Radiographic Scapholunate Interval in the Pediatric Population Decreases in Size as Age Increases.

BACKGROUND: Widening of the scapholunate (SL) interval greater than 2 mm is diagnostic of an injury in adults; however, this absolute number cannot be used for skeletally immature individuals due to the ossification of the carpal bones. The purpose of this study was to determine age-appropriate normative values for the radiographic SL interval in the skeletally immature population. METHODS: Normal pediatric wrist radiographs were identified. The radiographic SL interval was measured as the distance between the scaphoid and the lunate at the mid-joint space between the scaphoid and the lunate, and the SL and capitolunate angles were measured on lateral views. An initial inter-rater reliability assessment was completed with strong inter-rater reliability. RESULTS: In all, 529 radiographic series of children (276 male), aged 4 to 17 years, were reviewed. A negative linear correlation between chronological age and distance at the mid-joint space was observed. The average values for the radiographic SL interval ranged from 9.07 to 1.57 mm. The average SL and capitolunate angles were 52.0° and 10.6°, respectively. No linear relationship was found between chronological age and SL or capitolunate angle (R = 0.07 and 0.03, respectively). CONCLUSIONS: The visible radiographic distance between the scaphoid and the lunate decreases with increasing age as the carpal bones ossify. The normative values defined in this study can be used to determine whether a true widening of the SL interval is present in the pediatric population. No linear relationship exists between chronological age and SL or capitolunate angle.

Personalized volumetric assessment of lower body muscles in patients with knee injuries: A descriptive case series.

BACKGROUND: Patients with knee joint pathology present with variable muscular responses across the muscles of the lower limb and pelvis. Conventional approaches to characterizing muscle function are limited to gross strength assessments that may overlook subtle changes both in the thigh, hip and shank musculature. PURPOSE: To describe individualized patterns of lower extremity muscle volumes in patients with knee pathologies. METHODS: This was a retrospective case series performed in a University medical center. Nine patients diagnosed with meniscus tear recommended to undergo meniscectomy volunteered. Participants underwent 3.0 Tesla magnetic resonance imaging (MRI) of the lower extremities. Thirty-five MRI-derived muscle volumes were compared between limbs and expressed as percentage asymmetry. For additional context, z-scores were also calculated for mass- and height-normalized muscles and pre-determined muscle groupings relative to a normative database. RESULTS: There were no consistent patterns observed when considering between-limb asymmetries among all patients. The ankle musculature (dorsiflexors, plantar flexors, and invertors) was the only muscle group to be consistently smaller than normal for all patients, with the psoas major and flexor hallucis longus being the only individual muscles. The severity or chronicity of injury and presence of surgical intervention did not appear to have a clear effect on muscle volumes. CONCLUSION: Patients with a history of meniscal pathology demonstrate inconsistent patterns of lower extremity muscle volumes about the hip, knee, and ankle between limbs and in comparison to uninjured individuals. These data support the need for individualized assessment and intervention in this population.

The Efficacy of Nonsurgical and Surgical Interventions in the Treatment of Pediatric Wrist Ganglion Cysts.

PURPOSE: The treatment of ganglion cysts of the wrist remains understudied in the pediatric population, with the literature showing variable recurrence rates following different interventions. This study sought to determine whether surgical and nonsurgical management of pediatric ganglion cysts was associated with improved resolution rates when compared to observation alone. METHODS: We identified 654 cases of pediatric ganglion cysts treated across 5 institutions between 2012 and 2017. The mean age at presentation was 11.6 ± 5.2 years. Of the patients, 315 had >2 years (mean, 50.0 months) of follow-up, either via chart review or telephone callbacks. There were 4 different treatment groups: (1) observation, (2) cyst aspiration, (3) removable orthosis, and (4) surgical excision. RESULTS: For patients followed >2 years, the cyst resolved in 44% (72/163) of those observed. Only 18% (9/49) of those treated with aspiration resolved, and 55% (12/22) of those treated with an orthosis resolved. Surgical excision was associated with resolution of the cyst in 73% (59/81) of patients. Observation had higher rates of resolution compared to aspiration. Orthosis fabrication and observation had similar rates of cyst resolution. Surgery had the highest rates of resolution when compared to observation and aspiration. Patients older than 10 years were less likely to have the cyst resolve with observation (35%; 28/80) than those younger than 10 years (53%; 44/83) at >2 years of follow-up. CONCLUSIONS: This study did not find evidence that nonsurgical treatments were associated with improved rates of cyst resolution compared to observation alone in a large pediatric sample. Surgical excision had the overall highest rate of resolution. Despite the costs and increased clinic time of orthosis fabrication and aspiration, these treatments were not associated with improved rates of cyst resolution in pediatric ganglion cysts compared to observation, with aspiration having higher rates of recurrence compared to observation. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Single Versus Double Tendon Transfer to Improve Shoulder External Rotation During the Treatment of Brachial Plexus Birth Palsy.

