Publications by authors named "Raymond W Liu"

138 Publications

Skeletal Maturity Using Knee X-rays: Understanding the Resilience of 7 Radiographic Parameters to Rotational Position.

J Pediatr Orthop 2021 Jul 26. Epub 2021 Jul 26.

Department of Orthopaedic Surgery, Rainbow Babies and Children's Hospital at Case Western Reserve University School of Medicine Center for Clinical Research, University Hospitals Cleveland Medical Center, Cleveland, OH.

Background: Recently, a skeletal maturity system using knee radiographs, named the modified Roche-Wainer-Thissen (RWT) system, has been developed using 7 discrete radiographic parameters. While the system has been shown to significantly outperform the Greulich and Pyle atlas, the effect of rotational variation of the knee radiograph on skeletal maturity determinations has not been studied.

Methods: Normal knee computed tomography scans of 12 male children ages 10 to 16 years and 8 female children ages 8 to 14 years were obtained retrospectively, converted into 3-dimensional reconstructions, and then used to simulate knee radiographs in 5 different rotational positions. Images were graded using the modified RWT system, and 1-way repeated measures analysis of variance was used to compare skeletal age in the patella centered view versus the other positions. We next retrospectively found 85 pediatric patients with both bilateral standing anteroposterior hip to ankles and separate knee radiograph within 6 months of each other. The skeletal maturity values from the 2 different radiographs were compared in 39 males between the ages of 10 and 16 years and 46 females between 8 and 14 years of age using paired t test and Wilcoxon-signed rank test.

Results: On the computed tomography scan-based images, there was no statistically significant effect of rotational position on the modified RWT score using repeat measures analysis of variance (P=0.210). Only the width ratio of the tibial epiphysis and metaphysis and the width ratio of the fibular epiphysis and metaphysis were statistically different between rotational positions (P<0.05). Comparing clinical full length versus knee radiographs, we found a small difference of 0.069 years which trended towards a statistically significant difference (P=0.009).

Conclusions: This retrospective study supports the resilience of the RWT model to rotational variation, reassuring clinicians that bone age estimation can be performed in a slightly rotated knee x-ray within a reasonable margin of error. These results can minimize the number of radiographs needed to assess skeletal maturity limiting radiation exposure and expedite clinical flow.

Level Of Evidence: Level-III-diagnostic study.
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http://dx.doi.org/10.1097/BPO.0000000000001870DOI Listing
July 2021

Estimating Skeletal Maturity Using Knee Radiographs During Preadolescence: The Epiphyseal: Metaphyseal Ratio.

J Pediatr Orthop 2021 Jul 26. Epub 2021 Jul 26.

Department of Orthopaedics, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center Division of Pediatric Orthopaedics, Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine Case Western Reserve University School of Medicine, Cleveland, OH.

Background: Though skeletal maturity is most relevant during adolescence, it has utility in treatment of younger patients in some circumstances. Accurate estimation of skeletal maturity using knee radiographs would be useful when treating limb length discrepancy and other general medical conditions in preadolescent patients. Currently, a quick, accurate, and reproducible method of estimating skeletal maturity in preadolescents is lacking.

Methods: Serial anteroposterior knee radiographs taken at historical growth study visits leading up to the chronological age associated with 90% of final height (an enhanced skeletal maturity standard as compared with peak height velocity) were analyzed in 75 children. Epiphyseal and metaphyseal widths of the distal femur, proximal tibia, and proximal fibula were measured and the epiphyseal:metaphyseal ratio was calculated. Greulich and Pyle (GP) bone ages were also assigned by an experienced pediatric endocrinologist using left hand radiographs. Stepwise linear regression and generalized estimating equation analyses were used to make a skeletal maturity model incorporating demographics (age+sex) and knee epiphyseal:metaphyseal ratios.

Results: A total of 258 left knee radiographs from 39 girls (mean age 8.6 y, range: 2.9 to 13 y) and 36 boys (mean age 10.6 y, range: 3.8 to 15 y) were included. The demographics+ratios model had similar prediction accuracy (0.49 vs. 0.48 y, P=0.84) and rate of outliers (11% vs. 9%, P=0.11) as the demographics+GP model. The demographics+ratios model outperformed all other models evaluated, including a demographics-only model (P<0.001 for all).

Conclusions: When combined with chronological age and sex, epiphyseal:metaphyseal ratio measurement in the knee allows for skeletal maturity estimation comparable to using the GP technique.

Clinical Relevance: We have defined a knee skeletal maturity system that could be applied in treatment of orthopaedic conditions in preadolescents where a knee radiograph is already obtained, avoiding the need for an additional hand radiograph.
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http://dx.doi.org/10.1097/BPO.0000000000001921DOI Listing
July 2021

Systematic Isolation of Key Parameters for Estimating Skeletal Maturity on AP Hip Radiographs.

J Pediatr Orthop 2021 Jul 16. Epub 2021 Jul 16.

Department of Orthopaedics, University Hospitals Cleveland Medical Center Division of Pediatric Orthopaedics, Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, OH Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT Department of Orthopaedics, University of North Carolina School of Medicine, Chapel Hill, NC.

Background: The ability to estimate skeletal maturity using a hip radiograph does not yet exist, but may have utility in the treatment of scoliosis, slipped capital femoral epiphysis, and lower limb deformity. We sought to develop a fast, accurate, and reproducible method.

Methods: Fourteen hip radiologic parameters were evaluated on serial anteroposterior hip radiographs from 3 years before to 2 years after the skeletal age associated with 90% of final height, a validated skeletal maturity definition which correlates with the timing of peak height velocity. The Greulich and Pyle (GP) left hand bone age was obtained for comparison. Stepwise linear regression and generalized estimating equation analyses were used to isolate key hip and demographic parameters, creating the "optimized Oxford" skeletal maturity system. The accuracy of the optimized Oxford system in predicting years from 90% of final height was evaluated and compared with systems of demographics only, the modified Oxford, demographics+modified Oxford, and demographics+GP.

Results: A total of 284 hip radiographs from 41 girls (range: 7 to 15 y) and 38 boys (range: 9 to 17 y) were included. Following multivariate analyses, 5 of the original 14 hip radiographic parameters remained significant. The predictions made by the optimized Oxford model had greater accuracy and fewer outlier predictions (predictions >1 y off from actual years from 90% of final height) than the demographics only and modified Oxford only models (P<0.05 for all). The optimized Oxford model had greater prediction accuracy than the demographics+modified Oxford model, but similar rates of outlier predictions (P=0.903). No differences in mean prediction accuracy or rate of outlier predictions were observed between the optimized Oxford and the demographics+GP model (P>0.05).

Conclusion: High precision in skeletal maturity estimation can be achieved by using chronological age, sex, and 5 hip radiographic parameters.

Clinical Relevance: We have developed a skeletal maturity system that utilizes anteroposterior hip radiographs and performs as accurately as GP.
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http://dx.doi.org/10.1097/BPO.0000000000001876DOI Listing
July 2021

The distal femur trochlear groove appears to compensate for tibial deformity but not femoral deformity in an investigation of five-hundred and seventy-nine cadaveric skeletons.

Arch Orthop Trauma Surg 2021 Jun 18. Epub 2021 Jun 18.

Department of Orthopedic Surgery, Victor M. Goldberg Professor in Orthopedic Surgery, University Hospitals/Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA.

