Surgeon Recommendations for Physical Activity in Patients With Pediatric Hip Conditions.

BACKGROUND: While physical activity (PA) is important during youth, it is unclear if children and adolescents with developmental dysplasia of the hip (DDH), Legg-Calvé-Perthes disease (LCPD), or slipped capital femoral epiphysis (SCFE) are expected or encouraged to return to PA once they have healed. This study examines the orthopaedic surgeons' role in advising pediatric hip patients on the PA they should engage in, assessing their practice, opinions, and consensus when making recommendations. METHODS: Orthopaedic surgeons were invited from member lists of 4 hip study groups. The survey included demographics, opinions regarding PA, and 10 case scenarios that queried respondents on the duration and intensity of PA as well as the restrictions on activity type that they would recommend for DDH, LCPD, or SCFE patients. Consensus was evaluated on a scale ranging from 0 to 1, with a value of 0 indicating no agreement among respondents and a value of 1 indicating complete agreement. RESULTS: A total of 51 orthopaedic surgeons responded. While 94% agreed that it is important for school-aged hip patients to return to PA after they have healed, 53% believed that PA may compromise the hip and contribute to the development of osteoarthritis. Average standardized consensus was 0.92 for suggesting the patient engage in some amount of PA, 0.44 for suggesting the recommended daily minimum of 60 minutes of moderate-to-vigorous physical activity (MVPA), and 0.33 for suggesting restrictions on activity type. The most frequently selected restrictions included avoiding impact activities (93%, 235/254) and contact activities (58%, 147/254), followed by weight-bearing activities (24%, 62/254). Respondents were not aware of existing PA guidelines, although 57% expressed interest in following guidelines and 39% were uncertain. CONCLUSIONS: While there is consensus among orthopaedic surgeons that children with chronic hip conditions should engage in PA, there is considerable variation when recommending the recommended daily MVPA minimum and placing restrictions on activity type. This study suggests interest among orthopaedic surgeons in developing PA guidelines that optimize outcomes for pediatric hip patients. LEVEL OF EVIDENCE: Level II-Survey study.

Protocol for extracting and isolating porcine bone-marrow-derived macrophages from ribs.

Due to anatomical and biological similarities with humans, pigs are increasingly used for inflammation- and immune-related studies in biomedical research, including the field of osteonecrosis and osteoimmunology. Here, we present a protocol for rib extraction, isolation of the bone marrow by centrifugation, and processing to obtain bone-marrow-derived macrophages (BMDMs). Then, we describe the procedures of in vitro experiments to evaluate the cell phenotype. For complete details on the use and execution of this protocol, please refer to Andre et al.1.

Pathogenic Gene Variants Identified in Patients Presenting With Perthes or Perthes-like Hip Disorder.

AIMS: Legg-Calve-Perthes disease (LCPD) is a diagnosis of exclusion. Various conditions, such as skeletal dysplasias, can closely mimic LCPD and these must be ruled out to provide appropriate treatment, prognosis, and counseling. Traditionally, genetic testing has not been readily available in pediatric orthopaedic practice. Furthermore, the clinical value of genetic testing patients with LCPD is unclear. With the advance of next-generation sequencing (NGS) technology, genetic testing has become clinically available as a lab test. The purposes of this study were to assess the clinical utility of genetic testing in select patients with LCPD and to determine the patient characteristics of those who tested positive for skeletal dysplasia. METHODS: This is an IRB-approved, retrospective study of 63 consecutive patients who presented with Perthes-like symptoms and/or x-ray findings and who had genetic testing. The reason(s) for genetic testing included bilateral hip disease, family history of LCPD, short stature, suspected skeletal dysplasia, atypical radiographic findings, and/or combinations of these reasons. RESULTS: Of the 63 patients, 19 patients (30%) were found to have a pathogenic gene variant. In 8 of the 19, a variety of skeletal dysplasia was diagnosed. The remaining 11 patients were found to be carriers of autosomal recessive disorders. All 19 patients were referred for genetic counseling. Of the 8 patients found to have skeletal dysplasia, 3 had bilateral disease, 3 were <10 percentile in height, 1 had a family history of "LCPD," and 3 had atypical x-ray findings. In addition to the pathogenic variants, numerous genetic variants of unknown significance were found with 2 gene variants showing exactly the same variant found in 2 unrelated patients. CONCLUSIONS: With 30% of the patients showing pathogenic results, genetic testing of select patients with Perthes-like disease is valuable in detecting an underlying genetic disorder or a carrier status of a genetic disorder.

