Background: Developmental dysplasia of the hip (DDH) relies on early detection. At present, the American Academy of Pediatrics recommends ultrasound (US) screening for patients <6 months of age with breech gestation or a first-degree family history. However, little data exists on long-term surveillance strategies for these high-risk patients with a normal initial screening US. Currently, institutional surveillance includes a follow-up pelvic radiograph (PXR); however, its utility in detection remains unknown. Hence, the goal of this quality improvement initiative was to determine the rates of delayed DDH requiring surgical intervention in high-risk patients with normal screening US. Methods: This quality improvement project was a retrospective cohort review of infants referred to a single pediatric orthopaedic centre from 2020 to 2023 who underwent DDH US screening from 5 weeks to 6 months of age and had a normal initial US. Referral criteria included: (1) a first degree relative with DDH or (2) breech gestation. The primary outcome was the prevalence of treatment with either closed or open reduction and/or other surgical interventions. Patients were excluded if they were referred for concerning physical examination findings or if they did not have risk factors, teratologic DDH, syndromic conditions, or neuromuscular conditions. Results: A total of 4233 patients were referred for a screening US, and 2497 (59.0%) returned for a surveillance PXR at 12 to 18 months. After the first follow-up, 271 (6.4%) had borderline dysplasia, requiring annual PXR surveillance. Of them, 28 (0.7%) remained under active surveillance. Until January 2026, none of the 4233 patients with risk factors and a normal screening US developed dysplasia requiring treatment. Conclusions: In patients with risk factors for DDH, referred for screening with a normal US, annual PXR surveillance did not identify any cases of delayed DDH requiring treatment. A manual chart review of a subset of 100 patients validated the database search strategy and identified no missed cases. However, the possibility of undetected cases in the overall cohort cannot be excluded, although these are expected to be rare. This suggests that surveillance protocols may be safely reduced to limit radiation, unnecessary hospital visits, and parental anxiety. Level of Evidence: Level III—retrospective cohort.
Background: Adolescent idiopathic scoliosis (AIS), a condition that can affect body image and psychological well-being, can be treated with posterior spinal fusion (PSF) to prevent later pain and respiratory distress when curves become severe. Efforts have been made to identify factors associated with improved patient-reported outcomes (PROs) after PSF. Across other elective orthopaedic procedures preoperative expectations have been shown to be associated with PROs. A methodical way of measuring expectations is needed to develop methods to modify them and ultimately improve outcomes. The purpose of this study is to develop and validate a survey measuring patient and guardian expectations for PSF in patients with AIS. Methods: Patients undergoing PSF for AIS and their guardians were preoperatively interviewed to collect expectations. Qualitative research techniques were used to create two 10-item Likert-scale surveys, one for patients and one for guardians. To validate the surveys, additional patients/guardians completed the survey twice preoperatively a week apart. Cohen quadratic kappa was calculated for each survey item. Results: A total of 15 patients and guardians were included in the survey development phase and an additional 15 patients and guardians were included in the survey validation phase. The 3 most cited expectations in interviews were return to physical/sporting activities, improvement in pain, and changes in physical appearance. On the validation surveys, guardians had substantial to great agreement (average κ=0.74), and patients had moderate to great agreement (average κ=0.64). Patients and guardians had great agreement with each other (κ>0.8) on only one question—avoid future medical treatment—substantial agreement (κ=0.61 to 0.8) on 2 questions—be more confident in appearance and full recovery without mobility or appearance issues—and poor to moderate agreement (κ<0.6) throughout the rest of the survey. Conclusions: It is possible to develop a preoperative expectation survey in patients undergoing PSF for AIS. There is moderate to great agreement between baseline and validation surveys for patients and guardians, but patient and guardian expectations differ. These surveys can help surgeons better counsel families to align expectations and potentially improve outcomes and satisfaction after PSF. Level of Evidence: Level IV.
