Journal of Pediatric Orthopaedics最新文献

Objectives: The first case report describing a pediatric fracture of the tibial tubercle was published in 1852 in the Medical Times and Gazette, a Journal of Medical Science, literature, criticism, and news. A century later, in 1955, Sir Watson-Jones introduced the first classification system for this fracture. Despite the existence of several classification systems for pediatric tibial tubercle fractures in the medical literature, a crucial aspect of their validation-reliability and reproducibility-has not yet been systematically evaluated.

Methods: In this study, a modified Watson-Jones (mWJ) classification system of tibial tubercle fractures in children was assessed for intraobserver and interobserver variability. Using the mWJ classification, 3 board-certified pediatric orthopaedic surgeons and 3 orthopaedic surgery residents, classified thirty tibial tubercle fractures based on anteroposterior and lateral radiographs on 2 separate occasions in a 2-week duration. Further comparison was made to evaluate the impact of advanced imaging, specifically computed tomography or magnetic resonance imaging, on diagnostic reliability and reproducibility.

Results: The study found substantial intraobserver reliability of the mWJ classification based on radiographs alone, with a Cohen weighted kappa (κ w ) coefficient of 0.733. When advanced imaging was utilized, the reliability of the classification improved to κ w = 0.783. Similarly, interobserver reliability demonstrated substantial consistency among observers when using radiographs alone (κ w = 0.69) and improved agreement with advanced imaging (κ w = 0.75). Notably, there was no significant difference in reliability scores between senior-level attendings and residents when analyzed as separate groups.

Conclusion: Fracture classification systems are clinically relevant tools that help organize and transfer knowledge efficiently, provide treatment guidance, propose prognostic expectations, and improve communication in academic literature. The present study demonstrated substantial reproducibility of an mWJ fracture classification system both between and within individual surgeon raters.

Level of evidence: Level III-diagnostic.

Background: Shortening of midshaft clavicle fractures has been described as a critical fracture characteristic to guide treatment. The degree to which shortening may change in the initial weeks following injury has not been well studied. The purpose of this study was to evaluate the change in shortening of adolescent clavicle fractures in the first 2 weeks following injury.

Methods: This was a multicenter study of prospectively collected data, which was acquired as a part of a cohort study of adolescent clavicle fractures. A consecutive series of patients 10 to 18 years of age with completely displaced diaphyseal clavicle fractures with baseline radiographs 0 to 6 days from the date of injury, as well as 7 to 21 days from the date of injury, were included. Measurements of end-to-end (EES) and cortex-to-corresponding-cortex (CCS) shortening were performed.

Results: A total of 142 patients were included. Baseline radiographs were obtained at a mean of 1.0 day following injury with mean EES of 22.3 mm, and 69% of patients demonstrating > 20 mm of shortening. Follow-up radiographs obtained at a mean of 13.8 days postinjury demonstrated a mean absolute change in EES of 5.4 mm. Forty-one percentage of patients had >5 mm of change in EES. When analyzing changes in shortening relative to the specific threshold of 20 mm, 18 patients (41%) with <20 mm EES increased to ≥20 mm EES, and 19 patients (19%) with ≥20 mm EES decreased to <20 mm EES at 2-week follow-up.

Conclusions: Clinically significant changes in fracture shortening occurred in 41% of adolescents with completely displaced clavicle fractures in the first 2 weeks after injury. In 26% of patients, this resulted in a change from above or below the commonly used shortening threshold of 20 mm, potentially altering the treatment plan by many providers. There is no evidence to suggest that adolescent clavicle fracture shortening affects outcomes, and as such, the authors do not advocate for the use of this parameter to guide treatment. However, among physicians who continue to use this parameter to guide treatment, this study supports that repeat radiographic assessment 2 weeks postinjury may be a better measure of the true shortening of this common adolescent injury.

Level of evidence: Level IV-case series.

Background: Although adolescent flexible flatfoot deformity (FFD) is common, little is known regarding the effect of weight on associated symptomatology. This study uses pedobarography and patient-reported outcome measures (PROs) to determine if overweight adolescents with FFD have more severe alterations in dynamic plantar pressures than normal body mass index percentiles (wnBMI) with FFD and if such alterations correlate with pain and activity.

Methods: A retrospective review of patients aged 10 to 18 years with nonsyndromic symptomatic FFD was performed. Overweight (BMI percentile ≥ 85%) patients were compared with wnBMI patients with regard to dynamic plantar pressure measures and PRO scores. Pedobarographic data were subdivided into regions: medial/lateral hindfoot and midfoot, and first, second, and third to fifth metatarsals. Plantar pressure variables were normalized to account for differences in foot size, body weight, and walking speed. Contact area (CA%), maximum force by body weight (MF%), and contact time as a percentage of the rollover process (CT%) were calculated. Two foot-specific PROs were assessed, including the Foot and Ankle Outcome Score and the Oxford Ankle Foot Measure for Children.