Background: The etiology of patellofemoral disorders is multifactorial. Preoperative patellofemoral anatomy evaluation is of great importance in patients undergoing surgery for patellofemoral disorders. Although anatomical risk factors of patellofemoral disorders have been thoroughly investigated in clinical and radiological studies, there are sparse data regarding the association between trochlear dysplasia with other anatomical parameters. This study sought to explore those associations using a large osteological collection.

Methods: Five-hundred and seventy-nine cadaveric skeletons were obtained from the Hamann-Todd osteological collection. Mechanical lateral distal femoral angle (mLDFA), medial proximal tibial angle (MPTA), femoral version, tibial torsion, lateral position of the tibial tubercle, and femoral length were modeled as predictors of medial and lateral flange height of the distal femur trochlea at various degrees of knee flexion.

Results: The average age and standard deviation for the 1158 lower extremities analyzed was 55.9 ± 10.2 years. There were 500 males (86%) and 79 females. Increasing MPTA or tibial valgus predicted increasing lateral femoral flange height at 0, 30, and 50 degrees of knee flexion [(standardized beta 0.111, p = 0.01), (standardized beta 0.129, p < 0.001), and (standardized beta 0.186, p < 0.001), respectively]. Increasing internal tibial torsion predicted increased medial flange height at 30 and 50° [(standardized beta - 0.114, p = 0.006), (standardized beta - 0.108, p = 0.006), respectively]. Increased femoral retroversion predicted increasing lateral flange height at 0 and 30 degrees [(standardized beta - 0.105, p = 0.005), (standardized beta - 0.098, p = 0.004), respectively].

Conclusions: To maintain the equilibrium necessary for effective patellar tracking, the depth of trochlear groove appears to effectively compensate for some of the anatomical parameters of the proximal tibia associated with patellofemoral disorders, and appears to be less influenced by femoral alignment. The clinical relevance of these findings warrants further investigation, and emphasizes the importance of carefully assessing the lower limb alignment in the management of patellofemoral disorders.
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http://dx.doi.org/10.1007/s00402-021-03998-7DOI Listing
June 2021

Exploring the Ethics of Stature Lengthening as Treatment for Height Dysphoria.

Strategies Trauma Limb Reconstr 2020 Sep-Dec;15(3):163-168

Department of Bioethics, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States.

Aim: To promote a discussion on the ethics and justifications of stature lengthening in patients without skeletal deformity.

Background: Stature lengthening for height gain in patients without skeletal deformity has stirred controversy within the orthopedic community. However, current literature does not delineate the ethical issues surrounding this procedure. Improvements in the techniques, technology, and safety profile of stature lengthening warrant an ethical discussion to challenge, justify, and guide the use of this surgical procedure.

Review Results: Examination of ethical issues leads to the distinction between the dual roles of stature lengthening as a vs an . The primary focus on stature lengthening as allows for exploration of "height dysphoria"-a psychological burden caused by a dissatisfaction with one's height-as the primary pathology that may justify surgical intervention.

Conclusion: In our opinion, additional work is required to establish "height dysphoria" as a true pathology in order to ethically justify stature lengthening as a legitimate form of treatment. Further discussion is needed to address the ethics of stature lengthening as an enhancement.

Clinical Significance: This paper addresses salient ethical issues of stature lengthening in patients without skeletal deformity by exploring historical, contemporary, and comparative contexts.

How To Cite This Article: Lee RC, Aulisio M, Liu RW. Exploring the Ethics of Stature Lengthening as Treatment for Height Dysphoria. Strategies Trauma Limb Reconstr 2020;15(3):163-168.
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http://dx.doi.org/10.5005/jp-journals-10080-1502DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8121106PMC
May 2021

"Retrograde intramedullary nailing of pediatric femoral shaft fractures does not result in growth arrest at the distal femoral physis - a retrospective cases series".

J Orthop Trauma 2021 Mar 16. Epub 2021 Mar 16.

Department of Orthopaedics, Case Western Reserve University School of Medicine, Cleveland, OH, USA Orthopedic Department, Second State Central Hospital, Mongolian National Diagnostic and Treatment Center, Ulaanbaatar, Mongolia SIGN Fracture Care International, Richland, WA, USA.

Objective: To evaluate femoral growth after placement of retrograde intramedullary nails (IMN) in the treatment of pediatric femoral shaft fractures.

Design: Retrospective case series.

Setting: Large urban trauma center in MongoliaPatients/Participants: Twenty-nine pediatric patients who sustained a diaphyseal femoral shaft fracture.

Intervention: Retrograde intramedullary nail fixation with the standard, fin, or pediatric fin SIGN nail across an open distal femoral physis.

Main Outcome Measures: Distance traveled by the intramedullary nail with respect to the distal femoral condyles and distal femoral physis from initial surgery to follow-up.

Results: The mean age of patients was 10.7 years (range: 7-14 years). Follow up occurred at a mean of 292 days (range: 53-714 days). Both condyle distance and physis distance were significantly positively correlated with follow-up days, with Pearson R values of 0.90 (p<0.001) and 0.84 (p<0.001), respectively. Multiple regression analysis revealed that follow-up days was the only significant predictor of physis distance, while age, sex, percent growth plate violation, and nail fully traversing physis were not significant predictors. The nail completely crossed the physis in 5 patients and no growth arrests were found.

Conclusions: This is the first study to our knowledge to evaluate treating femoral shaft fractures with a retrograde nail across an open distal femoral physis. In the pediatric population, the use of a retrograde femoral IMN does not appear to cause growth arrest of the injured femur during the postoperative period and may be a reasonable treatment option when other surgical options are not available. Additional study is necessary to further evaluate the safety profile.

Level Of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000002076DOI Listing
March 2021

The Relationship of Olecranon Apophyseal Ossification and Sanders Hand Scores with the Timing of Peak Height Velocity in Adolescents.

J Bone Joint Surg Am 2021 May 11. Epub 2021 May 11.

Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut.

Background: The onset of peak height velocity (PHV) guides the timing of interventions in the growing child. The purpose of the present study was to validate the Diméglio olecranon grading system and to compare these scores with the Risser/triradiate closure (TRC), proximal humerus, and Sanders hand scores.

Methods: Eighty children with annual serial radiographs were selected from the Bolton-Brush collection. The olecranon apophysis was graded with use of lateral radiographs of the elbow. The mean age to PHV was determined for each stage, and reliability was calculated with use of an intraclass correlation coefficient (ICC). Olecranon stage was combined with age, sex, and height in a generalized estimating equation (GEE) model to predict PHV. Predictive performance of this model was evaluated with use of tenfold cross-validation such that the model was trained on 90% of the radiographs and was asked to predict the PHV of the remaining 10%.

Results: PHV is closely associated with olecranon stage, with stage 1 occurring 3.0 years before PHV and stage 7 occurring 3.4 years after PHV. Stage 5 was found to occur at PHV. Scoring system reliability was high across an array of observers (ICC = 0.85 ± 0.07). The GEE model showed that this olecranon system outperforms the Risser/TRC system in predicting PHV and is comparable with the humerus and Sanders hand systems. When combined with age and sex, the olecranon system successfully predicted PHV such that 62% of PHV predictions were accurate within 6 months and 90% of PHV predictions were accurate within a year.

