ORCID Profile
0000-0002-3624-8273
Current Organisations
Gillette Children's Specialty Healthcare
,
University of Minnesota
,
Children's Hospitals and Clinics of Minnesota
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Publications
Can Femoral Rotation Be Localized and Quantified Using Standard CT Measures?
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 04-2015
Team Approach: Single-Event Multilevel Surgery in Ambulatory Patients with Cerebral Palsy
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 08-2017
DOI: 10.2106/JBJS.RVW.16.00101
Abstract: ➢ Assessment of the ambulatory patient who has cerebral palsy (CP) involves serial evaluations by orthopaedic surgeons, neurosurgeons, rehabilitation specialists, and therapists as well as 3-dimensional gait analysis (3DGA). The most common subtype of CP in ambulatory patients is diplegia, and the most common severity is Gross Motor Function Classification System (GMFCS) Levels I, II, and III. ➢ Increased tone in the skeletal muscle of patients with CP can be managed with focal or generalized, reversible or irreversible means. One method of irreversible tone control in spastic diplegia is selective dorsal rhizotomy. A careful preoperative assessment by a multidisciplinary team guides a patient’s tone-management strategy. ➢ Abnormal muscle forces result in abnormal skeletal development. Resultant lever-arm dysfunction of the lower extremities creates gait abnormality. A comprehensive assessment of gait is performed with 3DGA, supplementing the clinical and radiographic examinations for surgical decision-making. ➢ Single-event multilevel surgery (SEMLS) involves simultaneous correction of all musculoskeletal deformities of the lower extremities in a single setting. Specialized centers with attendant facilities and expertise are necessary. SEMLS often follows years of medical treatment, therapy, and planning. Some procedures can be performed with the patient in the prone position for technical ease and optimal assessment of transverse-plane alignment. ➢ Objective gains in patient function are made until 1 to 2 years after SEMLS. Most ambulatory children with diplegia undergoing SEMLS maintain function at their preoperative GMFCS level but can make quantifiable improvements in walking speed, oxygen consumption, gait quality, and patient-reported functioning.
The Cavovarus Foot in Hereditary Motor and Sensory Neuropathies
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 22-12-2015
Hip Arthroscopy and Hip Joint Preservation Surgery
Publisher: Springer International Publishing
Date: 2022
Association of back pain and pelvic tilt during gait in individuals with cerebral palsy
Publisher: Elsevier BV
Date: 10-2019
DOI: 10.1016/J.GAITPOST.2019.08.011
Abstract: Back pain prevalence may increase with lumbar lordosis during standing in in iduals with cerebral palsy (CP). Multiple interventions undertaken in in iduals with CP have been shown to increase anterior pelvic tilt. Are pelvic tilt and trunk tilt (proxy measurements for lumbar lordosis) during gait associated with back pain prevalence in ambulatory in iduals with CP? A retrospective investigation was performed among all patients with cerebral palsy visiting a single clinical motion analysis laboratory over a 3.5 year period (January 2015 - May 2018) who also had complete pain questionnaire data. Back pain prevalence and its association with sagittal plane kinematic parameters (pelvic tilt and trunk tilt) were analyzed. Among the 700 patients that met the inclusion criteria, 594 were children and 106 were adults. Back pain prevalence was 11.1% in children and 36.8% in adults. As pelvic tilt and age increased, back pain increased (odds ratio 95% confidence interval: 1.002-1.061 and 1.052-1.109, respectively). Walking with an assistive device was not associated with back pain, nor was trunk tilt. Back pain was more common with increasing age in ambulatory in iduals with CP. After controlling for assistive device use and age, there was a weak relationship between pelvic tilt and back pain. Future studies are needed to determine if this is this a causal relationship.
Motorized Plate Lengthening of the Femur in Children: A Preliminary Report
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 08-09-2022
DOI: 10.1097/BPO.0000000000002253
Abstract: Limb lengthening by distraction osteogenesis can be performed with motorized internal devices, but intramedullary implants risk avascular necrosis of the femoral head in young children. A method of internal limb lengthening using a motorized expandable plate has been developed and preliminary results are presented. Seven skeletally immature patients (ages 2.7 to 9.7 y) with congenital femoral deficiencies underwent femoral lengthening with the use of a magnetic expandable plate. Surgical details, lengthening parameters, Limb Lengthening and Reconstruction Society-Angular deformity, Infection, Motion index, and complications were reviewed and classified according to the modified Clavien-Dindo system. An average lengthening was 4.1 cm (range, 3.3 to 4.4 cm) comprising 18% of initial femoral segment length (range, 14% to 21%). The average lengthening phase was 50.2 days (range, 40 to 57 d) and weight-bearing was initiated at an average of 13 weeks from surgery (range, 8 to 18 wk). Limb deformities and length discrepancies were of moderate complexity, with an Limb Lengthening and Reconstruction Society-Angular deformity, Infection, Motion score of 6.57 (range, 6 to 7). Complication rates were comparable to previously reported methods of femoral lengthening. One patient underwent reoperation for patellar instability and 1 patient experienced radiographic hip subluxation which was observed. Small magnitude varus was observed in regenerate in 3 of 7 cases, none requiring treatment. Preoperative planning consisted of careful localization of the corticotomy site, acute deformity correction at the lengthening site in 3 cases, and implant orientation. Limb lengthening with motorized internal plates is feasible for young children with congenital femoral deficiency for whom intramedullary lengthening is unsafe or if external fixation is to be avoided. However, the fundamental principles of distraction osteogenesis and risks of lengthening for congenital discrepancies remain unchanged. Specific considerations herein include: careful planning of implant length and positioning, adjacent joint protection with adjunctive means, and mitigating deformity of the regenerate during distraction. Level IV, retrospective case series.
