Validated Pediatric Functional Outcomes of All-epiphyseal ACL Reconstructions: Does Reinjury Affect Outcomes?

BACKGROUND: Greater frequency and intensity level of sports participation may be contributing to an increasing incidence of anterior cruciate ligament (ACL) tears in skeletally immature athletes. Prior studies have assessed the functional outcomes of physeal-respecting ACL reconstruction in this patient population based on adult functional outcomes scoring systems; however, there is only sparse literature evaluating functional outcomes of this specific patient population. This study aimed to retrospectively evaluate a cohort of pediatric patients who had undergone all-epiphyseal ACL reconstruction (AEACLR) with a set of clinically validated, pediatric-specific patient-reported functional outcomes scores (PRFOS). We hypothesized that patients who had rerupture would have significantly lower outcomes scores compared with those who did not rerupture. METHODS: This was a retrospective evaluation of AEACLR patients at a single, tertiary care, children's hospital within a period of 2 years and had >6 months of initial clinical postoperative follow-up. Those who consented to participation were provided an online combined survey including questions relating to demographics and rerupture as well as 3 validated pediatric PRFOS. Statistical analysis of the cohort demographics, PRFOS, and subgroup analysis of the rerupture group compared with the ACL intact patients was performed. RESULTS: The mean functional outcome scores at a mean of 48.6 months from surgery demonstrated excellent return to functional activity (Mean International Knee Documentation Committee, 93.8; Pedi-Patient-Reported Outcomes Measurement Information System, 98.8; Pedi- Functional Activity Brief Score, 21.6). There was a 13% rerupture rate and rerupture patients had a significantly decreased Pedi-International Knee Documentation Committee (94.9 intact vs. 86.0 rerupture; P=0.001) and Pedi-Patient-Reported Outcomes Measurement Information System (99.4 intact vs. 95.4 rupture; P=0.001) scores. CONCLUSIONS: AEACLR patients have excellent outcomes based on pediatric-specific PRFOS. Rerupture patients demonstrated a decrease in functional outcomes scores compared with intact ACL patients. The results demonstrate the efficacy of AEACLR as measured by pediatric-specific functional outcome scores for the treatment of ACL rupture in skeletally immature athletes. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Site-specific Surgical Site Infection Rates for Rib-based Distraction.

BACKGROUND: Implantable rib-based distraction devices have revolutionized the treatment of children with early onset scoliosis and thoracic insufficiency syndrome. Unfortunately, the need for multiple skin incisions and repeated surgeries in a fragile patient population creates considerable infection risk. In order to assess rates of infection for different incision locations and potential risk factors, we generated a prospectively collected database of patients treated with rib-based distraction devices. METHODS: We analyzed a cohort of patients with thoracic insufficiency syndrome from various etiologies that our institution treated with rib-based distraction devices from 2013 to 2016. Surgery type (implantation, expansion, revision/removal), and surgeon adjudicated surgical site infection (SSI) were collected. For this study, we developed a novel, rib-based distraction device surgical site labeling system in which incisions could be labeled as either proximal or distal surgical exposure areas. Treating surgeons documented the operative site, procedure, and SSI site in real-time. RESULTS: A total of 166 unique patients underwent 670 procedures during the study period, producing 1537 evaluable surgical sites; 1299 proximal and 238 distal. Patients were 6.81±4.0 years of age on average. Forty-seven procedures documented SSIs (7.0%), while 40 (24.1%) patients experienced an infection. Analysis showed significant variation in the rate of infection between implantation, and expansion, and revision procedures, with implantation procedures having the highest infection rate at 13.1% (P<0.01). Infections occurred more frequently at distal sites than proximal ones (P=0.02). CONCLUSIONS: Our novel, surgeon-entered, prospective quality improvement database has identified distal surgical sites as being at higher risk for SSI than proximal ones. Further, rib-based distraction device implantation procedures were identified as being at a greater risk for SSI than expansion or revision procedures. We believe this data can lead to improved prevention measures, anticipatory guidance, and patient care. LEVEL OF EVIDENCE: Level II-prognostic study.

