https://journals.lww.com/pedorthopaedics/pages/currenttoc.aspx en-us Fri, 08 Aug 2025 04:06:12 -0500 Wolters Kluwer Health RSS Generator https://images.journals.lww.com/pedorthopaedics/XLargeThumb.01241398-202509000-00000.CV.jpeg https://journals.lww.com/pedorthopaedics/pages/currenttoc.aspx https://journals.lww.com/pedorthopaedics/fulltext/2025/09000/meralgia_paresthetica_in_children__case_series_and.1.aspx Background: Meralgia paresthetica is a painful compressive neuropathy of the lateral femoral cutaneous nerve, with minimal literature existing about the disorder in children. Easily overlooked, a misdiagnosis can lead to unnecessary imaging or surgical intervention. The purpose of this study was to increase provider awareness and compare patient-reported outcomes between surgical and nonsurgical management. Methods: We retrospectively reviewed records of pediatric patients treated for meralgia paresthetica by a single provider. Patients were initially treated with physical therapy, anti-inflammatories, and local injection to confirm the diagnosis. Individuals with persistent symptoms were offered surgical decompression. Patient-reported outcomes were assessed using the International Hip Outcome Tool 33 (iHOT-33) survey. Results: Twenty-four patients were treated. The mean age was 12.7 years (range: 9 to 17 y). Ninety-two percent were female, 63% had bilateral involvement, and 38% were referred with an alternate diagnosis. The average BMI was 20.96. Local injection provided immediate relief for all patients and lasted an average of 11 days. Seventy-one percent (17/24) had persistent symptoms in follow-up and underwent surgical decompression. All patients improved following initial decompression, but 4/17 (24%) had recurrence of symptoms requiring a second surgery. All recurrences had accessory nerves missed during the first surgery. Seventy-nine percent of patients (19/24) completed the iHOT-33 survey at an average of 33 months after intervention (injection or surgery). The average iHOT-33 score was higher in the operative group but was not statistically significant (7.88 vs. 6.72, P=0.250). Conclusions: Meralgia paresthetica can be readily diagnosed using physical examination and confirmed with a local injection, without the need for advanced imaging. In our cohort, it predominantly affected thin, adolescent females. Steroid injection provided definitive treatment for 29% of our patients. Persistent symptoms can be improved with surgical decompression, and we found a high rate of aberrant anatomy and accessory nerves in this population. Outcomes were not significantly different between local injection only and surgical management. More studies are needed to determine the role of ligation versus decompression. Level of Evidence: Level IV—case series.]]> Mon, 14 Jul 2025 00:00:00 GMT-05:00 01241398-202509000-00001 https://journals.lww.com/pedorthopaedics/fulltext/2025/09000/age_and_sex_based_frequency_of_graft_and_technique.2.aspx Objective: As the incidence of pediatric and adolescent anterior cruciate ligament (ACL) reconstruction rises, knowledge of contributing factors to decision-making regarding graft selection and technique is important. Variations in ACL reconstruction (ACLR) regarding graft choice, tunnel placement, and technique may depend on patient age, sex, and surgeon preference. The purpose of this study was to review technique and graft source of pediatric ACLR based on these factors. Methods: A prospective, surgeon-driven, multicenter quality/performance improvement registry was queried to evaluate graft selection and technique in primary ACLR. Data regarding ACLR in those 19 years or younger performed by 23 contributing surgeons was collected. Frequency of graft use and surgical technique were stratified by patient age and sex. Results: A total of 3968 ACLRs were included, with an average age of 15.1 years (range: 6 to 19 years), 53.7% males, with a majority using autograft (97.4%). Of ACLR, 82.9% of those under age 11 used iliotibial band (ITB) graft and extra-articular extraphyseal technique. ITB use was similar in females (80.0%) and males (83.5%). For ages 11 to 15, soft tissue quadriceps (STQT, 38.1%), hamstring (HS, 23.5%), and ITB (16.6%) were most frequently used. STQT use was 40.1% in females and 36.2% in males. ITB was used more in males than females (25.6% and 7.4%, respectively). After age 15, STQT (30.9%), bone patellar tendon bone (BTB, 27.8%), and HS (24.8%) were most common. STQT was the dominant graft in females (35.5%) in this group, while BTB (32.3%) was the most frequent in males. When comparing the early (2018 to 2020) to the late (2020 to 2022) portion of collection period, quadriceps tendon autograft use increased from 30.5% to 48.0%. Conclusions: Variation exists in graft selection and technique for pediatric and adolescent ACLR. ITB, extra-articular extraphyseal technique, is favored in patients under age 11. Quadriceps autograft use has increased in ACLR in this patient population in recent years. Level of Evidence: Level III—retrospective cohort study.]]> Wed, 16 Apr 2025 00:00:00 GMT-05:00 01241398-202509000-00002 https://journals.lww.com/pedorthopaedics/fulltext/2025/09000/intercondylar_notch_becomes_steeper_after.3.aspx Background: Transphyseal anterior cruciate ligament (ACL) reconstruction can be a reliable and safe treatment for skeletally immature patients, with low reported rates of major growth disturbances. However, more subtle knee morphologic and radiologic characteristics, such as the α-angle (sagittal orientation of the notch roof) and posterior tibial slope, may theoretically be affected by this surgical technique and potentially represent risk factors for ACL graft tears. The objective of this study was to compare radiologic knee morphology characteristics between the operated knee and the paired contralateral knee in skeletally immature patients following transphyseal ACL reconstruction. Methods: This is a retrospective matched within-subject case-control study on 25 skeletally immature patients with a radiologic follow-up 9 or more months after a transphyseal anatomic ACL reconstruction. The α-angle, medial posterior tibial slope, mechanical hip-knee-ankle angle, and leg length were assessed with a biplane x-ray imaging system (EOS) with the nonoperative limb used as an internal control. Results: The mean chronological age of the cohort was 11.8 years (range: 8.3 to 15.0). The α-angle was a mean of 3.3 degrees (SD=5.1) smaller, or more vertical, on the surgical knee than on the contralateral knee at a median of 2.1 years [interquartile range (IQR)=0.3 to 4.0], with mean α-angles of 36.6 degrees (SD=6.6 degrees) and 39.9 degrees (SD=5.3), respectively (P=0.002). Other radiologic parameters were not significantly different between sides. A post hoc analysis showed a median side-to-side difference in α-angles of −5.0 (IQR: −7.0 to −1.9) in males versus 0.6 (IQR: −4.3 to 3.8) in females (P=0.009). Conclusion: Transphyseal anatomic single-bundle ACL reconstruction in skeletally immature patients is associated with a relative decrease in α-angle, or verticalization of the notch roof, after a median follow-up of 2 years. A greater impact in α-angle was observed in male patients. Level of Evidence: Level III—prognostic case-control study.]]