Pediatric Device Innovation: An Analysis of Food and Drug Administration Authorizations Over Time.

BACKGROUND: Despite a tremendous increase in the number of orthopaedic devices authorized by the U.S. Food and Drug Administration (FDA), novel devices designed specifically for the pediatric population remain sparse. Surgeons frequently repurpose adult implants for "off-label" use in pediatric patients, with both legal and technical ramifications. This study seeks to objectively quantify and characterize the nature of pediatric device innovation over time. METHODS: The FDA employs 4 pathways for assessing safety and effectiveness of novel devices prior to authorization. Perceived device risk and novelty determine the pathway. Orthopaedic devices were identified from the FDA's online database. All devices approved since inception via the Humanitarian Device Exemption, Pre-Market Approval, and De Novo regulatory pathways were included and grouped as "highly innovative." Because of their number and the rapidity of their development, the evaluation of 510(k) devices was limited to those cleared from January 1, 2018, to December 31, 2022. Such 510(k) devices make up ∼97% of devices and by definition are less risky and less novel. Approval statements were assessed for pediatric indications within the approved labeling. As a secondary analysis, the impact of company size on developing a product with a pediatric indication was analyzed. RESULTS: Of the 1,925 devices cleared via the 510(k) pathway, 9 (0.5%) were designed exclusively for pediatrics and 160 (8.3%) included pediatric indications. Five of the 9 pediatrics-only devices were for spine and 4 were for trauma indications. Of the 97 highly innovative devices, only 2 (2%) were exclusively pediatric and another 2 (2%) included pediatric indications. The 2 pediatrics-only devices were for the spine. Large and medium-sized companies were 1.9 times and 1.6 times more likely to bring to market a device with pediatric indications than a small company, respectively. CONCLUSIONS: Innovation for pediatric orthopaedic devices lags substantially behind that for adult orthopaedic devices. These findings are consistent with clinical experience and the common practice of modifying adult implants for "off-label" use in pediatric patients. Despite long-standing efforts to stimulate innovation for this vulnerable population, our results suggest little progress.

Bringing Physical Exam Skills Back from the Dead.

Physical examination education begins early for medical learners. A hindrance to physical exam competency is lack of exposure to pathology in standardized patient settings. This research focuses on improving medical education through the utilization of cadavers that have undergone a soft-embalming technique: the Thiel method. Three scenarios were created in four Thiel cadavers: anterior cruciate ligament (ACL) tear, posterior cruciate ligament (PCL) tear, and sham incision. Students were asked to diagnose ACL tears using the Lachman exam. A total of 54 learners participated in the study. Post-surveys indicated most learners: (1) prefer to use standardized patients (SPs) and soft-embalmed cadavers in their physical examination courses, (2) increased their confidence in performing the Lachman exam on real patients, and (3) enhanced their Lachman technique. SPs ultimately cannot volitionally reproduce the physical exam findings of ACL deficiency. Consequently, learners cannot accurately identify positive versus negative examination findings. Thiel-embalmed cadavers are a valuable resource for physical examination education. (Journal of Surgical Orthopaedic Advances 30(2):112-115, 2021).

Musculoskeletal Education: An Assessment of the Value of the American Academy of Pediatrics Musculoskeletal Boot Camp Course in Improving Clinical Confidence of Pediatricians Managing Common Musculoskeletal Conditions.

In 2016, the American Academy of Pediatrics Section on Orthopaedics established an annual Musculoskeletal (MSK) Boot Camp course to fill the gaps in MSK knowledge, performance, and outcomes for pediatricians and primary care doctors. A standardized one-day curriculum of key MSK topics was developed including short lectures, hands-on workshops, debates, live webinars, and Q&A sessions. A survey was created to evaluate attendee confidence related to diagnosing 20 common MSK conditions in children and adolescents at the beginning and end of the course. Confidence in diagnosing the conditions was gauged using a 6-point Likert-type scale. A two-sample t test was used to compare overall confidence score pre- and post-seminar. In addition, each subtopic was analyzed. The average pre-seminar confidence score was 3.92 versus 4.86 post-seminar. All categories demonstrated a statistically increased confidence score post-seminar (P < .0001). Live MSK continuing education for pediatricians is effective in improving confidence in clinical practice.

