The levels of evidence in pediatric orthopaedic journals: where are we now?

BACKGROUND: In recent years, it has become common to publish a level of evidence grading for orthopaedic journal publications. Our primary research question is: is there an improvement in levels of evidence of articles published in pediatric orthopaedic journals over time? In addition, what is the current status of levels of evidence in pediatric orthopaedic journals? METHODS: All articles in Journal of Pediatric Orthopaedics-A (JPO-A) and Journal of Pediatric Orthopaedics-B (JPO-B) for 2001, 2002, 2007, and 2008 and those in Journal of Children's Orthopaedics (JCO) for 2007 and 2008, were collected by an independent reviewer. Of the 1,039 articles identified, animal, cadaveric and basic science studies, expert opinion and review articles were excluded. Seven hundred fifty remaining articles were blinded and randomized with respect to journal, title, publication date, author, and institution. According to the currently accepted grading system, study type and level of evidence was assigned to each article. Interobserver and intraobserver reliability were investigated. Statistical analysis was carried out using SPSS software. RESULTS: There were no statistically significant differences in study type or levels of evidence in articles published before and after 2003. Of articles published during 2007/2008, 3.0% were graded as level I, 5.0% as level II, 24.1% as level III, and 58.0% as level IV. Analysis of the separate journals for all 4 years revealed that JPO-A published 2.6% (13 of 503) level I studies, whereas JPO-B published 4.3% (7 of 163) and JCO published 1.2% (1 of 84). The intraobserver reliability was high for study type (κ, 0.842) and substantial for level of evidence (κ, 0.613). The interobserver reliability for study type and level of evidence was high (κ 0.921 and 0.860, respectively). CONCLUSIONS: Since the introduction of levels of evidence to orthopaedic journals in 2003, there has been minimal change in the quality of evidence in pediatric orthopaedic publications. We note a modest increase in level III articles and a corresponding decrease in level IV articles. Articles can be reliably graded by nonepidemiologically trained individuals. LEVEL OF EVIDENCE: Not applicable.

Management of severe crouch gait in children and adolescents with cerebral palsy.

BACKGROUND: Crouch gait in cerebral palsy is associated with spasticity and contracture of the hamstrings and weakness of the extensors of the hip and knee and ankle plantar flexors. Different treatment options have been described in the literature to deal with this difficult problem. We devised a different protocol of treatment aimed at correction of the flexion deformity of the knee, weakening of the hamstrings, and augmenting the power of the knee and hip extension, which we used on 17 children with severe crouch. METHODS: This surgery, performed in 2 stages, entailed shortening of the femur, plication of the patellar tendon, transfer of the semitendinous to the back of the femur, and fractional lengthening of the other hamstrings. The degree of fixed deformity, the popliteal angle, quadriceps power, range of knee motion, ambulatory status and the efficiency of gait, and the position of the patella were evaluated before surgery and again after a minimum 2-year follow-up. RESULTS: The gait improved and the power of the quadriceps and the range of knee motion increased. The flexion deformity and popliteal angle decreased significantly. Patella alta was corrected and all fragmentation of the tibial tuberosity and fractures of the patella healed. The Functional Mobility Scores and the ambulatory capacity increased in all the children. There was no evidence of damage to the sciatic nerve in any patient. CONCLUSIONS: The method of treatment of severe crouch gait outlined in this study seems to be an effective and safe method of dealing with this difficult problem. LEVEL OF EVIDENCE: IV.

Levels of evidence at the Pediatric Orthopaedic Society of North America annual meetings.