> Tue, 27 May 2025 00:00:00 GMT-05:00 01241398-202509000-00003 https://journals.lww.com/pedorthopaedics/fulltext/2025/09000/how_do_venous_thromboembolism_rates_in_adolescents.4.aspx Background: Arthroscopic knee procedures such as meniscus and ACL repairs are cornerstone interventions in pediatric and sports orthopaedics. While venous thromboembolism (VTE), including pulmonary embolism (PE) and deep vein thrombosis (DVT), is a rare yet devastating complication in major joint surgeries, its association with minimally invasive procedures remains relatively unexplored. Emerging evidence shows rates of VTE in adolescent orthopaedic patients approaching that of adults, highlighting the need to further characterize the unique risk profile of this population. Therefore, this study aims to compare VTE rates, risk factors, and chemoprophylaxis use in adolescents versus adults undergoing arthroscopic knee procedures. Methods: A retrospective cohort study using the TriNetX Research Network identified 301,585 patients who underwent knee arthroscopy from January 2003 to January 2023, including 29,984 adolescents (aged 14 to 17) and 271,601 adults (aged 18 years or older). Propensity score matching based on sex and relevant comorbidities, including diabetes mellitus, tobacco use, oral contraceptive (OCP) use, and obesity yielded balanced cohorts of 29,984 each. Univariate logistic regression analysis was performed for preliminary assessment of the risk factors associated with VTE. P<0.01 was considered significant. Results: Adults had a higher 90-day incidence of DVT (1.3% vs. 0.8%) and PE (0.3% vs. 0.2%) than adolescents. Combined DVT/PE incidence was 1.5% in adults and 0.8% in adolescents (RR: 1.782). Univariate analysis showed OCP use (OR: 3.167), obesity (OR: 3.445), tobacco use (OR: 23.975), and diabetes (OR: 34.064) were significant VTE risk factors in adolescents; sex was not. Adults more frequently received postoperative chemoprophylaxis (24% vs. 20%, P<0.001), with aspirin being the most common agent (23% in adults vs. 19% in adolescents, P<0.001). Conclusion: Adolescents undergoing knee arthroscopy have a lower risk of VTE compared with adults, with an incidence below 1%. Routine VTE prophylaxis may not be necessary for all adolescents but should be considered for those with significant risk factors, including diabetes, tobacco use, and obesity. Further research is warranted to refine prophylaxis guidelines in this population. Level of Evidence: Level III—retrospective cohort study.]]> Thu, 17 Apr 2025 00:00:00 GMT-05:00 01241398-202509000-00004 https://journals.lww.com/pedorthopaedics/fulltext/2025/09000/wait_or_drill__shared_decision_making_in.5.aspx Introduction: Treatment of stable juvenile osteochondritis dissecans (OCD) of the knee in adolescents is controversial. Traditionally, initial management has been nonoperative. However, early subchondral drilling is also a consideration to potentially reduce the recovery time because ∼50% of stable OCD lesions eventually require surgery after a period of failed nonoperative care. This study uses choice-based conjoint (CBC) analysis to explore patient and family preferences regarding initial nonoperative treatment versus early drilling. Methods: This study used a CBC survey using Sawtooth Software (Lighthouse Studio version 9.2.0) to collect demographic information and preferences on surgical scenarios. Anonymous participants were recruited through the Prolific crowdsourcing platform. Eligible participants were US residents over 18 years of age with children aged 12 to 17. Data were analyzed using Hierarchical Bayes and logistic regression to determine the importance of each attribute and correlate preferences with demographic variables. Results: Of the 474 participants, the highest importance was placed on minimizing treatment failure (46.3%), followed by the likelihood of needing surgery (22.4%), cost (11.8%), time on crutches (10.8%), and return to normal activities (8.7%). Simulation of surgical decision-making showed a strong preference for early surgery (90.8%) over conservative treatment (9.2%). Preferences varied slightly by demographics, with female participants valuing recovery time more and male participants prioritizing cost. Discussion: Our findings indicate a significant preference for early surgical intervention driven by concerns over treatment failure and the need for a future surgery with a second recovery period. Despite some demographic differences in attribute importance, no specific patient characteristic significantly influenced the overall treatment preference. Conclusion: Early drilling of stable OCD lesions of the knee is favored by most parents of adolescents, primarily to reduce the risk of future surgery/recovery. This preference underscores the importance of personalized treatment discussions and highlights the need for shared decision-making tools that incorporate individual patient values.]]> Tue, 22 Apr 2025 00:00:00 GMT-05:00 01241398-202509000-00005 https://journals.lww.com/pedorthopaedics/fulltext/2025/09000/comparative_analysis_of_postoperative_rotational.6.aspx Background: Supracondylar humeral fractures are common in children, and are typically treated with percutaneous pinning. Cross pinning (CP) and lateral entry pinning (LP) are widely used methods. Although previous studies have focused on outcomes such as Baumann and carrying angles, research on rotational malalignment is limited. Furthermore, there have been few comparative studies on alternative surgical techniques. This study aimed to compare rotational malalignment and clinical outcomes between CP and the lateral para-olecranon pinning (LPOP) technique. Methods: This retrospective study initially identified 208 pediatric patients who underwent percutaneous pinning for supracondylar humeral fractures between 2005 and 2023. After applying the inclusion and exclusion criteria, 180 patients were included in the study and divided into 2 cohorts: LPOP (n=146) and CP (n=34). The primary outcome was corrective loss of rotation, measured radiographically at surgery and at 4 weeks postoperatively. Rotational malalignment was assessed using the formula described by Henderson and colleagues. Secondary outcomes included Baumann angle, carrying angle, tilting angle, range of motion, anesthesia, and operation times. Results: No significant difference was found in corrective loss of rotation between LPOP and CP (θ=0.079±0.24 for LPOP vs. 0.10±0.20 for CP, P=0.57). Secondary outcomes, including the Baumann angle, carrying angle, tilting angle, and range of motion, were similar in both groups. However, the anesthesia and operation times were significantly shorter in the LPOP cohort (P<0.01): the LPOP cohort had a shorter duration of anesthesia (124.95±32.22 min) than the CP cohort (148.21±65.72 min) (P=0.009) and had a shorter operation time (52.02±31.56 min) than the CP cohort (71.82±43.69 min) (P=0.006). Complication rates, including reoperations and nerve injuries, were comparable between the cohorts. Conclusions: Both LPOP and CP resulted in similar rotational outcomes; however, LPOP offered shorter anesthesia and surgery times without increasing the risk of complications. LPOP might be a safe and more effective alternative technique, showing equivalent clinical results and lowering the incidence of iatrogenic nerve injuries. Level of Evidence: Level III—retrospective comparative study.]]