Kohler Disease: Avascular Necrosis in the Child.
Foot and ankle clinics
2019; 24 (1): 83–88
Trans-metaphyseal Screws Placed in Children: An Argument for Monitoring and Potentially Removing the Implants.
Journal of pediatric orthopedics
Kohler disease is a childhood condition of pain and swelling of the medial midfoot with associated osteochondrosis or avascular necrosis of the tarsal navicular. The age at presentation is between 2 and 10 years, with boys more likely to be affected than girls. Radiographs show increased sclerosis and sometimes flattening and fragmentation of the navicular. Long-term outcomes for Kohler disease are favorable regardless of the type of treatment, although a short period of immobilization with a short leg walking cast may reduce the duration of symptoms.
View details for DOI 10.1016/j.fcl.2018.09.005
View details for PubMedID 30685015
A Structured Review Instrument Improves the Quality of Orthopaedic Journal Club.
Journal of surgical education
BACKGROUND: Surgeons frequently use trans-metaphyseal screws in children to achieve osteosynthesis after fractures or stability after reconstructive osteotomies. Screws that were initially inserted below the cortex of bone can become prominent and symptomatic due to the process of funnelization that narrows the wide metaphysis to the diameter of the thinner diaphysis.METHODS: Case series presentation of 11 children who presented with screw prominence after the cutback process range in age from 19 to 169 months. We used the screws as radiographic markers to quantitate the amount of bone "cutback" or lost during the process of funnelization.RESULTS: The average length of screw protrusion beyond the edge of the bone when symptomatic was 8.7mm (range, 3.3 to 14.3mm). Time from implantation to the last radiograph averaged 40 months (range, 19 to 84mo). The average loss of bone width at the time of presentation was 21% (range, 7% to 36%).CONCLUSIONS: These cases suggest that orthopaedic surgeons should consider monitoring children after implantation of trans-metaphyseal screws and informing parents and patients about the possibility of screw prominence necessitating removal due to the process of metaphyseal funnelization.LEVEL OF EVIDENCE: Level IV.
View details for DOI 10.1097/BPO.0000000000001280
View details for PubMedID 30379707
Fast Comprehensive Single-Sequence Four-Dimensional Pediatric Knee MRI With T-2 Shuffling
JOURNAL OF MAGNETIC RESONANCE IMAGING
2017; 45 (6): 1700-1711
Fast comprehensive single-sequence four-dimensional pediatric knee MRI with T2 shuffling.
Journal of magnetic resonance imaging : JMRI
OBJECTIVE: We asked the following questions: 1. Does the use of an structured review instrument (SRI) at journal club increase presentation quality, as measured objectively by a standardized evaluation rubric? 2. Does SRI use increase the time required to prepare for journal club? 3. Does SRI use positively impact presenter perceptions about confidence while presenting, satisfaction, and journal club effectiveness, as measured by postparticipation surveys?DESIGN: A prospective study was designed in which a grading rubric was developed to evaluate journal club presentations. The rubric was applied to 24 presentations at journal clubs prior to introduction of the SRI. An SRI was developed and distributed to journal club participants, who were instructed to use it to prepare for journal club. The grading rubric was then used to assess 25 post-SRI presentations and scores were compared between the pre- and post-SRI groups. Presentations occurred at either trauma, pediatrics, or spine subspecialty journal clubs. Participants were also surveyed regarding time requirements for preparation, perceptions of confidence while presenting, satisfaction, and perceptions of overall club effectiveness.SETTING: A single academic center with an orthopaedic surgery residency program.PARTICIPANTS: Resident physicians in the department of orthopaedic surgery.RESULTS: Mean presentation scores increased from 14.0 ± 5.9 (mean ± standard deviation) to 24.4 ± 5.2 after introduction of the SRI (p < 0.001). Preparation time decreased from a mean of 47 minutes to 40 minutes after SRI introduction (p = 0.22). Perceptions of confidence, satisfaction, and club effectiveness among trainees trended toward more positive responses after SRI introduction (confidence: 63% positive responses pre-SRI vs 72% post-SRI, p = 0.73; satisfaction: 64% vs 91%, p = 0.18; effectiveness: 64% vs 91%, p = 0.19).CONCLUSIONS: The use of a structured review instrument to guide presentations at orthopaedic journal club increased presentation quality, and there was no difference in preparation time. There were trends toward improved presenter confidence, satisfaction, and perception of journal club effectiveness. SRI utilization at orthopaedic journal club may be an effective method for increasing the quality of journal club presentations. Future work should examine the relationship between presentation quality and overall club effectiveness.