Pediatric Pain Management in Plastic Surgery.

Adequate pediatric pain management is difficult to achieve for a variety of reasons. Pain assessment is more difficult in the pediatric population. There are a variety of different tools that may be used to accurately assess pain. There are many modalities to achieve pain control, including pharmacologic and nonpharmacologic means. These different modalities should be used in unison to achieve pain control. Compartment syndrome is a surgical emergency, and pediatric patients present differently from adult patients. The 3 As (anxiety, agitation, increase in analgesia requirement) should be monitored in all pediatric patients.

Accuracy of Closed Reduction of Pediatric Supracondylar Humerus Fractures Is Training in Pediatric Orthopedic Surgery Necessary?

BACKGROUND: Supracondylar humerus fractures account for two thirds of all hospitalizations for elbow injuries in children. A prevailing assumption exists regarding whether treatment quality varies by surgeon training background. This study compares radiographic outcomes of pediatric supracondylar humerus fractures treated by fellowship trained pediatric orthopedists (PO) and non-pediatric orthopedists (adult traumatologists, AT) with regard specifically to ability to obtain and maintain an operative closed reduction. METHODS: We retrospectively reviewed all pediatric patients between 2007 and 2013 operatively treated for closed extension-type supracondylar humerus fractures. Inclusion criteria included skeletally immature patients with Gartland classification type II and III fractures. Eighty-five cases were included with 37 fractures treated by four fellowship trained adult traumatologists at a level I trauma center and 48 fractures treated by five fellowship trained pediatric orthopedists at a tertiary referral center. Radiographs were analyzed for Baumann's angle and shaft-condylar angle, then statistical comparisons were performed to compare preoperative and postoperative measurements. RESULTS: There was no difference in age, gender, laterality, fracture classification, use of medial pins, or neurovascular injuries between PO and AT (p > 0.05). Change in Baumann's angle (p = 0.61) or shaft-condylar angle (p = 0.87) did not differ between PO and AT. There was no significant difference in operative and postoperative Baumann's angle (p = 0.18 and p = 0.59, respectively) and shaft-condylar angle measurements (p = 0.05 and p = 0.09, respectively) between PO and AT. There was no difference in loss of reduction between the two groups (p = 0.64). CONCLUSIONS: Radiographic analysis of supracondylar humerus fractures showed no significant difference in alignment or loss of reduction when treated by pediatric orthopedists compared to non-pediatric orthopedists. Though it seems that the trend is to send pediatric fracture care to tertiary referral centers it may not be necessary for simple fracture management.

Variation Among Pediatric Orthopaedic Surgeons When Treating Medial Epicondyle Fractures.

BACKGROUND: Medial epicondyle fractures are a common pediatric and adolescent injury accounting for 11% to 20% of elbow fractures in this population. This purpose of this study was to determine the variability among pediatric orthopaedic surgeons when treating pediatric medial epicondyle fractures. METHODS: A discrete choice experiment was conducted to determine which patient and injury attributes influence the management of medial epicondyle fractures by pediatric orthopaedic surgeons. A convenience sample of 13 pediatric orthopaedic surgeons reviewed 60 case vignettes of medial epicondyle fractures that included elbow radiographs and patient/injury characteristics. Displacement was incorporated into the study model as a fixed effect. Surgeons were queried if they would treat the injury with immobilization alone or open reduction and internal fixation (ORIF). Statistical analysis was performed using a mixed effect regression model. In addition, surgeons filled out a demographic questionnaire and a risk assessment to determine if these factors affected clinical decision-making. RESULTS: Elbow dislocation and fracture displacement were the only attributes that significantly influenced surgeons to perform surgery (P<0.05). The presence of an elbow dislocation had the largest impact on surgeons when choosing operative care (ß=-0.14; P=0.02). In addition, for every 1 mm increase in displacement, surgeons tended to favor ORIF by a factor of 0.09 (P<0.01). Sex, mechanism of injury, and sport participation did not influence decision-making. In total, 54% of the surgeons demonstrated a preference for ORIF for the included scenarios. On the basis of the personality Likert scale, participants were neither high-risk takers nor extremely risk adverse with an average-risk score of 2.24. Participant demographics did not influence decision-making. CONCLUSIONS: There is substantial variation among pediatric orthopaedic surgeons when treating medial epicondyle fractures. The decision to operate is significantly based on the degree of fracture displacement and if there is a concomitant elbow dislocation. There is no standardization regarding how to treat medial epicondyle fractures and better treatment algorithms are needed to provide better patient outcomes. LEVEL OF EVIDENCE: Level V.