> Mon, 05 May 2025 00:00:00 GMT-05:00 01241398-202509000-00006 https://journals.lww.com/pedorthopaedics/fulltext/2025/09000/opioid_prescription_patterns_30_days_after.7.aspx Background: Supracondylar humerus fractures (SCH) are the most common type of elbow fracture in children, with many cases requiring surgery. Treatment of postoperative pain for SCH has high variability, but can often be treated effectively with minimal or no opioids. Furthermore, there is significant morbidity related to pediatric opioid consumption. The goal of this study was to characterize prescription patterns in the United States following closed reduction and percutaneous pinning (CRPP) of SCH. Methods: All patients aged 10 or younger years who underwent CRPP of SCH from January 2010 to December 2021 were identified in the PearlDiver Mariner Claims Database. The primary outcome was postoperative pain medication prescriptions in the 30 days following SCH CRPP. Patient demographics, prescription duration, and morphine milligram equivalents (MME) were analyzed. Multivariable-log-binomial mixed regression models were constructed to assess factors associated with increased opioid prescription. Results: In total, 43,611 SCH CRPP cases in patients aged 10 or younger were identified from 2010 to 2021. Throughout the study period, 48.6% of patients (21,191/43,611) received and filled a narcotic pain prescription. The percentage of patients receiving opioid medication decreased from 54.7% in 2010 to 27.4% in 2021. Opioid prescriptions totaled a mean of 6.1±2.1 days of narcotics with a mean of 79.2 MME prescribed per patient. Increased patient age, increased Elixhauser comorbidity index, and Medicaid insurance were all associated with increased opioid prescription (P<0.001). Living in the Northeast, increased family income, and commercial insurance were associated with decreased opioid prescriptions (P<0.001). Conclusions: Nearly half of the patients over the past decade treated with CRPP for SCH received a narcotic prescription. However, there has been a steady decline in the proportion of patients being prescribed opioids, with only 27.4% receiving opioids in 2021. Further, patients with increased comorbidities or those insured by Medicaid with lower mean family income may be at risk for increased opioid prescription. While efforts have been made to reduce opioid overprescribing, there continues to be room for further reduction in opioid utilization after CRPP for SCH moving forward.]]> Mon, 02 Jun 2025 00:00:00 GMT-05:00 01241398-202509000-00007 https://journals.lww.com/pedorthopaedics/fulltext/2025/09000/modifiable_risk_factors_for_complications.8.aspx Background: Tibial tubercle fractures (TTF) commonly occur in an athletic adolescent population and typically require operative reduction and fixation. Surgical techniques and postoperative restrictions are varied, with limited knowledge on factors that may affect outcome. We hypothesize that surgical technique and postoperative rehabilitation protocol can affect risk of postoperative complications following surgical treatment of TTF. Methods: Retrospective review was conducted including all consecutive surgically treated TTF at a single level 1 pediatric trauma center between January 2010 and December 2022. Patients were excluded for skeletal dysplasia, <10 weeks of follow-up, or periosteal avulsion only. They were classified into “accelerated” (postoperative weight-bearing and motion allowed within 21 d) or “conservative” (did not meet accelerated criteria) groups. Postoperative complications were recorded and graded by the modified Clavien-Dindo (C-D) classification. Univariate and multivariate logistic regression analysis were used to investigate factors associated with C-D grade II and III complications. Results: Totally, 183 knees (177 patients) met criteria for analysis. Median follow-up was 27.3 weeks. Fifty-three knees (29%) qualified for the “accelerated” group and 129 knees (71%) were “conservative.” Initial postoperative casting was performed in 38% of the conservative group compared with 1.9% in the accelerated group (P<0.001). Overall complication rate was 44.3% (81/183), with 33.3% (61/183) being a grade II or III complication. The most common complication was symptomatic implant (19.7%). There were 4 cases of fracture displacement and 1 case of implant displacement, all occurring in the conservative group. In multivariate analysis female sex (OR: 4.9), initial postoperative casting (OR: 2.6), and lower BMI percentile (OR: 1.02) were independently associated with higher grade II and III complication rate, while distal repair of the avulsed periosteum was associated with lower rate (OR: 0.26). Conclusion: Postoperative casting and repair of the distal periosteal avulsion are modifiable treatment decisions impacting risk of complications following surgical treatment of TTF. Decreasing variability in care, including implementing an accelerated rehabilitation protocol, may improve outcomes. Level of Evidence: Level III.]]> Wed, 23 Apr 2025 00:00:00 GMT-05:00 01241398-202509000-00008 https://journals.lww.com/pedorthopaedics/fulltext/2025/09000/financial_implications_associated_with_the_use_of.9.aspx Background: Waterproof casting materials have been demonstrated to improve the patient experience through subjective patient satisfaction and discomfort measures. However, the increased cost of raw materials has limited its wide adoption as a standard of care. The purpose of this study was to compare unplanned healthcare utilization and the financial implications of using waterproof versus cotton liners for nonoperative fractures in pediatric patients. Methods: A single institution retrospective chart review analyzed 950 pediatric patients with 977 nonoperative upper and lower extremity fractures who received either standard or waterproof cast liners from January 1, 2020, to December 31, 2021. Generalized logistic and linear models were used to determine whether cast liner material was associated with recasting and to what extent this was associated with the total cost of casting materials over the course of fracture care. Incremental Cost Effectiveness Ratio (ICER) was calculated based on casting material costs and the likelihood of unplanned cast changes between groups. Results: Of the 977 castings included, 804 (82.3%) had standard casts, and 173 (17.7%) had waterproof casts placed as initial treatment. The proportion of casts requiring recasting was significantly higher in patients with standard casts (43.3%) compared with those with waterproof casts (11.6%) (P<0.001). Similarly, the rate of unplanned recasting was higher in the standard cast group (23.8%) than in the waterproof cast group (7.5%) (P<0.001). When accounting for factors affecting cost in nonoperative fracture care, casts with waterproof lining were, on average, $16.46 more expensive than standard (P<0.001). The ICER for waterproof cast liners was $81.42. Conclusions: The findings of this study show that standard cotton liners are associated with increased unplanned recasting rates. While only accounting for raw material costs to the provider, waterproof liner material costs were greater than standard. However, we argue that waterproof casting is cost-effective when considering other associated costs with unplanned recasting, such as application time and additional visits. Level of Evidence: Level III.]]