Obesity impairs revascularization and bone healing in a mouse model of osteonecrosis.

Osteonecrosis of the femoral head (ONFH) is a devastating bone disease that is caused by a disruption of blood supply leading to necrotic cell death. Clinically, it was found that obesity has a high prevalence with ONFH. However, it remains unclear how obesity may directly affect tissue regeneration and bone healing in osteonecrosis (ON). The purpose of this study is to investigate the effects of obesity and weight loss (WL) on ON healing. In this study, we induced obesity and WL in an established surgery-induced ON mouse model via feeding a high-fat diet (HFD) and altering the diet respectively. All mice received a surgical induction of ON of distal femoral epiphysis at the age of 12 weeks. HFD was switched to normal diet (ND) after ON surgery to induce WL. Mouse body weight was recorded weekly. Mouse body composition was scanned by DEXA (Dual-energy X-ray absorptiometry) right after sacrifice at the age of 16 weeks. The distal femoral bone samples were fixed and embedded for histology such as H&E, immunohistochemistry, and TRAP staining. In this study, we found that HFD-induced obesity impaired revascularization and bone remodeling showing decreased vessel areas and reduced osteoblast and osteoclast numbers. WL could rescue obesity-induced bone healing defects. Our study is the first to test the direct effects of obesity and WL on ON bone healing. We believe our work may provide new concepts for osteonecrosis treatment in obese patients.

Percutaneous transphyseal screw induces varus proximal femoral growth modulation in a growing pig model-A three-dimensional analysis.

Bone and joint angular deformities are common pediatric orthopedic problems that are often corrected surgically. Previous studies successfully demonstrated proximal femoral growth modulation in animal models, however outcome measurements were limited by two-dimensional analysis. In this study, six Yorkshire cross male piglets were treated with unilateral percutaneous transphyseal screw placement across the medial aspect of the proximal femoral physis and analyzed using three-dimensional (3D) techniques. Three primary outcome measures were considered-physis angle, version, and femoral length. Compared to paired controls, all treated femurs displayed varus correction and shortening after an average treatment period of 10 weeks. The amount of varus change was 11.6 ± 2.8° (mean ± SD) (p = 0.0002, 95% confidence interval [CI] [8.659, 14.589]) and shortening was 4.3 ± 1.6 mm (p = 0.0011, 95% CI [2.672, 5.942]). Four animals demonstrated retroversion and two demonstrated anteversion compared to controls (4.1 ± 5.4° retroversion, p = 0.1169, 95% CI [-1.483, 9.765]). The amount of varus correction was strongly correlated with the orientation of the screw relative to the medial/lateral axis of the physis (r = -0.887, p = 0.0183, 95% CI [-0.988, -0.271]). The amount and direction of version was strongly correlated with how eccentrically anterior or posterior the screw was placed relative to the center of the physis (r = -0.850, p = 0.0322, 95% CI [-0.983, -0.123]) as well as the angle of the screw relative to the posterior condylar axis of the femur (r = -0.980, p = 0.0006, 95% CI [-0.998, -0.822]). This study is the first to use 3D analysis to quantify proximal femur growth modulation and identify associations between the growth modulation outcomes and screw placement parameters.

Does Screening Ultrasound Timing in Developmental Dysplasia of the Hip Need to be Adjusted for Moderate Preterm and Near-term Infants: A Prospective Study.

