Publications by authors named "Deirdre Ryan"

44 Publications

Why do we need to implement the ICD-11? When pain science and practice meet policies.

Eur J Pain 2022 Jul 28. Epub 2022 Jul 28.

European Pain Federation EFIC, Societal Impact of Pain Platform (SIP), Brussels, Belgium.

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http://dx.doi.org/10.1002/ejp.2015DOI Listing
July 2022

Women's Preferences and Design Recommendations for a Postpartum Depression Psychoeducation Intervention: User Involvement Study.

JMIR Form Res 2022 Jun 23;6(6):e33411. Epub 2022 Jun 23.

Department of Obstetrics & Gynaecology, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.

Background: Postpartum depression (PPD) is one of the leading causes of maternal morbidity, affecting up to 18% of Canadian new mothers. Yet, PPD often remains untreated due to numerous barriers in access to care, including location and cost. Development of eHealth interventions in collaboration with patient partners offers an exciting opportunity to fill this care gap and provide effective and affordable care to new parents across British Columbia.

Objective: Our aim was to determine the content and design preferences of women previously diagnosed with PPD to inform changes to the development of a web-enabled intervention for education and management of PPD.

Methods: Webpage prototypes were created to mimic the web-enabled resource using findings from completed focus group research that assessed what women want in a web-enabled support resource for PPD. A convenience sample of women aged >18 years and previously diagnosed with PPD was recruited. Feedback was collected on the content and design of the prototypes via semistructured interviews and online surveys. Qualitative, inductive analytic, and quantitative methods were used.

Results: A total of 9 women (mean age 37.2 years, SD 4.8 years) completed the interview and a majority of the survey. The following 6 themes were identified: (1) inefficacy of text-heavy layouts, (2) highlighting key information, (3) clarity/understandability of the language, (4) finding support groups, (5) validation and immediate help for feelings of isolation, and (6) helpfulness and accessibility of the resource. Each theme identified elements of content or design that were either effective or may be improved upon. Most women (8/9, 89%) favored content relating to foundational knowledge of PPD, such as symptoms and management options. The layout, language, and content were found to be generally easy to understand, clear, trustworthy, and helpful.

Conclusions: Six key areas were identified by women previously diagnosed with PPD, as requiring focus in a web-enabled psychoeducation program. Consistent with past research, this study also found that support and enthusiasm for web-enabled programs support PPD management as an adjunct to other evidence-based treatments.
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http://dx.doi.org/10.2196/33411DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9264129PMC
June 2022

The effect of combined action observation therapy and eccentric exercises in the treatment of mid-portion Achilles tendinopathy: study protocol for a feasibility pilot randomised controlled trial.

Pilot Feasibility Stud 2022 Feb 7;8(1):30. Epub 2022 Feb 7.

UCD School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Ireland.

Background: Mid-portion Achilles tendinopathy (AT) is a common overuse injury which can be difficult to successfully rehabilitate. Whilst peripherally directed treatment approaches that strengthen the Achilles tendon complex can be efficacious for some individuals, others will continue to experience long-standing pain and functional deficits. Expanding our rehabilitation approach beyond the tendon mechanical properties to include techniques which target the central neurophysiological changes which can occur in chronic injuries, including mid-portion AT, may improve our rehabilitation outcomes. Action observation therapy (AOT) is one such technique which targets central changes and can enhance motor learning. To our knowledge, there is currently no available information on the combined effect of AOT and eccentric exercises in the rehabilitation of mid-portion AT, nor understanding of the feasibility of conducting randomised controlled trials that investigate this combined centrally and peripherally directed treatment approach. This protocol outlines the design of a remotely conducted parallel-group randomised controlled trial comparing the efficacy of combined AOT and eccentric loading exercises versus eccentric loading exercises alone for mid-portion AT.

Methods: Participants recruited throughout Ireland with mid-portion AT will be randomly assigned to one of the following groups: (i) The AOT group will observe videos of the eccentric exercises prior to the physical performance of the eccentric exercises. (ii) The control group will observe videos of landscapes prior to the performance of the eccentric exercises. This is a 12-week daily intervention as per the Alfredson loading protocol and outcome measures will be assessed at baseline, week 6 and week 12. Primary feasibility outcomes will include data on numbers of eligible participants, recruitment and retention rates, along with exercise compliance and acceptability of treatment. The primary clinical outcome measure will be the Victorian Institution Symptom Assessment-Achilles Questionnaire (VISA-A) assessing disability. Secondary clinical outcomes will address the remaining core domains as outlined by the International Scientific Tendinopathy Symposium consensus (ICON group) including pain, participation, functional, physical function capacity, quality of life and psychological factors. Widespread bodily pain and centralised pain features and patient satisfaction levels will also be evaluated.

Discussion: This study will provide scientific direction for future randomised controlled trials exploring the effect of AOT and eccentric exercises in the treatment of mid-portion AT on pain, centralised pain features, motor and non-motor functions, quality of life and patient satisfaction levels. The feasibility of the conducting a study remotely from participant screening to final follow-up assessment will also be provided.

Trial Registration: ISRCTN58161116.
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http://dx.doi.org/10.1186/s40814-022-00981-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8819879PMC
February 2022

A cross-sectional study of the relationship between CYP2D6 and CYP2C19 variations and depression symptoms, for women taking SSRIs during pregnancy.

Arch Womens Ment Health 2022 04 7;25(2):355-365. Epub 2021 Jul 7.

Departments of Psychiatry, University of British Columbia (UBC), 938 W28th Ave, Vancouver, BC, V5Z 4H4, Canada.

Depression during pregnancy affects 10-15% of women, and 5% of women take antidepressants during pregnancy. Clinical guidelines provide recommendations for selective serotonin reuptake inhibitor (SSRI) drug choice and dose based on CYP2D6 and CYP2C19 genotype; however, they are based on evidence from non-pregnant cohorts. This study aimed to test the hypothesis that women with function-altering variants (increased, decreased, or no function) in these pharmacogenes, taking SSRIs prenatally, would have more depression symptoms than women whose pharmacogenetic variants are associated with normal SSRI metabolism. Comprehensive CYP2D6 and CYP2C19 genotyping using a range of methods, including gene copy number analysis, was performed as secondary analyses on two longitudinal cohorts of pregnant women (N = 83) taking the SSRIs paroxetine, citalopram, escitalopram, or sertraline. The Kruskal-Wallis test compared mean depression scores across four predicted metabolizer groups: poor (n = 5), intermediate (n = 10), normal (n = 53), and ultrarapid (n = 15). There were no significant differences between mean depression scores across the four metabolizer groups (H(3) = .73, p = .87, eta-squared = .029, epsilon-squared = .0089). This is the first study of the relationship in pregnancy between CYP2C19 pharmacogenetic variations and depression symptoms in the context of SSRI use. Findings from this initial study do not support the clinical use of pharmacogenetic testing for SSRI use during the second or third trimesters of pregnancy, but these findings should be confirmed in larger cohorts. There is an urgent need for further research to clarify the utility of pharmacogenetic testing for pregnant women, especially as companies offering direct-to-consumer genetic testing expand their marketing efforts.
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http://dx.doi.org/10.1007/s00737-021-01149-wDOI Listing
April 2022

Effect of Action Observation Therapy in the Rehabilitation of Neurologic and Musculoskeletal Conditions: A Systematic Review.