Conclusions: Our data show that stage 5 occurs at PHV, contrary to previously published data. When combined with age and sex, the olecranon system successfully predicts PHV within a year in 90% of cases, establishing a single lateral view of the olecranon as a simple alternative to more complex grading systems. Last, we describe novel 3 variations in olecranon morphology and provide a guide for accurate olecranon staging.

Clinical Relevance: Understanding PHV is critical in the treatment of many pediatric orthopaedic disorders. The revised olecranon staging system will allow for more accurate determination of this variable.
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http://dx.doi.org/10.2106/JBJS.20.01856DOI Listing
May 2021

The association between femoral neck shaft angle and degenerative disease of the hip in a cadaveric model.

Hip Int 2021 May 2:11207000211013029. Epub 2021 May 2.

Division of Paediatric Orthopaedics, Rainbow Babies and Children's Hospitals at Case Western Reserve University, Cleveland, OH, USA.

Background: While the influences of acetabular dysplasia and overcoverage on hip arthritis have been studied, the impact of femoral neck-shaft angle on hip arthritis is much more poorly understood. The purpose of this study is to determine if a relationship exists between neck shaft angle and the development of osteoarthritis, a better understanding of which would be useful to surgeons planning osteotomies about the hip.

Methods: 533 cadaveric femora and acetabulae (1066 total) from the Hamann-Todd Osteological Collection (Cleveland, OH) were acquired. We measured true neck shaft angle using an AP photograph with the femoral neck parallel to the table. Femoral head volume to acetabular volume ratio, representing femoral head coverage, as well as femoral version were utilised. Correlation between neck shaft angle, femoral version, femoral head coverage and osteoarthritis were evaluated with multiple regression analysis.

Results: The mean age and standard deviation was 56 ± 10 years. There were 64 females (12%) and 469 males. There were 380 Caucasians (71%) and 153 African-Americans. Mean femoral version was 11° ± 12° and mean true neck shaft angle was 127.7° ± 5.9° There was a strong correlation between age and arthritis (standardised beta 0.488,  < 0.001). There was a significant correlation between increasing true neck shaft angle and decreasing hip arthritis (standardised beta -0.024,  = 0.038). In the femoral head overcoverage subset, increasing true neck shaft angle was still significantly associated with decreasing hip arthritis (standardised beta -0.088,  = 0.018), although this relationship was not significant with femoral head undercoverage subset.

Conclusions: With sufficient acetabular coverage, a relative increase in femoral neck shaft angle within the physiologic range is associated with decreased hip osteoarthritis.

Clinical Relevance: An understanding of the relationship between femoral neck shaft angle and hip osteoarthritis could be useful for surgeons planning pelvic or proximal femur osteotomies in children.
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http://dx.doi.org/10.1177/11207000211013029DOI Listing
May 2021

Is Cam Morphology Found in Ancient and Medieval Populations in Addition to Modern Populations?

Clin Orthop Relat Res 2021 08;479(8):1830-1838

Department of Pediatric Orthopaedics, Rainbow Babies and Children's Hospital, Case Western Reserve University, Cleveland, OH, USA.

Background: Cam morphology is thought to originate near puberty and reflects a response of the peripheral aspect of the proximal femoral physis to increased local load. Participation in particular sports activities has been associated with cam morphology in contemporary patient populations; however, it is unclear whether cam is a recent phenomenon. There are limited data regarding the frequency of its occurrence and the general deviations in femoral anatomy in different historical populations. Such information may help to understand the possible influence of lifestyle and diet on cam morphology.

Questions/purposes: The purpose of this study was to evaluate femoral morphology in three historical populations. We asked: (1) Was cam morphology present in the three study populations, did those populations differ, and were there differences between sexes? (2) Were there differences in neck-shaft angle, version, or inclination between and among the examined populations?

Methods: We examined 204 adult femurs from the Neolithic population from Iran (n = 37, 3000 BC to 1631 BC), medieval population from Poland (n = 135, 10th to 13th centuries), and contemporary Australian aborigines (n = 32, early 20th century), provided by the Open Research Scan Archive, Museum of the First Piasts at Lednica and the University of Wrocław, respectively. All three human populations represent different chronologic periods and lifestyles. All bones were scanned using CT and then measured on their three-dimensional (3-D) reconstructions in selected planes. Cam impingement was defined as an alpha angle > 55° measured on the inclination view. To evaluate the differences in anatomy between populations, we measured the true neck-shaft angle on the true AP view, apparent neck-shaft angle on the apparent AP view, the version angle on the version view, and the inclination angle on the inclination view. The prevalence of cam morphology and other anatomic parameters were compared among groups using chi-square test, one-way ANOVA with post hoc Tukey test, and paired t-test.

Results: Cam morphology was present in 5% of the Neolithic population from Iran, in 7% of the medieval population from Poland, and 3% of the contemporary Australian aborigine femurs (OR Neolithic population from Iran/the medieval population from Poland 0.7 [95% CI 0.2 to 3.4]; p = 0.67; OR Neolithic population from Iran/contemporary Australian aborigines 1.8 [95% CI 0.2 to 20.5]; p = 0.65; OR the medieval population from Poland/contemporary Australian aborigines 2.5 [95% CI 0.3 to 20.1]; p = 0.40). There were differences in the presence of cam morphology between the sexes in the medieval population from Poland with both femurs (females: 1% [1 of 76]; males: 15% [9 of 59]; p = 0.002). There was a difference in true neck-shaft angle between the Neolithic population from Iran (121° ± 6°) and contemporary Australian aborigines (131° ± 5°; mean difference 10° [95% CI 7° to 13°]; p < 0.001) and between the medieval population from Poland (124° ± 5°) and the contemporary Australian aborigines (mean difference 7° [95% CI 5° to 9°]; p < 0.001). Apparent neck-shaft angle differed between the Neolithic population from Iran (126° ± 6°) and the contemporary Australian aborigines (134° ± 5°; mean difference 8° [95% CI 6° to 11°]; p < 0.001), and between the medieval population from Poland (126° ± 6°) and the contemporary Australian aborigines (mean difference 9° [95% CI 7° to 11°]; p < 0.001). Moreover, we observed a difference in the version angle between the Neolithic population from Iran (19° ± 7°) and the medieval population from Poland (12° ± 9°; mean difference 7° [95% CI 4° to 10°]; p < 0.001] and in the inclination angle between aforementioned groups (18° ± 7° versus 11° ± 8°; mean difference 7° [95% CI 5° to 10°]; p < 0.001).

Conclusion: This study found that cam morphology existed in historical populations at rates comparable with a contemporary population.

Clinical Relevance: The presence of cam morphology in historical populations suggests that cam morphology can develop outside of the intense sports activity seen in modern adolescents. Further study will help elucidate the etiology of cam morphology, which may be useful in the development of preventive strategies.
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http://dx.doi.org/10.1097/CORR.0000000000001771DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8277248PMC
August 2021

A Cadaveric Anatomical Study of the Relationship between Proximal Tibial Slope and Coronal Plane Deformity.

J Knee Surg 2021 Apr 28. Epub 2021 Apr 28.

Division of Pediatric Orthopaedic Surgery, Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, Ohio.