Displaced Distal Radius Fracture Treatment: A Survey of POSNA Membership
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 07-04-2020
DOI: 10.1097/BPO.0000000000001561
Abstract: Distal radius fractures (DRFs) are the most common pediatric orthopaedic fracture, of which 20% are displaced injuries. Displaced metaphyseal DRFs are often treated with sedated or anesthetized reduction. The necessity of reduction treatment of displaced fractures to achieve good clinical outcomes is unclear. The purpose of this investigation was to determine the treatment preferences for DRFs among pediatric orthopaedic surgeons and to determine whether they were uncertain enough in their decisions to randomize treatment. Twenty-eight DRF scenarios in children aged 3 to 10 years were constructed in an electronic survey to represent a spectrum of age, angulation in sagittal and coronal planes, and displacement. The survey was disseminated to the full membership of the Pediatric Orthopaedic Society of North America (POSNA). Respondents could select either a treatment of (a) attempt anatomic reduction with sedation or (b) nonsedated immobilization. Respondents also denoted whether they would be willing to randomize the treatment of each injury scenario. Patient, fracture, and surgeon characteristics were analyzed to develop predictors of treatment recommendations and willingness to randomize treatment. A total of 319 surgeons responded (23% of POSNA membership). Respondents were a characteristic representation of POSNA membership (well distributed by years in practice, 78% academic, 91% whose work is % pediatrics, and 84% work with residents). Predictors of sedated reduction were complete displacement [odds ratio (OR), 9.23 95% confidence interval (CI), 2.27-37.51 P =0.002] and coronal angulation (per 1-degree increase, OR, 1.09 95% CI, 1.02-1.17 P =0.016), Willingness to randomize was inversely related to larger coronal plane angulation (per 1-degree increase, OR, 0.96 95% CI, 0.93-0.99 P =0.01). A majority of surgeons were willing to randomize 7 of the 8 scenarios involving complete displacement and shortening, and % of surgeons were willing to randomize 5 of these 8 scenarios. POSNA members recommend sedated reduction of DRFs primarily based on existence of complete displacement. Although most completely displaced DRFs would undergo reduction, most surgeons would be willing to randomize the treatment of these injuries. This suggests that most POSNA members do not know whether their recommended treatment for displaced DRFs is necessary or correct. This survey establishes the groundwork for a randomized, prospective trial comparing nonsedated immobilization with sedated/anesthetized reduction in the treatment of displaced pediatric DRFs. Level II—survey study.
What’s New in Limb Lengthening and Deformity Correction
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 21-08-2019
Preventing Distal Junctional Kyphosis by Applying the Stable Sagittal Vertebra Concept to Selective Thoracic Fusion in Adolescent Idiopathic Scoliosis
Publisher: Springer Science and Business Media LLC
Date: 2018
DOI: 10.1016/J.JSPD.2017.06.007
Abstract: Multicenter retrospective review. To assess the effectiveness of using the stable sagittal vertebra (SSV) for selecting the lowest instrumented vertebrae (LIV) to prevent distal junctional kyphosis (DJK) in selective thoracic fusions. Cho et al. reported that including the SSV in a fusion decreased the rate of DJK in thoracic hyperkyphosis. A retrospective review was performed of patients from two pediatric hospitals with adolescent idiopathic scoliosis who underwent selective posterior thoracic fusion with the LIV at L2 or above from 2000 to 2012. Patients with less than 2 years' follow-up were excluded. The primary outcome measure was DJK, defined radiographically as ≥10° between the superior end plate of the LIV and the inferior end plate of the vertebra below on a standing lateral radiograph. We investigated the SSV, which was defined as the vertebral level at which 50% of the vertebral body was in front of the posterior sacral vertical line (PSVL) on a standing lateral radiograph. This particular definition was referred to as SSV. A total of 113 patients met the inclusion criteria. Mean age was 14.4 years. Mean Cobb angle was 58°. The overall rate of DJK was 7% (8/113). When the LIV was superior to SSV, the rate of DJK was 17% (8/46) versus 0% (0/67) when the LIV was at or inferior to SSV (p=.01). The rates of DJK for patients with the LIV one, two, and three levels above SSV were 17% (4/24), 7% (1/14), and 43% (3/7), respectively. There was no significant association between preoperative or postoperative maximum kyphosis, thoracic kyphosis, thoracolumbar kyphosis, pelvic incidence, sagittal balance or coronal balance, and development of DJK. Although LIV selection is complex, choosing the LIV at or below the SSV is a simple rule that minimizes the risk of DJK. Level IV.
A Comparison of Hip Spica Casting to Short Leg Casts and Bar after Hip Reconstruction in Cerebral Palsy
Publisher: Cureus, Inc.
Date: 08-05-2020
DOI: 10.7759/CUREUS.8028
The presentation of Legg−Calvé−Perthes disease in females
Publisher: SAGE Publications
Date: 08-2015
DOI: 10.1007/S11832-015-0671-Y
Abstract: Legg−Calvé−Perthes disease (LCPD) is uncommon in girls. The presentation of LCPD in female patients has been reported as later in onset and associated with certain high-impact activities. Our aim is to characterize the presentation of female LCPD at a large center, with particular attention to the clinical and radiographic features of late-onset disease ( ten years of age). We perceived an increasing burden of late-onset disease with adult-like radiographic features. All patients presenting to a single large urban children's hospital from 1990−2014 with a diagnosis of LCPD were reviewed. Demographic, clinical, and radiographic data for all female patients were examined and compared to historical norms. Four-hundred and fifty-one patients presented with LCPD in the study period, of which 82 (18.2 %) were female. The average age at presentation was 6.58 years in girls, which is similar to the classically reported mean age. Fourteen patients participated in high-impact repetitive activities or those with deep flexion and abduction, although few were late presenters. There were four female patients who presented for initial diagnosis ten years of age. There was a paucity of late-onset LCPD in girls in the study population, and the females with LCPD had a very similar age and character to their presentation as did males. Although their presentation is infrequent, three of four older females with LCPD were engaged in high-level physical activity, and their disease may be attributed to high-impact, repetitive athletics. Case series, Level IV.