Variation Among Pediatric Orthopaedic Surgeons When Diagnosing and Treating Pediatric and Adolescent Distal Radius Fractures.

BACKGROUND: Distal radius fractures are the most common injury in the pediatric population. The purpose of this study was to determine the variation among pediatric orthopaedic surgeons when diagnosing and treating distal radius fractures. METHODS: Nine pediatric orthopaedic surgeons reviewed 100 sets of wrist radiographs and were asked to describe the fracture, prescribe the type of treatment and length of immobilization, and determine the next follow-up visit. κ statistics were performed to assess the agreement with the chance agreement removed. RESULTS: Only fair agreement was present when diagnosing and classifying the distal radius fractures (κ=0.379). There was poor agreement regarding the type of treatment that would be recommended (κ=0.059). There was no agreement regarding the length of immobilization (κ=-0.004).Poor agreement was also present regarding when the first follow-up visit should occur (κ=0.088), whether or not new radiographs should be obtained at the first follow-up visit (κ=0.133), and if radiographs were necessary at the final follow-up visit (κ=0.163). Surgeons had fair agreement regarding stability of the fracture (κ=0.320).A subgroup analysis comparing various traits of the treatment immobilization showed providers only had a slight level of agreement on whether splint or cast immobilization should be used (κ=0.072). There was poor agreement regarding whether long-arm or short-arm immobilization should be prescribed (κ=-0.067).Twenty-three of the 100 radiographs were diagnosed as a torus/buckle fracture by all 9 surgeons. κ analysis performed on all the treatment and management questions showed that each query had poor agreement. CONCLUSIONS: The interobserver reliability of diagnosing pediatric distal radius fractures showed only fair agreement. This study demonstrates that there is no standardization regarding how to treat these fractures and the length of immobilization required for proper fracture healing. Better classification systems of distal radius fractures are needed that standardize the treatment of these injuries. LEVEL OF EVIDENCE: Level II.

Percutaneous versus open reduction and fixation for Tillaux and triplane fractures: a multicenter cohort comparison study.

The goal of this study was to compare open reduction versus percutaneous fixation of adolescent ankle fractures with regards to the incidence of growth disturbance. We performed a retrospective cohort analysis of adolescent patients with triplane or Tillaux fractures. There was an even distribution of triplane fractures and mean initial displacement between cohorts. Analysis of follow-up radiographs revealed no instances of growth disturbance in the percutaneous fixation group and six in the open reduction group (P=0.29). Growth disturbance does not pose a significant concern when selecting a surgical approach. Owing to the rarity of these fractures this study was underpowered.

Evaluation and Management of Pediatric Bone Lesions.

Bone abnormalities on pediatric radiographs are not uncommon findings for both the general orthopedist as well as the specialist. Although the majority of lesions encountered are benign, the treating physician should also be aware of more concerning diagnoses. General orthopedists and pediatric orthopedists should exhibit a basic level of comfort with working up and diagnosing these benign lesions. When evaluating the pediatric patient with a bone lesion it is crucial to keep in mind important aspects of the clinical history, physical exam, and radiographic findings. Here we provide a review of important findings for the orthopedic surgeon in each of these areas. Many times diagnoses can be made with these alone. With better understanding of clinical and radiographic features of these lesions the orthopedist should be comfortable knowing which lesions he or she can reasonably treat and which should be referred to an oncologic specialist.