INTRODUCTION: An initial screening ultrasound is essential for patients at higher risk of developmental dysplasia of the hip (DDH) due to breech presentation or a family history of DDH. The American Academy of Pediatrics recommends screening ultrasounds to be performed after 6 weeks of age to reduce the rate of false positives. However, there is limited evidence regarding whether these screening ultrasounds need to be adjusted for gestational age in prematurity. The purpose of this study was to evaluate the influence of moderate preterm and near-term births on screening hip ultrasounds for high-risk DDH populations. METHODS: We identified all prospectively enrolled patients in a single-center database referred for screening hip ultrasound for DDH. We included those hips referred for risk factors of DDH, including breech presentation, family history of DDH, or hip click, and excluded those with known dysplasia or referral for hip instability. Each ultrasound was measured by a pediatric radiologist to determine the alpha angle and femoral head coverage. Patients were classified as "premature" if born at <37 weeks gestation or "full term" if born at ≥37 weeks gestation. All patients underwent screening hip ultrasound between 5 and 8 weeks of age. Sonographic markers of dysplasia and the incidences of abnormal ultrasound and Pavlik harness treatment were compared between cohorts. Significance was set at P <0.05. RESULTS: A total of 244 hips in 122 patients were included, 58 hips in the premature cohort and 186 hips in the full-term cohort. The premature cohort had a significantly decreased gestational age compared with the full-term cohort (35.4 ± 1.1 vs 38.5 ± 1.1 wk, respectively, P < 0.001). However, there was no difference between premature and full-term cohorts in sex distribution (69% vs 75%, females, P = 0.39), unadjusted age at the time of ultrasound (6.6 ± 0.7 vs 6.8±0.7 wk, respectively, P = 0.07), or referral reason ( P = 0.14). On hip ultrasound, there was no difference between premature and full-term cohorts with respect to alpha angle (62.6 ± 3.3 vs 62.2 ± 5.3 degrees, P = 0.41), femoral head coverage (54.9 ± 6.3 vs 55.1 ± 10.6, P = 0.19), rate of abnormal ultrasound (18.3% vs 20.7%, respectively, P = 0.68), or the rate of Pavlik harness treatment (0% vs 5.3%, respectively, P = 0.12). DISCUSSION: There was no significant difference in alpha angle or femoral head coverage between premature and full-term patients at 5 to 8 weeks of unadjusted age. This preliminary data suggests that screening ultrasounds can be performed without adjusting for prematurity. LEVEL OF EVIDENCE: Level II, prognostic study.

Does brace treatment following closed reduction of developmental dysplasia of the hip improve acetabular coverage?

Aims: Abduction bracing is commonly used to treat developmental dysplasia of the hip (DDH) following closed reduction and spica casting, with little evidence to support or refute this practice. The purpose of this study was to determine the efficacy of abduction bracing after closed reduction in improving acetabular index (AI) and reducing secondary surgery for residual hip dysplasia. Methods: We performed a retrospective review of patients treated with closed reduction for DDH at a single tertiary referral centre. Demographic data were obtained including severity of dislocation based on the International Hip Dysplasia Institute (IHDI) classification, age at reduction, and casting duration. Patients were prescribed no abduction bracing, part-time, or full-time wear post-reduction and casting. AI measurements were obtained immediately upon cast removal and from two- and four-year follow-up radiographs. Results: A total of 243 hips underwent closed reduction and 82% (199/243) were treated with abduction bracing. There was no difference between those treated with or without bracing with regard to sex, age at reduction, severity of dislocation, spica duration, or immediate post-casting AI (all p > 0.05). There was no difference in hips treated with or without abduction brace with regard to AI at two years post-reduction (32.4° (SD 5.3°) vs 30.9° (SD 4.6°), respectively; p = 0.099) or at four years post-reduction (26.4° (SD 5.2°) vs 25.4° (SD 5.1°), respectively; p = 0.231). Multivariate analysis revealed only IHDI grade predicted AI at two years post-reduction (p = 0.004). There was no difference in overall rate of secondary surgery for residual dysplasia between hips treated with or without bracing (32% vs 39%, respectively; p = 0.372). However, there was an increased risk of early secondary surgery (< two years post-reduction) in the non-braced group (11.4% vs 2.5%; p = 0.019). Conclusion: Abduction bracing following closed reduction for DDH treatment is not associated with decreased residual dysplasia at two or four years post-reduction but may reduce rates of early secondary surgery. A prospective study is indicated to provide more definitive recommendations.

Local BMP2 hydrogel therapy for robust bone regeneration in a porcine model of Legg-Calvé-Perthes disease.

Legg-Calvé-Perthes disease is juvenile idiopathic osteonecrosis of the femoral head (ONFH) that has no effective clinical treatment. Previously, local injection of bone morphogenetic protein-2 (BMP2) for ONFH treatment showed a heterogeneous bone repair and a high incidence of heterotopic ossification (HO) due to the BMP2 leakage. Here, we developed a BMP2-hydrogel treatment via a transphyseal bone wash and subsequential injection of BMP2-loaded hydrogel. In vitro studies showed that a hydrogel of gelatin-heparin-tyramine retained the BMP2 for four weeks. The injection of the hydrogel can efficiently prevent leakage. With the bone wash, the injected hydrogel had a broad distribution in the head. In vivo studies on pigs revealed that the BMP2-hydrogel treatment produced a homogeneous bone regeneration without HO. It preserved the subchondral contour and restored the subchondral endochondral ossification, although it increased growth plate fusions. In summary, the study demonstrated a promising BMP2-hydrogel treatment for ONFH treatment, especially for teenagers.

Abduction Bracing Following Anterior Open Reduction for Developmental Dysplasia of the Hip Does Not Improve Residual Dysplasia or Reduce Secondary Surgery.

