Publications by authors named "Kevin M Neal"

18 Publications

  • Page 1 of 1

Inter- and intra-rater reliability and accuracy of Sanders Skeletal Maturity Staging System when used by surgeons performing vertebral body tethering.

Spine Deform 2021 Jul 22. Epub 2021 Jul 22.

Department of Orthopedics and Traumatology, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey.

Purpose: Pediatric orthopedic surgeons must accurately assess the skeletal stage of adolescent idiopathic scoliosis (AIS) patients for selection and timing of optimal treatment. Successful treatment using vertebral growth modulation is highly dependent on skeletal growth remaining. We sought to evaluate the current-state use of the Sanders Skeletal Maturity System (SSMS) in regard to precision and accuracy. We hypothesized that pediatric orthopedic surgeons currently use SSMS with moderate precision and accuracy.

Methods: Eight practicing pediatric orthopedic surgeons who perform vertebral body tethering surgery without specific training in SSMS were asked to assign the SSMS stage for 34 de-identified hand radiographs from AIS patients. Precision was evaluated as inter-rater reliability, using both Krippendorff's α and Weighted Cohen's kappa statistics, and as intra-rater reliability, using only Weighted Cohen's kappa statistics. Surgeon accuracy was evaluated using Weighted Cohen's kappa statistics with comparison of surveyed surgeons' responses to the gold standard rating.

Results: Inter-rater reliability across the surveyed surgeons indicated moderate to substantial agreement using both statistical methods (α = 0.766, κ = 0.627) with the majority of discord occurring when assigning SSMS stages 2 through 4. The surveyed surgeons displayed substantial accuracy when compared to the gold standard (κ = 0.627) with the majority of inaccuracy involving the identification of stage 3B. When re-surveyed, the surgeons showed substantial intra-rater reliability (κ = 0.71) with increased inconsistencies when deciding between SSMS stage 3A and stage 3B.

Conclusion: The current-state use of SSMS across pediatric orthopedic surgeons for evaluation of AIS patients displays adequate but imperfect precision and accuracy with difficulties delineating SSMS stages 2 through 4, which correlate with adolescent growth periods germane to scoliosis growth modulation surgery. Centralized assessment of hand-bone age may help ensure standardized reporting for non-fusion scoliosis research.
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July 2021

Orthopaedic Manifestations of Transverse Myelitis in Children.

J Pediatr Orthop 2021 May 13. Epub 2021 May 13.

Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE Seton Hall Orthopaedics, St. Joseph's University Medical Center, Paterson, NJ Icahn School of Medicine at Mount Sinai, New York, NY Department of Orthopaedic Surgery, Nemours Children's Specialty Care, Jacksonville, FL.

Background: Transverse myelitis (TM) is a rare inflammatory disorder of the spinal cord. It can have a heterogeneous presentation with sensory, motor, and autonomic dysfunction. Neurological sequelae of TM include autonomic dysfunction, motor weakness, and/or spasticity. Studies describing orthopaedic deformities and treatments associated with TM are nonexistent. This purpose of this study was to describe the orthopaedic manifestations of TM in children.

Methods: A multicenter retrospective review was conducted of patients, 0 to 21 years of age, with TM presenting over a 15-year period at 4 academic children's hospitals. Those with confirmed diagnosis of TM and referred to an orthopaedic surgeon were included. Demographics, orthopaedic manifestations, operative/nonoperative treatments, and complications were recorded. Descriptive statistics were used for data reporting.

Results: Of 119 patients identified with TM, 37 saw an orthopaedic surgeon. By etiology, 23 were idiopathic (62%), 10 infectious (27%), 3 (8%) inflammatory/autoimmune, and 1 (3%) vascular. The mean age at diagnosis was 6.7 (SD: 5.5) years and at orthopaedic presentation was 8.4 (SD: 5.2) years. Orthopaedic manifestations included scoliosis in 13 (35%), gait abnormalities in 7 (19%), foot deformities in 7 (19%), upper extremity issues in 7 (19%), symptomatic spasticity in 6 (16%), lower extremity muscle contractures in 6 (16%), fractures in 6 (16%), hip displacement in 3 (8%), pain in 2 (5%), and limb length discrepancy in 2 (5%) patients. Seven children (19%) were seen for establishment of care. In all, 14 (38%) underwent operative intervention, mainly for soft-tissue and scoliosis management. Four patients had baclofen pump placement for spasticity management. Postoperative complications occurred in 36% of cases, most commonly because of infection. Neither topographic pattern nor location of lesion had a significant relationship with need for hip or spine surgery.