View details for DOI 10.1016/j.jsurg.2018.06.017
View details for PubMedID 30093334
Biomechanical and Clinical Correlates of Stance-Phase Knee Flexion in Persons With Spastic Cerebral Palsy
2016; 8 (1): 11-18
Caput valgum associated with developmental dysplasia of the hip: management by transphyseal screw fixation.
Journal of children's orthopaedics
2015; 9 (5): 371-379
To develop and clinically evaluate a pediatric knee magnetic resonance imaging (MRI) technique based on volumetric fast spin-echo (3DFSE) and compare its diagnostic performance, image quality, and imaging time to that of a conventional 2D protocol.A 3DFSE sequence was modified and combined with a compressed sensing-based reconstruction resolving multiple image contrasts, a technique termed T2 Shuffling (T2 Sh). With Institutional Review Board (IRB) approval, 28 consecutive children referred for 3T knee MRI prospectively underwent a standard clinical knee protocol followed by T2 Sh. T2 Sh performance was assessed by two readers blinded to diagnostic reports. Interpretive discrepancies were resolved by medical record chart review and consensus between the readers and an orthopedic surgeon. Image quality was evaluated by rating anatomic delineation, with 95% confidence interval. A Wilcoxon rank-sum test assessed the null hypothesis that T2 Sh structure delineation compared to conventional 2D is unchanged. Intraclass correlation coefficients were calculated for interobserver agreement. Imaging time of the conventional protocol and T2 Sh was compared.There was 81% and 87% concordance between T2 Sh reports and diagnostic reports, respectively, for each reader. Upon consensus review, T2 Sh had 93% sensitivity and 100% specificity compared to clinical reports for detection of clinically relevant findings. The 95% confidence interval of diagnostic or better rating was 95-100%, with 34-80% interobserver agreement. There was no significant difference in structure delineation between T2 Sh and 2D, except for the retinaculum (P < 0.05), where 2D was preferred. Typical imaging time for T2 Sh and the conventional exam was 7 and 13 minutes, respectively.A single-sequence pediatric knee exam is feasible with T2 Sh, providing multiplanar, reformattable 4D images. Level of Evidence 2 J. Magn. Reson. Imaging 2016;00:000-000.
View details for DOI 10.1002/jmri.25508
View details for PubMedID 27726251
Biomechanical and clinical correlates of swing-phase knee flexion in individuals with spastic cerebral palsy who walk with flexed-knee gait.
Archives of physical medicine and rehabilitation
2015; 96 (3): 511-517
A late finding of some hips treated for developmental dysplasia of the hip (DDH) is a growth disturbance of the lateral proximal femoral physis, which results in caput valgum and possibly osteoarthritis. Current treatment options include complete epiphysiodesis of the proximal femoral physis or a corrective proximal femoral osteotomy. Alternatively, a transphyseal screw through the inferomedial proximal femoral physis that preserves superolateral growth might improve this deformity.This study evaluates the effect of such a transphyseal screw on both femoral and acetabular development in patients with caput valgum following open treatment of DDH. These patients were followed clinically and radiographically until skeletal maturity. Preoperative and postoperative radiographs were assessed, measuring the proximal femoral physeal orientation (PFPO), the head-shaft angle (HSA), Sharp's angle and the center edge angle of Wiberg (CE angle).Thirteen hips of 11 consecutive patients were followed prospectively. The age at the time of transphyseal screw placement was between 5 and 14 years. The mean improvement of the PFPO and HSA was 14° (p < 0.01) and 11° (p < 0.001), respectively. The mean improvement of Sharp's angle and CE angle was 4.7° (p < 0.01) and 5.8° (p < 0.02), respectively. Five patients underwent screw revision.A transphyseal screw across the proximal femoral physis improved the proximal femur and acetabular geometry.