Medial proximal tibial angle (MPTA) and posterior proximal tibial angle (PPTA) are commonly used to characterize the geometry of proximal tibia and are important considerations in lower extremity realignment procedures and total knee arthroplasty. This study utilized a large cadaveric collection to explore relationships between tibial slope and coronal plane deformity of the tibia. We utilized 462 well-preserved skeletons (924 tibiae), excluding any with fracture or obvious rheumatologic or infectious findings. Custom cards were made with different sized arcs on the bottom surface, so that they could rest on the anterior and posterior aspects of the medial and lateral tibial plateaus of each bone to measure PPTA. Previously measured MPTA values for the same bones were also utilized. Multiple regression analysis was used to determine relationship between MPTA and medial and lateral PPTAs. The mean age was 56 ± 10 years, with 13% female and 31% African American (remainder Caucasian). The mean MPTA was 87.2 ± 2.4 degrees. The mean medial plateau PPTA was 81.5 ± 3.8 degrees and mean lateral plateau PPTA was 81.3 ± 3.7 degrees. Regression analysis found that MPTA was significantly associated with both medial and lateral PPTAs (standardized betas 0.197 and 0.146, respectively,  < 0.0005 for both). There was a significant correlation between lateral and medial PPTAs ( = 0.435,  = 0.03). The clinical significance of these findings warrants further investigation and emphasizes the importance of carefully assessing the sagittal plane when planning reconstruction of a tibia with varus or valgus deformity, particularly high tibial osteotomies.
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http://dx.doi.org/10.1055/s-0041-1728816DOI Listing
April 2021

Subtle Slipped Capital Femoral Epiphysis Is not Associated With Idiopathic Cam Morphology.

J Pediatr Orthop 2021 Apr;41(4):216-220

Division of Pediatric Orthopaedic Surgery, Case Western Reserve University School of Medicine, Cleveland, OH.

Background: The etiology of idiopathic cam morphology remains unclear. One theory suggests that subtle slipped capital femoral epiphysis (SCFE) leads to proximal femoral changes resulting in cam morphology. The purpose of this study was to evaluate the association between subtle SCFE and cam morphology in a large osteological collection.

Methods: We examined 962 cadaveric hips to measure 2 markers of cam morphology, alpha angle and anterior femoral head-neck offset (AHNO), and a validated, objective marker of subtle SCFE deformity (calcar ridge line offset). When the femur is viewed medially, the calcar ridge line extends from the lesser trochanter proximally along the postero-inferior femoral neck and points toward the fovea. In SCFE-like deformity, the fovea deviates posteriorly from this projected line. Pearson correlations were performed to evaluate for possible association of calcar ridge line offset with alpha angle and AHNO. In addition, a multiple regression analysis was performed to determine the influence of age, alpha angle, and AHNO on calcar ridge line offset.

Results: There was no clinically relevant association between the calcar ridge line offset and alpha angle (r=-0.02, P=0.58) or AHNO (r=0.08, P=0.012). Furthermore, specimens whose calcar ridge line deviated 1 SD above the mean (more SCFE-like deformity) had a smaller alpha angle (46.6±9.1 vs. 48.3±10.6, P=0.046) and greater AHNO (0.83±0.19 vs. 0.77±0.16, P<0.001), both reflecting less cam-like morphology. On regression analysis, increasing age and increasing AHNO (decreased cam morphology) predicted increased calcar ridge line offset, though the model accounted for only 1.2% of the variance.

Conclusions: Subtle SCFE-like deformity, as objectively measured from the calcar ridge line, was not predictive of more cam-like morphology, and in fact mild opposite associations were found. Further study is needed to identify other potential etiologies of idiopathic cam morphology.

Clinical Relevance: We present evidence from a large, well-documented osteological collection indicating that subtle SCFE is not associated with idiopathic cam morphology.
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http://dx.doi.org/10.1097/BPO.0000000000001737DOI Listing
April 2021

The Natural History of Benign Bone Tumors of the Extremities in Asymptomatic Children: A Longitudinal Radiographic Study.

J Bone Joint Surg Am 2021 04;103(7):575-580

Department of Orthopaedics, University Hospitals Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, Ohio.

Background: Benign bone tumors are common incidental findings in the pediatric population during radiographic evaluation. Counseling these patients requires reassurance and raises questions about the natural history of these tumors over time. The purpose of this study was to estimate the prevalence and observe the behavior of benign childhood bone tumors in an asymptomatic population.

Methods: A historical, longitudinal radiographic collection of healthy children was reviewed, which included comprehensive left-sided radiographs of the extremities at yearly intervals. In this study, 262 subjects with 25,555 radiographs were screened for benign bone tumors at a median age of 8 years (range, 0 to 18 years). All potential tumors were reviewed by a multidisciplinary panel, which confirmed the radiographic diagnosis of each lesion, the age at which the lesion first appeared, and the age at which it had resolved. Prevalence rates were calculated using the number of distinct subjects available for each radiographic location and age.

Results: Thirty-five tumors were identified in 33 subjects, including 19 nonossifying fibromas, 8 enostoses, 6 osteochondromas, and 2 enchondromas. The prevalence rate for all tumors combined increased with age and was 18.9% overall. The overall prevalence rates for specific tumor types were 7.5% for nonossifying fibromas, 5.2% for enostoses, 4.5% for osteochondromas, and 1.8% for enchondromas. Nonossifying fibromas demonstrated a bimodal distribution of prevalence, with a peak at 5 years (10.8%) and another after skeletal maturity (13.3%). The median age at the first appearance for all tumors combined was 9 years (range, 2 to 15 years), but varied by tumor type. Nonossifying fibromas often resolved (7 [37%] of 19), with further resolution possible beyond the last available radiograph. Enostoses, osteochondromas, and enchondromas persisted until the last available radiographs in all subjects.

Conclusions: The prevalence of benign childhood bone tumors of the extremities was 18.9% in a historical asymptomatic population. Longitudinal radiographs allowed observation of the timing of the first appearance and the potential for resolution for each tumor type. These findings provide unique evidence to answer many commonly encountered questions when counseling patients and their families on benign bone tumors.

Level Of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.2106/JBJS.20.00999DOI Listing
April 2021

Optimal Fluoroscopic Angulation to Determine Intercondylar Notch Violation during Pediatric Medial Patellofemoral Ligament Reconstruction.

J Knee Surg 2021 Feb 26. Epub 2021 Feb 26.

Department of Orthopaedic Surgery, Rainbow Babies and Children's Hospitals at Case Western Reserve University, Cleveland, Ohio.

Previous anatomic data has suggested that during pediatric medial patellofemoral ligament (MPFL) reconstruction, the femoral tunnel must be angled distally and anteriorly to avoid damage to the distal femoral physis and then intercondylar notch. The purpose of this study was to determine the optimal degree of fluoroscopic angulation necessary to radiographically determine the presence of intercondylar notch violation. Fourteen adult cadaveric human femora were disarticulated and under fluoroscopic guidance, Schöttle's point was identified. A 0.62-mm Kirschner wire was then drilled through the condyle to create minimal notch violation. The femur was then placed on a level radiolucent table and coronal plane radiographs angled from -15 to 60 degrees were obtained in 5-degree increments to determine the fluoroscopic angle at which intercondylar notch violation was most evident. Grading of optimal fluoroscopic angle between two authors found that violation of the notch was the best appreciated at a mean angle of 43 ± 15 degrees from neutral. Results from this study emphasize the importance of angling the beam to essentially obtain a notch view to assess for a breech.
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http://dx.doi.org/10.1055/s-0041-1724131DOI Listing
February 2021

Purposeful Closed Reduction and Pinning in Unstable Slipped Capital Femoral Epiphysis Results in a Rate of Avascular Necrosis Comparable to the Literature Mean.