Conclusions: This report describes the orthopaedic manifestations associated with TM in children, nearly 40% of whom required operative intervention(s). Understanding the breadth of musculoskeletal burden incurred in TM can help develop surveillance programs to identify and treat these deformities in a timely manner.

Level Of Evidence: Level IV.
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May 2021

Can a Checklist Improve the Informed Consent Process?

Cureus 2021 Feb 5;13(2):e13148. Epub 2021 Feb 5.

Pediatrics, Nemours Children's Health System, Jacksonville, USA.

Informed consent often fails to provide patients and families with a full understanding of the proposed procedure. We developed an informed consent checklist for identifying specific aspects of the surgical consent that were not fully understood by families. The purpose of this study was to measure the effect of using this checklist on families' knowledge, satisfaction, experience, and decisional conflict during the consent process. The families of pediatric patients scheduled for an orthopaedic preoperative visit were prospectively randomized into one of two groups: checklist or traditional appointment. Families in the checklist group completed the informed consent checklist which was then used by the surgeon to further discuss aspects of the surgery that needed clarification. Those in the traditional group had similar discussions about surgery without the aid of a checklist. Sixty-one families participated in the study; 27 in the checklist group and 34 in the traditional group without a checklist. The checklist group reported no difference in mean scores for all satisfaction (P = 0.37), decisional conflict (P = 0.51), and knowledge items (P = 0.31). For patient experience, the traditional group reported the visits were significantly more relaxed (mean 4.9, 95% confidence interval (CI) 4.8-5.0) than the checklist group (mean 4.5, 95% CI 4.3-4.7). Our results suggest that having a family member complete the informed consent checklist prior to meeting with the surgeon did not improve, and may worsen, the consent experience for some families. Other methods need to be evaluated to determine the optimal consent process from the family's perspective.
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February 2021

Conservation Genomics of the Threatened Western Spadefoot, Spea hammondii, in Urbanized Southern California.

J Hered 2020 12;111(7):613-627

Department of Ecology and Evolutionary Biology, and La Kretz Center for California Conservation Science, University of California Los Angeles, Los Angeles, CA.

Populations of the western spadefoot (Spea hammondii) in southern California occur in one of the most urbanized and fragmented landscapes on the planet and have lost up to 80% of their native habitat. Orange County is one of the last strongholds for this pond-breeding amphibian in the region, and ongoing restoration efforts targeting S. hammondii have involved habitat protection and the construction of artificial breeding ponds. These efforts have successfully increased breeding activity, but genetic characterization of the populations, including estimates of effective population size and admixture between the gene pools of constructed artificial and natural ponds, has never been undertaken. Using thousands of genome-wide single-nucleotide polymorphisms, we characterized the population structure, genetic diversity, and genetic connectivity of spadefoots in Orange County to guide ongoing and future management efforts. We identified at least 2, and possibly 3 major genetic clusters, with additional substructure within clusters indicating that individual ponds are often genetically distinct. Estimates of landscape resistance suggest that ponds on either side of the Los Angeles Basin were likely interconnected historically, but intense urban development has rendered them essentially isolated, and the resulting risk of interruption to natural metapopulation dynamics appears to be high. Resistance surfaces show that the existing artificial ponds were well-placed and connected to natural populations by low-resistance corridors. Toad samples from all ponds (natural and artificial) returned extremely low estimates of effective population size, possibly due to a bottleneck caused by a recent multi-year drought. Management efforts should focus on maintaining gene flow among natural and artificial ponds by both assisted migration and construction of new ponds to bolster the existing pond network in the region.
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December 2020

Anterior vertebral body tethering shows mixed results at 2-year follow-up.