Anteverting Bernese periacetabular osteotomy in the treatment of neurogenic hip dysplasia in cerebral palsy
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 11-2018
DOI: 10.1097/BPB.0000000000000513
Abstract: All patients with hypertonic cerebral palsy undergoing Bernese periacetabular osteotomy (PAO) between 2005 and 2014 were reviewed. Clinical and radiographic parameters, including the cerebral palsy hip classification and anterior and posterior wall indices were collected to assess acetabular reorientation. Twenty (83%) of 24 procedures involved the correction of posterolateral acetabular insufficiency and were ‘anteverting PAOs’. All 20 experienced improvements in radiographic indices. Eleven (58%) of 19 PAOs in ambulatory patients were performed in the setting of other multilevel orthopedic surgery. The anteverting PAO is successful in correcting the posterolateral acetabular insufficiency present in spastic hip dysplasia, and can be performed in conjunction with a single-event multilevel surgery.
Intraoperative Neurological Monitoring in Lower Limb Surgery for Patients With Mucopolysaccharidoses
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 14-12-2020
Glove Perforation in Orthopaedics: Probability of Tearing Gloves During High-Risk Events in Trauma Surgery
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 09-2018
DOI: 10.1097/BOT.0000000000001233
Abstract: To assess the risk of glove perforation during common maneuvers or events in trauma-related orthopaedic surgical procedures. Four investigators executed 6 high-risk maneuvers in a simulated laboratory setting. Alternative techniques were also performed for most maneuvers. Glove integrity was examined by 2 standard methods of fluid leak testing. The rates of perforation were compared between techniques using χ 2 and Fisher exact tests. Investigators were only able to identify 14.3% of perforations. Cleaning drill bit flutes by hand had the highest overall tear rate (85%). Catching a glove along the guide wire when passing a cannulated drill bit resulted in a 50% perforation rate. Catching a glove around a rotating drill shaft had a tear rate of 40%. Palpating the end of a flexible nail cut with a wire cutter had a significantly higher perforation rate than a nail cut with a proprietary, nail-specific tool (35% vs. 5%, P = 0.022). Blind digital fracture reduction had a tear rate that was not statistically different than directly visualizing the reduction (20% vs. 15%, P = 0.5). Inserting screws while stabilizing the threads with one's fingers resulted in a perforation rate of 15%. Orthopaedic surgeons should be aware that microperforation of surgical gloves often goes undetected and should consider modifying or using alternative techniques when performing certain surgical maneuvers. The results of this study can be used by orthopaedic and surgical first assist training programs to promote safe surgical practice.
Validation of the Gait Outcomes Assessment List questionnaire and caregiver priorities for individuals with cerebral palsy
Publisher: Wiley
Date: 17-09-2021
DOI: 10.1111/DMCN.15054
Abstract: To expand upon previous validation of the Gait Outcomes Assessment List (GOAL) questionnaire in in iduals with cerebral palsy (CP), to rank items by importance, and to summarize written‐in (free text) goals. For this cross‐sectional study, the parent‐version 5.0 of the GOAL was completed by 310 consecutive caregivers of 310 in iduals aged 3 to 25 years with CP (189 males, 121 females mean [SD] age: 10y [4y 2mo] Gross Motor Function Classification System [GMFCS] levels I–IV) concurrent with a gait analysis. Distribution properties and validity were quantified using questionnaires, kinematics, and oxygen consumption. Items classified as at least ‘difficult’ to perform and ‘very important’ to improve were considered caregiver priorities and rank ordered. Free text goals were categorized. Results were summarized for everyone and by GMFCS level. Most scores were normally distributed. Validity was acceptable, with concurrent greater than construct validity. Among all 310 caregivers, fatigue was the highest priority, followed by gait pattern and appearance items. The rank of priorities varied by GMFCS level. Common free text goals included toileting independently as well as improved fine motor and ball sport skills. The GOAL is a valid tool that can help prioritize goals across GMFCS levels I to IV. Identifying the top goals may improve shared decision‐making and prioritize research for this s le.
Proximal Humeral Nonunion Treated With an Intramedullary Tantalum Cylinder
Publisher: SLACK, Inc.
Date: 12-2013
DOI: 10.3928/01477447-20131120-22
Abstract: Nonunion is uncommon after proximal humerus fracture surgery. There is no agreement about preferred method of treatment. Traditional approaches have included laterally based locking plates, autogenous grafting, and endosteal support to provide improved biomechanical stability. Open reduction and internal fixation (ORIF) of proximal humeral nonunion has been performed with various methods, including blade plates and bone grafting, as well as intramedullary support with autologous or allogenic grafts. Both malunion and nonunion have occurred after ORIF with locking plates. Endosteal support in the form of a fibular allograft incorporated into the locking plate construct can increase mechanical stability in selected cases. An ideal implant for proximal humeral nonunion provides medial column mechanical support and osteoconductive and osteoinductive properties. Porous intramedullary tantalum metal may play a role in nonunion surgery as an alternative to fibular allograft because of its versatility of use and salutary biological effects. It offers many material advantages for use in nonunion surgery. Tantalum is extensively porous (75%–80%), has a stiffness close to that of native bone, and offers the possibility of being a carrier for osteoinductive materials. It may also be suitable for patients who refuse allograft material. This article describes a 65-year-old woman with recalcitrant proximal humeral nonunion who was successfully treated with revision ORIF with intramedullary tantalum cylinder augmentation with a lateral-based locking plate and autogenous cancellous bone grafting. At 5-year follow-up, she had excellent motion and clinical and radiographic union.