Orthopedics 2021 Mar-Apr;44(2):92-97. Epub 2021 Feb 10.

The standard treatment of stable slipped capital femoral epiphysis (SCFE) is generally accepted to be in situ pinning. Controversy exists regarding the treatment of unstable SCFE, including the role of a purposeful closed reduction or open reduction. The objective of this study was to investigate the rate of avascular necrosis (AVN) with purposeful closed reduction and in situ pinning of unstable SCFE. The authors retrospectively reviewed 221 patients with 302 SCFE hips treated with in situ pinning between 2000 and 2014. Forty-eight patients (50 hips) presented with an unstable SCFE. All unstable SCFEs were treated by a gentle reduction method with traction and hip internal rotation followed by pinning. Southwick angles were measured prior to reduction and at the first postoperative visit. No stable SCFEs developed AVN. Thirteen (26%) unstable SCFEs developed AVN. Avascular necrosis developed in 7 of 17 (41%) hips screened with magnetic resonance imaging vs 6 of 33 (18%) hips screened with plain radiographs alone. Mean change in Southwick angle was 28°±8° in the AVN group vs 18°±18° in the no AVN group (=.18). Despite potentially inflating the rate with the use of early detection magnetic resonance imaging, the authors found an AVN rate comparable to that in the published literature with the use of gentle purposeful reduction on a fracture table, and no statistical differences in reduction amount between patients with and without AVN. Gentle purposeful reduction appears to be a reasonable low morbidity option in the treatment of unstable SCFE without a clear increase in risk of AVN. [. 2021;44(2):92-97.].
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http://dx.doi.org/10.3928/01477447-20210201-02DOI Listing
July 2021

Systematic Isolation of Key Parameters for Estimating Skeletal Maturity on Knee Radiographs.

J Bone Joint Surg Am 2021 05;103(9):795-802

Department of Orthopaedics, Case Western Reserve University School of Medicine, Cleveland, Ohio.

Background: The ability to estimate skeletal maturity using a knee radiograph would be useful in anterior cruciate ligament (ACL) injuries and limb-length discrepancy in immature patients. Currently, a quick, accurate, and reproducible method is lacking.

Methods: Serial knee radiographs made 3 years before to 2 years following the chronologic age associated with 90% of final height (an enhanced skeletal maturity gold standard compared with peak height velocity) were analyzed in 78 children. The Pyle and Hoerr (PH) knee method was simplified by developing discrete stages for the distal part of the femur, the proximal part of the tibia, the proximal part of the fibula, and the patella. The Roche-Wainer-Thissen (RWT) knee method was simplified from the 36 original parameters to 14 parameters by removing parameters that were poorly defined, were not relevant to the peripubertal age range, were poorly correlated with 90% final height, or were poorly reliable on a 20-radiograph pilot analysis. We also compared the recently described central peak value (CPV) of the distal part of the femur. The Greulich and Pyle (GP) left-hand bone age was included for comparison.

Results: In this study, 326 left knee radiographs from 41 girls (age range, 7 to 15 years) and 37 boys (age range, 9 to 17 years) were included. Stepwise linear regression showed higher correlation in predicting years from 90% final height using the modified RWT and demographic characteristics (R2 = 0.921) compared with demographic characteristics alone (R2 = 0.840), CPV and demographic characteristics (R2 = 0.866), GP and demographic characteristics (R2 = 0.899), and PH and demographic characteristics (R2 = 0.902). Seven parameters were excluded from the RWT and demographic characteristics model using stepwise linear regression and generalized estimating equations analysis, leaving 7 parameters (2 femoral, 4 tibial, and 1 fibular) in the final model. Compared with RWT and demographic characteristics (R2 = 0.921), there were minimal incremental increases by adding CPV (R2 = 0.921), GP (R2 = 0.925), or PH (R2 = 0.931).

Conclusions: This large analysis of knee skeletal maturity systems isolated 7 discrete radiographic knee parameters that theoretically outperform the GP bone age in estimating skeletal maturity.

Clinical Relevance: We present a modified knee skeletal maturity system that can potentially preclude the need for additional imaging of the hand and wrist in reliably estimating skeletal maturity.
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http://dx.doi.org/10.2106/JBJS.20.00404DOI Listing
May 2021

Is Bony Knee Alignment Representative of the True Joint Surface in Skeletally Immature Patients? A Magnetic Resonance Imaging Study.

Strategies Trauma Limb Reconstr 2020 May-Aug;15(2):79-83

Department of Pediatric Orthopaedics, Rainbow Babies and Children's Hospital at Case Western Reserve University, Cleveland, Ohio, USA.

Aim And Objective: In deformity correction around the knee, the mechanical lateral distal femoral angle (mLDFA) and medial proximal tibial angle (MPTA) are used in surgical planning routinely. While plain radiographs are generally adequate, some surgeons utilise intraoperative arthrograms to visualise the articular contours and assess a younger child's true joint alignment, often with findings that these are discrepant from that measured just using bone alignment. The age cutoff for a discrepancy between the two is not defined.

Materials And Methods: We queried our picture archiving and communication systems (PACS) database for MRIs with a radiological read of "normal" for patients between the ages of 4 and 16 years at the time of the study. Anatomic axes were used to determine the anatomic LDFA (aLDFA) and MPTA angles using end-cartilage and end-bone landmarks independently.

Results: We reviewed 116 MRIs, 56% male, with approximately 9 studies per year of age. There were no significant overall differences between aLDFA and MPTA when measured at the bone vs cartilage surfaces ( = 0.42 and = 0.53, respectively). In the 4- to 6-year age range, there was a significant difference between bony and cartilaginous aLDFA ( = 0.02) but not MPTA ( = 0.88).

Conclusion: In children 6 years of age and younger, intraoperative arthrogram should be considered while treating knee deformity, as plain films may not fully represent the true deformity of the distal femur in particular.

Clinical Significance: Supports the need for advanced imaging or intraoperative arthrogram for joint corrective surgery in young patients.

Level Of Evidence: Level 3 diagnostic.

How To Cite This Article: Bigach SD, Carender CN, Liu RW. Is Bony Knee Alignment Representative of the True Joint Surface in Skeletally Immature Patients? A Magnetic Resonance Imaging Study. Strategies Trauma Limb Reconstr 2020;15(2):79-83.
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http://dx.doi.org/10.5005/jp-journals-10080-1465DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7801901PMC
January 2021

Height and Extremity-Length Prediction for Healthy Children Using Age-Based Versus Peak Height Velocity Timing-Based Multipliers.

J Bone Joint Surg Am 2021 02;103(4):335-342

Yale University, New Haven, Connecticut.

Background: The age-based multiplier method described by Paley et al. markedly simplifies height and limb length predictions but may not adequately accommodate children's maturational differences. Multipliers can be derived relative to any maturity measure. This study compares Paley age-based multipliers with those based on peak height velocity (PHV) timing.

Methods: In a longitudinal cohort of healthy children (66 male and 70 female), actual adult heights and limb lengths were compared with the measurements predicted using the Paley multipliers and multipliers developed relative to PHV timing. The age-based multipliers (adult divided by current) in our series were compared with those reported by Paley et al. to ensure that there were no systematic differences between the series. Absolute differences between the actual and predicted adult heights and limb lengths and the standard deviations of those differences were compared between the 2 methods.