Spine Deform 2021 Mar 28;9(2):481-489. Epub 2020 Oct 28.

Department of Pediatric Orthopedic Surgery, Nemours Children's Specialty Care, 807 Children's Way, Jacksonville, FL, 32207, USA.

Study Design: Retrospective chart review.

Objective: To report 2-4-year outcomes of anterior vertebral body tethering (AVBT) for adolescent idiopathic scoliosis (AIS). AVBT is a relatively new procedure to correct AIS spine curvature and few outcomes studies have been published.

Methods: Patients from 2015 to 2017 with 2-year follow-up were included. Successful outcomes were defined as curves 35° or less without revision surgery. We also compared outcomes between thoracic and lumbar ABVT.

Results: There were 19 AVBTs in 17 patients, 13 thoracic and 6 lumbar. Nine curves (47%) in nine patients (53%) were successful. Preoperative kyphosis averaged 26° in the successful group and 14° in the unsuccessful group (P = 0.0337). Immediate correction for lumbar ABVTs (76%) was greater than thoracic ABVTs (43%) (P = 0.0140). Correction per level per month was greater in lumbar ABVTs (2.9° vs. 0.1°) (0.0440). Preoperative Sanders Maturity Scale (SMS) was 3.7 for successful cases and 2.5 for unsuccessful cases (P = 0.0232). Final SMS was 7.7 for successful cases and 5.7 for unsuccessful cases (P = 0.0518). All successful cases and 50% of unsuccessful cases were mature at final follow-up (P = 0.0294). There were four (24%) revision procedures, and three involving lumbar AVBTs. There were nine (47%) broken tethers.

Conclusions: Despite several final curves > 35°, four revisions, and nine broken tethers, the majority of patients (53%) were considered successful. Lumbar ABVTs correct more intraoperatively and faster postoperatively. Patients who are tethered during or slightly after the curve acceleration phase of growth may have more successful outcomes than patients tethered prior to the curve acceleration phase. AVBT requires further study with longer outcomes to define best practices for indications, level selections, and surgical techniques.

Level Of Evidence: IV.
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March 2021

Improving Quality in the Treatment of Pediatric Forearm Fractures: Minimizing the Need for Repeat Intervention With Long-arm Extension Casting.

J Pediatr Orthop 2020 Aug;40(7):329-333

Department of Orthopedics and Sports Medicine, Nemours Children's Hospital and Specialty Care, Orlando, FL.

Purpose: Repeat intervention for pediatric forearm fractures after closed manipulation is as high as 46% with flexed elbow (FE) long-arm casts. Casting with the elbow extended (EE) has been advocated as an alternative technique. We documented outcomes of patients treated with closed manipulation and casting with EE long-arm casts for displaced, diaphyseal both-bone forearm fractures.

Methods: We retrospectively reviewed charts for patients who had sedated manipulations and casting for closed, diaphyseal forearm fractures. Open fractures, immediate surgical intervention, metabolic bone disease, recurrent fractures, and Monteggia injuries were excluded. Closed manipulations were performed by orthopaedic residents assisted by cast technicians, with sedation provided by emergency department physicians. Radiographic angulation and displacement of the radius and ulna on immediate postreduction radiographs and all follow-up radiographs were recorded. Patients requiring repeat intervention were compared with those who did not by using the Mann-Whitney U and Fisher exact tests.

Results: Of 86 patients (7.2±2.8 y) available for analysis, 82 (95.3%) completed treatment after a single-sedated manipulation and placement of an EE long-arm cast. There were no malunions or nonunions. The average follow-up was 50 days. Four (4.7%) patients required repeat interventions (2 had surgery, 1 had a repeat sedated manipulation, and 1 had a nonsedated manipulation). There were no statistically significant differences in age, sex, laterality, fracture position in the diaphysis, or immediate postreduction angulation of the radius or ulna. A literature review showed average repeat intervention rates of 14.9% (range, 0% to 45.9%) for FE casts and 3.3% (range, 0% to 15%) for EE casts.