Predicting Periarticular Infection in Children With Septic Arthritis of the Hip: Regionally Derived Criteria May Not Apply to All Populations.

BACKGROUND: The management of septic arthritis of the hip in children can be complicated by the presence of additional coexisting periarticular infections (PAIs). Criteria predicting the presence of PAI have recently been proposed by Rosenfeld and colleagues with the goal of using magnetic resonance imaging (MRI) efficiently in the workup of septic arthritis. The purpose of this study was to determine the applicability of recently published predictive criteria for PAI (developed in the Southwestern United States using a variety of joints) to septic arthritis of the hip treated at a large Northeastern tertiary care center. METHODS: We studied patients treated for septic arthritis of the hip with irrigation and debridement in a large Northeastern tertiary care center over a 10-year period. Laboratory and clinical variables related to presentation, treatment, and outcome were collected. Subjects with and without a perioperative MRI were compared with published criteria by Rosenfeld and colleagues. RESULTS: Fifty-one subjects (53 hips) were identified with a mean age of 7.0 years (range, 1.2 to 19.3 y) and mean follow-up was 16 months (range, 2 to 85 mo). MRIs were obtained in 20 subjects (43%). Coexisting osteomyelitis was revealed in 7/20 of these studies (35% of MRIs); 4 of which showed coexisting intramuscular abscesses. Within our MRI cohort, the Rosenfeld criteria were found to have a sensitivity of 86%, a specificity of 54%, and a false-positive rate of 50% for the hip (compared with originally reported sensitivity of 90%, specificity of 67%, and false-positive rate of 33%). Overall, advanced imaging changed management in 5/51 patients (9%) by influencing the need for further treatment, whereas the remainder underwent isolated treatment of the septic hip joint with no adverse outcomes. One patient in the MRI cohort (without PAI) developed osteonecrosis of the femoral head. CONCLUSIONS: We found lower sensitivity and specificity and higher false-positive rates for the Rosenfeld criteria in the hip for our geographically distinct population. Using the Rosenfeld criteria, MRIs would have been ordered unnecessarily in half of our series. Because of potential differences in regional microbiology and anatomic-specific factors, general predictive criteria for coexisting PAI based a single geographic region may be less generalizable to cases of hip sepsis in other geographic areas such as the Northeastern United States. LEVEL OF EVIDENCE: Level 4-retrospective cohort study.

Surgeon and Caregiver Agreement on the Goals and Indications for Scoliosis Surgery in Children With Cerebral Palsy.

STUDY DESIGN: Prospective multicenter comparative study. OBJECTIVES: We aimed 1) to survey surgeons and caregivers to rank the surgical indications for spinal fusion of pediatric patients with neuromuscular scoliosis secondary to cerebral palsy in order of importance and 2) to characterize the agreement of surgeons and caregivers on major (top three) indications. SUMMARY OF BACKGROUND DATA: Surgery for spinal deformity in children with cerebral palsy is a multifaceted and individualized decision that may lead to miscommunication during informed consent. Little data exist on communication effectiveness between surgeon and caregiver during preoperative discussion. METHODS: This is a multicenter, prospective survey of Harms Study Group patient caregivers and their surgeons. Participants ranked their most important of 15 indications in descending level of importance, where the top 3 selections were considered major indications for surgery for the particular patient in question. Demographic and other perioperative factors were recorded. Surgeon-caregiver agreement on major indications was determined, taking into account preoperative factors and intersurgeon differences. RESULTS: 126 surgeon-caregiver pairs responded. The greatest percentage agreement that an indication was major was "to improve sitting" (69.0% major, 0.8% nonmajor), followed by "to prevent pulmonary compromise" (33.3% major, 24.6% nonmajor), "to improve pain" (31.7% major, 20.6% nonmajor), and "to improve head control/position" (20.7% major, 69.0% nonmajor). Preoperative pain showed an association with surgeon-caregiver agreement on pain as a major indication (p=.004), and intersurgeon differences in agreement on gastrointestinal and pain considerations existed (p=.002, p=.007, respectively). CONCLUSIONS: Surgeon-caregiver agreement is greater where literature support for a particular surgical indication is strong (ie, spinal fusion's known improvement of sitting posture in children with neuromuscular scoliosis). Stronger literature support may bolster surgeons' confidence in recommending a particular procedure, fostering greater communication, understanding, and agreement on surgical necessity between caregivers and surgeons. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Unicortical Fixation is Sufficient for Surgical Treatment of Tibial Tubercle Avulsion Fractures in Children.