Results: Of the 48 adolescents studied, 27 (56%) were overweight and 21 (44%) were wnBMI. After normalization of the data, overweight patients had significantly greater medial midfoot MF%, whereas CT% was increased across the medial and lateral midfoot and hindfoot regions. Correlations showed positive trends: as BMI percentile increases, so will CA and MF in the medial midfoot, as well as CT in the medial and lateral midfoot and hindfoot. Significant differences were seen between groups, with the overweight group reporting lower sports and recreation subscores than the wnBMI group. No significant differences were seen in the pain and disability subscores.

Conclusions: Although overweight adolescents with FFD exhibit greater forces and more time spent during the rollover process in the medial midfoot than normal-weight patients, they did not report worse pain or disability associated with their flat foot deformity.

Level of evidence: Therapeutic level 3.

Background: To lessen surgical times for patients with adolescent idiopathic scoliosis (AIS) undergoing posterior spinal instrumentation and fusion (PSIF), our department developed a quality improvement initiative where 2 AIS cases were completed in 1 day by the same 2 surgeons operating together in 1 operating room (OR). We describe the results of this initiative, comparing operative times and outcomes to cases of these surgeons operating individually.

Methods: From 2017 to 2023, patients aged 10 to 18 years with AIS undergoing PSIF were prospectively enrolled for "Two Spine Tuesday." Patients were matched by age, sex, curve severity, and number of levels fused to historical AIS controls. Outcomes included surgery time, total OR time, estimated blood loss (EBL), volume of cell saver transfused, allogenic blood transfusion, length of stay, 90-day readmissions, Clavien-Dindo-Sink Complication Classification System complication rates, and percentage who achieved the minimal clinically important difference (MCID) for SRS-22.

Results: Fifty-five patients composing the 2-spine group (group 2) were compared with 55 historical sex-matched and age-matched controls (group 1). Major coronal curve and average number of levels fused were similar between groups. Overall surgery time (203 vs. 296 min, P <0.001), total OR time ( P <0.001), and EBL (400 vs. 550 mL, P <0.001) were lower for group 2. Group 2 had fewer complications [n=17 (31%) vs. n=28 (51%), P =0.03].

Conclusions: Performing 2 AIS cases in 1 OR by 2 surgeons the same day resulted in shorter surgery times, less total time in the operating room, lower complication rates, and less blood loss compared with single-surgeon matched controls.

Level of evidence: Level III-retrospective comparative study.

Objective: Pulmonary function can be impaired in patients with adolescent idiopathic scoliosis (AIS). Maximal voluntary ventilation (MVV) has been shown to be more strongly correlated with major coronal curve, and a more easily obtained measurement of pulmonary function, than forced vital capacity (FVC). We evaluated changes in pulmonary function using these 2 measures in patients with AIS in relation to changes in major coronal curves over time.

Methods: Forty-seven patients with AIS with thoracic curves ≥10 degrees performed pulmonary function tests using the Carefusion MicroLoop Spirometer at enrollment and 1 year later. Major coronal curve worsening >5 degrees was considered curve progression.

Results: At enrollment, 47 patients had a mean major coronal curve of 38 degrees (range: 10 to 76 degrees). One year later, 17 patients had undergone posterior spinal fusion, 9 had curve progression >5 degrees, and 21 had no progression. MVV and major coronal curve were negatively correlated (r = -0.36, P = 0.01) at enrollment. After fusion, the major coronal curve improved by a mean of 41 degrees, and MVV improved by 23% (P < 0.01), but FVC did not improve significantly (6%, P = 0.29). In stable curves, MVV improved 12% (P = 0.01) and FVC improved 9% (P = 0.007). In patients without surgery whose curves progressed an average of 11 degrees, there was no significant change in MVV or FVC (P > 0.44).

Conclusion: This is the first study using office-based spirometry in an orthopaedic clinic showing improved pulmonary function with posterior spinal fusion and growth in patients with AIS. It is notable that MVV improved after spinal fusion, but FVC did not, as MVV appears to be a more sensitive measurement for the assessment of pulmonary function in these patients.

Level of evidence: Level II.

Background: Artificial intelligence (AI) represents and exciting shift for orthopaedic surgery, where its role is rapidly evolving. ChatGPT is an AI language model which is preeminent among those leading the mass consumer uptake of AI. Artamonov and colleagues compared ChatGPT with orthopaedic surgeons when considering the diagnosis and management of anterior shoulder instability; they found a limited correlation between them. This study aims to further explore how reliable ChatGPT is compared with orthopaedic surgeons.