Conclusions: There was a low rate of repeat interventions (4.7%) in patients with EE casts compared with historical rates for FE casts. Improving the quality of health care involves identifying and implementing practices that provide the best outcomes at the lowest costs. The use of EE long-arm casts following closed manipulation of pediatric forearm fractures may decrease the rate of repeat manipulation or surgery compared with conventional FE casts.

Level Of Evidence: Level IV-case series.
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August 2020

Impact of Race Subgroups on the Assessment of Vitamin D Status in Adolescent Idiopathic Scoliosis.

Orthopedics 2019 May;42(3):158-162

The authors' main objective was to demonstrate the confounding effect of combining subgroup data, specifically race, on the prevalence of vitamin D deficiency in adolescent idiopathic scoliosis (AIS). This was a retrospective chart review. Vitamin D deficiency was defined as 25-hydroxyvitamin D (25[OH]D) less than 20 ng/mL. Data were compared between white patients and black and Hispanic patients. Vitamin D status in girls with AIS was also compared with that in girls without AIS who had a history of fracture and with the medical literature to determine if deficiency in AIS was equal to or greater than other cohorts. Mean age was 13.9±2.3 years for the white girls with AIS (n=221) and 13.6±2.2 years for pooled non-whites (n=134). Significant racial differences were found that biased interpretation of the total pooled cohort. Mean 25(OH)D was 27.9±8.5 ng/mL for white girls with AIS vs 21.9±10.3 ng/mL for non-whites (P<.0001). Deficiency was present in 13.1% of white girls vs 47.8% of non-white girls (P<.0001). Compared with girls with fractures and with the published literature, the race-matched deficiency rates were not abnormally high in girls with AIS. Prevalence of deficiency was greater in non-whites with AIS than in whites. However, percent deficiency was not greater in girls with AIS than in race-matched cohorts without AIS. Without separating data by race, interpretation of vitamin D status can be confounded. [Orthopedics. 2019; 42(3):158-162.].
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May 2019

Pitfalls with Vitamin D Research in Musculoskeletal Disorders and Recommendations on How to Avoid Them

J Clin Res Pediatr Endocrinol 2019 09 14;11(3):220-226. Epub 2019 Feb 14.

Children’s Hospital of Philadelphia, Center for Bone Health, Division of Endocrinology and Diabetes, Pennsylvania, USA

Reports suggesting that vitamin D may have extraskeletal roles have renewed interest in vitamin D research and stimulated publication of an increasing number of new studies each year. These studies typically assess vitamin D status by measuring the blood concentration of 25-hydroxyvitamin D [25(OH)D], the principal circulating metabolite of vitamin D. Unfortunately, variations in assay format, inconsistency in interpreting 25(OH)D concentrations, cohort bias (age, body mass index, race, season of measurements etc.) and failure to measure critical variables needed to interpret study results, makes interpreting results and comparing studies difficult. Further, variation in reporting results (reporting mean values vs. percent of the cohort that is deficient, no clear statement as to clinical relevance of effect size, etc.) further limits interstudy analyses. In this paper, we discuss many common pitfalls in vitamin D research. We also provide recommendations on avoiding these pitfalls and suggest guidelines to enhance consistency in reporting results.
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September 2019

Results of Nonoperative Treatment for Symptomatic Tarsal Coalitions.

Cureus 2018 Jul 8;10(7):e2944. Epub 2018 Jul 8.

Orthopaedics, Nemours Children's Hospital, Jacksonville , USA.

Introduction: Recommendations for the initial treatment (nonoperative measures to surgical excision) of symptomatic tarsal coalitions vary. Because nonoperative outcomes are poorly established, we retrospectively evaluated their success in preventing surgery and achieving pain relief for pediatric patients with symptomatic tarsal coalitions.

Materials And Methods:  A retrospective study of pediatric patients with symptomatic tarsal coalitions treated at a single institution was undertaken. Clinical notes were examined for treatment methods, response to treatment, and need for additional procedures. A statistical analysis was performed using the chi-square and Mann-Whitney U tests.