BACKGROUND: Although open reduction and internal fixation are recommended for displaced tibial tubercle avulsion fractures in young athletes, whether to use unicortical or bicortical fixation is debatable. The purpose of this study is to compare the outcomes of unicortical versus bicortical fixation in a series of pediatric tibial tubercle avulsion fractures. METHODS: We reviewed a consecutive series of patients with tibial tubercle fractures treated surgically at 2 level-1 pediatric tertiary care centers over a 12.5-year period. Patients aged below 18 years of age who received surgical treatment for displaced tibial tubercle fractures with postoperative follow-up were included. Fractures were classified using a modified Ogden classification system. The relative proportion of fracture types treated and incidence of complications were compared. RESULTS: The cohort included 90 fractures in 86 patients. There were 82 male and 4 female individuals; average age was 14.7 years (range, 9.0 to 18 y). In total, 87 of 90 were treated with open reduction and internal screw fixation [51 unicortical (59%), 13 mixed (15%), 23 bicortical (26%)] and 3 with percutaneous pinning. All patients were followed-up until healing and postoperative follow-up average was 8 months (range, 3 to 34 mo). There were no significant differences between the 2 groups with regard to patient age (P=0.22), patient weight (P=0.22), and activity clearance times [unicortical: 19.9 wk (range, 10.4 to 42.3 wk); bicortical: 17.7 wk (range, 12.1 to 32 wk); P=0.19]. The mixed cortical group was cleared at an average of 19.9 weeks (range, 10.6 to 29.1 wk). The relative proportion of fracture patterns treated differed negligibly between the unicortical and bicortical groups. Complications were noted in 9 of 90 procedures (10% rate); all subjects showed evidence of full radiographic healing at last follow-up. CONCLUSIONS: There was no difference in outcome whether unicortical or bicortical fixation was used. All patients exhibited full healing and return to activities with very low-complication rates. The results of this study suggest the adequacy of unicortical fixation for treating tibial tubercle fractures in young athletes. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

How Often Do You Lengthen? A Physician Survey on Lengthening Practice for Prosthetic Rib Devices.

STUDY DESIGN: Physician survey. OBJECTIVES: To identify physician practice patterns in use of prosthetic rib devices. BACKGROUND: Management of scoliosis with prosthetic ribs involves repeated expansions. Despite this, there is a paucity of literature on expansion practice. We believe that despite minimal literature, there exist surgeon practice patterns. METHODS: Thirty-seven surgeons from the Children's Spine Study Group, with prosthetic rib experience, were anonymously surveyed about their expansion practice. RESULTS: There was strong consensus that elapsed time since previous surgery was the most important factor in choosing lengthening intervals, with 94.5% of responders agreeing. Surgeons indicated that they often apply a standard expansion interval. 97.3% reported using one in >25% of cases, with 70.3% using a standard interval in >80% of cases. Six months was the most commonly reported elapsed time interval, with 78.4% of responders in agreement. There was also consensus on non-time factors. Patient maturity was cited a major factor in choosing lengthening interval in >80% of cases by 59.5% of responders. Patient age was frequently cited as a factor, with 73% of surgeons using it in >25% of cases. Additionally, there was consensus on factors that were not utilized. More than three-fourths (75.7%) stated that they use patients' bone quality <25% of the time. Similarly, 70.3% used resistance encountered in the last lengthening <25% of the time, with 13.5% never considering. CONCLUSION: Despite the lack of evidence-based guidelines regarding lengthening practice for prosthetic ribs, there is some consensus on the factors used to choose an appropriate expansion interval. The greatest consensus surrounded the use of a standard six-month elapsed time interval between expansions. From these data, we conclude that specialists have reached relative consensus on factors important for choosing an appropriate expansion interval. We believe these data are an important step toward developing best practice guidelines and identifying areas of equipoise amenable for future research. LEVEL OF EVIDENCE: Level V.