Arch Rehabil Res Clin Transl 2021 Mar 27;3(1):100106. Epub 2021 Jan 27.

UCD School of Public Health, Physiotherapy, and Sports Science, Dublin, Ireland.

Objective: To investigate the effect of action observation therapy (AOT) in the rehabilitation of neurologic and musculoskeletal conditions.

Data Sources: Searches were completed until July 2020 from the electronic databases Allied and Complementary Medicine Database (via OVID SP), Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, EMBASE, MEDLINE, and the Physiotherapy Evidence Database.

Study Selection: Randomized controlled trials comparing AOT with standard care were assessed. Musculoskeletal (amputee, orthopedic) and neurologic (dementia, cerebral palsy, multiple sclerosis, Parkinson disease, stroke) conditions were included. There were no age limitations. Articles had to be available in English.

Data Extraction: Two reviewers independently screened titles, abstracts and full extracts of studies for eligibility and assessed the risk of bias of each study using the Cochrane Risk of Bias Tool. Data extraction included participant characteristics and intervention duration, frequency, and type.

Results: The effect of AOT in different outcome measures (OMs) was referenced in terms of body structures and functions, activities and participation, and environmental factors as outlined by the International Classification of Functioning, Disability, and Health (ICF). Of the 3448 articles identified, 36 articles with 1405 patients met the inclusion criteria. Seven of the 11 meta-analyses revealed a significant effect of intervention, with results presented using the mean difference and 95% CI. A best evidence synthesis was used across all OMs. Strong evidence supports the use of AOT in the rehabilitation of individuals with stroke and Parkinson disease; moderate evidence supports AOT in the rehabilitation of populations with orthopedic and multiple sclerosis diagnoses. However, moderate evidence is provided for and against the effect of AOT in persons with Parkinson disease and cerebral palsy.

Conclusions: This review suggests that AOT is advantageous in the rehabilitation of certain conditions in improving ICF domains. No conclusions can be drawn regarding treatment parameters because of the heterogeneity of the intervention. AOT has been considerably less explored in musculoskeletal conditions.
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http://dx.doi.org/10.1016/j.arrct.2021.100106DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7984987PMC
March 2021

Digital Health Needs of Women With Postpartum Depression: Focus Group Study.

J Med Internet Res 2021 01 6;23(1):e18934. Epub 2021 Jan 6.

Women's Health Research Institute, BC Women's Hospital + Health Centre, Vancouver, BC, Canada.

Background: Although approximately 10% of new mothers in Canada develop postpartum depression (PPD), they face many barriers when accessing care. eHealth offers a unique opportunity to provide psychosocial skills and support to new mothers; however, patient populations are not consistently engaged in eHealth development processes. Thus, the diversity of women's backgrounds and needs are often not reflected in existing tools.

Objective: This study aims to engage women from a variety of backgrounds and locations around British Columbia (BC) who have previously experienced PPD to determine the unmet psychoeducational needs of women with PPD and how a web-enabled platform used to deliver psychosocial skills and education to assist in the management of PPD could fulfill those needs.

Methods: Focus groups were conducted in 7 cities across BC with a total of 31 women (mean age 34.5 years, SD 4.9), with each group ranging from 2-7 participants. Focus groups were cofacilitated by the study coordinator and a local service provider in each community using a semistructured guide to discuss participants' needs, ideas, and opinions as they relate to the use of technology in PPD management. Transcripts were approached inductively using thematic analysis to identify themes and qualitative description to frame what was observed in the data.

Results: A total of 5 themes were identified: bridging gaps to meet needs; providing validation to combat stigma; nurturing capacity to cope, manage, and/or reach wellness; empowering people to take ownership over their mental health; and offering customization to ensure relevance. Each theme identified a need (eg, combatting stigma) and a way to address that need using a web-enabled intervention (eg, providing validation). At the intersection of these themes was the overarching value of promoting agency for women experiencing PPD.

Conclusions: Ultimately, new mothers require accessible mental health care that promotes their agency in mental health care decision making. Our participants believed that a web-enabled intervention could help meet this need. These data will be used to guide the design of such an intervention, with the eventual implementation of this resource as a first-line management option for PPD.
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http://dx.doi.org/10.2196/18934DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7817361PMC
January 2021

The Risk of Relapse of Depression During Pregnancy After Discontinuation of Antidepressants: A Systematic Review and Meta-Analysis.

J Clin Psychiatry 2020 06 9;81(4). Epub 2020 Jun 9.

Reproductive Mental Health Program, BC Children's Hospital, Vancouver, British Columbia, Canada.

Objective: The aim of this systematic review and meta-analysis was to determine the effect of antidepressant discontinuation on the risk of relapse of depression during pregnancy.

Data Sources: MEDLINE, EMBASE, CINAHL, and PsycInfo were searched from the inception of each database through March 2019 using keywords such as antidepressants, pregnancy, preconception, discontinuation, stop, recurrence, reintroduction, and relapse.

Study Selection: Original studies that involved pregnant women who discontinued antidepressants during preconception (ie, 3 months prior to pregnancy) or pregnancy and examined the relapse of depression during pregnancy (ie, the reemergence of depression or reintroduction of medication) and published in English were included. A total of 2,172 records were identified, and the full texts of 37 articles were reviewed. Eight studies met the inclusion criteria, 6 of which fulfilled the quality criteria, with 4 studies providing data for the meta-analysis.

Data Extraction: Data were extracted using a data extraction form developed for the purpose of this study. The Cochrane Collaboration Review Manager software version 5.3 was used to conduct the meta-analysis.

Results: Pooled data did not show higher risk of relapse of depression during pregnancy for women who discontinued antidepressants than for those who continued antidepressants (risk ratio [RR] = 1.74; 95% CI, 0.97 to 3.10; P = .06). In the subanalysis based on the severity and recurrence of depression in the study populations, the risk of relapse was significantly higher for populations suggestive of severe or recurrent depression (RR = 2.30; 95% CI, 1.58 to 3.35) but not for populations suggestive of mild or moderate depression severity (RR = 1.59; 95% CI, 0.83 to 3.04).