Results:  Fifty symptomatic tarsal coalitions (mean patient age, 11.4 years; range, 8.1-17.9) were treated with nonoperative measures. Surgery was not required in 79% of calcaneonavicular and 62% of talocalcaneal coalitions. Pain relief was achieved in 53% of 81 nonoperative treatment trials. Continuous immobilization via casting, intermittent immobilization via walking boot, and supportive measures were not significantly different in pain relief (p = 0.35) or preventing surgery (p = 0.62).

Conclusion:  Nonoperative treatment methods have the potential to achieve pain relief and prevent or delay surgery for symptomatic tarsal coalitions. However, some families may elect to forgo nonoperative measures knowing that surgery may eventually be required.
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July 2018

Maturity Indicators and Adolescent Idiopathic Scoliosis: Evaluation of the Sanders Maturity Scale.

Spine (Phila Pa 1976) 2018 04;43(7):E406-E412

Department of Orthopedic Surgery, Nemours Children's Specialty Care, Jacksonville, FL.

Study Design: Retrospective review.

Objective: To determine the correlation between the Sanders Maturity Scale (SMS) and Risser stages, between both systems and menarche, and whether Risser can be used to predict SMS.

Summary Of Background Data: Predicting curve progression is critical to understanding adolescent idiopathic scoliosis and making treatment recommendations. The SMS is a better predictor of the curve acceleration phase of growth than the Risser stage. However, Scoliosis Research Society bracing criteria utilize the Risser stage and menarche.

Methods: Consecutive female patients, 8 to 16 years old, evaluated for idiopathic scoliosis or spinal asymmetry over a 31-month period were included. Main curve size, Risser stage, menarchal status, and SMS stage were recorded for each encounter, and analyzed using Spearman rank correlation and regression models.

Results: Six hundred fifty-six encounters (452 patients) were included with SMS staging, including 402 encounters that included menarchal data. The correlation between the Risser stage and the SMS stage was 0.9031 (P < 0.0001). However, ranges for the SMS at each Risser stage were large. Correlation between Risser stage and menarche was 0.7327 (P < 0.0001), and between SMS and menarche was 0.8355 (P < 0.0001). Eighty-five percent of SMS 3 patients were Risser 0, with or without open triradiate cartilages. Eighty-one percent of Risser 1 patients were SMS 4 or greater.

Conclusion: When assessing maturity in idiopathic scoliosis, SMS correlates strongly with Risser stages, and both SMS and Risser correlate with menarche. However, Risser stage is a poor predictor of the exact SMS stage for individual patients due to the large ranges. The majority of patients who are ≥Risser 1 have passed the curve acceleration phase of growth. Developing brace criteria based upon the SMS stage may allow more accurate predictions regarding which patients will benefit from bracing.

Level Of Evidence: 2.
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April 2018

The Educational Opportunities Provided by a Pediatric Orthopedic Urgent Case Review Conference: Keep Score to Provide a Better Experience.

J Surg Educ 2018 Jul - Aug;75(4):901-906. Epub 2017 Nov 7.

Stanford University Department of Orthopaedics, Palo Alto, California.

Objective: To evaluate the distribution of conditions presented at a case conference to assess resident educational exposure to acute pediatric orthopedic conditions.

Design: Retrospective review of emergency department and inpatient consultations presented at a daily pediatric orthopedic case conference over a 3-year period. Consultations were divided into 3-month resident rotation blocks for analysis.

Setting: Tertiary children's hospital in the southern United States which host residents from 2 orthopedic surgery residency programs.

Participants: The case conference is attended by pediatric orthopedic surgeons, 1 pediatric orthopedic fellow, and 4 PGY III/IV residents.