Extramedullary Motorized Lengthening of the Femur in Young Children
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 26-06-2020
DOI: 10.1097/BPO.0000000000001593
Abstract: Limb lengthening by distraction osteogenesis is now achievable via motorized intramedullary devices, mitigating many complications of lengthening by external fixation. In young patients, antegrade intramedullary nailing of the femur risks avascular necrosis of the femoral head. A method of extramedullary placement of a motorized expandable intramedullary nail has been employed by the senior author to safely achieve femoral lengthening without the use of an external fixator in young patients. Eleven skeletally immature patients with lower limb length discrepancy were reviewed who underwent extramedullary placement of a magnetic, expandable intramedullary nail for lengthening of the femur. Surgical details, lengthening parameters, and complications were reviewed and classified according to the modified Clavien-Dindo Classification. Average lengthening was 32.3 mm (range: 27 to 40 mm) comprising an average 14.8% of femoral segment length. The average lengthening duration was 6.3 weeks, and average full weight-bearing began at 12.6 weeks. All but 1 patient underwent early removal of the device at an average of 4.5 months, and 5 had immediate plating of the femur. Complications rates were comparable to other methods of femoral lengthening, including varus or procurvatum through the regenerate, and unplanned reoperation in 3 of 11 cases. Preoperative considerations included careful planning of implant length due to short femoral segments and protection of the knee joint from contracture or iatrogenic instability. Extramedullary placement of a magnetic expandable intramedullary lengthening nail can achieve lengthening of the femur without the use of external fixation. Considerations with this technique include careful planning of implant length relative to trochanteric-physeal distance, protection against knee subluxation during lengthening, and mitigating deformity of the regenerate. Off-label, extramedullary use of these devices can be considered to decrease the burdens of external fixation in young children. The technique begs the advent of future all-internal technology specifically designed for safe limb lengthening in this age group. Level IV—retrospective case series.
Does Perfusion MRI After Closed Reduction of Developmental Dysplasia of the Hip Reduce the Incidence of Avascular Necrosis?
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 05-2016
Changing presentation of knee dislocation and vascular injury from high-energy trauma to low-energy falls in the morbidly obese
Publisher: Elsevier BV
Date: 05-2013
DOI: 10.1016/J.JVS.2012.11.067
Abstract: Reports in the literature of low-energy (LE) knee dislocation (KD) in obese patients have been increasing. This study was undertaken to define the risk factors for KD by LE mechanisms and the outcomes of these patients compared with those with high-energy (HE) trauma. All patients with a complete KD presenting to the emergency department of a large urban level I trauma center were reviewed. Patient information collected included age, sex, weight, height, body mass index (BMI), injury mechanism, neurovascular and orthopedic injuries, and operations performed to treat vascular injuries. Risk factors for KD and concomitant injuries were compared between HE traumatic dislocations and LE dislocations in obese patients (BMI >30 kg/m(2)), including stratification for increasing levels of obesity. Between January 1995 and April 2012, 53 patients with KD were identified. The mechanism of injury was HE in 28 (53%) and LE in 25 (47%). Of the LE KDs, 18 (72%) were related to obesity (BMI >30 kg/m(2)). Obese patients with LE trauma were more likely to have associated nerve injuries (50% vs 6% P 40 kg/m(2). Although all LE KDs in the obese involved an isolated extremity, the hospital lengths of stay were comparable to those with HE KDs who frequently had multisystem trauma (8.7 vs 11.4 days). During a 17-year period, LE KDs in the obese represented an increasing proportion, from 17% in 1995 to 2000 up to 53% in 2007 to 2012, and the eventual majority of all KDs at our institution (P = .024). LE KDs in obese patients are becoming increasingly prevalent. These patients are more likely to have nerve and vascular injuries and are more likely to undergo vascular repair than patients with HE trauma. The epidemic of obesity in the United States presents unique challenges in the identification and treatment of patients with LE KD and their associated injuries.
Management of hypertonia in cerebral palsy
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 02-2018
Anterior Guided Growth of the Distal Femur for Knee Flexion Contracture: Clinical, Radiographic, and Motion Analysis Results
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 05-2019
DOI: 10.1097/BPO.0000000000001312
Abstract: Fixed knee flexion deformity is common in children with neuromuscular disorders. Anterior guided growth (AGG) of the distal femur can achieve gradual correction in patients who are skeletally immature. Little outcome data are available on this procedure. This is a retrospective matched cohort study. Forty-two knees (26 patients) underwent AGG surgery at our institution between 2007 and 2017. All patients underwent instrumented 3-dimensional gait analysis (3DGA). A nonsurgical control group of 49 knees (43 patients) was selected that matched for age, severity of preoperative knee contracture, and 3DGA parameters. Clinical, radiographic, and 3DGA outcomes were assessed and compared. Average preoperative knee flexion deformity in AGG group was 13±8 degrees. Following AGG, deformity improved by 8±7 degrees ( P .001) as measured radiographically and by 7±7 degrees ( P .001) as measured on physical examination. Average rate of correction was 0.7±0.6 degrees per month or 8±8 degrees per year. The 3DGA parameters such as minimum stance phase knee flexion and knee flexion at initial contact were also significantly improved following AGG. In contrast, flexion deformity as measured radiographically worsened by 3±3 degrees ( P =0.002) in the control group. Twelve knees (29%) had failure of correction. Predictors of failure included older age, lower level of function, and greater severity of preoperative deformity. The age at time of surgery and the anteroposterior position of plate fixation relative to the distal femoral physis were associated with rate of correction. In children with neuromuscular disorders, AGG of the distal femur is effective in improving degree of fixed knee flexion deformity as well as objective gait parameters. A significant portion of knees experience inadequate correction. Addressing factors associated with correction failure (ie, age and plate placement) may improve the procedure’s success. Level III—case control study
Beware of Ultra-Low-Velocity Knee Dislocation
Publisher: SLACK, Inc.