> Fri, 11 Apr 2025 00:00:00 GMT-05:00 01241398-202509000-00009 https://journals.lww.com/pedorthopaedics/fulltext/2025/09000/pavlik_harness_treatment_for_infantile_hip.10.aspx Introduction: Breastfeeding is recommended exclusively until at least 6 months of age by the American Academy of Pediatrics. For mothers of children with hip dysplasia (DDH), Pavlik harness treatment may impact breastfeeding. The aim of this study was to assess how Pavlik harness treatment may impact breastfeeding by evaluating patient-reported outcomes (PRO) associated with breastfeeding. Methods: This was a prospective cohort study of mothers of patients treated in a Pavlik harness for DDH at <3 months of age. Controls were recruited from patients evaluated for DDH who had normal ultrasounds. Patients with neuromuscular/developmental conditions were excluded. The validated beginning breastfeeding survey-cumulative (BBS-C), breastfeeding self-efficacy scale-short form (BSES-SF), and patient health questionnaire-8 (PHQ8) were administered to mothers at the initial clinic appointment and 2, 4, 6 weeks postbaseline. Results: A total of 29 cases and 29 controls were enrolled. There were no differences in baseline demographics or socioeconomic/educational status between maternal cohorts. There were similarly no differences in demographics or birth characteristics between children except presenting age was lower in the DDH cohort (30.7±22.1 vs. 58.7±21.4 d, P<0.001). PROs were similar at enrollment. Six weeks after harness initiation, 76% of the DDH cohort were still breastfeeding (vs. 89% of controls, P=0.303), and 52% (vs. 77%, P=0.052) reported breastfeeding >80% of the time. Mothers of 13% of DDH patients reported that the Pavlik usually/always negatively impacted their breastfeeding ability at 6 weeks. The DDH cohort had lower BBS-C problem scores at 4 (17.6±6.4 vs. 20.8±3.7, P=0.045) and 6 weeks (17.2±6.2 vs. 20.2±3.3, P=0.029). BSES-SF scores were additionally lower among the DDH group at 2 (47.6±11.8 vs. 54.1±10.2, P=0.047) and 4 weeks (48.5±13.0 vs. 55.6±10.3, P=0.040). There were no differences in PHQ-8 scores. Conclusion: Pavlik harness treatment for DDH was associated with lower patient-reported breastfeeding efficacy PROs. Pavlik harness treatment did not lead to earlier breastfeeding cessation 6 weeks after harness initiation. Lower breastfeeding efficacy for these mothers may justify early education regarding effective breastfeeding methods in a harness. Level of Evidence: Level II—prospective therapeutic cohort study.]]> Mon, 21 Apr 2025 00:00:00 GMT-05:00 01241398-202509000-00010 https://journals.lww.com/pedorthopaedics/fulltext/2025/09000/novel_use_of_the_o_arm_following_open_reduction_of.11.aspx Background: Surgical treatment of a dislocated hip at walking age includes open reduction (OR) with or without osteotomies of the pelvis and/or femur. Three-dimensional imaging, such as computerized tomography (CT), can be utilized postoperatively to determine femoral head position following cast placement. Alternatively, intraoperative 3D imaging (O-arm) may be used for the same purpose. Disadvantages of CT include limited access to the patient’s airway and high radiation dose. The current study aimed to determine the ability of O-arm imaging to visualize femoral head position following surgical treatment of a dislocated hip, and compare radiation dosage between CT and O-arm. Methods: Thirteen patients (16 hips) with a dislocated hip at walking age who underwent OR with pelvic ± femoral osteotomies at a single institution were retrospectively reviewed. All patients underwent CT or O-arm evaluation following surgery and spica cast application. Total radiation dose per kilogram was compared between the CT (n=8 hips) and O-Arm 14 (n=8 hips) groups. Radiographic parameters and complication rates were analyzed. Image quality was blindly assessed by 3 fellowship-trained pediatric orthopedic surgeons with hip expertise. Results: The mean age was 4.68 years (range: 3.1–7.8) in the CT group and 4.31 (range: 1.2–7.5) in the O-Arm group. The average radiation dose from the O-arm was lower than CT (4.51 19 mGy/kg vs. 6.12 mGy/kg, P=0.37). Five hips in the CT cohort were scanned post-extubation. All surgeons agreed that femoral head position was adequately visualized in all images from both groups. No patient in either group required a cast change post-scanning due to a malpositioned femoral head. Conclusion: The O-arm is a reasonable alternative to CT following surgical treatment of a dislocated hip. It may decrease radiation dose and provides adequate visual information to determine femoral head position following surgical intervention and casting. Utilization of the O-arm keeps the patient in the operating room during the study, allowing for immediate revision of the cast position or revision reduction if necessary, while maximizing access to the patient’s airway and minimizing risk for adverse anesthetic events. Level of Evidence: Level III, retrospective comparative study.]]> Mon, 21 Jul 2025 00:00:00 GMT-05:00 01241398-202509000-00011 https://journals.lww.com/pedorthopaedics/fulltext/2025/09000/assessing_venous_thromboembolism_risk_in_hip.12.aspx Background: Hip arthroscopy is a commonly performed procedure in adolescents with hip pathology. However, there is limited data on venous thromboembolism (VTE) events in this population, resulting in minimal guidance on appropriate VTE prophylaxis, with the bulk of current guidance extrapolated from the adult population. Therefore, this study aims to assess overall rates of VTE in the adolescent population as well as compare these rates to a matched cohort of adult patients undergoing hip arthroscopy. Methods: This retrospective cohort study drew data from the TriNetX platform between January 1, 2003 and March 1, 2024. Adolescent patients, ages 13 to 18, were matched to adult patients (19 and older) undergoing hip arthroscopy, accounting for sex, tobacco use, oral contraceptive use, diabetes mellitus, and overweight/obesity. Outcomes of interest were deep vein thrombosis (DVT) or pulmonary embolism (PE) within 90 days after the procedure. Overall rates were calculated and compared between cohorts. Statistical significance was set at P<0.01. Results: A total of 3655 patients were successfully matched with a mean age of 16 in the adolescent cohort and 35 in the adult cohort. The overall rates of DVT were similar between cohorts, at 1% for adolescent patients and 0.9% for adults (RR: 0.892; 95% CI: 0.559-1.423; P=0.63). All VTE events (combined DVT and PE) were also similar at 1.1% for adolescent patients and 1.0% in adults (RR: 0.925; 95% CI: 0.593-1.443; P=0.73). Conclusion: This study found no significant difference in VTE between adolescent and adult patients undergoing hip arthroscopy. The overall rate of VTE was relatively high in adolescent patients, at 1.1%, suggesting additional attention to VTE and potential chemoprophylaxis may be warranted in select patients. Level of Evidence: Level III—case-control study or retrospective cohort study.]]