Background: Arthrofibrosis is a challenging complication that can occur after anterior cruciate ligament reconstruction (ACLR), restricting range of motion and impairing function. Risk factors have been identified for arthrofibrosis in adults, but data in pediatric patients are limited, particularly regarding the role of graft type. In this study, we compared clinical, surgical, and postoperative variables between pediatric patients who underwent ACLR with hamstring tendon (HT) autograft or quadriceps tendon (QT) autograft and assessed associations between arthrofibrosis development and postoperative clinical outcomes. Methods: We retrospectively compared data from 154 pediatric patients (mean±SD age 15.1±1.8 years; 46% female) who underwent primary ACLR using HT (n=84) or QT (n=70) autografts from June 2015 to June 2024. We excluded patients with concomitant ligament injuries, prior ACLR, lateral extraarticular tenodesis, chondral procedures, or <5-month follow-up. Arthrofibrosis was defined as loss of ≥10 degrees of knee extension, loss of ≥20 degrees of knee flexion, or mechanical symptoms. Statistical analyses comprised Fisher exact tests, t tests, and Wilcoxon rank-sum tests. α=0.05. Results: Compared with the HT group, the QT group had higher incidence of chondral injury (39% vs. 20%, P =0.020), higher incidence of positive Lachman test (100% vs. 85%, P =0.004), higher incidence of arthrofibrosis (7% vs. 0%, P =0.018), and a larger mean graft diameter (8.8±0.8 vs. 8.1±0.8 mm, P <0.001). The HT group had longer mean operative time (161±33 min) than the QT group did (142±35 min) ( P <0.001). P atients who developed arthrofibrosis had less knee extension at 5 months postoperatively (9±0.6 degrees vs. –0.4±2 degrees, P =0.018) and greater incidence of additional surgery (100% vs. 14%, P <0.001) compared with those who did not develop arthrofibrosis. Conclusions: In pediatric patients who underwent ACLR, QT autografts were associated with higher incidence of arthrofibrosis and postoperative stiffness compared with HT autografts. These results suggest that graft selection may influence postoperative motion and should be tailored to individual patient factors, including concomitant chondral injury and baseline ligamentous laxity. Level of Evidence: Level III.
Background: Tibial tubercle fractures (TTFs) are an uncommon injury among children, typically occurring in male adolescent athletes during physical activity involving jumping. These injuries may be treated nonoperatively, but operative treatment typically involves open reduction and internal fixation (ORIF). Outcomes following ORIF of TTFs have not been described in a large, population-based sample. The aim of this study was to evaluate demographic characteristics associated with TTFs and evaluate postoperative outcomes following ORIF. Secondarily, we aimed to determine the prevalence of pre-existing Osgood-Schlatter disease within this sample. Methods: The TriNetX US Collaborative platform was queried to identify patients 17 years old and younger with tibial tubercle fractures who received open reduction and internal fixation. Demographic factors like age, race, sex, and BMI were identified. Postoperative outcomes were evaluated at 30-day, 90-day, 180-day, and 2-year follow-up. A secondary analysis determining the prevalence of pre-existing Osgood-Schlatter disease (OSD) diagnosis within the sample was also performed. Results: Seven hundred ninety-six patients met the inclusion criteria. There were 708 (89%) male patients with a mean age of 13.7±1.3 years and 87 (11%) female patients with a mean age of 11.6±1.9 years. The mean BMI was 25.6±6.9, and the mean BMI percentile was 81±24. Rates of serious complications like compartment syndrome, SSI, and osteomyelitis remained uncommon throughout the study period at <1.5%. Revision ORIF was more common at 30-day follow-up (5.1%), and implant removal was prevalent at 2 years (13%). 51 (6.4%) patients had a previous OSD diagnosis. Conclusion: Similar to previous studies, our results demonstrate that males demonstrate significantly higher rates of tibial tubercle fractures. Treatment with ORIF is safe and generally exhibits low rates of postoperative complications. However, revision ORIF and postoperative implant removal were prevalent at short-term and long-term follow-up, respectively. Previous diagnosis of OSD was relatively uncommon, potentially due to undercoding. Levels of Evidence: Level III.