Date: 10-2014
What’s New in Limb Lengthening and Deformity Correction
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 22-06-2021
Oblique Opening Wedge Osteotomy for Distal Tibial Varus Secondary to Physeal Arrest
Publisher: SAGE Publications
Date: 09-2021
Estimating Causal Treatment Effects of Femoral and Tibial Derotational Osteotomies on Foot Progression in Children with Cerebral Palsy
Publisher: Cold Spring Harbor Laboratory
Date: 08-03-2021
DOI: 10.1101/2021.03.04.21252476
Abstract: Foot progression deviations are a common and important problem for children with CP. Tibial and femoral derotational osteotomies (TDO, FDO) are used to treat foot progression deviations, but outcomes are unpredictable. The available evidence for the causal effects of TDO and FDO is limited and weak, and thus modeling approaches are needed. We queried our clinical database for in iduals with a diagnosis of cerebral palsy (CP) who were less than 18 years old and had baseline and follow up gait data collected within a 3-year time span. We then used the Bayesian Causal Forest (BCF) algorithm to estimate the causal treatment effects of TDO and FDO on foot progression deviations (separate models). We examined average treatment effects and heterogeneous treatment effects (HTEs) with respect to clinically relevant covariates. The TDO and FDO models were able to accurately predict follow-up foot progression (r 2 ∼0.7, RMSE ∼8°). The estimated causal effect of TDO was bimodal and exhibited significant heterogeneity with respect to baseline levels of foot progression and tibial torsion as well as changes in tibial torsion at follow-up. The estimated causal effect of FDO was unimodal and largely homogeneous with respect to baseline or change characteristics. This study demonstrated the potential for causal machine-learning algorithms to impact treatment in children with CP. The causal model is accurate and appears sensible – though no gold-standard exists for validating the causal estimates. The model results can provide guidance for planning surgical corrections, and partly explain unsatisfactory outcomes observed in prior observational clinical studies.
Demonstrating the Utility of Instrumented Gait Analysis in the Treatment of Children with Cerebral Palsy
Publisher: Cold Spring Harbor Laboratory
Date: 14-10-2023
Pediatric Lyme Disease Presenting as a Ruptured Popliteal Cyst
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 2022
Abstract: This case report describes 3 pediatric patients presenting with acute calf or knee pain, calf swelling, and a ruptured popliteal cyst diagnosed by magnetic resonance imaging. Lyme disease was serologically confirmed in each case. In all instances, treatment was delayed because of atypical presentation. All patients responded favorably after antibiotic therapy. The differential diagnosis of Lyme disease should be considered in the context of children presenting with atraumatic unilateral calf pain and a ruptured popliteal cyst. Otherwise, this unusual presentation could delay diagnosis or result in unnecessary surgical intervention, particularly in pediatric patients.
Anterior Knee Pain in Children and Adolescents: Overview and Management
Publisher: Georg Thieme Verlag KG
Date: 28-02-2018
Abstract: Anterior knee pain (AKP) is a common presenting complaint for pediatricians and orthopaedic surgeons and is often seen in young athletes. AKP is multifactorial and has a broad differential diagnosis. The growth changes, biomechanics, and anatomy around the knee add to the complexity of diagnosis and treatment of AKP. Common causes of AKP include Osgood–Schlatter's disease, patellar tendinitis, and patellofemoral instability. In the diagnosis of AKP, it is important to rule out serious and morbid causes of pain, including infection and tumor. It is crucial to complete a detailed history and physical examination and obtain appropriate imaging studies. In general, the majority of patients will respond to nonoperative measures targeted to correct neuromuscular control and kinetic chain dysfunction.
Distal Tibial Guided Growth for Anterolateral Bowing of the Tibia: Fracture May Be Prevented
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 22-10-2020
Abstract: Congenital pseudarthrosis of the tibia is a rare and challenging pediatric condition. The pre-fracture state, called congenital tibial dysplasia or anterolateral bowing of the tibia, presents a high fracture risk due to underlying bowing and dysplasia. After fracture, there is a substantial risk of nonunion. Any union achieved may be complicated by refracture, deformity, leg-length discrepancy, stiffness, pain, and dysfunction. We present the results of using distal tibial growth modulation to improve tibial alignment and to decrease fracture risk in this condition. To our knowledge, this is the first report of isolated distal tibial growth modulation as the primary surgical treatment for this condition. This is a retrospective study of 10 patients with congenital tibial dysplasia who presented prior to pseudarthrosis and underwent distal tibial growth modulation as a primary treatment. The medical records and radiographs were reviewed for age at the times of diagnosis and treatment, fracture, secondary procedures, complications, residual deformity, cystic changes, and leg-length discrepancy. Ten patients had a mean follow-up (and standard deviation) of 5.1 ± 1.9 years. No patient sustained a tibial fracture, and no patient developed a tibial pseudarthrosis after guided growth was initiated. The mean age at the initiation of growth modulation was 2.6 ± 1.3 years. Six patients required a plate exchange. The mean residual tibial diaphyseal angular deformity at the most recent follow-up was 4.3° ± 3.2° of varus and 8.4° ± 5.8° in the sagittal plane. Only 1 patient had a clinically important leg-length discrepancy, with the affected leg being longer. In this series of 10 patients with congenital tibial dysplasia, distal tibial growth modulation delayed or possibly prevented fracture, decreased tibial malalignment, improved radiographic appearance of bone quality, and preserved leg length. No patient developed tibial fracture or pseudarthrosis after the initiation of guided growth treatment. Although early results are promising, follow-up to maturity is required to define the exact role of this simple outpatient procedure in congenital tibial dysplasia. Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.
Short-term causal effects of common treatments in ambulatory children and young adults with cerebral palsy: three machine learning estimates
Publisher: Springer Science and Business Media LLC
Date: 12-05-2022
DOI: 10.1038/S41598-022-11875-5
Abstract: Orthopedic and neurological impairments (e.g., muscle contractures, spasticity) are often treated in children and young adults with cerebral palsy (CP). Due to challenges arising from combinatorics, research funding priorities, and medical practicalities, and despite extensive study, the evidence base is weak. Our goal was to estimate the short-term effectiveness of 13 common orthopedic and neurological treatments at four different levels of outcome in children and young adults diagnosed with CP. The outcome levels considered were body structures, specific gait kinematic deviations, overall gait kinematic deviations, and functional mobility. We used three well-establish causal inference approaches (direct matching, virtual twins, and Bayesian causal forests) and a large clinical gait analysis database to estimate the average treatment effect on the treated (ATT). We then examined the effectiveness across treatments, methods, and outcome levels. The dataset consisted of 2851 limbs from 933 in iduals (some in iduals underwent multiple treatment episodes). Current treatments have medium effects on body structures, but modest to minimal effects on gait and functional mobility. The median ATT of 13 common treatments in children and young adults with CP, measured as Cohen’s D, bordered on medium at the body structures level (median [IQR] = 0.42 [0.05, 0.60]) and became smaller as we moved along the causal chain through specific kinematic deviations (0.21 [0.01, 0.33]), overall kinematic deviations (0.09 [0.03, 0.19]), and functional mobility (-0.01 [-0.06, 0.13]). Further work is needed to understand the source of heterogeneous treatment effects, which are large in this patient population. Replication or refutation of these findings by other centers will be valuable to establish the generalizability of these results and for benchmarking of best practices.