> Wed, 16 Apr 2025 00:00:00 GMT-05:00 01241398-202509000-00012 https://journals.lww.com/pedorthopaedics/fulltext/2025/09000/a_new_skeletal_maturity_methodology_for_children.13.aspx Background: Legg-Calve-Perthes disease (LCPD) outcomes are largely determined by their age and maturity at onset. In LCPD, there is a known association with delayed skeletal maturity of up to 1.9 years in affected children based on maturity assessment with the Greulich and Pyle (GP) maturity atlas. The GP atlas is the standard for assessing bone age but requires obtaining a separate radiograph of the hand. A new methodology for assessing skeletal maturation in comparison to the GP bone age in children with LCPD was sought. Methods: A retrospective review of a prospective, multicenter study of patients with LCPD treated from 1984 to 1991 and followed to skeletal maturity was performed. Patients were included if they had LCPD diagnosed on anteroposterior pelvis radiographs that included the contralateral hip who had bone age radiographs obtained at the time of presentation. Patients were excluded if they presented with bilateral LCPD, the contralateral hip was not visualized on their presenting radiographs, they lacked bone age radiographs at the time of presentation, or they presented outside the range for the Optimized Oxford system. A formula using the greater trochanteric height to femoral head diameter ratio and patient sex (GT+ Sex) for predicting GP bone age was developed. The GP and GT+ Sex bone ages were compared with the chronologic age (CA) to determine the mean discrepancy. Results: Seventy-one patients were included (mean 9.5 ± 1.2 y at presentation, 42.2% females). Skeletal maturity assessment by the GP bone age method demonstrated a mean discrepancy of 1.4 years younger than CA (95% CI: 1.01-1.76 y). GT+ Sex bone age assessment demonstrated a mean discrepancy of 1.4 years younger than CA (95% CI: 1.03-1.75 y). The GP bone age was a mean of 0.00 years different than the GT+ Sex assessment bone age (95% CI: −0.3 to 0.3 y). The GT+ Sex assessment bone age correlated significantly with GP bone age (R=0.89, P<0.0001). Male patients had a significantly younger GP bone age relative to CA compared with female patients (1.8 vs. 0.86 y, P = 0.02); however, there were fewer sex differences in the GT+ Sex assessment bone age relative to CA (male, 1.77 y younger vs. 1.12 y younger; P = 0.01). Conclusions: The GT+ Sex skeletal maturity assessment system in children with LCPD significantly correlated with the GP bone age system when compared. The GT+ Sex assessment may provide an assessment of the true bone age in LCPD patients without the need for hand radiographic imaging studies. Level of Evidence: Level III—retrospective review and analysis.]]> Mon, 28 Apr 2025 00:00:00 GMT-05:00 01241398-202509000-00013 https://journals.lww.com/pedorthopaedics/fulltext/2025/09000/how_urgent_are_stable_scfes__a_multisite.14.aspx Background: Stable slipped capital femoral epiphysis (SCFE) is often considered semi-urgent, prompting admission for in situ screw fixation (ISF), which may increase the cost/burden of care. Avascular necrosis (AVN) affects 25% to 50% of patients with unstable SCFE, yet it is uncommon after stable SCFE. Among patients presenting with stable SCFE, little is known about the relationship between diagnosis and surgical timing with regard to slip progression or complications. Methods: This retrospective observational study included all patients younger than 18 years with stable SCFE at initial diagnosis treated with ISF between 2000 and 2020 at 4 centers. Patients with Loder unstable SCFE at the time of initial SCFE diagnosis were excluded. Timing data included time from (1) symptom onset to diagnosis, (2) symptom onset to surgical team evaluation, (3) symptom onset to surgery, (4) diagnosis to surgical team evaluation, (5) surgical team evaluation to surgery, and (6) diagnosis to surgery. Regression analyses explored relationships between timing and slip progression to unstable, subsequent procedures, and complications as graded by the modified Clavien-Dindo-Sink system. Results: A total of 298 patients with 362 stable SCFEs were included. The mean time from symptom onset to diagnosis was 134 days, from diagnosis to surgical team evaluation was 3.2 days, and from surgical team evaluation to surgery was 2.1 days. The mean follow-up was 2.4 years. Eighteen percent of hips were affected by a complication. Two patients initially diagnosed with stable SCFE progressed to unstable SCFE, having experienced falls after diagnosis and before orthopaedic evaluation; one of these went on to develop AVN. Time elapsed between symptom onset, diagnosis, surgical team evaluation, and surgery was not associated with the incidence or severity of complications or subsequent procedure. Conclusions: The urgency of surgical treatment of stable SCFE does not appear to affect mid-term outcomes. If surgical management of stable SCFE is not performed urgently, it is critical to avoid weight bearing and falls to reduce progression to an unstable SCFE. Level of Evidence: Level III, therapeutic.]]> Thu, 01 May 2025 00:00:00 GMT-05:00 01241398-202509000-00014 https://journals.lww.com/pedorthopaedics/fulltext/2025/09000/the_impact_of_lumbar_partial_microdiscectomy_for.15.aspx Background: Lumbar partial microdiscectomy (LPM) in adolescents is an infrequently performed procedure, reserved for pain and neurological symptoms unresponsive to nonsurgical management. Most studies have focused on the interventional impact on pain outcomes creating a paucity of data on physical function and mental health outcomes. The study hypothesis is LPMs in adolescents will provide improvements in measured PROMIS domains (mental health, physical function, and pain) at 2 years postoperatively. Methods: This study is a retrospective analysis of patients under 21 years of age who underwent LPM surgery by 2 surgeons at a tertiary-care pediatric hospital. PROMIS scores [mobility (MOB), pain interference (PI), upper extremity (UE), physical functioning (PF), peer relationships (PR), anxiety, and depression] were obtained preoperatively and 6 weeks, 3 months, 6 months, 1 year, and 2+ years postoperative. The changes in PROMIS scores were then analyzed and compared at each time point using a mixed model analysis. Results: Thirty-six patients with a mean age of 16.6 years (range: 13 to 20 y) at surgery were included in the analysis (2015 to 2022). All patients underwent nonsurgical treatments, which varied according to symptom type and severity and included over-the-counter medications, pain management or physiatry consultations, physiotherapy, selective nerve root and epidural injections, and bracing for a minimum of 3 months. Preoperatively, 4 patients had motor weakness, 11 lower extremity numbness, and 35 lower extremity radicular pain. Postoperatively, there were improvements for MOB (P≤0.05) at each time point, with an estimated mean difference of +11.3 at 2 years (P=0.0027). In PI there was a significant decrease (P≤0.0001) immediately after surgery with sustained improvement (−8.6) at 2 years (P=0.0009). For UE and PR, there was a statistically significant improvement from the preoperative baseline scores to the 1-year postoperative visit for UE (+10.6; P=0.008) and PR (+8.0; P=0.01), but no difference at 2 years. PF, anxiety, and depression domains did not demonstrate any statistically significant changes. Conclusion: Using the PROMIS instrument, there were significant improvements postoperatively after LPM in adolescents in MOB, PI, UE, and PR up to 1 year postoperatively, and continued improvement in MOB and PI. These data demonstrate LPM can provide sustained improvement in PROMIS domains up to 2 years of follow-up after surgery. Level of Evidence: Level III—retrospective, single cohort study.]]