet. Severe “cupping” requiring surgical correction has not been previously reported. We explore the embryology and pathogenesis of the phenotype and present the surgical technique and results after the correction of the cupping deformity in a case series of 3 children. Patients and Methods: Two children had severe deformity of the postaxial toes, and they were stepping on the dorsal aspect of these rays. Correction was done with dorsal wedge osteotomies of the metatarsals. One child required correction of 1 hand. He underwent syndactyly release, release of the tight volar skin at the metacarpophalangeal joints, and volar plate release of the metacarpophalangeal joints. Results: Partial correction of the deformity was achieved in all 3 children. All children were followed up for more than 5 years. The former 2 children were stepping on the plantar aspect of the toes, and the latter child was using his hand well in daily activities. All parents were satisfied with the results. Conclusion: Cupping of the hands and feet is severe enough to require surgery in some patients with familial Synpolydactyly Type I. Our surgical technique partially corrects the deformity, but it resulted in a good functional outcome. Level of Evidence: Level IV—case series.