Conclusions: Women with severe or recurrent depression should be informed about the increased risk of relapse following antidepressant discontinuation, and those who discontinue antidepressants should be monitored for relapse.
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http://dx.doi.org/10.4088/JCP.19r13134DOI Listing
June 2020

Fever after varus derotational osteotomy is common, but not a risk factor for infection.

Medicine (Baltimore) 2020 Jan;99(1):e18613

Children's Orthopedic Center, Children's Hospital Los Angeles.

Postoperative fever in pediatric patients following reconstructive hip surgery is of unknown significance. This study identifies the prevalence of postoperative fever after corrective hip surgery, its relationship to infection, and whether preventative use of anti-pyretics affects patient outcomes.Overall, 222 patients who underwent a varus derotational osteotomy (VDRO) between 11/1/2004 to 8/1/2014 with minimum 6 months follow up were retrospectively identified. Variables included diagnosis, inpatient stay, daily maximum temperature, duration of fever, fever workup, and administration of scheduled anti-pyretics. Fever was defined as temperature ≥38°C.In total, 123/222 (55.4%) and 70/222 (31.5%) had postoperative fevers of ≥38°C and ≥38.5°C, respectively. Average inpatient stay was 2.7 days postoperatively. Temperature (mean = 38.0°C) was greatest on postoperative day 1 (POD1), and 43.7% of patients had T ≥38°C on POD1. Anti-pyretics did not influence the duration of fever. Anti-pyretics on the day of surgery (POD0) did not influence the incidence of fever. Acetaminophen on POD0 significantly reduced likelihood of fever on POD1 (P = .02). Average length of fevers ≥38°C and 38.5°C were 8.4 and 4.2 hours, respectively. 3/18 (16.7%) fever workups administered were positive. Postoperative fever did not predict infection. 9/222 (4/1%) patients had postoperative infection - 5/123 (4.1%) with fever ≥38°C and 4/70 (5.7%) with fever ≥38.5°C. Rates of infection in patients with and without fevers were not significantly different (P = .97 for T ≥38°C and P = .38, for T ≥38.5°C).Though common, postoperative fever does not increase risk of infection. The low prevalence of positive cultures indicates routine fever workups can safely be avoided in most patients.Level of Evidence: III, retrospective comparative study.
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http://dx.doi.org/10.1097/MD.0000000000018613DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6946189PMC
January 2020

Predictors of Walking Activity in Children and Adolescents With Myelomeningocele.

Arch Phys Med Rehabil 2020 03 26;101(3):450-456. Epub 2019 Nov 26.

Children's Orthopaedic Center, Children's Hospital Los Angeles, Los Angeles, California. Electronic address:

Objective: To assess the relationship between real-world walking activity in children and adolescents with myelomeningocele (MMC) and gross measures of lower extremity strength, range of motion, demographics, and medical history.

Design: Prospective study.

Setting: Participants recruited in outpatient clinics; data collected in a hospital-based motion analysis laboratory and in the community.

Participants: Children and adolescents (N=52) with daily step count data available from a larger study of ambulatory children and adolescents with MMC.

Interventions: Not applicable.

Main Outcome Measure: Univariate and multivariate regression was used to assess which participant characteristics and clinical factors were related to average number of steps per day.

Results: Univariate analysis showed a lower number of steps per day correlated with older age, male sex, higher body mass index, higher lesion level, use of assistive devices for ambulation, history of shunt placement, more television (TV) watched per week, lower hip extension and abduction strength, knee flexion strength, and ankle dorsiflexion and plantarflexion strength, and decreased knee and hip range of motion. Only assistive device usage and hours of TV watched per week remained in the final multivariate model predicting number of steps per day.

Conclusions: Walking activity in children and adolescents with MMC was best predicted by assistive device use and amount of sedentary activity. Other predictors of walking activity from univariate analysis were related to assistive device use. This information can help tailor rehabilitation efforts and educate patients and families. Interventions targeting early prevention of strength loss and contractures may be important to retain or increase walking activity in children and adolescents with MMC.
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http://dx.doi.org/10.1016/j.apmr.2019.10.186DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7050431PMC
March 2020

Clamping the Umbilical Cord in Premature Deliveries (CUPiD): Neuromonitoring in the Immediate Newborn Period in a Randomized, Controlled Trial of Preterm Infants Born at <32 Weeks of Gestation.

J Pediatr 2019 05 14;208:121-126.e2. Epub 2019 Mar 14.

Department of Pediatrics and Child Health, Cork University Maternity Hospital, Cork Ireland; Irish Centre for Fetal and Neonatal Translational Research, University College Cork, Cork, Ireland.

Objective: To compare cerebral activity and oxygenation in preterm infants (<32 weeks of gestation) randomized to different cord clamping strategies.

Study Design: Preterm infants born at <32 weeks of gestation were randomized to immediate cord clamping, umbilical cord milking (cord stripped 3 times), or delayed cord clamping for 60 seconds with bedside resuscitation. All infants underwent electroencephalogram (EEG) and cerebral near infrared spectroscopy for the first 72 hours after birth. Neonatal primary outcome measures were quantitative measures of the EEG (17 features) and near infrared spectroscopy over 1-hour time frames at 6 and 12 hours of life.

Results: Forty-five infants were recruited during the study period. Twelve infants (27%) were randomized to immediate cord clamping, 19 (42%) to umbilical cord milking, and 14 (31%) to delayed cord clamping with bedside resuscitation. There were no significant differences between groups for measures of EEG activity or cerebral near infrared spectroscopy. Three of the 45 infants (6.7%) were diagnosed with severe IVH (2 in the immediate cord clamping group, 1 in the umbilical cord milking group; P = .35).

Conclusions: There were no differences in cerebral EEG activity and cerebral oxygenation values between cord management strategies at 6 and 12 hours.

Trial Registration: ISRCTN92719670.
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http://dx.doi.org/10.1016/j.jpeds.2018.12.039DOI Listing
May 2019

Outcomes of salvage hip surgery in children with cerebral palsy.

J Pediatr Orthop B 2019 Jul;28(4):314-319

Children's Orthopedic Center, Children's Hospital Los Angeles, Los Angeles, California.