Results: The average age-based multipliers in our series were nearly identical to those reported by Paley et al. The differences between the predicted and actual adult values showed wide ranges when either the Paley or the PHV multipliers were used during infancy. The Paley method performed better than the PHV method throughout pre-growth-spurt childhood. The PHV-timing-derived multipliers became superior as children entered their growth spurt, whereas the performance of the age-based multipliers worsened. In adolescence, the maximum standard deviation for adult-height-prediction errors with use of the Paley multipliers occurred at the age of 13.5 years for boys and 11.5 years for girls and was 7.0 cm for boys and 5.6 cm for girls. For limb lengths, the maximum standard deviations occurred 6 months earlier and were 3.9 cm for boys and 3.2 cm for girls. The maximum standard deviation for the height prediction error with the age-based method occurred at the average time of PHV for the population. The PHV method became better than the Paley method just before growth-spurt initiation, at age 8 in girls and 11 in boys.

Conclusions: The age-based multipliers described by Paley et al. are superior to PHV-timing-based multipliers prior to the adolescent growth spurt for predicting height. They become less predictive, with wide standard deviations, as children enter their growth spurts, and PHV-derived multipliers become superior. The Paley height multipliers should be used before the age of 8 years in girls and 11 years in boys. After this, PHV-derived multipliers are superior for height and limb length prediction. In practice, these predictions are currently made using skeletal maturity, which is closely related to PHV during adolescence.
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http://dx.doi.org/10.2106/JBJS.20.00040DOI Listing
February 2021

Prediction of adolescent pelvis development using femoral head and acetabulum growth in a longitudinal radiographic study.

Clin Anat 2021 Jul 17;34(5):726-735. Epub 2020 Dec 17.

Division of Pediatric Orthopaedic Surgery, Case Western Reserve University, Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA.

Introduction: Adolescent total hip arthroplasty (THA) is guarded partially due unclarity as to when pediatric hip joints reach full development. This study sought to identify when maximum acetabular and femoral head diameters are achieved with relation to chronological and skeletal age.

Materials And Methods: Consecutive femoral head and acetabular diameters were measured in a random sample of 54 female and 78 male subjects, which were queried from a historical collection of annual radiographs of children. Femoral head and triradiate physeal plates were scored according to Oxford bone parameters.

Results: At 14 years females had femoral diameters of 4.16 +/- 0.23 cm and acetabular diameters of 5.15 +/- 0.30 cm. At 16 years males had femoral diameters of 4.85 +/- 0.30 cm and acetabular diameters of 5.90 +/- 0.35 cm. In the year following maximal femoral Oxford scores, no significant change was seen in femur and acetabulum diameters in females and in femur diameters in males. In the year following maximal acetabular Oxford scores, there was a significant increase in both femur and acetabulum diameters in both females and males.

Conclusions: Females on average reach maximum pelvis maturity at 14 years and males reach maximum pelvis maturity at 16 years. A closed femoral head was found to be a good marker of full hip growth, while a closed triradiate was not. This study provides anatomical data for surgeons to consider in assessing risk factors of THA failure in adolescents.
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http://dx.doi.org/10.1002/ca.23708DOI Listing
July 2021

Greater Trochanter Height: A Quantitative Predictor of Skeletal Maturity.

J Pediatr Orthop 2021 Feb;41(2):99-104

Department of Orthopaedic Surgery.

Background: The purpose of this investigation was to develop a quantitative and reproductible method for estimating skeletal maturity based on measurements of the height of the bony greater trochanter (GT) using timing to 90% of final height as a gold standard.

Methods: Bony GT height was measured using serial anteroposterior pelvic radiographs in 76 healthy pediatric patients obtained from the Bolton-Brush (BB) Study with corresponding Greulich-Pyle (GP) bone ages. Chronologic age at 90% of final height was calculated. GT height was then measured in 300 contemporary patients aged 4 to 18 years, evenly divided based on sex and race. Bony GT height was compared between BB and contemporary patients, while linear mixed-effects models were used to examine for potential predictors of years to 90% final height using patient sex, GP bone age and bony GT height measurements.

Results: Bony GT height was measured in 303 radiographs from the BB Collection (n=37 males; n=39 females) with corresponding GP bone ages, chronological ages, and heights to represent skeletal maturity. Mean age at 90% final height was 13.3±0.6 years for males and 11.4±0.8 years for females. When controlling for patient age and sex, multiple regression analysis revealed that contemporary patients possessed significantly greater bony GT height (mean difference: 1.15 mm; P=0.001) when compared with BB patients. Multivariate analysis showed that combining bony GT height, GP bone age, and sex significantly predicted years to 90% total growth (P<0.001) and explained ∼85% (95% confidence interval for R2: 82%-87%) of the total variance in years using 90% of final height, with sex, GP bone age, and GT height all significant contributors.

Conclusions: Including bony GT height provides more accurate prediction of 90% final height when combined with GP bone age and sex. GT height offers an efficient and accurate parameter that may be utilized in pediatric orthopedic conditions requiring a quantitative estimate of bone age in children with prior pelvis or hip imaging.

Level Of Evidence: Level II-diagnostic study.
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http://dx.doi.org/10.1097/BPO.0000000000001724DOI Listing
February 2021

Medicare Physician Fee Schedule 2020: IR Practice Economic Health and Strategies to Mitigate the Undervaluing of IR Services.

J Vasc Interv Radiol 2020 10 16;31(10):1726-1727. Epub 2020 Sep 16.

Department of Radiology, SUNY Upstate University Hospital, Syracuse, New York.

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http://dx.doi.org/10.1016/j.jvir.2020.06.024DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7492832PMC
October 2020

An Anatomical Evaluation of the Trapezium and Its Relationship to Basilar Joint Osteophytic Change.

Hand (N Y) 2020 Sep 16:1558944720946490. Epub 2020 Sep 16.

Case Western Reserve University, Cleveland, OH, USA.

Background: To perform a comprehensive osteologic investigation into trapezium anatomy and investigate the relationship between anatomical factors and osteophyte formation, focusing on sex-specific differences.

Methods: This was a cadaveric study involving 1233 trapezia and first metacarpals. Two subgroups ("Control" and "Main Study") were established. The "Control" cohort was used to identify features of the trapezium in specimens devoid of osteophytic change. The prevalence and severity of osteophytic change were investigated in the "Main Study" cohort. Sex differences were specifically assessed. Regression analyses were used to identify factors associated with osteophyte formation.

Results: Three discrete surface morphologies exist at the trapezium trapeziometacarpal (TM) facet: heart, quadrilateral, and bean. Controlling for height, men have a larger trapezium TM facet surface area. However, the trapezium assumes the same off-center saddle shape in both sexes. The presence of osteophytes at the basilar joint is a common finding; no differences in osteologic prevalence exist between sexes. The progression of osteophytic change complements the radiographic Eaton-Littler classification system. The trapezium TM facet increases the surface area with incremental osteophyte involvement, with the degree of surface area expansion correlated with increases in the severity of osteophytic change. Increased age, increased surface area, bean morphology, and decreased volar joint depth are associated with more severe osteophyte formation.

Conclusions: Anatomical features of the trapezium may contribute to osteophyte development. Although the prevalence of osteophytic disease appears equal between sexes, sex differences exist in some anatomical parameters. These differences may help explain the increased prevalence of symptomatic basilar joint disease in women.
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http://dx.doi.org/10.1177/1558944720946490DOI Listing
September 2020

Use of a Suture Anchor Technique to Replace the Tethering Effect of the Ligamentum Teres in the Treatment of Complex Hip Dysplasia.