Background: Tendon transfers are commonly performed in patients with brachial plexus birth palsy (BPBP) to improve function. Transferring 2 tendons in patients with C5-7 injury has the potential complication of loss of midline function. The purpose of this study was to investigate whether a single tendon transfer (1TT) as opposed to the traditional double tendon transfer (2TT) resulted in any differences in functional outcomes in patients with C5-7 BPBP. Methods: A retrospective review of all patients with C5-7 BPBP who underwent tendon transfers to improve shoulder external rotation over a 5-year period was performed at 2 institutions. Outcomes were assessed using the modified Mallet (MM) classification scores. Results: Twenty-two C5-7 patients had complete records of preoperative and postoperative MM scores, including 11 sex-matched patients in both the 1TT and 2TT groups. When comparing preoperative and postoperative MM categories, there were significant improvements in both the 1TT and 2TT groups for global abduction (P < .05 and P < .01, respectively) and external rotation (P < .00001 for both). Modified Mallet (MM) hand to neck scores were significantly improved in the 2TT group (P < .05) but not in the 1TT group (P = .053). Internal rotation scores significantly decreased in both groups (P < .001). Both groups demonstrated significant increases in total scores from the preoperative MM scores (P < .01). Conclusion: The 1TT and 2TT procedures result in substantial gains in upper extremity functions for patients with C5-7 BPBP as measured by the MM score, specifically within the global abduction and external rotation subcategories. However, a significant loss occurs in internal rotation for both groups.

Hospital and Surgeon Reimbursement Trends for Femoral Neck Fractures Treated With Hip Hemiarthroplasty and Total Hip Arthroplasty.

BACKGROUND: The economic impact of hip fractures on the health care system continues to rise with continued pressure to reduce unnecessary costs while maintaining quality patient care. This study aimed to analyze the trend in hospital charges and payments relative to surgeon charges and payments in a Medicare population for hip hemiarthroplasty and total hip arthroplasty (THA) for femoral neck fracture. METHODS: The 5% Medicare sample database was used to capture hospital and surgeon charges and payments related to 32,340 patients who underwent hemiarthroplasty and 4323 patients who underwent THA for femoral neck fractures between 2005 and 2014. Two values were calculated: (1) charge multiplier (CM, ratio of hospital to surgeon charges), and (2) payment multiplier (PM, ratio of hospital to surgeon payments). Year-to-year variation and regional trends in patient demographics, Charlson Comorbidity Index (CCI), length of stay (LOS), 90-day and 1-year mortality, CM, and PM were evaluated. RESULTS: Hospital charges were significantly higher than surgeon charges and increased substantially for hemiarthroplasty (CM of 13.6 to 19.3, P < .0001) and THA (CM of 9.8 to 14.9, P = .0006). PM followed a similar trend for both hemiarthroplasty (14.9 to 20.2; P = .001) and THA (11.9 to 17.4; P < .0001). LOS decreased significantly for hemiarthroplasty (3.78 to 3.37d; P < .0001) despite increasing CCI (6.36 to 8.39; P = .018), whereas both LOS (3.71 to 3.79 days; P = .421) and CCI (5.34 to 7.08; P = .055) remained unchanged for THA. CONCLUSION: Hospital charges and payments relative to surgeon charges and payments have increased substantially for hemiarthroplasty and THA performed for femoral neck fractures.