This study compared the outcomes of four salvage procedures in treating painful dislocated hips in patients with cerebral palsy: Schanz osteotomy, Girdlestone, Castle, and McHale procedures. A retrospective review of cerebral palsy patients treated between 1990 and 2014 with minimum 6-month follow-up was carried out. Of 69 hips (62 patients), there were 36 McHales, 24 Castles, four Girdlestones, and five Schanz procedures at a mean age of 13.9 years. All four procedures provided pain relief. Proximal femoral migration was similar following the procedures, but heterotopic ossification was more common after the Castle procedure. Bone resorption and revision surgery were more frequent after the McHale procedure.
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http://dx.doi.org/10.1097/BPB.0000000000000566DOI Listing
July 2019

Impact of gait analysis on pathology identification and surgical recommendations in children with spina bifida.

Gait Posture 2019 01 9;67:128-132. Epub 2018 Oct 9.

Children's Hospital Los Angeles, Los Angeles, CA, USA.

Background: Gait analysis provides quantitative data that can be used to supplement standard clinical evaluation in identifying and understanding gait problems. It has been established that gait analysis changes treatment decision making for children with cerebral palsy, but this has not yet been studied in other diagnoses such as spina bifida.

Research Question: To determine the effects of gait analysis data on pathology identification and surgical recommendations in children with spina bifida.

Methods: Two pediatric orthopaedic surgeons and two therapists with >10 years of experience in gait analysis reviewed clinical, video, and gait analysis data from 43 ambulatory children with spina bifida (25 male; mean age 11.7 years, SD 3.8; 25 sacral, 18 lumbar). Primary gait pathologies were identified by each assessor both before and after consideration of the gait analysis data. Surgical recommendations were also recorded by the surgeons before and after consideration of the gait analysis data. Frequencies of pathology and surgery identification with and without gait analysis were compared using Fisher's exact test, and percent change in pathology and surgery identification was calculated.

Results: Pathology identification often changed for common gait problems including crouch (28% of cases), tibial rotation (35%), pes valgus (18%), excessive hip flexion (70%), and abnormal femur rotation (75%). Recognition of excessive hip flexion and abnormal femur rotation increased significantly after consideration of gait analysis data (p < 0.05). Surgical recommendations also frequently changed for the most common surgeries including tibial derotation osteotomy (30%), antero-lateral release (22%), plantar fascia release (33%), knee capsulotomy (25%), 1 metatarsal osteotomy (60%), and femoral derotation osteotomy (89%). At the patient level, consideration of gait analysis data altered surgical recommendations for 44% of patients.

Significance: Since gait analysis data often changes pathology identification and surgical recommendations, treatment decision making may be improved by including gait analysis in the patient care process.
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http://dx.doi.org/10.1016/j.gaitpost.2018.10.003DOI Listing
January 2019

Foam Padding in Postoperative Lower Extremity Casting: An Inexpensive Way to Protect Patients.

J Pediatr Orthop 2018 Sep;38(8):e470-e474

Children's Orthopaedic Center, Children's Hospital Los Angeles, Los Angeles, CA.

Background: Although postoperative cast immobilization is routinely used in children, it is not without complications. Few studies have focused on interventions to decrease their frequency. The purpose of this study was to determine if foam padding in postoperative lower extremity casts decreased the rate of cast complications.

Methods: A retrospective review of patients who underwent lower extremity casting after elective surgery at a tertiary pediatric hospital from 2006 to 2013 was conducted. Postoperative casts were classified by type (A-frame, short leg, long leg, spica) and the presence of foam. Charts were reviewed for skin complications, cast splits for apparent neurovascular deficits, cast splits for patient complaints, unplanned outpatient returns for cast-related issues, and compartment syndrome.

Results: In total, 920 patients with 2,481 casts were included. In total, 612 (24.7%) casts had foam placed during casting. The incidence of skin complications was significantly lower in A-frame casts with foam (4.5%, 5/112) than without (13.4%, 11/82) (P=0.03) and long leg casts with foam (0.9%, 2/225) than without (4.3%, 19/444) (P=0.02). Patients with static encephalopathy casted with foam had a lower incidence of skin complications (0.7%, 2/279) than those without (3.6%, 22/615) (P=0.01). There was no difference in the overall incidence of skin complications in casts with and without foam (P=0.44), short leg casts (P=0.37), and spica casts (P=0.34). Patients with skin complications (20.3±7.1 kg/m) had a higher body mass index than those without (18.9±5.4 kg/m) (P=0.04). Postoperative A-frame casts with foam (0.0%, 0/112) were split less often for apparent neurovascular deficits than those without foam (4.5%, 3/67) (P=0.05). The cast split rates for apparent neurovascular deficits in casts with and without foam (P=0.58), long leg casts (P=0.67), short leg casts (P=0.63), and spica casts (P=1.0) were comparable.

Conclusions: The use of foam in postoperative lower extremity casting is an effective intervention to reduce the incidence of skin complications in patients with static encephalopathy, in an A-frame cast, or in a long leg cast.

Level Of Evidence: Level III-retrospective comparative study.
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http://dx.doi.org/10.1097/BPO.0000000000001212DOI Listing
September 2018

Feasibility of a mindfulness-based cognitive therapy group intervention as an adjunctive treatment for postpartum depression and anxiety.

J Affect Disord 2018 08 2;235:61-67. Epub 2018 Jan 2.

Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada. Electronic address:

Background: Many women experience moderate-to-severe depression and anxiety in the postpartum period for which pharmacotherapy is often the first-line treatment. Many breastfeeding mothers are reticent to increase their dose or consider additional medication, despite incomplete response, due to potential adverse effects on their newborn. These mothers are amenable to non-pharmacological intervention for complete symptom remission. The current study evaluated the feasibility of an eight-week mindfulness-based cognitive therapy (MBCT) intervention as an adjunctive treatment for postpartum depression and anxiety.

Methods: Women were recruited at an outpatient reproductive mental health clinic based at a maternity hospital. Participants had a diagnosis of postpartum depression/anxiety within the first year following childbirth. They were enrolled in either the MBCT intervention group (n = 14) or the treatment-as-usual control group (n = 16), and completed the Patient Health Questionnaire-9 (PHQ-9), the Generalized Anxiety Disorder-7 (GAD-7) questionnaire, and the Mindful Attention Awareness Scale (MAAS) at baseline and at 4 weeks, 8 weeks, and 3 months following baseline.

Results: Multivariate analyses demonstrated that depression and anxiety levels decreased, and mindfulness levels increased, in the MBCT group, but not in the control group. Many of the between-group and over time comparisons displayed trends towards significance, although these differences were not always statistically significant. Additionally, the effect sizes for anxiety, depression, and mindfulness were frequently large, indicating that the MBCT intervention may have had a clinically significant effect on participants.