> Wed, 30 Apr 2025 00:00:00 GMT-05:00 01241398-202509000-00015 https://journals.lww.com/pedorthopaedics/fulltext/2025/09000/rate_of_spinal_osteochondromas_diagnosed_in.16.aspx Background: Hereditary multiple osteochondromas (HMO) is a common pediatric condition defined by multiple cartilage-capped bony lesions. Spinal osteochondromas affect up to 68% of HMO patients. Although most are asymptomatic, intraspinal osteochondromas can cause significant neurological symptoms and morbidity. Limited guidelines exist regarding the use of advanced imaging to screen for spinal osteochondromas. This study evaluates the incidence of spinal osteochondromas detected through advanced imaging in pediatric HMO patients. Methods: A systematic review and meta-analysis were conducted following the Cochrane Handbook for Systematic Reviews of Interventions. Included studies reported on the use of computed tomography (CT) or magnetic resonance imaging (MRI) in HMO patients under the age of 21. The primary outcome was spinal osteochondroma incidence. Secondary outcomes included imaging indication, symptoms, intraspinal lesion incidence, surgical intervention incidence, and postoperative outcomes. A meta-analysis of single proportions determined the pooled incidence of spinal osteochondromas, intraspinal lesions, and spinal surgery in HMO patients. Results: Of 415 eligible articles, seven met inclusion criteria, including 198 HMO patients with a weighted mean age of 12 ± 1.0 years. MRI was the primary imaging modality in 175 patients (99%) with 136 (69%) imaged only per institutional screening protocols. Neurological symptoms were present in 41 subjects (21%) at the time of imaging. The pooled spinal osteochondroma incidence was 36% (95% CI, 24%–51%, event rate 72/183). Of these, 109 lesions (43%) were in the cervical spine, 41 lesions (38%) in the thoracic spine, and 21 lesions (19%) in the lumbar spine. Among those with spinal osteochondromas, 49% (95% CI, 37%–61%, event rate 41/85) had intraspinal lesions, and 21% (95% CI, 13%–33%, event rate 15/70) underwent surgery. Postoperatively, 17 patients (55%) experienced symptom resolution with no long-term complications reported. Conclusions: Although spinal osteochondromas are prevalent among HMO patients, standardized screening protocols remain limited. Nonetheless, initial and serial screening is needed to prevent irreversible neurological damage. As global guidelines evolve, large multicentre prospective studies are needed to identify and standardize optimal timing for spinal osteochondroma screening in HMO patients. Level of Evidence: Level III.]]> Wed, 23 Apr 2025 00:00:00 GMT-05:00 01241398-202509000-00016 https://journals.lww.com/pedorthopaedics/fulltext/2025/09000/surgical_treatment_of_infantile_shoulder.17.aspx Background: Glenohumeral dysplasia following brachial plexus birth injury (BPBI) can present as dislocation of the glenohumeral joint in infancy. Multiple nonoperative treatment strategies have been reported for these early dislocations, yet none are universally successful; thus, surgical treatment may be required. However, reports of surgical treatment in infancy are scarce. The present study retrospectively reviews the outcomes of patients with BPBI treated surgically for glenohumeral dislocation under 1 year of age. Methods: Medical records were retrospectively reviewed for patients treated surgically for glenohumeral dislocation under 1 year of age. Dislocation was defined on magnetic resonance imaging (MRI) as a percentage of the humeral head anterior to the scapular line (PHHA) <10%, or on ultrasound, as the humeral head ossific nucleus entirely posterior to the posterior scapular line. The primary outcome was defined as the need for reoperation. Additional outcomes included Mallet scores for global shoulder function and PHHA and glenoid version measurements on follow-up MRI. Patients with <1 year follow-up were excluded. Results: Thirty-two patients underwent surgical intervention for shoulder dislocation at ages 5 months to <1 year with average follow-up of 4.6 years. Of these 32 patients, 25 underwent internal rotation contracture release and external rotation tendon transfer (ERTT), with 3 (12.0%) requiring revision surgery; 7 underwent release alone, with 6 (85.7%) requiring revision surgery. Across all groups, patients ultimately had improved passive and active external rotation (20.0 to 80.0 degrees, -90.0 to 30.0 degrees, respectively, P<0.0001) and global Mallet scores (14.5/30 to 19.5/30, P<0.001) without worsened internal rotation function. The indications for requiring further surgical intervention for the 9 patients were recurrent IR contracture, redislocation, persistent ER weakness, and weak abduction. Conclusions: Surgical treatment of infantile shoulder dislocation following BPBI can improve glenohumeral alignment and global shoulder function. The inclusion of external rotation tendon transfers at the index procedure lowers the risk of reoperation, whereas not sacrificing internal rotation function when combined with partial subscapularis release. Level of Evidence: Level IV.]]> Mon, 28 Apr 2025 00:00:00 GMT-05:00 01241398-202509000-00017 https://journals.lww.com/pedorthopaedics/fulltext/2025/09000/a_comparison_study_of_major_and_minor.18.aspx Background: Interest in outpatient surgery has grown secondary to emphasis on the delivery of efficient, high-quality care. This study sought to compare 90-day complications between pediatric patients undergoing outpatient versus inpatient brachial plexus nerve surgery. Methods: A single institution database was queried for primary exploration and treatment of brachial plexus birth injuries from 2011 to 2022. Standard demographic data and the American Society of Anesthesiologists (ASA) classification were recorded. Operative procedures included neurolysis, nerve transfers, and/or nerve grafting. Outcome measures included operative time, postoperative emergency department (ED) visits, unplanned readmissions, and reoperation within 90 days. Results: The query yielded 19 patients. The mean age in the outpatient cohort was 7.1 months, and 5.9 months in the inpatient cohort. All patients were ASA I or II. The nerve injury levels, based on physical examination and intraoperative findings, revealed more global injuries in the inpatient group (P = 0.182). There was a significant difference (P = 0.001) in procedure length, with an average of 174.9 minutes for the outpatient cohort compared with 279.3 minutes for the inpatient cohort. This represents more extensive reconstructive surgery with concomitant nerve transfers and nerve grafting required for the inpatient group. There were zero unplanned readmissions or reoperations. When comparing surgeries performed from 2011 to 2016 to those performed from 2017 to 2022, inpatient admission odds decreased by 92% (OR: 0.08, P = 0.045). Those who represented the ED had 3 times the odds of inpatient care compared with those with no ED representation (OR: 3.43, P = 0.33). There were 3 ED visits in the inpatient cohort. Two patients presented due to minor parental incisional concerns that required no further management. The ED visit in the outpatient cohort was due to an unrelated fever. Conclusions: Over time, criteria were established to guide decision-making as more surgeries were safely conducted outpatient with no difference in complications. In appropriately selected patients, such as those of ASA I and II status, outpatient brachial plexus surgery may be safe and considered value-based care. Level of Evidence: Level III—retrospective cohort, nerve transfer, muscle transfer.]]