Hip Vascularity: A Review of the Anatomy and Clinical Implications
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 08-2016
Abstract: Throughout development, the vascular supply to the proximal femur and acetabulum undergoes a series of changes during which it is susceptible to injury. Before age 3 months, the ligamentum teres and lateral epiphyseal arteries are the dominant supply to the developing head. The dominant supply shifts to the lateral epiphyseal vessels by age 18 months. The distinct metaphyseal and epiphyseal circulations of the adult proximal femur form in adolescence when an increasingly rich metaphyseal circulation supplies the subphyseal region, terminating at the physeal plate. The acetabular blood supply derives from two independent systems, with the dominance of each changing throughout maturity. Most descriptions of the vascular contributions to the proximal femur and acetabulum have been gross anatomic and histologic studies. Advanced imaging studies (eg, CT angiography, perfusion MRI) have added to our understanding of the vascular anatomy of the proximal femur and acetabulum, its changes throughout development, and its clinical implications.
What’s New in Limb Lengthening and Deformity Correction
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 15-06-2020
Estimating the Efficacy of Common Treatments in Children and Young Adults Diagnosed with Cerebral Palsy Using Three Machine Learning Algorithms
Publisher: Cold Spring Harbor Laboratory
Date: 07-10-2021
DOI: 10.1101/2021.10.06.21264624
Abstract: Orthopedic and neurological deformity are often treated in children and young adults with cerebral palsy (CP). Due to challenges arising from combinatorics, research funding priorities, and medical practicalities, the efficacy of these treatments is not well studied. Our goal was to estimate the efficacy of 13 common orthopedic and neurological treatments at four different levels of outcome in children and young adults diagnosed with CP. The outcome levels considered were anatomy and physiology, gait parameter, overall gait pattern, and function. We used three well-establish causal inference approaches (direct matching, virtual twins, and Bayesian causal forests) and a large clinical gait analysis database to estimate the average treatment effect on the treated (ATT). We then examined the efficacy across treatments, methods, and outcome levels. The median ATT of 13 common treatments in children and young adults with CP, measured as Cohen’s D, bordered on medium at the anatomy and physiology level (median [IQR] = 0.42 [.05, .60]) and became smaller as we moved along the causal chain through gait parameter (0.21 [.01, .33]), overall gait pattern (0.09 [.03, .19]), and function (−0.01 [-.06, .13]). Current treatments have medium effects on anatomy and physiology, but modest to minimal efficacy on gait and function. Further work is needed to understand the source of heterogeneous treatment effects, which are large in this patient population. Replication or refutation of these findings by other centers will be valuable to establish the generalizability of these results and for benchmarking of best practices.
What’s New in the Orthopaedic Treatment of Ambulatory Children With Cerebral Palsy Using Gait Analysis
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 29-10-2019
DOI: 10.1097/BPO.0000000000001461
Abstract: Limb deformities in ambulatory children with cerebral palsy (CP) are common. The natural history of lower extremity deformities is variable and the impact on gait is managed with many treatment modalities. Effective interventions must consider the underlying pathophysiology, patient-specific goals, and incorporate objective outcome assessment. Evaluation and treatment include observation, tone management multilevel orthopaedic surgery to address muscle contractures and bony deformities, and the use of gait analysis for preoperative and postoperative assessment. A PubMed search of the orthopaedic literature for studies published between January 2016 and February 2019 was performed. Eligible abstracts included the use of 3-dimensional instrumented gait analysis in the evaluation and treatment of the lower extremities in ambulatory children with CP. Seven hundred twenty abstracts were reviewed, with 84 papers identified as eligible, of which 45 full manuscripts were included for detailed review. The review summarized recent advances regarding the treatment of torsional alignment, knee deformities and clinical gait evaluation with visual assessment tools compared with instrumented gait analysis. Gait analysis of ambulatory children with CP remains essential to evaluation and surgical decision-making. Promising results have been reported with the goal of maintaining or reaching a higher level of function and increased endurance. Level IV—literature review.
Prevalence of acetabular labral tears in asymptomatic children
Publisher: SAGE Publications
Date: 04-2016
DOI: 10.1007/S11832-016-0717-9
Abstract: Magnetic resonance imaging (MRI) is a sensitive, non-invasive modality to diagnose acetabular labral pathology, and the normal variants of the acetabular labrum have been characterized in adults. However, the prevalence of labral pathology in the asymptomatic pediatric population is unknown. All pelvic MRIs performed at a large tertiary-care children's hospital were reviewed during one calendar year (2014). Only patients aged between 2 and 18 years were included, and scans were excluded for hip pain athology or technical inadequacy. A blinded pediatric musculoskeletal radiologist read all eligible scans for the presence or absence of a labral tear. Three hundred and ninety-four pelvic MRIs were screened, and patients were excluded for hip pain athology (85 subjects), or technical inadequacy (190 subjects). One hundred and eight subjects (216 hips) met the inclusion criteria and were technically adequate for analysis. Labral tears were visualized in three of 216 (1.4 %) hips (two of the 110 subjects 1.9 %). There is a low rate of asymptomatic labral pathology by MRI in pediatric patients. The clinical history remains the means of differentiating real labral pathology from spurious imaging findings. Case series (prevalence).