Do Professional Society Advocacy Campaigns Have an Impact on Pediatric Orthopaedic Injuries?

PURPOSE: The American Academy of Orthopaedic Surgeons (AAOS) and the American Academy of Pediatrics (AAP) both advocate for childhood injury prevention by publishing recommendations to orthopaedic surgeons, pediatricians, and the public. Popular topics of advocacy campaigns have included trampolines, all-terrain vehicles (ATVs), and lawnmowers. The purpose of this study was to investigate the temporal relationship between AAOS/AAP advocacy and pediatric orthopaedic injury rates, using these topics as examples. We hypothesized that pediatric orthopaedic injury rates decline in years, following related AAOS/AAP recommendations. METHODS: A retrospective review of fractures associated with trampolines, lawnmowers, and ATVs among patients aged 2 to 18 years from 1991 to 2014 was performed using the National Electronic Injury Surveillance System (NEISS). Fracture rates and percent changes year-to-year were calculated. A timeline of AAOS and AAP advocacy statements published on the products was created. RESULTS: Trampoline-related fractures rose 14% yearly from 1991 to 1999, reached a plateau from 1999 to 2003, corresponding with a 1999 AAP statement. Injury rates dropped 4.3% from 2006 to 2010 after 2005 and 2006 statements, and reached another plateau thereafter, as 2010 and 2012 statements were published. ATV-related fractures rose 14% yearly between 1997 and 2002, then dropped 15% from 2007 to 2010 following yearly AAP or AAOS statements from 2004 to 2007. From 2010 to 2014, the injury rate held constant during which time 2010, 2013, and 2014 statements were published. Lawnmower injury rates did not fall despite statements in 1998 and 2001 and a poster campaign in 2001. A 25% drop from 2007 to 2008 coincided with an AAOS statement in 2008. Fracture rates further dropped 31% from 2009 to 2011 and 21% from 2012 to 2014, amidst 2012 and 2014 statements. For ATV-related and lawnmower-related injuries, more male individuals were affected than female individuals, and for ATVs alone, injury rates increased with age. CONCLUSIONS: Although AAOS/AAP statements did not universally coincide with dropping fracture rates, statements often were associated with substantial decreases in following years. This is likely because injury prevention messages are dispersed from providers to the public over time and outcomes depend on highly variable patient behaviors. LEVEL OF EVIDENCE: Level V-systematic review of descriptive data.

Identifying Predictive Factors of Pediatric Septic Arthritis of the Knee in a Lyme Endemic Area.

BACKGROUND: Septic arthritis of the knee in the pediatric patient is a diagnosis that requires prompt identification and treatment. The purpose of this study was to identify clinical and laboratory parameters that allow differential diagnosis of septic arthritis from non-septic arthritis in children. METHODS: Fifty-four pediatric patients with atraumatic isolated knee pain were retrospectively identified at three institutions and diagnosed with septic arthritis (SA, N = 28), Lyme arthritis (LA, N = 11), or transient synovitis (TS, N = 15). Clinical and laboratory data were analyzed to identify which factors were most predictive of SA of the knee. RESULTS: Fever at time of presentation, a negative anti-streptolysin-O (ASO), erythrocyte sedimentation rate (ESR) > 40 mm/hr, and C-reactive protein (CRP) > 20 mg/L were the most predictive factors for distinguishing between septic arthritis (SA) and non-septic arthritis (transient synovitis or Lyme arthritis). Elevated ESR and CRP were both significantly higher in patients with SA when compared to TS or LA. CONCLUSION: When evaluating children with atraumatic isolated knee pain, a combination of the above factors should be utilized when ruling out septic arthritis.