Analysis of Femoral Version in Patients Undergoing Periacetabular Osteotomy for Symptomatic Acetabular Dysplasia.

INTRODUCTION: A paucity of information exists on the range of femoral version, its effect on hip stability, clinical examination, and presentation in patients with symptomatic acetabular dysplasia. The purpose of this study was to describe the range of version in symptomatic acetabular dysplasia, the association between femoral version and proximal femoral morphology and degree of dysplasia, and the effect of version on clinically measured hip range of motion and on preoperatively measured hip outcome scores. METHODS: We reviewed 314 patients prospectively enrolled in a longitudinal clinical study on periacetabular osteotomy between January 2014 and August 2015 and measured femoral version, morphologic characteristics of the upper femur and acetabulum, and preoperative clinical outcome scores. RESULTS: The average femoral version was 19.7° ± 11.2° (range, -20° to 50°). Femoral version correlated strongly with clinically measured hip range of motion but did not correlate linearly with either radiographic severity of acetabular dysplasia or preoperative symptomatology. DISCUSSION: Despite concerns that transverse plane femoral anatomy influences the stability of the hip joint after skeletal maturity, we did not find a statistical association between femoral version and severity of dysplasia or presenting symptomatology. This finding suggests that femoral version is not a major influence on the clinical presentation of acetabular dysplasia. LEVEL OF EVIDENCE: Level IIIb.

Treatment of the Dislocated Hip in Infants With Spasticity.

BACKGROUND: Although many studies have separately investigated the treatment of developmental dysplasia of the hip and spastic hip disease, little data exist regarding the treatment of infants with dislocated hips and underlying spasticity. The purpose of this study was to review our results after the surgical treatment of these infants. METHODS: We retrospectively reviewed all children below 3 years of age who underwent hip reconstruction for dislocated hips in the setting of cerebral palsy or other spastic/high-tone neuromuscular disease. Medical records were reviewed for clinical data including treatment course, complications, and need for further surgery. Preoperative and postoperative radiographs were used to determine International Hip Dysplasia Institute (IHDI) grade of dislocation, acetabular index, migration percentage, and presence of avascular necrosis according to the Salter criteria. RESULTS: Eleven patients with 15 hips met our inclusion criteria with a mean age of 20±8 (range, 6 to 34) months. Preoperatively, 12 of 15 hips (80%) were IHDI grade 4 and 3 of 15 (20%) were IHDI grade 3. Mean acetabular index was 29±8 (range, 19 to 46) degrees. Patients underwent open reduction (15 hips), adductor tenotomy (14 hips), femoral osteotomy (10 hips), and pelvic osteotomy (12 hips). At a mean follow-up of 40±16 (range, 13 to 71) months, 13 of 15 hips were IHDI grade 1 (86.7%), 1 was IHDI grade 2 (6.7%), and 1 hip was IHDI grade 3 (6.7%). The mean postoperative migration index was 7%±24% (range, -30% to 46%); the mean acetabular index was 22±8 (range, 9 to 38) degrees. No patients developed radiographically significant osteonecrosis. Complications included 2 femur fractures (13.3%) and 1 symptomatic implant that required early removal. One patient underwent further reconstructive hip surgery. CONCLUSIONS: In this series of infants with hip dislocations and underlying spasticity, open reduction±pelvic osteotomy and/or femoral osteotomy has a nearly 90% success rate in achieving and maintaining adequate hip reduction at intermediate-term follow-up. In the unique population of infants with dislocated hips and underlying spasticity, comprehensive hip reconstruction is largely successful with an acceptable rate of complications. LEVEL OF EVIDENCE: Level IV-retrospective.