A model for understanding the causes and consequences of walking impairments
Publisher: Public Library of Science (PLoS)
Date: 28-12-2022
DOI: 10.1371/JOURNAL.PONE.0270731
Abstract: Walking is an important skill with positive impacts on health, function, and well-being. Many disorders impair walking and its positive impacts through a variety of complex and interrelated mechanisms. Any attempt to understand walking impairments, or the effects of interventions intended to treat these impairments, must respect this complexity. Therefore, our main objectives in conducting this study were to (1) propose a comprehensive model for quantifying the causes and consequences of walking impairments and (2) demonstrate the potential utility of the model for supporting clinical care and addressing basic scientific questions related to walking. To achieve these goals, we introduced a model, described by a directed acyclic graph, consisting of 10 nodes and 23 primary causal paths. We gave detailed descriptions of each node and path based on domain knowledge. We then demonstrated the model’s utility using a large s le of gait data (N = 9504) acquired as part of routine care at a regional referral center. We analyzed five relevant ex les that involved many of the model’s nodes and paths. We computed causal effect magnitudes as Shapley values and displayed the overall importance of variables (mean absolute Shapley value), the variation of Shapley values with respect to underlying variables, and Shapley values for in idual observations (case studies). We showed that the model was plausible, captured some well-known cause-effect relationships, provided new insights into others, and generated novel hypotheses requiring further testing through simulation or experiment. To aid in transparency, reproducibility, and future enhancements we have included an extensively commented Rmarkdown file and a deidentified data set.
Sagittal Plane Considerations During Long Cephalomedullary Nailing: Optimal Distal Positioning and the Role of Intraoperative Nail Bending
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 11-2019
DOI: 10.1097/BOT.0000000000001577
Abstract: To retrospectively review a large population of long cephalomedullary nails with special attention to distal implant position in the sagittal plane and assess the ability to avoid anterior cortical contact (ACC) by bending the distal tip of the nail intraoperatively. Retrospective review of single surgeon experience. Single Level 1 trauma center. Radiographic position of the cephalomedullary nail with respect to the anterior femoral cortex and the effects of intraoperative bending of the distal tip of the nail. A total of 215 patients who underwent long cephalomedullary nailing for peritrochanteric hip fractures between 2007 and 2017 were reviewed. In the period between 2007 and October 2013, ACC of the distal portion of the nail in the sagittal plane was a common finding. Its incidence significantly decreased after intraoperative bending of long cephalomedullary nails was incorporated into practice in cases where sagittal plane impingement was detected ( P 0.0001). ACC was more prevalent if the final nail position was proximal to the level of the patella. Careful attention should be paid to sagittal plane anatomy and distal ACC during insertion of a long cephalomedullary nail. One strategy to prevent anterior impingement or perforation may be intraoperative bending of the distal end of the nail. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Screening and referral for children with physical disabilities
Publisher: Wiley
Date: 17-10-2017
DOI: 10.1111/JPC.13735
Abstract: The clinical care of children with physical disabilities is a major priority for paediatricians and paediatric orthopaedic surgeons. Cerebral palsy (CP) is the prototypical condition and remains the most common cause of physical disability in developed countries. The incidence is approximately 2 per 1000 live births, translating to between 600 and 700 new children per annum in Australia, with approximately 34 000 children and adults currently living with CP. This figure is predicted to rise inexorably over the next 20 years. The care of children with physical disabilities, including those with CP, is usually coordinated by paediatricians, general practitioners and allied health teams including physiotherapists, with input from paediatric orthopaedic surgeons when appropriate. The emphasis in care for children with CP has moved from 'reactive' to 'proactive'. In the past, children are often referred when symptomatic, for ex le when a hip dislocation had occurred and became painful. The emphasis now is on coordinated, multidisciplinary care in which musculoskeletal manifestations of disability are identified by screening programmes. Systematic screening, especially when population-based and linked to a register, avoids children getting 'lost in the system'. Early and more effective interventions may be offered for the prevention of contractures, dislocation of the hip and spinal deformities. In this review, we will focus on the assessment of gait in children with physical disabilities, and monitoring for hip and spine deformity.
Slipped Capital Femoral Epiphysis
Publisher: Elsevier BV
Date: 12-2014
DOI: 10.1016/J.PCL.2014.08.001
Abstract: Slipped capital femoral epiphysis (SCFE) involves displacement of the proximal femoral metaphysis relative to a fixed epiphysis, usually during a period of rapid growth and unique physeal susceptibility. Patients have characteristic clinical, histologic, and radiologic features. Several clinical signs and medical diagnoses should prompt radiologic and laboratory workup. Limp or hip or knee pain in a patient 10 to 16 years old should include SCFE in the differential. If confirmed, appropriate treatment involves proximal femoral physeal stabilization and/or realignment. The optimal surgical treatment of severe SCFE and its late sequela remain an evolving and controversial subject.
Regionalization of Isolated Pediatric Femur Fracture Treatment: Recent Trends Observed Using the Kids’ Inpatient Database
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 12-09-2019
DOI: 10.1097/BPO.0000000000001452
Abstract: Isolated pediatric femur fractures have historically been treated at local hospitals. Pediatric referral patterns have changed in recent years, erting patients to high volume centers. The purpose of this investigation was to assess the treatment location of isolated pediatric femur fractures and concomitant trends in length of stay and cost of treatment. A cross-sectional analysis of surgical admissions for femoral shaft fracture was performed using the 2000 to 2012 Kids’ Inpatient Database. The primary outcome was hospital location and teaching status. Secondary outcomes included the length of stay and mean hospital charges. Polytrauma patients were excluded. Data were weighted within each study year to produce national estimates. A total of 35,205 pediatric femoral fracture cases met the inclusion criteria. There was a significant shift in the treatment location over time. In 2000, 60.1% of fractures were treated at urban, teaching hospitals increasing to 81.8% in 2012 ( P .001). Mean length of stay for all hospitals decreased from 2.59 to 1.91 days ( P .001). Inflation-adjusted total charges increased during the study from $9499 in 2000 to $25,499 in 2012 per episode of treatment ( P .001). Total charges per hospitalization were ∼$8000 greater at urban, teaching hospitals in 2012. Treatment of isolated pediatric femoral fractures is regionalizing to urban, teaching hospitals. Length of stay has decreased across all institutions. However, the cost of treatment is significantly greater at urban institutions relative to rural hospitals. This trend does not consider patient outcomes but the observed pattern appears to have financial implications. Level III—case series, database study.