Orthopedics 2020 Sep 6;43(5):e480-e485. Epub 2020 Aug 6.

After open hip reduction in hip dysplasia, some hips can have persistent instability, even after pelvic and femoral osteotomies as well as capsulorrhaphy. While the diseased ligamentum teres in a dislocated hip is thought to contribute to inadequate reduction, the native ligament is thought to provide some level of stability. As such, the purpose of this study was to investigate the utility of a suture augment that replaces the function of the ligamentum teres to provide added stability. [Orthopedics. 2020;43(5):e480-e485.].
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http://dx.doi.org/10.3928/01477447-20200721-08DOI Listing
September 2020

Emergency Department Utilization After Outpatient Hand Surgery.

J Am Acad Orthop Surg 2020 Aug;28(15):639-649

From the Department of Orthopaedics, the University Hospitals Cleveland, Case Western Reserve University, Cleveland, OH (Dr. Sivasundaram, Dr. Wang, Dr. Kim, Dr. Trivedi, Dr. Liu, Dr. Voos, and Dr. Malone), the Department of Orthopaedics, the University Hospitals Cleveland, Sports Medicine Institute, Cleveland, OH (Dr. Voos), and the Department of Orthopaedics, the MetroHealth Medical Center, Cleveland, OH (Dr. Bafus).

Background: The purpose of this study was to identify the utilization rate and most common reasons for presentation to the emergency department (ED) after elective outpatient hand surgery and to determine preoperative risk factors for these ED visits.

Methods: Patients who underwent elective hand surgery at an ambulatory surgery center between 2014 and 2015 were retrospectively evaluated using the New York and Florida State Databases. The primary outcome was all-cause 7- and 30-day ED utilization rates. Reasons for presentation to the ED were recorded and manually stratified. Bivariate and multivariate analyses were performed to identify independent predictors of ED utilization.

Results: From 2014 to 2015, 212,506 procedures were identified; the 7- and 30-day ED visit rates were 1.8% and 4.4%, respectively. Postoperative pain was the most common cause of an ED visit after outpatient hand surgery at 7 days (25.4%) and 30 days (16.1%) postoperatively. Overall, 98% of patients presenting to the ED for postoperative pain were subsequently discharged home. After controlling for confounding, comorbid congestive heart failure, chronic lung disease, diabetes, renal failure, schizophrenia, and depression were independent risk factors for an ED visit at up to 30 days postoperatively. Those with Medicare insurance were 94% more likely to present to the ED within 30 days than those with private health insurance, whereas those with Medicaid were more than three times as likely to present to the ED as those with private insurance.

Discussion: ED utilization after outpatient hand surgery is low, with postoperative pain being the most common cause of an ED visit at all time points. Nearly 98% of patients presenting to the ED for postoperative pain are subsequently discharged home.

Level Of Evidence: Level III, Retrospective Cohort.
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http://dx.doi.org/10.5435/JAAOS-D-19-00527DOI Listing
August 2020

Current use of patient-reported outcomes in pediatric limb deformity surgery.

J Pediatr Orthop B 2021 Jul;30(4):399-404

Division of Pediatric Orthopaedic Surgery, Case Western Reserve University, Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA.

Patient-reported outcome (PRO) instruments are critical to evaluate the natural history of conditions and treatment effects, but have not been well studied in pediatric limb deformity. The goal of this study was to identify and assess the most commonly used PROs in pediatric limb deformity surgery across a representative sample of the recent orthopedic literature. A review was performed from 1 January 2016 to 31 December 2018 in five orthopedic journals previously identified as having the greatest impact: Journal of Pediatric Orthopaedics, Journal of Pediatric Orthopaedics B, Journal of Children's Orthopaedics, The Journal of Bone and Joint Surgery, and The Bone and Joint Journal. Clinical research studies involving pediatric population, operative management of limb deformity, and PRO measures were reviewed. The initial search of 3489 publications found 130 clinical articles involving operative management of pediatric limb deformity. Thirty-one studies (24%) met inclusion criteria, in which a total of 23 different PRO instruments were used. An average of 1.5 PRO instruments was reported per study (range 1-4). No outcome instrument was used by more than five different studies in this review, and no instrument validated in the pediatric population was used by more than three different studies. PROs currently used in pediatric limb deformity surgery are highly heterogeneous, as well as underutilized. Future research is necessary to either validate a current PRO in pediatric limb deformity or to develop a new instrument using pediatric Patient-Reported Outcomes Measurement Information System or Pediatric Outcomes Data Collection Instrument as a benchmark.
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http://dx.doi.org/10.1097/BPB.0000000000000782DOI Listing
July 2021

A prospective randomised study on efficacy of music for decreasing preoperative anxiety in children.

J Perioper Pract 2021 Jul-Aug;31(7-8):268-273. Epub 2020 Jul 10.

Division of Pediatric Orthopaedic Surgery, 2546Case Western Reserve University, Rainbow Babies and Children's Hospital, Cleveland, USA.

Background: The operating room can be a frightening environment for paediatric patients. This study investigated whether music medicine can mitigate preoperative anxiety in children.

Materials And Methods: One hundred and fifty children undergoing general anaesthesia were randomised to listen to music of the child's choice, lullaby music or no music before induction. Heart rates were measured in the waiting room, upon first entry into the operating room and just prior to induction.

Results: There was no significant difference in average heart rate change from the waiting room to induction in the patient choice, lullaby and control groups. Older age was associated with higher heart rate changes between baseline and entering the operating room. Pharmacologic sedation showed a significant beneficial effect on heart rate change at induction.

Conclusion: Use of music medicine in the operating room does not show efficacy to reduce anxiety in children based on heart rate changes.
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http://dx.doi.org/10.1177/1750458920939780DOI Listing
July 2020

Longitudinal analysis of pediatric distal radius alignment parameters in a cohort of serial radiographs.

Clin Anat 2021 Apr 21;34(3):365-370. Epub 2020 Sep 21.

Rainbow and Babies Hospitals at Case Western Reserve University, Cleveland, Ohio, USA.

Background: Growth in pediatric patients necessitates changes to bony structures throughout the entire body to suit development. Changes in the distal radius during growth are of interest in the pediatric population due to the high incidence of fractures. The purpose of this study was to assess for trends in three radiographic measurements (height of the radial styloid process, radial inclination, ulnar variance) of the distal radius using serial radiographs in subjects aged between 6 and 14 years of age.

Materials And Methods: Longitudinal radiographs from 68 healthy children (n = 34 males, 34 females) with a minimal of three annual radiographs between 6 and 14 years of age were analyzed. Measurements of height of the radial styloid process, radial inclination, and ulnar variance were performed in each available radiograph. Repeated measures analysis of variance (ANOVA) was performed to measure the association between alignment values and subject age.

Results: A total of 436 images in 68 subjects were analyzed, comprising a mean of 6.5 ± 2.0 radiographs per subject. Repeated measures ANOVA demonstrated that all measurement variables changed significantly with age (p < .001). Ulnar variance demonstrated the most variability with negative ulnar variance in younger children, and trends towards a more neutral ulnar variance by approximately 7 years in females and 11 years in males, while height of the radial styloid process and radial inclination changed relatively minimally with development.