BACKGROUND: Abduction bracing is commonly used following open reduction and spica casting of developmental dysplasia of the hip. However, there is little evidence to support or refute this practice that carries associated cost and burden for families. The purpose of this study was to determine the efficacy of abduction bracing after open reduction in improving the acetabular dysplasia and reducing the rate of secondary surgery for residual dysplasia. METHODS: This is a retrospective study of patients treated with open reduction at a single tertiary referral center. Demographic data, severity of dislocation [International Hip Dysplasia Institute (IHDI) class], age at reduction, and casting duration were obtained. Patients were prescribed no bracing, part-time (≤18 h/d), or full-time (≥20 h/d) brace wear based on surgeon preference. Acetabular index (AI) measurements were obtained at cast removal and at 2- and 4-year follow-up. RESULTS: A total of 146 hips underwent open reduction with 61% (89/146) of hips treated with abduction bracing. There was no difference between braced and nonbraced cohorts with regards to sex, age at time of reduction, dislocation severity, cast duration, immediate postcasting AI, or incidence of medial open reduction. There was no difference in hips treated with or without brace following open reduction with regards to AI at 2 years postreduction (31.8±6.7 vs. 30.4±6.1 degrees, P =0.27) or at 4 years postreduction (24.9±6.5 vs. 24.7±6.5 degrees, P =0.97). However, further analysis showed lower mean AI at 2-year follow-up for braced versus nonbraced patients following medial open reduction (30.0±5.7 vs. 34.5±7.0 degrees, P =0.02). This difference was no longer present at 4-year follow-up (26.6±6.8 vs. 24.2±6.6 degrees, P =0.44). However, 4/19 (21%) nonbraced hips underwent secondary surgery for residual dysplasia and were consequently excluded from the AI measurement at 4 years postreduction (compared with 4/39 [10%] braced hips within the same time period). There was no difference in the rate of secondary surgery between braced and nonbraced hips (30% vs. 33%, respectively, P =0.70). Multivariate analysis demonstrated that neither IHDI classification, bracing, nor age at reduction predicted residual dysplasia. CONCLUSIONS: Abduction bracing following anterior open reduction for developmental dysplasia of the hip is not associated with decreased residual dysplasia at 2/4 years postreduction or with decreased secondary surgery. These results suggest that abduction bracing following anterior open reduction may not provide clinical benefit. However, abduction bracing may be beneficial following medial open reduction. A prospective study is necessary to provide more definitive recommendations. LEVEL OF EVIDENCE: Level III-therapeutic study.

Interleukin-6 receptor blockade improves bone healing following ischemic osteonecrosis in adolescent mice.

Objective: Juvenile ischemic osteonecrosis (JIO) of the femoral head is one of the most serious hip disorders causing a permanent deformity of the femoral head in childhood. We recently reported that interleukin 6 (IL-6) is significantly increased in the hip synovial fluid of patients with JIO and that articular chondrocytes are primary source of IL-6. Adolescent JIO is particularly challenging to treat and has poor outcome. This study determined if IL-6 receptor blockade prevents bone loss and improves the bone healing in adolescent JIO. Method: Adolescent mice (12-week-old) surgically induced with JIO were treated with either saline or MR16-1, an IL-6 receptor blocker. Results: Micro-CT assessment showed significantly increased bone volume (p â€‹< â€‹0.001, Cohen's d â€‹= â€‹2.0) and trabecular bone thickness (p â€‹< â€‹0.001, d â€‹= â€‹2.3) after the MR16-1 treatment. Histomorphometric assessment showed significantly increased osteoblast number (p â€‹< â€‹0.01, d â€‹= â€‹2.3), bone formation rate (p â€‹< â€‹0.01, d â€‹= â€‹4.3), and mineral apposition rate (p â€‹< â€‹0.01, d â€‹= â€‹4.1) after the MR16-1 treatment. The number of osteoclasts was unchanged. Histologic assessment showed significantly increased revascularization (p â€‹< â€‹0.01) and restoration of the necrotic marrow with new hematopoietic bone marrow (p â€‹< â€‹0.01). Vascular endothelial growth factor (VEGF) expression was increased in the revascularized area and the articular cartilage, and in the cultured chondrocytes treated with IL-6 receptor inhibitor. Conclusion: IL-6 blockade in adolescent mice with JIO enhanced bone formation and revascularization. The findings suggest IL-6 receptor blocker as a potential medical therapy for adolescent JIO.