> Mon, 21 Jul 2025 00:00:00 GMT-05:00 01241398-202509000-00018 https://journals.lww.com/pedorthopaedics/fulltext/2025/09000/high_preoperative_body_mass_index_is_associated.19.aspx Introduction: Magnetically controlled growing rods (MCGRs) have become the current standard in the growth-friendly treatment of patients with early-onset scoliosis (EOS). MCGRs allow noninvasive lengthenings with external lengthening device and reduce the need for surgical procedures. The association of preoperative body mass index (BMI) and the outcomes of the MCGR treatment is not well known. Methods: Prospectively collected international database was reviewed for EOS patients treated with MCGR. Patients without preoperative BMI data or follow-up <2 years were excluded. Patients were classified as healthy weight, overweight, and underweight using Centers for Disease Control and Prevention (CDC) growth charts. Quality of life was assessed using EOSQ-24. Results were analyzed from the 2-year follow-up. Results: A total of 663 patients were categorized into underweight (n=91), healthy weight (n=417), and overweight (n=155) groups. There were no significant differences in major curve correction or thoracic height increase among the BMI groups, irrespective of etiology. Distribution of BMI categories differed significantly by etiology (P=0.009), with lower healthy weight proportions in the syndromic group (92/167, 55%) compared with idiopathic (131/177, 74%) (adjusted P=0.004), and a higher underweight proportion in neuromuscular (36/244, 15%) compared with idiopathic (15/177, 8.5%) (adjusted P=0.044). Higher BMI z-scores were associated with an increased incidence of complications, including implant-related complications (RR 1.1, 95% CI 1.0-1.3) and implant breakage (RR 1.3, 95% CI 1.1-1.7). Healthy weight and underweight patients experienced lower overall complication rates compared with overweight patients. Implant-related complications were less common in underweight patients compared with overweight patients (RR 0.45, 95% CI 0.20-0.90). Higher BMI z-score was a significant predictor of implant breakage, whereas preoperative major curve, kyphosis, and etiology were not. EOSQ-24 scores did not differ significantly among BMI groups, and changes in scores were comparable across groups during follow-up. Conclusion: BMI status did not influence curve correction, thoracic height increase, or EOSQ-24 outcomes in early-onset scoliosis patients. However, the higher incidence of implant breakage in overweight patients suggests that elevated BMI should be carefully considered when planning treatment. Level of Evidence: Level III.]]> Mon, 05 May 2025 00:00:00 GMT-05:00 01241398-202509000-00019 https://journals.lww.com/pedorthopaedics/fulltext/2025/09000/psychometric_validation_and_responsiveness_of_the.20.aspx Background: Patients with early-onset scoliosis (EOS) can experience compromised health-related quality of life (HRQoL). EOSQ-SELF was developed to assess HRQoL directly from patients, yet its responsiveness remains unclear. We aimed to evaluate the psychometric properties and responsiveness of the cross-culturally adapted traditional Chinese version of EOSQ-SELF. Methods: Patients were consecutively recruited at an orthopaedic specialist clinic. Included patients must be diagnosed with EOS, aged 8 to 18 years at recruitment, and could read traditional Chinese. EOSQ-SELF underwent double-forward single-backward translations. At recruitment and at 6-month follow-up, patients completed the traditional Chinese EOSQ-SELF, refined Scoliosis Research Society-22 item (SRS-22r) questionnaire, and EuroQol-5-dimension 5-level. Psychometric properties of the EOSQ-SELF were assessed, with sensitivity analysis via known group comparison. Responsiveness was evaluated through an anchor-based approach using a global rating of change (GRC) scale. Results: A total of 139 patients were recruited, with 132 (92.4% responsiveness) included for analyses. Traditional Chinese EOSQ-SELF has good internal consistency, test-retest reliability, convergent, and construct validity. The EOSQ-SELF total score showed no ceiling/floor effects, correlated with SRS-22r total score (rs: 0.788, P<0.001), EQ index score (rs: 0.680, P<0.001), and EQ VAS (rs: 0.527, P<0.001). Discriminative validity was demonstrated: syndromic EOS had a lower transfer domain score (vs. idiopathic and congenital), and a lower EOSQ-SELF total score (median: 71.3 vs. idiopathic 81.1, P=0.023). On the basis of the GRC, 7.4%, 46.7%, and 45.9% of patients had worsened, unchanged, and improved overall health, respectively. The improvement group showed significantly higher EOSQ-SELF total score at 6 months (median: 83.4 vs. baseline 78.7, P=0.015), and none had total scores decrease reaching MCID. Conclusions: Traditional Chinese EOSQ-SELF is a reliable instrument for assessing HRQoL and its changes reported by older patients (aged 8 years or above). It is sensitive in differentiating patients with improved overall health from those who are stable/worsened. EOSQ-SELF can enhance clinical care and monitoring of EOS patients through assessing their HRQoL and detecting changes effectively. Level of Evidence: Level II.]]> Mon, 05 May 2025 00:00:00 GMT-05:00 01241398-202509000-00020 https://journals.lww.com/pedorthopaedics/fulltext/2025/09000/selecting_patient_reported_outcome_measures_for.21.aspx Background: Patient-reported outcome measures (PROMs) are important in understanding pediatric upper extremity outcomes. Little guidance is available to help clinicians select appropriate PROMs, which are often used beyond their scope of validation. This systematic review analyzed the content, readability, and psychometrics of existing PROMs of pediatric upper extremity function. Methods: PubMed, Embase, CINAHL, and Scopus were searched. Eligible studies evaluated psychometrics of global upper extremity function PROMs in pediatric patients. Following PRISMA guidelines, 2 reviewers screened studies, extracted data, assessed risk of bias, and rated psychometrics using the COnsensus-based Standards for selection of health Measurement INstruments (COSMIN). Content was analyzed using the Occupational Therapy Practice Framework and well-established readability indices. Results: Reviewers screened 2513 studies; 44 reports on 9 PROMs were included. The Pediatric Outcomes Data Collection Instrument (PODCI) showed strong evidence of validity and responsiveness for the widest range of conditions, covered all upper extremity functional categories and occupational domains, and easily achieved the American Medical Association’s readability standards. The Upper-Extremity Cerebral Palsy Profile of Health and Function Computerized Adaptive Test (UE-CP-PRO) showed stronger psychometrics for cerebral palsy and brachial plexus birth injury. The Infant Motor Activity Log (IMAL) is the strongest option for infants under 2 years old. The Patient-Reported Outcomes Measurement Information System Upper Extremity Module (PROMIS-UE) has strong potential but requires more diagnosis-specific validation. Conclusions: We recommend the PODCI, UE-CP-PRO, and IMAL as outlined. We also urge further validation of the PROMIS-UE computerized adaptive test and short form as shorter, more customizable alternatives to the PODCI. Level of Evidence: Level II—systematic review of level I and level II studies.]]