Limitations: Limitations include small sample size and the non-equivalent control group design.

Conclusions: We demonstrated that MBCT has potential as an adjunctive, non-pharmacological treatment for postpartum depression/anxiety that does not wholly remit with pharmacotherapy. (249 words).
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http://dx.doi.org/10.1016/j.jad.2017.12.065DOI Listing
August 2018

Molding Spica Casts to Maintain Alignment of Femur Fractures.

J Pediatr Orthop 2018 May/Jun;38(5):e267-e270

Children's Orthopaedic Center, Children's Hospital Los Angeles, Los Angeles, CA.

Background: Femur fractures in young children are frequently treated with spica casting. Texts recommend molding spica casts into valgus and recurvatum to counter deforming muscular forces, but how much overcorrection to aim for has not been evaluated. Our goal was to determine how much valgus and recurvatum is optimal at the time of casting to end up with anatomic alignment.

Methods: Patients 1 to 6 years old with femur fractures treated with spica casts between January 1, 2008 and January 31, 2014 who were followed until radiographic union were included in the study. Patients with underlying medical comorbidities affecting bone quality, refractures, or preexisting femur deformities or that did not have intraoperative imaging were excluded.

Results: A total of 52 patients met the inclusion criteria. Average intraoperative angulation was 2.6 degrees of valgus (range: 9 degrees varus to 13 degrees valgus, SD: 4.5) and 1.1 degrees of recurvatum (range: 10 degrees recurvatum to 17 degrees procurvatum, SD: 4.8). At the initial postoperative visit, the average angulation was 2.7 degrees of varus (range: 21 degrees varus to 11degrees valgus, SD: 6.4) and 7.2 degrees of procurvatum (range: 6 degrees recurvatum to 25 degrees procurvatum, SD: 6.6). At the time of radiographic union/wedging average angulation was 2.0 degrees of varus (range: 15 degrees varus to 10 degrees valgus, SD: 5.8) and 8.5 degrees of procurvatum (range: 5 degrees recurvatum to 29 degrees procurvatum, SD: 7.5). Between the intraoperative period to time of union or wedging, fracture alignment gained an average of 4.6 degrees of varus (range: 17 degrees varus to 13 degrees valgus, SD: 6.6) and 9.8 degrees of procurvatum (range: 8 degrees recurvatum to 30 degrees procurvatum, SD: 9.1). Seven patients underwent cast wedging due to loss of reduction before radiographic union, 2 patients underwent reoperation due to excessive angulation in the early postoperative period, and 5 patients developed malunions.

Conclusion: Femur fractures treated with spica casts gain 5 degrees of varus and 10 degrees of procurvatum between cast application and fracture union.

Level Of Evidence: Level IV.
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http://dx.doi.org/10.1097/BPO.0000000000001165DOI Listing
August 2018

Advanced skeletal maturity in children and adolescents with myelomeningocele.

J Pediatr Rehabil Med 2017 12;10(3-4):283-293

Children's Orthopaedic Center, Children's Hospital Los Angeles, Los Angeles, CA, USA.

Purpose: Atypical skeletal development is common in youth with myelomeningocele (MM), though the underlying reasons have not been fully elucidated. This study assessed skeletal maturity in children and adolescents with MM and examined the effects of sex, age, sexual development, ethnicity, anthropometrics and shunt status.

Methods: Forty-three males and 35 females with MM, 6-16 years old, underwent hand radiographs for bone age determination. The difference between bone age and chronological age was evaluated using Wilcoxon sign rank tests. Relationships between age discrepancy (skeletal-chronological) and participant characteristics were assessed using multiple linear regression with forward selection.

Results: Overall, forty percent (31/78) of MM participants had an advanced bone age of 1 year or greater (median: 2.5 years), while 47% (37/78) were within 1 year above or below their chronological age (-0.001 years) and 13% (10/78) were delayed by more than 1 year (-1.4 years). Bone age was advanced compared to chronologic age in both males and females (p⩽ 0.024). Advanced bone age was observed in early to late puberty and after maturation (p⩽ 0.07), as well as in Hispanic participants (p= 0.003) and in those with a shunt (p= 0.0004). Advanced bone age was positively correlated with height, weight and body mass index (BMI) percentiles (p= 0.004). In multiple linear regression analysis, advanced bone age was most strongly associated with higher Tanner stage of sexual development, and higher weight, height or BMI percentile.

Conclusions: Advanced skeletal maturity is common in children/adolescents with MM over 8 years of age who have reached puberty (65%), particularly those who are overweight (80%). Hormonal effects associated with adiposity and sexual maturity likely influence skeletal maturation. Clinicians may use Tanner stage and weight or BMI to gain insight into skeletal maturity.
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http://dx.doi.org/10.3233/PRM-170458DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6373769PMC
December 2017

Walking activity during daily living in children with myelomeningocele.

Disabil Rehabil 2017 07 6;39(14):1422-1427. Epub 2016 Jul 6.

a Children's Orthopaedic Center, Children's Hospital Los Angeles , Los Angeles , CA , USA.

Purpose: To quantify the walking activity of children with myelomeningocele during daily living.

Method: Walking activity was measured using a StepWatch activity monitor over one week in 47 children with myelomeningocele (27 males; 9 years 11 months SD 2 years 7 months; 18 sacral, 9 low lumbar, 20 mid-high lumbar) and seven children with typical development (5 males; 11 years 1 month SD 1 year 11 months) in a prospective, cross-sectional study. Average total steps per day, number of steps and minutes spent at low, medium and high intensity stepping were evaluated. Groups were compared using t-tests and chi-squared tests with Bonferroni post-hoc adjustment.

Results: Children with sacral and low lumbar myelomeningocele exhibited no significant differences in demographic characteristics or walking performance compared to typically developing children. Children with mid-high lumbar myelomeningocele exhibited higher BMI percentile than the control group (p = 0.04) and took fewer total steps per day than all other groups (p ≤ 0.04). Children with mid-high lumbar myelomeningocele also spent significantly less time taking steps at all intensity levels, particularly medium-intensity, than the sacral and low lumbar groups (p ≤ 0.04).

Conclusions: Children with sacral and low lumbar myelomeningocele had walking performance similar to typically developing children despite a common need for braces and assistive devices. Children with mid-high lumbar myelomeningocele were less active, which may lead to heightened risk for secondary health conditions in addition to those associated with myelomeningocele. Implications for Rehabilitation Obesity, muscle weakening and disuse osteoporosis are issues for those with myelomeningocele, all of which are affected by walking activity. Understanding walking activity and intensity in children and adolescents with myelomeningocele may aid in developing focused rehabilitation interventions and strategies. Real world walking activity as an objective and quantified measure has the potential to help guide therapists and surgeons to more effective treatments.
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http://dx.doi.org/10.1080/09638288.2016.1198429DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5218985PMC
July 2017

Differentiating Transient Synovitis of the Hip from More Urgent Conditions.