Results: A total of 1762 consultations were presented at the conference. The consultations were obtained for traumatic injuries, 86.5% (1524/1762); infections, 7.7% (136/1762); and congenital/other problems, 5.8% (102/1762). The 3 most common consultations per rotation were fractures: both-bone forearm (mean, 46.1; range: 24-64), supracondylar humerus (mean, 23.8; range: 17-31), and distal radius (mean, 13.8; range: 7-33). Less common consultations per rotation were septic arthritis (mean, 1.6; range: 0-5), child abuse (mean, 1.3; range: 0-5), Monteggia fracture (mean, 0.3; range: 0-1), compartment syndrome (mean, 0.2; range: 0-1) and patella sleeve fracture (mean, 0.1; range: 0-1).

Conclusions: There was a large disparity between conditions in the number of times presented and reviewed within a 3-month rotation at the daily case conference, with some important conditions not being discussed at all in each rotation. This finding documents a disadvantage of case conferences based on limiting discussion to current patients, and highlights an opportunity for educational improvement.
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August 2019

Strategies for Surgical Management of Large, Stiff Spinal Deformities in Children.

J Am Acad Orthop Surg 2017 Apr;25(4):e70-e78

From the Department of Orthopaedic Surgery, Nemours Children's Specialty Care, Jacksonville, FL.

Management of large, severe, stiff spinal deformities in children can be challenging. Adjunctive treatments used in conjunction with spinal osteotomy, instrumentation, and fusion can improve the ultimate degree of deformity correction. These adjunctive treatments include preoperative halo-gravity traction, intraoperative halo-femoral traction, temporary internal spinal distraction, and anterior spinal release. Each of these techniques has unique indications and individual risks. When the appropriate protocols are followed, these techniques can be safe and efficacious.
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April 2017

Atlantoaxial rotatory subluxation in children.

J Am Acad Orthop Surg 2015 Jun;23(6):382-92

Atlantoaxial rotatory subluxation is a rare condition in which patients present with the acute onset of torticollis. Atlantoaxial rotatory subluxation represents a spectrum of disease from muscle spasm to a fixed mechanical block to reduction of the atlantoaxial complex. If left untreated, some cases may resolve spontaneously; however, other cases may result in the development of secondary changes in the bony anatomy of the atlantoaxial joint, leading to persistent deformity. Diagnosis of the condition is largely clinical but can be aided by various imaging modalities, including radiographs, dynamic CT scanning, three-dimensional CT reconstructions, or MRI. Consideration should always be given to infection or other inflammatory disease as an underlying, precipitating cause. Treatments include observation, the use a cervical collar and analgesics, halter or skeletal traction, and posterior fusion of C1-C2. The most important factor for success of conservative treatment is the time from the onset of symptoms to recognition and the initiation of treatment.
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June 2015

Conservation genetics and genomics of amphibians and reptiles.

Annu Rev Anim Biosci 2015 2;3:113-38. Epub 2015 Jan 2.

Department of Ecology and Evolutionary Biology.

Amphibians and reptiles as a group are often secretive, reach their greatest diversity often in remote tropical regions, and contain some of the most endangered groups of organisms on earth. Particularly in the past decade, genetics and genomics have been instrumental in the conservation biology of these cryptic vertebrates, enabling work ranging from the identification of populations subject to trade and exploitation, to the identification of cryptic lineages harboring critical genetic variation, to the analysis of genes controlling key life history traits. In this review, we highlight some of the most important ways that genetic analyses have brought new insights to the conservation of amphibians and reptiles. Although genomics has only recently emerged as part of this conservation tool kit, several large-scale data sources, including full genomes, expressed sequence tags, and transcriptomes, are providing new opportunities to identify key genes, quantify landscape effects, and manage captive breeding stocks of at-risk species.
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January 2016

The location of medial patellofemoral ligament injury in adolescents and children.

J Pediatr Orthop 2012 Apr-May;32(3):241-4

Department of Orthopaedics and Rehabilitation, University of Florida College of Medicine, Jacksonville, FL, USA.

Background: The location of medial patellofemoral ligament (MPFL) tears has been well documented in the adult population, with most occurring at the insertion of the ligament on the adductor tubercle. It is not clear whether a difference exists in the pediatric and adolescent populations. The location of the injury has implications for treatment recommendations and planning surgical approaches. The purpose of this study is to determine whether the location of MPFL injury differs among the adult and younger populations. Our hypothesis is that the location of MPFL tears in adolescents and children is not predominantly at the adductor tubercle.