> Wed, 30 Apr 2025 00:00:00 GMT-05:00 01241398-202509000-00021 https://journals.lww.com/pedorthopaedics/fulltext/2025/09000/enhanced_recovery_with_combined_epidural_and.22.aspx Background: Pediatric patients with cerebral palsy (CP) undergoing hip reconstruction face significant postoperative pain challenges. This study aimed to assess the efficacy and safety of epidural anesthesia combined with general anesthesia compared with general anesthesia alone in reducing postoperative opiate usage, postoperative complications, and length of hospital stay in this vulnerable population. Methods: A retrospective cohort study was conducted, analyzing medical records of pediatric CP patients who underwent bilateral proximal femoral osteotomy between 2003 and 2023, using a large national US health care database. Patients were dichotomized into 2 groups based on anesthesia technique: general anesthesia only (General) and general anesthesia with adjunct epidural anesthesia (Epidural). The primary outcome measured was the use of IV opiates within the first 3 days postoperation. Secondary outcomes included the use of per os (PO) opiates, length of stay (LOS), and postoperative complications such as ICU admission, mortality, pneumonia, respiratory failure, urinary retention, and urinary tract infections within 90 days postoperatively. Patient characteristics, including age, BMI percentile, gastrostomy and tracheostomy status, as well as concomitant hamstring lengthening and pelvic osteotomy, were propensity matched between groups. Results: In total, 1303 CP patients were identified, including 502 patients with general plus epidural anesthesia and 801 patients with general anesthesia only. After matching, there remained 361 patients in each group (a total of 722 patients who were included for analysis). The Epidural group demonstrated a significantly lower proportion of IV opiate usage within the first 3 days postoperation. There were no significant differences in the rates of ICU admissions, mortality, pneumonia, respiratory failure, urinary retention, or urinary tract infections between groups. However, the general plus epidural anesthesia group demonstrated lower usage of PO opiates 90 days postoperatively compared with the general anesthesia only group. The epidural group further demonstrated a 1.3-days shorter LOS. Conclusions: The addition of epidural anesthesia to general anesthesia in pediatric CP patients undergoing proximal femoral osteotomy reduces hospital stay and IV opioid use postoperatively, without increasing complications. These findings support considering epidural anesthesia to enhance recovery and reduce opioid-related side effects in these patients. Level of Evidence: Level III—therapeutic study.]]> Mon, 21 Apr 2025 00:00:00 GMT-05:00 01241398-202509000-00022 https://journals.lww.com/pedorthopaedics/fulltext/2025/09000/anterior_distal_femoral_hemiepiphysiodesis.23.aspx Background: Anterior distal femoral hemiepiphysiodesis (ADFH) is an effective surgery to correct knee flexion contractures. ADFH entails inserting 2 screws through the anterior third of the distal femoral physis, typically inserted in an antegrade fashion (proximal to distal across the physis). However, the screws must traverse significant soft tissue structures, thereby impeding simple insertion parallel to the mechanical axis of the femur. Our surgeons have developed a novel technique using a retrograde approach with a shorter path through soft tissue and an entry point with a broad surface for screw insertion. It is unknown how retrograde ADFH impacts surgical time, clinical outcomes, and complication rates. The purpose was to compare retrograde to antegrade ADFH on surgical times, maximum knee extension angles, and complications. Methods: Twenty-eight patients (53 knees) who underwent ADFH [12 antegrade (23 knees); 16 retrograde (30 knees)] were retrospectively reviewed. Surgical approach, time, pre and 2-year post-ADFH knee extension angles, and complications were retrieved. The effect of the approach on surgical time was analyzed through an independent t test. The differences between surgical approach on pre-ADFH and post-ADFH knee extension angles were analyzed using a mixed factor RMANOVA. χ2 performed on complication frequencies. Alpha set to P≤0.05. Results: No statistically significant difference was found between surgical insertion and removal times for antegrade ADFH (insertion: 85.2±30.2 min; removal: 118.0±106.0 min) compared with the retrograde ADFH (insertion: 61.7±29.4 min; removal: 56.2±22.8 min). A main effect of time was observed for knee extension angles (P<0.001). Both groups improved knee extension at 2-year post ADFH (antegrade 5.9±7.3 degrees; retrograde 8.6±8.7 degrees). No differences were found between antegrade and retrograde ADFH on knee extension (P>0.05). One complication was observed in each approach (retrograde: 1/16 patients, 2/30 knees; antegrade: 1/12 patients, 1/23 knees). Conclusions: Retrograde had comparable clinical effectiveness and complication rate as antegrade. An advantage of retrograde is the ease of hardware insertion and removal. Combined, these findings suggest retrograde insertion as a viable alternative approach to ADFH. Level of Evidence: Level III.]]> Thu, 17 Apr 2025 00:00:00 GMT-05:00 01241398-202509000-00023 https://journals.lww.com/pedorthopaedics/fulltext/2025/09000/changes_in_the_alignment_of_the_spine_and_lower.24.aspx Background: Achondroplasia (ACH) is the most common skeletal dysplasia and is characterized by a short-limbed short stature, sagittal spinal malalignment, and genu varum. Vosoritide promotes longitudinal bone growth in children with ACH; however, its effects on various disease-specific complications, other than short stature, are unknown. This study aimed to investigate the therapeutic effects of vosoritide on spinal and lower limb malalignment in children with ACH. Methods: This single-center, open-label, prospective study included patients with ACH aged younger than or equal to 15 years who received vosoritide treatment and had a minimum follow-up period of 1 year. To evaluate alignment after vosoritide treatment, radiologic parameters were measured from sagittal radiographs of the spine and anteroposterior radiographs of the bilateral lower limbs before the administration of vosoritide and 12 months after treatment. Paired t tests were used to compare parameters before and after vosoritide treatment. Results: Seventeen patients (mean age, 7.6±2.7 y) were included. After 1-year treatment of vosoritide, the mean height increased by 5.4±1.3 cm. Changes in spinal alignment after 1 year of vosoritide treatment were 1.5 degrees for cervical lordosis, −1.3 degrees for thoracic kyphosis, −2.8 degrees for thoracolumbar kyphosis, −5.2 degrees for lumbar lordosis (LL), −2.2 degrees for pelvic tilt, −2.6 degrees for pelvic incidence, −0.4 degrees for sacral slope, and 2.6 mm for C7 sagittal vertical axis. Alignment changes in the lower limbs were −3.4 degrees for mechanical axis angle (MAA), 1.7 degrees for mechanical lateral proximal femoral angle (mLPFA), −2.8 degrees for mechanical lateral distal femoral angle (mLDFA), −0.2 degrees for medial proximal tibial angle, and −0.5 degrees for lateral distal tibial angle. The LL, MAA, mLPFA, and mLDFA levels showed statistically significant changes towards the normal range after treatment. Conclusions: One-year treatment of vosoritide decreased the exaggerated LL and improved genu varum deformity in children with ACH. Vosoritide therapy may not only increase longitudinal bone growth but also improve spinal and lower limb malalignment in children with ACH. Level of Evidence: Level II: prospective comparative study.]]> Tue, 15 Apr 2025 00:00:00 GMT-05:00 01241398-202509000-00024 https://journals.lww.com/pedorthopaedics/fulltext/2025/09000/magnetic_resonance_imaging_in_pediatric_pyogenic.25.aspx No abstract available]]> Fri, 23 May 2025 00:00:00 GMT-05:00 01241398-202509000-00025 https://journals.lww.com/pedorthopaedics/fulltext/2025/09000/optimal_timing_for_advanced_imaging_in_childhood.26.aspx No abstract available]]> Tue, 27 May 2025 00:00:00 GMT-05:00 01241398-202509000-00026