Patient Adherence to Wide Abduction Brace Treatment for Legg-Calvé-Perthes Disease.

BACKGROUND: A wide abduction brace called the A-frame brace is used to contain the deformed femoral head and improve femoral head remodeling in patients with Legg-Calvé-Perthes disease (LCPD). While there is some data showing the efficacy of brace treatment, little is known about patient adherence. The purpose of this study was to measure A-frame brace adherence using temperature sensors and to identify factors that influence adherence. METHODS: This is an IRB-approved retrospective study of 61 patients with LCPD treated with an A-frame brace between ages 5 and 11. Brace wear was measured using built-in temperature sensors. Pearson correlation coefficient and multiple regression were used to determine relationships between patient characteristics and brace adherence. RESULTS: Of 61 patients, 80% were male. Mean age at LCPD onset was 5.9±1.8 years and the mean age at initiation of brace treatment was 7.1±1.5 years. Fifty-eight patients (95%) were in the fragmentation or reossification stage at the start of bracing, with 23 patients (38%) having lateral pillar B, 7 (11%) lateral pillar B/C, and 31 (51%) lateral pillar C. Forty-two (69%) patients were treated with a Petrie cast for 6 weeks before the A-frame brace. Mean adherence, defined as the ratio of measured over prescribed brace wear, was 0.69±0.32. Mean adherence improved with age ( P <0.05), increasing from 0.57 in patients less than 6 to 0.84 in patients aged 8 to 11. Patients first treated with a Petrie cast had significantly better adherence than those without (0.77 vs. 0.50; P <0.005). Adherence was negatively associated with the amount of prescribed brace wear per day ( P <0.005). Adherence did not change significantly between the start and end of treatment and was not significantly associated with sex or attention deficit hyperactivity disorder. CONCLUSIONS: A-frame brace adherence was significantly associated with age at treatment, prior Petrie casting, and the amount of daily prescribed brace wear. These findings provide new insight into A-frame brace treatment, which will lead to better patient selection and counseling to optimize adherence. LEVEL OF EVIDENCE: III Therapeutic Study.

The Significance of Isolated Hip Click as a Sign of DDH: Implications on Referral Guidelines.

BACKGROUND: The clinical significance of an isolated hip click remains unclear. The rates of developmental dysplasia of the hip (DDH) in those referred for hip click vary from 0% to 28%. The purpose of this study was to evaluate the rate of DDH in patients prospectively referred for isolated hip click. METHODS: We prospectively enrolled patients referred to a single pediatric orthopaedic center with concern for DDH secondary to isolated hip click felt by the pediatrician on examination. Patients with known sonographic abnormalities or risk factors for DDH (breech presentation or positive family history) were excluded. Ultrasounds were obtained upon initial presentation and defined as abnormal if alpha angle <60 degrees and/or femoral head coverage (FHC) <50%. Mild dysplasia, analogous to Graf IIa physiological immaturity, was defined as alpha angle 50<α<60 and/or <50% FHC in a patient <3 months age. Severe dysplasia was defined as ≤33% FHC, which has been proposed to be sonographically consistent with a hip dislocation. RESULTS: Two hundred fifty-five children were referred for isolated hip click. One hundred eighty-nine patients (74%) had normal ultrasound whereas 66 patients (26%) had sonographic abnormalities (mean age 6.5±6.2 wk at initial ultrasound). Fifty patients (19.6%) demonstrated physiological immaturity, 3 patients (1.2%) demonstrated moderate sonographic dysplasia, and 13 patients (5.1%) had sonographic findings consistent with severe dysplasia or dislocated hip. Hips with severe dysplasia were younger than the remaining population (2.8±2.4 wk vs. 6.6±6.2 wk, P <0.001) with no difference in sex distribution ( P =0.07) or first-born birth order ( P =0.36). For those with sonographic abnormality, 18 (27%) patients were treated with Pavlik harness, 1 (2%) was treated with abduction orthosis, and the remainder (71%) were observed for resolution of physiological immaturity. CONCLUSIONS: Infants with isolated hip click identified by their pediatrician may have higher rates of dysplasia than previously reported. We recommend screening ultrasound and/or orthopaedic referral for all infants with isolated hip click. LEVEL OF EVIDENCE: Level II-prospective prognostic study.

Ex vivo study of detergent-assisted intraosseous bone wash treatment of osteonecrosis.