Perfusion is Not Measurably Decreased in Idiopathic Clubfoot.

BACKGROUND: Vascular aberration has been accepted as a potential etiology of clubfoot, and abnormal vasculature has been observed in as high as 85% of children with severe clubfoot. The perfusion index (PI) corresponds to the ratio of pulsatile to nonpulsatile blood flow at a monitoring site and can be used to quantify perfusion of the extremities. The purpose of this study was to use PI to compare the perfusion of clubfeet to controls in order to further assess the role of abnormal vasculature in clubfoot. METHODS: A Masimo Radical 7 Pulse Oximeter (Masimo Corporation, Irvine, California) was used to measure the PI and oxygen saturation (SpO2) of the feet of children 5 years of age and younger with and without clubfoot. The sensor was placed on the great toe. Patients with clubfoot undergoing non-operative treatment and control patients undergoing treatment in a clinic for orthopedic concerns not involving the foot and with no known vascular issues were assessed. The PI and SpO2 for the following three groups were compared: 1. affected feet of patients with bilateral or unilateral clubfoot, 2. unaffected feet of patients with unilateral clubfoot, and 3. control feet. RESULTS: One hundred and twenty-eight patients were enrolled, 64 with clubfoot (31 bilateral and 33 unilateral) and 64 controls. No significant differences in PI or SpO2 were found between: 64 clubfeet and 64 feet of controls (PI of 2.9 vs. 2.9, p = 0.984; SpO2 of 97.1 vs. 98.1, p = 0.192); unaffected feet of 30 patients with unilateral clubfoot and 64 controls (PI of 3.0 vs.2.9, p = 0.907; SpO2 of 96.9 vs. 98.1, p = 0.224); and affected and unaffected feet of 30 patients with unilateral clubfoot (PI of 3.3 vs.3.0, p = 0.500; SpO2 of 97.4 vs. 96.9, p = 0.527). CONCLUSIONS: No difference was observed in the PI or SpO2 when comparing affected clubfoot limbs with unaffected limbs, suggesting that vascular anomalies cannot fully explain the development of clubfoot.

The Etiology of Cam-type Femoroacetabular Impingement: A Cadaveric Study.

BACKGROUND: There is a dearth of literature examining the causes of cam-type femoroacetabular impingement (FAI) and when such morphology appears. The purpose of the current study was to analyze how the ossific portion of the proximal femur develops over time with respect to standard cam-type FAI parameters. METHODS: A collection of 193 femurs from cadavers aged 4 to 21 years were evaluated. The age, sex, ethnicity, and status of the proximal femoral physes (open or closed) of each were recorded. Each specimen was digitally photographed in standardized anteroposterior and modified axial positions. From these photographs, the anterior offset, anterior offset ratio (AOR), and α-angle were determined. A cam lesion was defined as an α-angle >55 degrees on the lateral view. RESULTS: The mean age of the specimens was 17.5±4.2 years. The majority were male (69%) and African American (79%) with closed physes (78%). There were significant differences among discrete age groups with respect to α-angle (P=0.01), anterior offset (P<0.01), and AOR (P<0.01). In addition, younger femurs with open physes had a significantly higher mean α-angle (P<0.01), lower mean anterior offset (P<0.01), and higher mean AOR (P<0.01) compared with older ones with closed physes. Specimens defined as having a cam deformity had a statistically higher α-angle (P<0.01) and lower anterior offset (P<0.01), but there was no difference in AOR values compared with specimens without a cam lesion (P=0.1). CONCLUSIONS: The apparent decline in α-angles as age increases indicates that the traditional α-angle in younger patients measures a different anatomic parameter (ossified femur excluding the cartilaginous portion) than in older patients (completely ossified femur). This suggests that the bony α-angle is inappropriate in the evaluation of cam lesions in the immature physis. The AOR, rather than the anterior offset, may be more accurate in the evaluation of the growing proximal femur. CLINICAL RELEVANCE: This study provides novel insight into, and enhances the understanding of, the development of cam-type FAI.