Regionalization of Isolated Pediatric Femur Fracture Treatment: Recent Trends Observed Using the Kids’ Inpatient Database
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 19-02-2020
Lengthening of the Humerus Using a Motorized Lengthening Nail: A Retrospective Comparative Series
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 23-09-2019
DOI: 10.1097/BPO.0000000000001453
Abstract: Lengthening of the humerus has traditionally been accomplished by the use of external fixation. Intramedullary motorized lengthening nails are now frequently used for lower limb lengthening, and this technology is slowly being adopted for use in the humerus. A retrospective, single-surgeon experience of pediatric humeral lengthenings was performed. The time period surveyed included use of external fixation (EF) for lengthening, and the use of a motorized nail (MN) for lengthening. The primary outcome measures were lengthening magnitude achieved, duration of lengthening, frequency and type of complications encountered, or further procedures required, during each lengthening. From 1999 to 2018, 13 humeral lengthenings were performed in 9 patients. Six lengthenings were performed using the MN technique and 7 using the EF technique. The average absolute lengthening achieved was 8.5±1.3 cm in the EF group and 6.6±2.3 cm in the MN group. The duration of lengthening averaged 114 days in the MN group and 103 days in the EF group. The average duration of EF time was 215 days. Two patients underwent an initial EF lengthening of a humerus and then underwent a second lengthening using the MN technique. Two of 6 (33%) MN lengthenings and 3 of 7 (43%) EF lengthenings experienced complications during treatment. Two patients in the MN group underwent planned reversal and redeployment of their motorized nails to attain the planned lengthening magnitude. Humeral lengthening using motorized intramedullary nails is a safe technique that mitigates some of the complications of EF including pin site infection. It is well tolerated by patients. For lengthenings of a large magnitude, reversal and reuse of MN can be considered.
Response to Letter to the Editor on “A Prospective Double-Blind Placebo Controlled Trial of Topical Tranexamic Acid in Total Knee Arthroplasty”
Publisher: Elsevier BV
Date: 04-2020
Suture Fixation of the Syndesmosis Using Readily Available Materials
Publisher: SAGE Publications
Date: 25-06-2015
Massive Post-traumatic Femoral Cyst Resulting in Pathologic Fracture in a Child
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 2020
Abstract: A 10-year-old boy experienced a pathologic diaphyseal femur fracture through a large cyst encompassing 40% of femoral length. At age 5, he had had a traumatic ipsilateral diaphyseal femur fracture, treated with flexible nailing. Biopsy at age 10 revealed a simple bone cyst with components of aneurysmal bone cyst. Curettage, antegrade nailing, and allograft resulted in successful osseous healing. Post-traumatic cysts of long bones are rare and have not been reported to cause pathologic fracture in children. This case highlights that close scrutiny of follow-up radiographs of long bone fractures may identify clinically important post-traumatic cysts.
Complications of Limb Lengthening With Motorized Intramedullary Nails
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 08-06-2020
Abstract: Intramedullary limb lengthening (LL) is now achievable through motorized intramedullary devices. While this technology mitigates some complications of external-fixation-based lengthening, many complications common to all lengthening procedures persist. New challenges and complications exclusive to this newer technology are also presented. The LL surgeon should be aware of and ready to respond to complications involving device malfunctions, poor local bony and soft-tissue biology, patient compliance, neurovascular compromise, joint instability, regenerate problems, and others. While technology will continue to evolve, study of and adherence to foundational principles of LL will minimize risks and optimize patient outcomes.
Slipped Capital Femoral Epiphysis: Acute and Chronic
Publisher: Springer New York
Date: 14-10-2014
A Prospective Double-Blind Placebo Controlled Trial of Topical Tranexamic Acid in Total Knee Arthroplasty
Publisher: Elsevier BV
Date: 09-2013
DOI: 10.1016/J.ARTH.2013.03.038
Abstract: Tranexamic acid (TNA) reduces postoperative blood loss in general and obstetrical surgery but there is limited orthopaedic literature regarding its use in the topical setting. To study the effect of topical TNA after primary total knee arthroplasty (TKA), 101 patients were randomized to topical administration of 2.0g TNA in 75mL of normal saline (50 patients) or placebo (51 patients). Operative technique, drug administration, and venous thromboembolism prophylaxis were standardized. All patients underwent screening ultrasound of the operative extremity. Total blood loss was lower in the TNA group (940.2±327.1mL) than the placebo group (1293.1±532.7mL)(P<0.001), and four patients in the placebo group and none in the TNA group received postoperative transfusion (P=0.118). We recommend administration of topical TNA in primary TKA in healthy patients to decrease perioperative blood loss.
Park-Harris Lines
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 21-09-2022
Abstract: Park-Harris lines are radiographically apparent linear opacities that occur in a metaphyseal bone in proximity to a physis. Lines correspond to a temporary interruption of the normally ossifying physis with a sclerotic line corresponding to transversely oriented trabeculae. They were first appreciated in the long bones of diabetic children and have since been described in various metabolic, endocrinologic, infectious, neoplastic, and posttraumatic conditions as well as in response to systemic medications. Park-Harris lines are clinically useful in demarcating notable events in whole-body or in idual bone development, in tracking longitudinal growth, or in assessing physeal arrest and responses to its treatment. There remains controversy about whether these lines are pathologic or a component of physiologic development and whether they constitute true “growth arrest” or rather “growth recovery.” In this review, the history, pathophysiology, imaging, and clinical use of Park-Harris lines as well as an anthropological perspective on their utility for studying illness, nutrition, and historical living conditions over time are discussed.
Related Organisations
The Children's Hospital Of Philadelphia
Location: United States of America
Gillette Children's Specialty Healthcare
Location: United States of America
The Ohio State University College Of Medicine
Location: United States of America
Children's Hospitals And Clinics Of Minnesota
Location: United States of America
Related Funding Activities
No related grants have been discovered for Andrew Georgiadis.