Avascular necrosis (AVN) involves ischemic cell death of the bone. AVN leaves an abundance of necrotic lipids and debris in the bone marrow, which instigates inflammatory bone repair. Consequently, the necrotic bone microenvironment stimulates excessive bone resorption, leading to joint deformities and osteoarthritis. Here, we performed a detergent-assisted bone wash using poloxamer 407 (P407) to clean the necrotic bone environment by removing lipids and necrotic debris. The new concept was tested using an established ex vivo AVN model of porcine cadaver humeral heads. The P407 wash was performed using P407 solution and followed with saline via two intraosseous needles. Visual inspection and image analyses of average pixel light intensity showed that the P407 wash produced a better-cleaned bone than the saline wash. Analyses of the collected bone wash solution showed a two-fold increase in triglycerides (101 vs. 53 mmol/head, p = 0.006) and a 10-fold increase in the dry weight of the removed debris (1.34 vs. 0.13 g/head, p = 0.02) with the P407 wash compared to saline. The histological evaluation showed significantly decreased Oil-Red-O (fats) staining in the P407-washed bone compared with the saline-washed bone. The in vitro assays of Alizarin red and qPCR showed the P407 wash neither altered the osteogenic behaviors of porcine bone marrow-derived mesenchymal cells (pBMMCs) nor raised inflammatory responses of porcine bone marrow-derived macrophages (pBMMs). In conclusion, detergent-assisted bone wash using P407 produced a better removal of nonsoluble debris from the bone marrow space than the saline wash without causing changes to osteogenesis or inflammatory reactions.

Do Weightbearing Restrictions Cause Excess Weight Gain in Children With LEGG-Calvé-Perthes Disease?

BACKGROUND: Restricted weight bearing is commonly prescribed in Legg-Calvé-Perthes Disease (LCPD), raising concerns of causing overweight or obesity. This study utilizes prospectively collected data to address the following questions: (1) does body mass index (BMI) Z-score increase over the course of LCPD follow-up; (2) is having a BMI category of normal, overweight, or obese at baseline associated with BMI Z-score changes over the course of follow-up; and (3) is the duration of weight bearing restrictions (no restrictions, <3, 3 to <6, 6 to 9, or >9 mo) associated with BMI Z-score changes. METHODS: Data of 130 children aged 5 to 12 years with unilateral early-stage LCPD were extracted from an international database. Nation-specific BMI Z-scores and percentile-based weight categories were determined, and the duration of follow-up and weight bearing restrictions were calculated. Longitudinal changes in BMI Z-scores were evaluated for the 3 study questions using mixed effects linear regression models with surgery as a covariate. Sensitivity analyses were used to determine the influence of socio-cultural background (USA vs. India) for each study question. RESULTS: During the 35.5±15.9 months of follow-up, no statistically significant increase in BMI Z-scores was observed across the entire cohort, or following stratification by baseline weight categories or the duration of the weight bearing restriction. Sensitivity analyses indicated that patients in the USA had no change in their BMI Z-score. When stratified by weight categories, the normal weight of US children had a small increase in their BMI Z-score (0.005 per mo, 95% confidence interval: 0.0002, 0.009), but this was not seen in other BMI categories. The cohort of Indian children had a small but significant decrease in their BMI Z-score (-0.005/mo, 95% CI: -0.009, -0.0002). After stratification by weight categories, a small decrease of the BMI Z-score was observed only in the Indian overweight children (-0.016 per mo, 95% CI: -0.027, -0.005) and no other BMI category. CONCLUSIONS: Weightbearing restrictions over the course of follow-up for our cohort of children with early-stage LCPD were not associated with clinically meaningful increases of BMI Z-scores. Weight gain is multi-factorial and probably not caused by weight bearing restrictions alone. LEVEL OF EVIDENCE: III Diagnostic Study.

How are adults who had Perthes' disease functioning? : results of over 900 participants from an international web-based survey.

AIMS: Perthes' disease (PD) is a childhood hip disorder that can affect the quality of life in adulthood due to femoral head deformity and osteoarthritis. There is very little data on how PD patients function as adults, especially from the patients' perspective. The purpose of this study was to collect treatment history, demographic details, the University of California, Los Angeles activity score (UCLA), the 36-Item Short Form survey (SF-36) score, and the Hip disability and Osteoarthritis Outcome score (HOOS) of adults who had PD using a web-based survey method and to compare their outcomes to the outcomes from an age- and sex-matched normative population. METHODS: The English REDCap-based survey was made available on a PD study group website. The survey included childhood and adult PD history, UCLA, SF-36, and HOOS. Of the 1,182 participants who completed the survey, the 921 participants who did not have a total hip arthroplasty are the focus of this study. The mean age at survey was 38 years (SD 12) and the mean duration from age at PD onset to survey participation was 30.8 years (SD 12.6). RESULTS: In comparison to a normative population, the PD participants had significantly lower HOOS scores across all five scales (p < 0.001) for all age groups. Similarly, SF-36 scores of the participants were significantly lower (p < 0.001) for all scales except for age groups > 55 years. Overall, females, obese participants, those who reported no treatment in childhood, and those with age of onset > 11 years had significantly worse SF-36 and HOOS scores. Pairwise correlations showed a strong positive correlation within HOOS scales and between HOOS scales and SF-36 scales, indicating construct validity. CONCLUSION: Adult PD participants had significantly worse pain, physical, mental, and social health than an age- and sex-matched normative cohort. The study reveals a significant burden of disease on the adult participants of the survey, especially females.Cite this article: Bone Joint J 2022;104-B(12):1304-1312.