Youth and Experience: The Effect of Surgeon Experience on Outcomes in Cerebral Palsy Scoliosis Surgery.

BACKGROUND: Series on the learning curve in spinal deformity surgery have been published, but none has addressed neuromuscular spinal deformity, comprised of arguably the most complex cases. We present the first multi-center analysis of the impact of surgeon experience on neuromuscular spinal deformity surgery. METHODS: A multi-center prospective study of spinal deformity surgery for cerebral palsy (CP) with at least 2 years of follow-up provided the dataset for assessment. Surgeons were categorized into one of two groups based on their self-reported first year of practice: an experienced surgeons (ES) group included those with at least 10 years of experience at the time of surgery and a young surgeons (YS) group included those with fewer than 10 years of experience at time of surgery. Groups were compared in multiple pre-operative, operative, and post-operative outcomes. RESULTS: The YS group had 8 surgeons who performed 59 surgeries; the ES group had 13 surgeons who performed 103 cases, with one surgeon's cases distributed in both groups. The YS group had a greater proportion of patients with severe mental retardation (89.7% vs. 68.6%, p = .01). Duration of surgery was greater in the YS group (456 vs. 344 minutes, p < .001). The mean number of levels fused was greater in the ES group (15.9 vs. 15.6, p = .024), caused by increased variation in the upper level of fusion among the ES group. No significant differences were found between groups for estimated blood loss, length of hospitalization, or in percentage of Cobb correction. Years of experience of the operating surgeon was inversely correlated with duration of surgery (rho = -0.476, p < .001). CONCLUSIONS: In performing scoliosis surgery on CP patients, surgeons with fewer than ten years of practice experience demonstrate significantly greater average operative time and decreased mean number of levels fused, yet produce similar clinical outcomes to more experienced surgeons. LEVEL OF EVIDENCE: Level III, therapeutic.

Concussion in Sports: What Do Orthopaedic Surgeons Need to Know?

A concussion is a relatively common sports-related injury that affects athletes of all ages. Although not expected to replace sports medicine physicians and neurologists with regard to the management of concussions, orthopaedic surgeons, particularly those who are fellowship-trained in sports medicine, must have a current knowledge base of what a concussion is, how a concussion is diagnosed, and how a concussion should be managed. Orthopaedic surgeons should understand the pathophysiology, assessment, and management of concussion so that they have a basic comprehension of this injury that is at the forefront of the academic literature and North American media. This understanding will prepare orthopaedic surgeons to work in concert with and assist sports medicine physicians, athletic trainers, and physical therapists in providing comprehensive care for athletes with a concussion.

Sports-related Concussion in Children and Adolescents.

Concussions are becoming increasingly important to manage properly as sports participation continues to rise. Repeated injuries occurring before the brain has had a chance to recover from an initial insult are particularly dangerous and must be prevented. Although much national media attention has been devoted to concussions in professional sports, it is important to appreciate that athletes in any age group, children and adolescents in particular, are at risk of sports-related concussion. It is crucial to remove an athlete from play any time concussion is suspected. Once removed from play, recovery then begins with a period of cognitive and physical rest, followed by a gradual return to cognitive and athletic activities as symptoms resolve. Children and adolescents pose a unique challenge to the clinician managing their recovery, as the physical and cognitive rest periods required often involve time away from school and sports, which can be academically detrimental and socially isolating. Recently developed sideline assessment tools have greatly aided the urgent sideline assessment of an athlete suspected of having a concussion. In this article, a brief review of current guidelines is presented in tandem with the authors' preferred treatment of concussion.

Concussion in Sports: What Do Orthopaedic Surgeons Need to Know?