Wound Closure in Nonidiopathic Scoliosis: Does Closure Matter?

BACKGROUND: Postoperative wound complications after posterior spinal fusion are difficult to manage. The incidence in the nonidiopathic patient population is significantly higher than the adolescent idiopathic population. A comparison of wound complications after posterior spinal fusion for nonidiopathic scoliosis between the utilization of the orthopaedic surgical team at the time of closure performing a nonstandardized wound closure versus a plastic surgeon with a plastic multilayered closure technique and rotational flap coverage when needed had not previously been evaluated. The purpose of this study was to compare the complication rate between nonstandardized and plastic multilayered closure of the surgical incision in patients undergoing posterior spinal fusion for nonidiopathic scoliosis. METHODS: The charts of 76 patients with a primary diagnosis of scoliosis associated with a syndrome or neuromuscular disease and who underwent a posterior spinal fusion were reviewed. Forty-two patients had their incisions closed using the nonstandardized technique and 34 using the plastic multilayered technique. These 2 groups were compared for age, sex, primary diagnosis, number of levels fused, estimated blood loss, number of units transfused, operating room time, wound complication, and return to operating room. RESULTS: The wound complication rate in the nonstandardized closure group was 19% (8/42) compared with 0% (0/34) in the plastic multilayered closure group (P=0.007). The unanticipated return to the operating room rate was 11.9% (5/42) for the nonstandardized closure patients versus 0% (0/34) for the plastic multilayered closure patients (P=0.061). CONCLUSIONS: The use of the plastic multilayered closure technique in this patient population is important in an effort to decrease postoperative wound complications. The ability of the surgical team to decrease the infection rate of nonidiopathic scoliosis cannot be overstated. The method of wound closure plays a major role in lowering this incidence. LEVEL OF EVIDENCE: Level III-therapeutic.

What's New in the Orthopaedic Treatment of Cerebral Palsy.

BACKGROUND: The orthopaedic treatment of the patient with cerebral palsy (CP) is complex and must take into account the heterogeneity and natural history of the condition. Although the goals of management are for the most part universal, the specific interventions and outcome measures used to reach these goals are wide ranging. This update serves to summarize some of the recent publications in the field of pediatric orthopaedics that have made important contributions to our understanding and care of the patient with CP. METHODS: We searched the PubMed database using the following terms: "cerebral palsy" AND "orthopedic." The results were then filtered to include only review papers or clinical trials published in English from 2010 to 2014. The obtained list of references was then reviewed for publications in the fields of lower extremity muscle imbalance, foot and ankle deformities, hip and acetabular dysplasia, and advances in orthopaedic-related technology. RESULTS: Updates in the field of pediatric orthopaedics are constant and the current level of evidence for the effectiveness of specific treatment modalities in patients with CP was reviewed. The search method yielded 153 publications, of which 31 papers were identified as having contributed important new findings. CONCLUSIONS: Our understanding of orthopaedic treatments for children with CP continues to grow and expand. The studies reviewed illustrate just some of the strides we have taken in utilizing evidence-based surgical decision making in practice. Nevertheless, there remains a paucity of randomized controlled trials and higher evidence research, which may contribute to the variability in current practices among providers. By elucidating these gaps we can more purposefully delegate our time and resources into targeted areas of research. LEVEL OF EVIDENCE: Level 4-literature review.

Septic shoulder presenting as a shoulder dislocation in the pediatric patient: a case report.