Method: At our institution, we retrospectively reviewed 113 children aged 5 to 17, who were surgically treated for a patellar dislocation. All patients had confirmation of a patellar dislocation or severe subluxation. Imaging studies, clinic notes, and operative notes were used to determine the location of the MPFL injury.

Results: Proportion of MPFL injuries found intraoperatively at the adductor tubercle was larger than 0.5 (z test=2.97). Percentage of MPFL tears at the adductor tubercle was 73% of the cases studied.

Conclusions: The location of MPFL injuries found intraoperatively at the adductor tubercle was 73% in our series. This is slightly lower than MPFL tear location in the adult population, which has been reported to be between 80% and 100%. Our hypothesis that the location of MPFL tears in adolescents and children is not predominantly at the adductor tubercle was proven false. This study has clinical applications for treatment recommendations and planning surgical approaches for the pediatric patient with a tear of the MPFL.

Level Of Evidence: Level II-prognostic.
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July 2012

Healthy children with frequent fractures: how much evaluation is needed?

Pediatrics 2008 May;121(5):890-7

Division of Pediatric Endocrinology, Nemours Children's Clinic-Jacksonville, Jacksonville, FL 32207, USA.

Objective: We performed a case-control study to determine whether occult bone disease is associated with a history of frequent fractures in children.

Methods: Healthy children with > or = 2 incidences of low-energy fractures were recruited (n = 68). Children with no history of fractures served as control subjects (n = 57). Food logs, activity surveys, physical examinations, laboratory tests, and dual-energy radiographic absorptiometry were used.

Results: Bone mineral density z scores were significantly reduced in case subjects, compared with control subjects. Three case subjects (4.3%) and 1 control subject (1.8%) had bone mineral density z scores below the expected range. Of those 4 subjects, 2 had dairy avoidance and 2 had delayed puberty. An additional case subject had evidence of vitamin D deficiency. A significant number of subjects (20% of case subjects and 23% of control subjects) had idiopathic hypercalcuria, based on 24-hour urine collections. Among the case subjects, bone mineral density z scores were significantly lower for those with idiopathic hypercalcuria. Among the control subjects, the presence of idiopathic hypercalcuria did not affect bone mineral density. The case subjects with idiopathic hypercalcuria accounted for virtually all of the differences in bone mineral density between the case and control groups. Analysis of parathyroid hormone and 1,25-dihydroxy-vitamin D levels showed that children with frequent fractures and hypercalcuria had renal hypercalcuria, whereas children with no fractures and hypercalcuria had absorptive hypercalcuria.

Conclusions: We identified a significant association between a history of frequent fractures and hypercalcuria in children. We propose that the appropriate screening evaluation for children who present with a history of frequent fractures consists of a dietary history targeted at calcium and vitamin D intakes, a physical examination to assess for pubertal delay, and urinary calcium concentration/creatinine ratio determination to assess for hypercalcuria. Children with abnormalities in this screening should undergo dual-energy radiographic absorptiometry and appropriate evaluation.
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May 2008

Subtrochanteric femur fracture through osteotomy site 12 years after varus derotational osteotomy.

Orthopedics 2004 Apr;27(4):419-21

Department of Orthopedic Surgery and Rehabilitation, University of Oklahoma, Oklahoma City, Okla 73190, USA.

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April 2004

Anterior interosseous nerve syndrome: a case report.

J Okla State Med Assoc 2002 Apr;95(4):253-6

Orthopedic Surgery Department, University of Oklahoma Health Sciences Center, USA.

A patient presented with anterior interosseous nerve syndrome that did not respond to nonoperative treatment. At surgery, nerve compression was found to be from an anomalous fibrous band of the flexor digitorum superficialis extending to the brachialis muscle fascia and separate from the normal arcade passing over the median nerve. Additionally, there was a venous ring encircling the nerve at the level of the anomalous arcade. The patient's muscle weakness recovered after nerve decompression and releasing the anomalous structures.
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April 2002