Methods: Twenty-three statements were extracted from the article "Building Consensus: Development of a Best Practice Guideline (BPG) for Surgical Site Infection (SSI) Prevention in High-risk Pediatric Spine Surgery" by Vitale and colleagues. These included 14 consensus statements and an additional 9 statements that did not reach consensus. ChatGPT was asked to state the extent to which it agreed with each statement.

Results: ChatGPT appeared to demonstrate a fair correlation with most expert responses to the 14 consensus statements. It appeared less emphatic than the experts, often stating that it "agreed" with a statement, where the most frequent response from experts was "strongly agree." It reached the opposite conclusion to the majority of experts on a single consensus statement regarding the use of ultraviolet light in the operating theatre; it may have been that ChatGPT was drawing from more up to date literature that was published subsequent to the consensus statement.

Conclusions: This study demonstrated a reasonable correlation between ChatGPT and orthopaedic surgeons when providing simple responses. ChatGPT's function may be limited when asked to provide more complex answers. This study adds to a growing body of discussion and evidence exploring AI and whether its function is reliable enough to enter the high-accountability world of health care.

Clinical relevance: This article is of high clinical relevance to orthopaedic surgery given the rapidly emerging applications of AI. This creates a need to understand the level to which AI can function in the clinical setting and the risks that would entail.

Objective: Intramedullary rodding of lower extremity long bones in patients with osteogenesis imperfecta (OI) is a widely accepted technique for fracture treatment and prevention. Previous small studies with short to medium-term follow-up have shown that telescoping rods have longer survival times compared with static rods. However, there are no long-term studies (10 or more years) longitudinally evaluating the results of these procedures. The purpose of this study was to compare the rod survival duration and number of procedures in patients treated with static versus telescoping rods with 10 years minimum follow-up.

Methods: This was a multicenter retrospective comparative study of patients with a diagnosis of OI who had intramedullary nailing of the femur and/or tibia. Each bone included in the study had a 10-year minimum follow-up, only one type of rod utilized over the follow-up period, and no rod replacement surgeries outside of the primary hospital system. Patient demographics, clinical data, and details of each procedure were obtained. Groups were compared using univariate analysis with a 2-independent samples t test for continuous variables, χ2 for categorical variables, and the Kaplan-Meier method for survival analysis.

Results: A total of 119 bones in 52 patients met inclusion criteria. Average follow up was 13.1 (range: 10.2 to 18.4) years. There were no differences between groups in follow-up length, Sillence type, bisphosphonate use, or age at first-rod placement. There were significantly more tibias treated in the static rod group compared with the telescopic rod group. The average survival length was significantly longer for telescopic rods, 5.8 ± 3.9 years versus 4.0±3.6 years for static rods. On average, bones treated with telescopic rods had significantly fewer surgeries compared with static rods (2.2 ± 0.8 vs 3.3 ± 1.6).

Conclusion: At long term follow up, bone segments in patients with OI treated with telescopic rods required fewer surgeries and had longer implant survival times compared with those treated with static rods. When available, surgeons should consider telescopic rods as the initial implant choice in this patient population.

Purpose: The United States has seen an increase in opioid use and misuse over the last 2 decades. Infants have been impacted by the opioid epidemic, with a reported 5-fold increase in the incidence of neonatal abstinence syndrome (NAS) over the last 2 decades. There are many conditions associated with NAS, and thus, the current study sought to examine the association between NAS and clubfoot.

Methods: The study was retrospective, utilizing patient data from the Pediatric Hospital Information System (PHIS) database. Neonates presenting to any PHIS hospital between 2018 and 2022 were identified and included in the study. Patients with NAS and clubfoot were identified utilizing the International Classification of Diseases (ICD)-9 and 10 codes. Univariable and multivariable analyses were performed to investigate associations between clubfoot, race, ethnicity, insurance type, gestational age, length of stay, NAS, and comorbidity burden.

Results: A total of 458,274 patients were identified, of whom 2337 (0.5%) had a clubfoot diagnosis and 5431 (1.2%) had a diagnosis of NAS. Multivariable logistic regression revealed higher independent odds of clubfoot among patients with a diagnosis of NAS [odds ratio (OR): 1.49], patients with a greater number of comorbidities (OR: 4.75 for 1 comorbidity vs. none, and 21.19 for 2+ comorbidities, vs. none), patients with a greater gestational age (OR: 1.01 per week increase), and those with an increased length of stay (OR: 1.00 per day increase). A lower independent odds of clubfoot was observed among patients of Asian race (OR: 0.66), Hispanic/Latino ethnicity (OR: 0.80), non-Hispanic Black (OR: 0.75), and multiracial (OR: 0.80) ethnicity/race relative to non-Hispanic/Latino White patients (P<0.05 for all).

Conclusion: Patients with a diagnosis of NAS demonstrated higher odds of clubfoot, in addition to sociodemographic factors, as well as comorbidity burden.