Authors:
Deirdre D Ryan

Pediatr Ann 2016 Jun;45(6):e209-13

A variety of traumatic and infectious processes can cause acute onset of hip pain and difficulty walking. Without a history of trauma, a common cause is transient (or "toxic") synovitis, but serious infectious causes, such as septic arthritis of the hip or osteomyelitis, must be ruled out. Differentiating between septic arthritis of the hip (a true emergency) and transient synovitis of the hip (a much more benign inflammatory process) can be difficult. The Kocher criteria have proven to be helpful in making the distinction between these two conditions, and they are reviewed in this article. In addition, imaging studies, especially hip ultrasound, are extremely helpful in the evaluation of the painful hip. [Pediatr Ann. 2016;45(6):e209-e213.].
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http://dx.doi.org/10.3928/00904481-20160427-01DOI Listing
June 2016

Quantitative Analysis of Lower Leg Adipose Tissue Distribution in Youth with Myelomeningocele.

J Child Neurol 2016 07 9;31(8):979-84. Epub 2016 Mar 9.

Keck School of Medicine, University of Southern California, Los Angeles, CA, USA Children's Orthopaedic Center, Children's Hospital Los Angeles, Los Angeles, CA, USA.

Children with myelomeningocele have a high prevalence of obesity and excess fat accumulation in their lower extremities. However, it is not known if this is subcutaneous or intramuscular fat, the latter of which has been associated with insulin resistance and metabolic disorders. This study quantified lower leg bone, muscle, and adipose tissue volume in children with myelomeningocele, classifying adipose as subcutaneous or muscle-associated. Eighty-eight children with myelomeningocele and 113 children without myelomeningocele underwent lower leg computed tomographic scans. Subcutaneous and muscle-associated adipose were classified based on location relative to the crural fascia. No differences were seen in subcutaneous adipose. Higher level disease severity was associated with increased muscle-associated adipose volume and decreased muscle volume. Bone volume tended to decrease with higher levels of involvement. Increases in lower leg adiposity in children with myelomeningocele are primarily attributable to accumulation of muscle-associated adipose, which may signify increased risk for metabolic disorders.
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http://dx.doi.org/10.1177/0883073816634858DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4925233PMC
July 2016

Fasting serum blood measures of bone and lipid metabolism in children with myelomeningocele for early detection of cardiovascular and bone fragility risk factors.

J Spinal Cord Med 2017 03 14;40(2):193-200. Epub 2015 Dec 14.

b Children's Orthopaedic Center, Children's Hospital Los Angeles , Los Angeles , CA , USA.

Objective: This study examined serum levels in children with myelomeningocele to identify the prevalence of pre-clinical signs of disease.

Design: A prospective, cross-sectional study.

Setting: Patients were actively recruited from multidisciplinary care clinics at tertiary children's hospitals from 2010-2012. The control comparison group was recruited by word-of-mouth.

Patients: Twenty-eight children with myelomeningocele (93% Hispanic; 17 males; 10.0 ± 2.1 years) and 58 controls (84% Hispanic; 30 males; 10.4 ± 2.4 years) provided ≥ 8-hour fasting blood samples with concomitant dual-energy x-ray absorptiometry measurements of body fat.

Interventions: Not applicable.

Main Outcome Measures: The serum analysis included a lipid panel (cholesterol, triglycerides, high-density lipoprotein, low-density lipoprotein), insulin, glucose, leptin, aspartate aminotransferase, alanine transaminase, alkaline phosphatase, albumin, creatinine, calcium, phosphatase, parathyroid hormone, and vitamin D.

Results: Children with myelomeningocele had higher body fat (35.2% versus 29.9%, p=0.01) and altered lipid profiles (lower high-density lipoprotein levels, 43.9 mg/dL versus 51.6 mg/dL, P = 0.03) suggesting elevated risk of metabolic syndrome. They also had a higher prevalence of vitamin D deficiency (43% versus 17%, p=0.02) and significantly lower levels of calcium (9.4 mg/dL versus 9.7 mg/dL, P = 0.003) and alkaline phosphatase (187.0 U/L versus 237.0 U/L, P = 0.003). Unexpectedly children with myelomeningocele had lower parathyroid hormone levels (14.5 pg/mL versus 18.4 pg/mL, P = 0.02) than controls despite lower calcium, vitamin D and alkaline phosphatase levels. This suggests an alteration in the sensing mechanism or response of the parathyroid gland to normal physiological stimuli in patients with myelomeningocele.

Conclusions: Children with myelomeningocele have abnormal biochemical markers for cardiovascular disease, insulin resistance and bone and mineral metabolism. Early recognition and monitoring of these risk factors in patients with myelomeningocele may help prevent later complications.
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http://dx.doi.org/10.1080/10790268.2015.1101983DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5430477PMC
March 2017

Frailty: a costly phenomenon in caring for elders with cognitive impairment.

Int J Geriatr Psychiatry 2016 Feb 1;31(2):161-8. Epub 2015 Jul 1.

St James's Hospital, Mercer's Institute for Research on Ageing, Dublin, Ireland.

Objectives: Dementia draws on a variety of public and private resources. There is increasing pressure to define the cost components in this area to improve resource allocation and accountability. The aim of this study was to characterize frailty in a group of cognitively impaired community-dwelling elders and evaluate its relationship with cost and resource utilization.

Methods: We assessed a cross-sectional, convenient sample of 115 cognitively impaired patients of age >55 years who attended the National Memory Clinic in St James' University Hospital, a Trinity College-affiliated hospital in Dublin, Ireland. Participants had a clinical diagnosis of possible Alzheimer's disease or mild cognitive impairment. Frailty was measured using the biological syndrome model. Formal health and social care costs and daily informal caregiving costs were collected and the total costs of care estimated by applying the appropriate unit cost estimate for each resource activity. Stepwise regression models were constructed to establish the factors associated with increased care costs.

Results: Patient dependence, frailty and number of co-morbid illnesses explained 43.3% of the variance in observed daily informal care costs in dementia and cognitively impaired patients. Dependence was the sole factor retained in an optimal model explaining 19% of the variance in formal health and social care costs.