View details for DOI 10.1007/s11832-015-0681-9
View details for PubMedID 26362171
Management of the knee in spastic diplegia: what is the dose?
Orthopedic clinics of North America
2010; 41 (4): 561-577
To identify clinical and biomechanical parameters that influence swing-phase knee flexion and contribute to stiff-knee gait in individuals with spastic cerebral palsy (CP) and flexed-knee gait.Retrospective analysis of clinical data and gait kinematics collected from 2010 to 2013.Motion and gait analysis laboratory at a children's hospital.Individuals with spastic CP (N=34; 20 boys, 14 girls; mean age ± SD, 10.1±4.1y [range, 5-20y]; Gross Motor Function Classification System I-III) who walked with flexed-knee gait ≥20° at initial contact and had no prior surgery were included; the more-involved limb was analyzed.Not applicable.The magnitude and timing of peak knee flexion (PKF) during swing were analyzed with respect to clinical data, including passive range of motion and Selective Control Assessment of the Lower Extremity, and biomechanical data, including joint kinematics and hamstring, rectus femoris, and gastrocnemius muscle-tendon length during gait.Data from participants demonstrated that achieving a higher magnitude of PKF during swing correlated with a higher maximum knee flexion velocity in swing (ρ=.582, P<0.001) and a longer maximum length of the rectus femoris (ρ=.491, P=.003). In contrast, attaining earlier timing of PKF during swing correlated with a higher knee flexion velocity at toe-off (ρ=-.576, P<.001), a longer maximum length of the gastrocnemius (ρ=-.355, P=.039), and a greater peak knee extension during single-limb support phase (ρ=-.354, P=.040).Results indicate that the magnitude and timing of PKF during swing were independent, and their biomechanical correlates differed, suggesting important treatment implications for both stiff-knee and flexed-knee gait.
View details for DOI 10.1016/j.apmr.2014.09.039
View details for PubMedID 25450128
Sacral stress fractures in children.
American journal of orthopedics (Belle Mead, N.J.)
2009; 38 (5): 232-236
Infected Total Ankle Arthroplasty Following Routine Dental Procedure
FOOT & ANKLE INTERNATIONAL
2009; 30 (3): 252-257
Remodeling of birth fractures of the humeral diaphysis
JOURNAL OF PEDIATRIC ORTHOPAEDICS
2008; 28 (1): 10-13
This article discusses the sagittal gait patterns in children with spastic diplegia, with an emphasis on the knee, as well as the concept of the "dose" of surgery that is required to correct different gait pathologies. The authors list the various interventions in the order of their increasing dose. The concept of dose is useful in the consideration of the management of knee dysfunction.
View details for DOI 10.1016/j.ocl.2010.06.006
View details for PubMedID 20868885
Birth fractures of the humeral diaphysis are encountered at most pediatric medical centers and pediatric orthopaedic practices. The treatment strategy of these fractures is uniformly nonoperative. However, we have not found sufficient studies in the literature demonstrating the extent to which remodeling is possible and therefore how much deformity is acceptable in the treatment of these fractures.We reviewed the records of our institution's Orthopaedic Surgery Clinic and identified all children seen for birth fractures of the humerus from 2001 to 2005. The angulation and displacement at presentation and at follow-up were measured.All patients were treated nonoperatively, and most were managed by swaddling. In 9 patients with more than 4 months of radiographic follow-up, the mean initial angulation was 26 degrees in the coronal plane and 25 degrees in the sagittal plane. The mean angulation at final follow-up was 5 degrees in the coronal plane and 7 degrees in the sagittal plane. The maximum angulation at presentation was 66 degrees, which remodeled to 5 degrees at 7.3 months' follow-up.Our findings suggest that attempts to obtain an anatomical reduction or the use of more than the simplest immobilization methods are not necessary given the tremendous capacity for remodeling of these fractures in infants.
View details for Web of Science ID 000255766600003
View details for PubMedID 18157039