Shoulder dislocation is relatively uncommon in the younger pediatric population. Because of the relative strength of the surrounding soft tissue structures of the shoulder compared with the proximal humeral physis, subluxation or dislocation resulting from a traumatic event or application of force is rare and instead a proximal humeral physeal injury occurs. Case presentation - We present a 5-year-old male who presented to the office with post-traumatic left shoulder pain for about 1 week. Radiographs of the left shoulder indicated inferior subluxation of the humeral head. He was ultimately diagnosed and treated for a septic shoulder. Septic arthritis of the glenohumeral joint accounts for about 3% of all septic arthritis cases. About half of the pediatric patients with a septic arthritis will present with a concomitant osteomyelitis about the joint involved. Widening of the glenohumeral joint and subluxation clinically as well as radiographically have been described in cases of large joint effusions because of an increase in intra-articular fluid in adults. This inferior subluxation is often noted without a frank dislocation. The case described in this report is unique in that this is the first to describe a pediatric septic shoulder presenting as a shoulder subluxation. Given the rarity of pediatric shoulder dislocations and subluxations, the pediatric orthopaedist and pediatrician should maintain a suspicion for a septic joint. LEVEL OF EVIDENCE: Level V.

Calcaneonavicular Coalition with Naviculocuneiform and Cuneiform-First Metatarsal Coalitions A Case Report.

Coalitions involving three joints of the midfoot are rare. To our knowledge, this is the first report of a patient having fibrocartilaginous coalition of the calcaneonavicular joint along with partial osseous fusion of the naviculocuneiform (Chopart's joint) and medial cuneiform-first metatarsal joints. These multi-coalition pathologies are challenging to address operatively as pain can persist even after recognizing and surgically addressing each coalition in a patient.

Association between body mass index-for-age and slipped capital femoral epiphysis: the long-term risk for subsequent slip in patients followed until physeal closure.

BACKGROUND: Children who present with idiopathic slipped capital femoral epiphysis (SCFE) have an increased risk of developing bilateral disease. Predicting which patients will develop problems with bilateral hips is important for determining treatment algorithms. This is a retrospective observational study that evaluates the relationship and risk between body mass index (BMI)-for-age and unilateral and bilateral SCFE in patients followed until physeal closure. METHODS: This is a retrospective study of all patients with SCFE presenting to one institution from 1998-2005. Using the Center for Disease Control (CDC) references, BMI-for-age was calculated for each patient. The patients were followed up until complete closure of the bilateral proximal femoral physes, which was considered completion of the study. Statistical analysis for significant differences between groups was performed using the Kruskal-Wallis test for equality of populations. A logistic regression, controlling for age and gender, was used to identify BMI-for-age as a risk factor and to determine the significance of the odds ratios (ORs) for the relevant categorical variables-obese, overweight and healthy weight. RESULTS: Eighty patients (56 male, 24 female) presented to a single institution between 1998 and 2005 with a diagnosis of SCFE. The mean age of patients was 12.2 years at initial presentation (range 8.5-16). Forty-eight patients (32 male, 16 female) presented with unilateral SCFE, with 22 of the 48 patients having a BMI for-age percentile ≥95 %. Thirty-two patients (24 male, 8 female) presented with bilateral SCFE, with 29 of the 32 patients having a BMI-for-age percentile ≥95 %. Patients with a BMI-for-age ≥95 % had a significantly increased risk of presentation with bilateral slips (OR 4.83; relative risk [RR] 3.01; p < 0.05]. All but one patient in this study with bilateral SCFE or unilateral SCFE with subsequent contralateral involvement had a BMI-for-age ≥85 % (44 out of 45 patients). Additionally, the overall risk of developing bilateral SCFE until physeal closure with a BMI-for-age ≥95 % was significantly increased (OR 3.84; RR 2.02; p < 0.05; number needed to treat [NNT] 3.01). CONCLUSIONS: Previous work has established a relationship between BMI and SCFE. The CDC BMI-for-age growth charts more accurately measure obesity in the pediatric population compared to BMI and are therefore a more appropriate reference tool. This study demonstrates an association between obesity measured by BMI-for-age percentiles and SCFE. This study also demonstrates an association between BMI-for-age and risk for bilateral SCFE at presentation as well as overall incidence of developing bilateral SCFE in the obese pediatric population. By defining the at-risk population through BMI-for-age, physicians can screen the pediatric patient population and provide early strategies for therapeutic weight loss which may reduce the incidence of SCFE.