What is the adult experience of Perthes' disease? : initial findings from an international web-based survey.

AIMS: Perthes' disease is an uncommon hip disorder with limited data on the long-term outcomes in adulthood. We partnered with community-based foundations and utilized web-based survey methodology to develop the Adult Perthes Survey, which includes demographics, childhood and adult Perthes' disease history, the University of California Los Angeles (UCLA) Activity Scale item, Short Form-36, the Hip disability and Osteoarthritis Outcome Score, and a body pain diagram. Here we investigate the following questions: 1) what is the feasibility of obtaining > 1,000 survey responses from adults who had Perthes' disease using a web-based platform?; and 2) what are the baseline characteristics and demographic composition of our sample? METHODS: The survey link was available publicly for 15 months and advertised among support groups. Of 1,505 participants who attempted the Adult Perthes survey, 1,182 completed it with a median timeframe of 11 minutes (IQR 8.633 to 14.72). Participants who dropped out were similar to those who completed the survey on several fixed variables. Participants represented 45 countries including the USA (n = 570; 48%), UK (n = 295; 25%), Australia (n = 133; 11%), and Canada (n = 46; 4%). Of the 1,182 respondents, 58% were female and the mean age was 39 years (SD 12.6). RESULTS: Ages at onset of Perthes' disease were < six years (n = 512; 43%), six to seven years (n = 321; 27%), eight to 11 years (n = 261; 22%), and > 11 years (n = 76; 6%), similar to the known age distribution of Perthes' disease. During childhood, 40% (n = 476) of respondents had at least one surgery. Bracing, weightbearing restriction, and absence of any treatment varied significantly between USA and non-USA respondents (p < 0.001, p = 0.002, and p < 0.001, respectively). As adults, 22% (n = 261) had at least one total hip arthroplasty, and 30% (n = 347) had any type of surgery; both more commonly reported among women (p = 0.002). CONCLUSION: While there are limitations due to self-sampling, our study shows the feasibility of obtaining a large set of patient-reported data from adults who had childhood Perthes' from multiple countries. Cite this article: Bone Jt Open 2022;3(5):404-414.

The Clinical Significance of Infolded Limbus on Postreduction Arthrogram in Developmental Dysplasia of the Hip.

BACKGROUND: The purpose of this study was to investigate whether presence of an infolded limbus on hip arthrogram at index closed reduction was associated with increased residual dysplasia or secondary surgery. METHODS: We retrospectively reviewed all patients who underwent closed reduction for dysplasia of the hip with a minimum 2-year follow-up between 1980 and 2016. Demographic data was obtained including the age at reduction and severity of dislocation based on the International Hip Dysplasia Institute (IHDI) classification. Arthrograms performed at time of closed reduction were separately reviewed by 3 fellowship-trained pediatric orthopaedic surgeons to evaluate for an infolded limbus. The primary radiographic outcome was acetabular indices at 2 and 4 years postreduction. We also assessed the presence of avascular necrosis and rate of secondary reconstructive surgery for residual dysplasia. RESULTS: A total of 182 hips in 165 patients underwent closed reduction at a mean age of 9.8±4.5 mo and were followed a mean of 9.0±4.9 y. An infolded limbus was identified in 20.3% (37/182) hips with substantial agreement among the 3 graders (Fleiss κ=0.75). The frequency of labral infolding increased with the severity of dislocation (8.8%% of IHDI II, 26.7% IHDI III, and 25.0% of IHDI IV hips; P=0.03). Hips with infolded limbus were older at reduction (12.4±5.3 vs. 9.2±5.8 mo, P=0.001). The mean acetabular index was higher in hips with infolded limbus than hips without at 2 years postreduction (34.8±4.8 vs. 32.6±5.8 degrees, respectively; P=0.04). However, multivariate analysis revealed that only the severity of dislocation predicted dysplasia at 2 years postreduction. No significant difference in acetabular index was seen at 4 years postreduction (27.2±7.4 vs. 25.4±6.5 degrees, P=0.24). There was no difference in avascular necrosis between groups (P=0.74). There was no difference in rate of secondary surgery between hips with labral infolding and those without (35% vs. 30%, respectively; P=0.52). CONCLUSIONS: An infolded limbus was more common in older patients with more severe dislocations. However, it is not associated with increased residual dysplasia or secondary surgery and may have limited utility in decision-making during closed reduction. LEVEL OF EVIDENCE: Level II-prognostic study.