A concussion is a relatively common sports-related injury that affects athletes of all ages. Although orthopaedic surgeons are not expected to replace sports medicine physicians and neurologists with regard to the management of concussions, orthopaedic surgeons, particularly those who are fellowship-trained in sports medicine, must have a current knowledge base of what a concussion is, how a concussion is diagnosed, and how a concussion should be managed. Orthopaedic surgeons should understand the pathophysiology, assessment, and management of concussion so that they have a basic comprehension of this injury, which is at the forefront of the academic literature and North American media. This understanding will prepare orthopaedic surgeons to work in concert with and assist sports medicine physicians, athletic trainers, and physical therapists in providing comprehensive care for athletes with a concussion.

Nitration of Hsp90 induces cell death.

Oxidative stress is a widely recognized cause of cell death associated with neurodegeneration, inflammation, and aging. Tyrosine nitration in these conditions has been reported extensively, but whether tyrosine nitration is a marker or plays a role in the cell-death processes was unknown. Here, we show that nitration of a single tyrosine residue on a small proportion of 90-kDa heat-shock protein (Hsp90), is sufficient to induce motor neuron death by the P2X7 receptor-dependent activation of the Fas pathway. Nitrotyrosine at position 33 or 56 stimulates a toxic gain of function that turns Hsp90 into a toxic protein. Using an antibody that recognizes the nitrated Hsp90, we found immunoreactivity in motor neurons of patients with amyotrophic lateral sclerosis, in an animal model of amyotrophic lateral sclerosis, and after experimental spinal cord injury. Our findings reveal that cell death can be triggered by nitration of a single protein and highlight nitrated Hsp90 as a potential target for the development of effective therapies for a large number of pathologies.

Genetically encoded tetrazine amino acid directs rapid site-specific in vivo bioorthogonal ligation with trans-cyclooctenes.

Bioorthogonal ligation methods with improved reaction rates and less obtrusive components are needed for site-specifically labeling proteins without catalysts. Currently no general method exists for in vivo site-specific labeling of proteins that combines fast reaction rate with stable, nontoxic, and chemoselective reagents. To overcome these limitations, we have developed a tetrazine-containing amino acid, 1, that is stable inside living cells. We have site-specifically genetically encoded this unique amino acid in response to an amber codon allowing a single 1 to be placed at any location in a protein. We have demonstrated that protein containing 1 can be ligated to a conformationally strained trans-cyclooctene in vitro and in vivo with reaction rates significantly faster than most commonly used labeling methods.

Generating permissive site-specific unnatural aminoacyl-tRNA synthetases.

Genetically incorporated unnatural amino acid (UAA) technologies are powerful tools that are greatly enhancing our ability to study and engineer biological systems. Using these techniques, researchers can precisely control the position and number of novel chemical moieties in a protein, via introducing the novel R group of UAAs, that are genetically encoded in the protein's primary structure. The substrate recognition properties of a natural aminoacyl-tRNA synthetase (aaRS) must be modified in order to incorporate UAAs into proteins. Protocols to do so are technically simple but require time and optimization, which has significantly limited the accessibility of this important technology. At present, engineered unnatural aminoacyl-tRNA synthetases (UaaRS) are evaluated on their translational efficiency (the extent to which they allow for incorporation of UAAs into protein) and fidelity (the extent to which they prevent incorporation of natural amino acids). We propose that a third parameter of substrate recognition, permissivity, is equally important. Permissive UaaRSs, whose relaxed substrate recognition properties allow them to incorporate multiple unnatural amino acids (but not natural amino acids), would eliminate the need to generate new UaaRSs for many new UAAs. Here, we outline methods for quickly and easily assessing the permissivity of existing UaaRSs and for generating permissive UaaRSs. In proof of principle experiments, we determined the degree of permissivity of two UaaRSs for a family of structurally related fluorinated UAAs ((19)F-UAAs). We then increased the permissivity of the initial UaaRSs to allow for incorporation of the family of (19)F-UAAs. Finally, we validated the utility of these new (19)F-UAAs as probes for fluorine NMR studies of protein structure and dynamics. We expect that results of this work will increase the accessibility of UAA technology and the use of new UAAs in proteins.