Conclusion: Frailty retained a strong association with daily informal care costs even in the context of other known risk factors for increasing care costs. Interventions that reduce frailty as well as patient dependence on others may be associated with cost savings.
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http://dx.doi.org/10.1002/gps.4306DOI Listing
February 2016

Variability of the Anterior Humeral Line in Normal Pediatric Elbows.

J Pediatr Orthop 2016 Mar;36(2):e14-6

*Children's Orthopaedic Center, Children's Hospital Los Angeles †University of Southern California, Los Angeles, CA ‡Children's Hospital New Orleans/Louisiana State University Health Science Center, Orthopaedic Department, New Orleans, LA.

Background: The anterior humeral line (AHL) is considered a valuable radiographic tool in the assessment of pediatric elbow sagittal plane alignment following injury. However, few studies exist that examine the validity of the AHL. The purpose of this study is to report the variability of the AHL in skeletally immature children with normal elbows.

Methods: A total of 124 true lateral elbow radiographs of normal pediatric elbows were retrospectively identified and examined for the relationship of the AHL to the capitellum. The percentage of AHLs falling outside the middle third of the capitellum was compared among different age and sex groups using Fisher exact tests.

Results: In 100% of patients, the AHL touched the ossific nucleus of the capitellum. In 100% (52/52) of patients ≥5 years the AHL goes through the middle third of the capitellum, but this is significantly different from patients less than 5 years of age in whom 25% (18/72) of patients the AHL fell outside of the middle third of the capitellum (P<0.001). In children less than 2 years of age, the AHL was in the anterior third in 30% of the cases.

Conclusions: Traditional teaching that the AHL touches the capitellum on a lateral radiograph of a normal elbow in a child is correct, so if the AHL does not touch the capitellum it is appropriate to look for pathology. Similarly, in children 5 years and older the AHL goes through the middle third of the capitellum in all patients, so if it does not, it is appropriate to look for pathology. However, with decreasing age variability increases, with the AHL touching the anterior third of the capitellum in almost 1/3 of children.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1097/BPO.0000000000000529DOI Listing
March 2016

Foam padding in casts accommodates soft tissue swelling and provides circumferential strength after fixation of supracondylar humerus fractures.

J Pediatr Orthop 2015 Jan;35(1):24-7

Children's Orthopaedic Center, Children's Hospital Los Angeles, Los Angeles, CA.

Background: Varying casting techniques are used after surgical treatment of pediatric supracondylar humerus fractures. The goals are to maintain fracture reduction, while accommodating soft tissue swelling and minimizing the risk of compartment syndrome.

Methods: A retrospective chart review of consecutive patients aged 0 to 14 years who underwent surgical treatment of supracondylar humerus fractures over a 9½-year period at a pediatric trauma center was performed. A new method of casting, in which one half inch sterile foam is applied directly to the skin and overwrapped by circumferential fiberglass, is presented and compared with traditional casts.

Results: A total of 541 consecutive patients were included. Foam had been used in 35% (190/541) of patients. Foam was used significantly more frequently in Gartland type 3 fractures (133/314 patients, 42%) than in type 2 fractures (57/227 patients, 25%) (P<0.001). Foam was also used more often in patients with preoperative neurovascular deficits (34/57, 60%) than in those without (156/484, 32%) (P<0.001). No patient in either group developed compartment syndrome postoperatively. Both patients in the study who required revision closed reduction and pinning were casted without foam, and one of these casts had been split. Reoperation was not associated with cast splitting (P=0.216) or foam use (P=0.543).

Conclusions: For postoperative immobilization of supracondylar humerus fractures we present a new method of placing foam directly on the skin, followed by circumferential fiberglass casting. This method offers the theoretical advantage of the strength of a circumferential cast, plus the benefit of allowing for swelling. Although the novel foam and cast combination was used in more severe fractures, results were comparable to traditional casts and may reduce the need for cast splitting.

Level Of Evidence: Therapeutic-Level III.
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http://dx.doi.org/10.1097/BPO.0000000000000216DOI Listing
January 2015

Fat distribution in children and adolescents with myelomeningocele.

Dev Med Child Neurol 2015 Mar 23;57(3):273-8. Epub 2014 Sep 23.

Children's Orthopaedic Center, Children's Hospital Los Angeles, Los Angeles, CA, USA.

Aim: To evaluate fat distribution in children and adolescents with myelomeningocele using dual-energy X-ray absorptiometry (DXA).

Method: Cross-sectional DXA measurements of the percentage of fat in the trunk, arms, legs, and whole body were compared between 82 children with myelomeningocele (45 males, 37 females; mean age 9y 8mo, SD 2y 7mo; 22 sacral, 13 low lumbar, 47 mid lumbar and above) and 119 comparison children (65 males, 54 females; mean age 10y 4mo, SD 2y 4mo). Differences in fat distribution between groups were evaluated using univariate and multivariate analyses.

Results: Children with myelomeningocele had higher total body fat (34% vs 31%, p=0.02) and leg fat (42% vs 35%, p<0.001) than comparison children, but no differences in trunk or arm fat after adjustment for anthropometric measures.

Interpretation: Children with myelomeningocele have higher than normal total body and leg fat, but only children with higher level lesions have increased trunk fat, which may be caused by greater obesity in this group. Quantifying segmental fat distribution may aid in better assessment of excess weight and, potentially, the associated health risks.
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http://dx.doi.org/10.1111/dmcn.12591DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4323886PMC
March 2015

A line drawn along the radial shaft misses the capitellum in 16% of radiographs of normal elbows.

J Pediatr Orthop 2014 Dec;34(8):763-7

Children's Hospital Los Angeles, Los Angeles, CA.

Background: The radiocapitellar line (RCL) is a routinely referenced radiographic measurement for evaluating injury of the pediatric elbow, such as a Monteggia fracture. It is most commonly described as a line drawn along the radius that should intercept the center of the capitellum in a normal elbow. However, the RCL has not been rigorously defined or validated in young children.

Methods: The RCL was drawn out on the anteroposterior and lateral radiographs of 116 normal pediatric elbows by 3 examiners. On each radiograph, lines were drawn along the longitudinal center of the radial neck as well as the radial shaft. The distance from each of these lines to the center of the capitellum was defined as the line-capitellar distance (LCD). The LCD was standardized to the patient size and correlated with patient variables.