The Role of the Artery of Ligamentum Teres in Revascularization in Legg-Calve-Perthes Disease.

INTRODUCTION: A recent cadaveric study supported that most immature hips are supplied by the artery of ligamentum teres and suggested this medial vascular source may influence the pattern of revascularization in Legg-Calve-Perthes disease (LCPD). The purposes of this study were to characterize the perfusion pattern of the capital femoral epiphysis and determine the role of the artery of ligamentum teres in early revascularization of LCPD. METHODS: Retrospective review of perfusion magnetic resonance imaging (pMRI) from 64 hips in early stage LCPD (Waldenström stage I to IIa) was performed. Two independent graders categorized perfusion pattern based on the presence of perfusion medially (from artery of ligamentum teres) and/or laterally (from the medial femoral circumflex artery) on coronal and sagittal MRI series: type 1-lateral perfusion only, type 2-separate medial and lateral perfusion, or type 3-coalescent medial and lateral perfusion. Lateral pillar classification was obtained for hips that reached mid-fragmentation. RESULTS: We identified 64 patients (75% male) with mean age at diagnosis of 8.5±2.1 years. 36% (23/64) hips underwent pMRI during stage I and 64% (41/64) during stage IIa. pMRI revealed separate and distinct medial and lateral sources of perfusion (type 2) in 50% (32/64) hips. In stage I, the distribution of type 1/2/3 hips was found to be 26%/52%/22%. However, in stage IIa there was a nonsignificant trend toward greater coalescence of the medial and lateral perfusion with a distribution of type 1/2/3 of 7%/49%/44% (P=0.07). There was a nonsignificant trend toward weak negative linear correlation between lower initial perfusion grade and worsened lateral pillar classification at mid-fragmentation (r=-0.25, P=0.05). CONCLUSION: The presence of separate and distinct areas of perfusion of medial and lateral capital femoral epiphysis provides further evidence of the role of the ligamentum teres vessels in revascularization during the early stages of LCPD. The changes in perfusion pattern with disease progression likely reflect that medial femoral circumflex artery and ligamentum teres vessel revascularization occur separately, but ultimately coalesce posteriorly over time. LEVEL OF EVIDENCE: Level II-prognostic study.

Does the Deformity Index Reliably Predict the Shape of the Femoral Head at Healing of Legg-Calvé-Perthes Disease?

BACKGROUND: Treatment of Legg-Calvé-Perthes disease (LCPD) aims to preserve the spherical shape of the femoral head. The deformity index (DI) <0.3, measured 2 years from disease onset, is a surrogate measure that predicts that the femoral head will be Stulberg class I or II at skeletal maturity. There is no study that compares the predictive value of DI against a quantitative measure of the shape of the femoral head when the disease heals. We undertook this study to assess the reproducibility of a new method of measurement of DI and see if DI could predict the shape of the femoral head when the disease healed. METHODS: DI was measured 2 years after disease onset and the Sphericity Deviation Score (SDS) was measured at healing of LCPD on radiographs of 43 children. Reproducibility of measurement was tested. Each healed femoral head was classified as spherical or aspherical based on subjective visual assessment. The DI values were compared with SDS values. RESULTS: The reproducibility of measurement of SDS was excellent and superior to that of DI. The mean duration of disease was 3.97±0.96 years. Only 17 of 32 hips with DI values <0.3 at 2 years had spherical femoral heads at healing (SDS <10). Three hips with SDS values <10 had DI values >0.3. The positive and negative predictive values of a DI <0.3 in predicting if the femoral head will be spherical (SDS <10) when the disease healed were 53% and 73%, respectively. CONCLUSION: Though DI can be reproducibly measured the predictive value of a DI <0.3, to accurately identify hips that are likely to heal with spherical femoral heads, is not sufficiently high to justify its use as an outcome measure.