BACKGROUND: Since 2003, levels of evidence have been used in the orthopaedic literature to inform the reader of the study quality and its relative significance. Our primary research question was to identify if, since their introduction, there has been an improvement in the levels of evidence of the scientific papers presented at Pediatric Orthopaedic Society of North America (POSNA) meetings. METHODS: The abstract of every paper presented orally at the POSNA annual meeting were identified for the years 2001, 2002 (pre-2003) and 2007, 2008 (post-2003). In all, 364 abstracts were identified by an independent reviewer who then excluded cadaver, animal, and basic science studies. The 307 included abstracts were then independently blinded and randomized. Two nonepidemiologically trained pediatric orthopaedic fellows independently assigned a study type and level of evidence to each abstract based on the primary research question. The first reviewer reanalyzed 50 randomly selected abstracts. Disagreement was resolved by consensus opinion with an epidemiologically trained pediatric orthopaedic surgeon. The interobserver and intraobserver reliability was calculated for the assignment of study type and levels of evidence. Changes in the study types and levels of evidence were analyzed to compare papers presented pre-2003 and post-2003. RESULTS: For study type and levels of evidence the interobserver reliability between the authors showed substantial agreement (kappa 0.755 and 0.647, respectively). The intraobserver reliability also showed substantial agreement (kappa 0.806 and 0.789, respectively). Comparing pre-2003 and post-2003 studies there were no significant differences between the types of study presented. An increase in the number of level III studies was identified. A decrease in level I and level IV studies was identified. CONCLUSIONS: There has been no significant improvement in the scientific quality of studies presented at POSNA Annual Meetings as measured by levels of evidence since their introduction. We have shown substantial agreement between nonepidemiologically trained orthopaedic surgeons when categorizing abstracts using this system. Study types and levels of evidence can be difficult to assign from the current abstract format due to their brevity and structure. LEVEL OF EVIDENCE: Not applicable.

Congenital aplasia of the patella and the distal third of the quadriceps mechanism.

Congenital absence of the patella and aplasia of the muscles are very rare anomalies. We describe a 4-year-old boy with bilateral congenital aplasia of the patella and agenesis of the distal third of the quadriceps muscle who was unable to walk owing to the lack of active knee extension. The features of this child differed from all other conditions associated with patellar aplasia. The continuity of the quadriceps mechanism was restored and he began walking normally. This appears to be the first report of the combination of aplasia of the patella and the distal third of the quadriceps that was successfully treated.

Measurement of tissue hardness: can this be a method of diagnosing compartment syndrome noninvasively in children?

In order to assess the feasibility of using the measurement of tissue hardness as a method of diagnosing compartment syndrome noninvasively in children, a simple hand-held device to measure tissue hardness was fabricated. The relationship between hardness and compartmental pressure was studied in an experimental model and in three fresh amputated lower limbs. Normal tissue hardness of the forearm was measured in 189 children and 20 adults to identify the factors that influence normal tissue hardness. The reproducibility of measurement of tissue hardness was assessed on the experimental model, on the amputated limbs and in normal individuals. Experimental data from this study suggest that there is a nonlinear relationship between intracompartmental pressure and tissue hardness. The study also shows that tissue hardness can be measured reproducibly in the forearm of children with the device. Several factors influence tissue hardness such as the age of the child, the site of measurement on the limb, the hand dominance and active muscle contraction. These factors may affect the specificity of this measure as a screening tool for diagnosing compartment syndrome. Further refinement of the measuring device and well designed clinical trials are needed to establish whether compartmental syndrome can be diagnosed reliably by measuring tissue hardness noninvasively.

Evaluation of outcome of treatment of congenital clubfoot.

The study was undertaken to determine whether existing systems of outcome evaluation of clubfoot are comparable; to determine the relationship between the shape of the foot, its function, and radiological tarsal relationships; and to identify which objective variables used in the assessment of clubfeet are reproducible. Fifty treated idiopathic clubfeet were assessed by the scoring systems of Laaveg and Ponseti, McKay, Magone, and Ghanem and Seringe. Although there was a good correlation between the scores, there was very poor agreement between the grading of feet by these different systems. The feet were also evaluated using a new scoring system that has 3 domains of evaluation, viz, morphological, functional, and radiological. Comparison of the scores in each of these domains showed that there was a correlation between morphology, function, and radiological measurements of tarsal alignment. Several of the criteria used in this new scoring system were reproducible.

Congenital distal humeral dysplasia: a case report.

Congenital dysplasia of the humerus is very rare. It is characteristically seen in omodysplasia and has also been reported as one of the associated features of Larsen's syndrome. We report a 4-year-old girl with bilateral humero-ulnar dysplasia, with dislocation of the elbows, facial dysmorphism, ball-and-socket ankles and foot deformities. Although the elbow dysplasia is similar to that seen in Larsen's syndrome, other pathognomic features of Larsen's syndrome were absent. The changes seen in the elbows in this patient are also different from those encountered in omodysplasia. We believe that this condition may be a distinct form of skeletal dysplasia hitherto undescribed.