Results: Of the 2052 RCLs drawn, 50% (1029/2052) fell outside the middle third of the capitellum and 8.6% (176/2052) missed the capitellum completely. Lines drawn along the radial neck in the anteroposterior and lateral views missed the capitellum less frequently (1.2% vs. 12.7%, P<0.0001) and passed through its central third less (77.8% vs. 44.7%, P<0.0001) when compared with lines drawn using the radial shaft. Lines along the radial neck intersected the capitellum significantly more often on the lateral view than on the anteroposterior view (98.8% vs. 96.8%, P=0.06) and were more likely to pass through the center third of the capitellum (77.8% vs. 55.5%, P<0.0001). With both techniques of drawing the RCL, the percent of measurements falling within the middle third of the capitellum was higher in patients above 5 years of age (P<0.001). The RCL is more reliable in older patients and shows considerable variation in infants.

Conclusions: The RCL does not invariably bisect or fall within the middle third of the capitellum in normal pediatric elbows. Therefore, an abnormal RCL is suggestive but not pathognomonic for injury such as Monteggia fracture. An RCL drawn along the radial shaft will miss the capitellum in 15.6% of elbows. The most consistent RCL is drawn along the radial neck on the lateral view. Patient variables such as age and sex should be considered in the ability of the RCL to identify elbow injury.

Level Of Evidence: Diagnostic Level 3.
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http://dx.doi.org/10.1097/BPO.0000000000000199DOI Listing
December 2014

Iatrogenic nerve injuries in the treatment of supracondylar humerus fractures: are we really just missing nerve injuries on preoperative examination?

J Pediatr Orthop 2014 Jun;34(4):388-92

Children's Orthopaedic Center, Children's Hospital Los Angeles, Los Angeles, CA.

Background: Recent studies report the rate of iatrogenic nerve injury in operatively treated supracondylar humerus (SCH) fractures is 3% to 4%. A reliable neurological examination can be difficult to obtain in a young child in pain. We hypothesized that nerve injuries may be missed preoperatively, later noted postoperatively in a more compliant patient, and then falsely considered an iatrogenic injury.

Methods: A prospective study was conducted on patients who presented between April 2011 and April 2013 with an extension-type SCH fracture that was managed surgically. A neurological examination was performed preoperatively, postoperatively, and at follow-up visits by a fellowship-trained attending pediatric orthopaedic surgeon. Only patients in whom the attending surgeon felt a reliable neurovascular examination was obtained were included in this study.

Results: Of the 100 patients, 16% had a nerve injury recognized on preoperative examination and 3% had a new nerve injury on postoperative examination (1 anterior interosseous, 1 median sensory, and 1 radial motor). The Gartland type (P=0.421), type of reduction (open vs. closed; P=0.720), and number of lateral-entry (P=0.898) or medial-entry (P=0.938) pins used were not associated with patients who had a new nerve injury found postoperatively. A trend was seen between fracture severity and rate of a preoperative nerve injury: type II 7% (2/28), type III 19% (9/58), and type IV 36% (5/14) (P=0.058). Preoperatively, nerve injuries were noted at the following rates: median 12% (12/100) (including 8 anterior interosseous nerve injuries), radial 8% (8/100), ulnar 3% (3/100).

Conclusions: In this prospective study, in patients who were able to comply with a preoperative neurological examination done by an attending pediatric orthopaedic surgeon, the rate of iatrogenic nerve injury after operative treatment of SCH fractures is 3%. We conclude that this finding is true, and not a result of inadequate preoperative neurological examinations.

Level Of Evidence: Level I prognostic study.
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http://dx.doi.org/10.1097/BPO.0000000000000171DOI Listing
June 2014

Heterogeneity of muscle fat infiltration in children with spina bifida.

Res Dev Disabil 2014 Jan 26;35(1):215-22. Epub 2013 Oct 26.

Children's Orthopaedic Center and Department of Radiology, Children's Hospital Los Angeles, United States. Electronic address:

Children with spina bifida have well recognized functional deficits of muscle, but little is known about the associated changes in muscle anatomy and composition. This study used water-fat magnetic resonance imaging (MRI) to measure fat infiltration in the lower extremity muscles of 11 children with myelomeningocele, the most severe form of spina bifida. MRI measurements of muscle fat fraction (FF) were compared against manual muscle test (MMT) scores for muscle strength. The FF measurements were objective and reliable with mean inter-rater differences of <2% and intraclass correlation coefficients>0.98. There was a significant inverse relationship between muscle FF and MMT scores (P ≤ 0.001). Surprisingly, however, muscles with negligible strength (MMT 0-1) exhibited a bimodal distribution of FF with one group having FF>70% and another group having FF<20%. The MRI also revealed striking heterogeneity amongst individual muscles in the same muscle group (e.g., 4% fat in one participant's lateral gastrocnemius vs. 88% in her medial gastrocnemius), as well as significant asymmetry in FF in one participant with asymmetric strength and sensation. These results suggest that quantitative water-fat MRI may serve as a biomarker for muscle degeneration which may reveal subclinical changes useful for predicting functional potential and prognosis.
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http://dx.doi.org/10.1016/j.ridd.2013.10.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3873476PMC
January 2014

Differences in implementation of gait analysis recommendations based on affiliation with a gait laboratory.

Gait Posture 2013 Feb 4;37(2):206-9. Epub 2012 Aug 4.

Children's Orthopaedic Center, Children's Hospital Los Angeles, Los Angeles, CA 90027, United States.

This study examined the extent to which gait analysis recommendations are followed by orthopedic surgeons with varying degrees of affiliation with the gait laboratory. Surgical data were retrospectively examined for 95 patients with cerebral palsy who underwent lower extremity orthopedic surgery following gait analysis. Thirty-three patients were referred by two surgeons directly affiliated with the gait laboratory (direct affiliation), 44 were referred by five surgeons from the same institution but not directly affiliated with the gait laboratory (institutional affiliation), and 18 were referred by 10 surgeons from other institutions (no affiliation). Data on specific surgeries were collected from the gait analysis referral, gait analysis report, and operative notes. Adherence to the gait analysis recommendations was calculated by dividing the number of procedures where the surgery followed the gait analysis recommendation (numerator) by the total number of procedures initially planned, recommended by gait analysis, or done (denominator). Adherence with the gait analysis recommendations was 97%, 94%, and 77% for the direct, institutional, and no affiliation groups, respectively. Procedures recommended for additions to the surgical plan were added 98%, 87%, and 77% of the time. Procedures recommended for elimination were dropped 100%, 89%, and 88% of the time. Of 81 patients who had specific surgical plans prior to gait analysis, changes were implemented in 84% (68/81) following gait analysis recommendations. Gait analysis influences the treatment decisions of surgeons regardless of affiliation with the gait laboratory, although the influence is stronger for surgeons who practice within the same institution as the gait laboratory.
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http://dx.doi.org/10.1016/j.gaitpost.2012.07.008DOI Listing
February 2013
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