Conclusions: In the adolescent age range, ulnar variance, height of the radial styloid process and inclination are all relatively stable and adult parameter values can be used to judge restoration of distal radius alignment.
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http://dx.doi.org/10.1002/ca.23642DOI Listing
April 2021

Patellar Morphology and Osteoarthritis: A Cadaveric Analysis.

J Knee Surg 2020 Jun 22. Epub 2020 Jun 22.

Division of Orthopaedic Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio.

Previous studies have attempted to characterize patellar morphology and its relation to patellofemoral osteoarthritis but have utilized relatively small samples. We designed a large-scale cadaveric analysis to elucidate any potential relationship. Patellar morphology in 1,032 patellae was characterized using patellar facet concavity patterns initially developed by Wiberg and using the ratio of the lateral and medial facet lengths. Patellofemoral arthritis grading for specimens was previously completed based primarily on osteophytic burden. The average age at time of death was 56 ± 10 years. Wiberg's grading returned kappa values of 0.43 for intrarelator reliability and 0.27 for interrelator reliability. Using multiple regression analysis, Wiberg's type II was found to be correlated with patellofemoral arthritis ( = 0.003). Lateral to medial facet ratio measurements returned intraclass coefficients of 0.91 for intrarelator reliability and 0.85 for interrelator reliability. There was no association between lateral to medial facet ratio and osteoarthritis. Regression analysis between Wiberg's typing and lateral-to-medial ratio (L:M) resulted in a coefficient of determination of 0.14. To our knowledge, this is the largest study evaluating the relationship between patellar morphology and arthritis. Although there was a relationship between Wiberg's type II and patellofemoral arthritis, the Wiberg systems was not easily reproducible in our study and returned a correlation with arthritis different then anatomically expected. A more reproducible system of lateral to medial facet ratio was investigated but did not find an association with arthritic changes. Given these findings, we did not find a patella morphology grading system which is both reliable and valid in regard to association with patellofemoral arthritis.
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http://dx.doi.org/10.1055/s-0040-1713127DOI Listing
June 2020

Clinical Outcomes of Triplane Fractures Based on Imaging Modality Utilization and Management: A Systematic Review and Meta-analysis.

J Pediatr Orthop 2020 Nov/Dec;40(10):e936-e941

Case Western University, School of Medicine.

Background: Because of the complex nature and relatively rare prevalence of triplane fractures, ideal imaging and optimal treatment remain controversial. The purpose of this investigation was to systematically review and compare clinical outcomes in skeletally immature patients with triplane fractures on the basis of imaging modalities [radiography alone vs. radiography+computed tomography (CT)] and fracture management (operative vs. nonoperative).

Methods: A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement using a PRISMA checklist. All the literature related to skeletally immature patients with triplane fractures published from January 1988 to March 2020 were identified. Inclusion criteria consisted of skeletally immature patients with triplane fractures with reported imaging modality performed during diagnosis, fracture management, and postoperative outcomes on the basis of functional scores and the incidence of any complications.

Results: A total of 11 articles met inclusion criteria, comprising a total of 203 skeletally immature patients with 203 documented triplane fractures. Male individuals were significantly older at the time of injury (14.2±0.6 y) when compared with female individuals (12.6±0.9 y) (P=0.006). Fracture diagnosis and management were evaluated using radiography+CT in 63% (128/203) of patients, whereas 37% (75/203) underwent radiography only. No significant differences in good/excellent Modified Weber Protocol scores were reported in patients treated nonoperatively versus those undergoing operative treatment (P=0.78), whereas Modified Weber Protocol scores were significantly higher in patients using radiography alone (P=0.02). No significant difference in complication incidence was reported on the basis of management type (nonoperative, 16%; operative, 15%; P=0.47).

Conclusions: Patients undergoing operative management of triplane fractures achieved comparable functional outcomes scores without an increased incidence of complications when compared with patients undergoing nonoperative treatment. Further investigations analyzing outcomes at middle and long-term follow-up are necessary to determine the clinical utility of CT and various treatment modalities for the management of triplane fractures.

Level Of Evidence: Level IV-Systematic review.
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http://dx.doi.org/10.1097/BPO.0000000000001613DOI Listing
February 2021

The point of epiphyseal penetration affects rotational stability of screw fixation in slipped capital femoral epiphysis: A biomechanical study.

J Orthop Res 2020 12 22;38(12):2634-2639. Epub 2020 May 22.

Department of Orthopedic Surgery, Boston Children's Hospital, Boston, Massachusetts.

The epiphyseal tubercle, a posterosuperior projection of the epiphysis into the metaphysis, serves as the axis of rotation in slipped capital femoral epiphysis (SCFE) and a source of physeal stability. We hypothesized that in a biomechanical model of single screw fixation of stable SCFE, a screw passing through the epiphyseal tubercle (the axis of rotation) would confer less rotational stability than a centrally placed screw. Three femurs were selected from a sample population of 8- to 15-year-old healthy hips to represent three stages of maturation: a "young" femur with a prominent epiphyseal tubercle and decreased epiphyseal cupping around the metaphysis, a "median" femur with a subsiding tubercle, and a "mature" femur with a subsided epiphyseal tubercle and increased peripheral epiphyseal cupping. Specimens were three-dimensional printed with one of two screw trajectories: passing centrally in the epiphysis or directly through the epiphyseal tubercle. Resistance to rotational displacement was measured through stiffness and maximum torque over 30° degrees of displacement. In the "young" model, epiphyseal tubercle screw position conferred less rotational stiffness and required less maximum torque during rotational displacement when compared to a centrally placed screw (P < .001). In the "median" and "mature" models where the tubercle has subsided and is replaced by peripheral epiphyseal cupping, screw position through the tubercle was associated with equal or greater rotational stiffness and maximum torque during displacement as a centrally placed screw.
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http://dx.doi.org/10.1002/jor.24747DOI Listing
December 2020

The Interval Between Preoperative Radiation and Surgery Is Not Associated with Overall Survival for Soft-tissue Sarcomas: An Analysis of the National Cancer Database.

Clin Orthop Relat Res 2021 03;479(3):506-517

C. D. Collier, C.-Y. Kim, R. W. Liu, P. J. Getty, Department of Orthopaedics, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA.

Background: Most cancer centers prefer preoperative radiation therapy (preRT) over postoperative therapy to treat soft-tissue sarcoma (STS) to limit long-term fibrosis, joint stiffness, and edema. Surgery is often delayed after preRT to allow for tissue recovery and to reduce wound complications. However, the association between the time interval between preRT and surgery and survival is unknown.

Questions/purposes: (1) What factors are associated with the preRT-surgery interval in patients with STS? (2) Is the preRT-surgery interval associated with overall survival?

Methods: The National Cancer Database, a nationwide registry that includes 70% of all new cancers in the United States with 90% follow-up, was reviewed to identify 6378 patients who underwent preRT and surgical resection for a localized extremity or pelvic STS from 2004 to 2014. Patients were excluded if they had lymphatic or metastatic disease at diagnosis (23%; n = 1438), underwent neoadjuvant chemotherapy (24%; 1531), were missing vital status (8%; 487), had chemosensitive histologies (9%; 603), underwent radiation other than external beam (1%; 92), were missing preRT-surgery interval (1%; 45), or had a preRT-surgery interval greater than 120 days (< 1%; 6). A total of 2176 patients were included for analysis, with a mean preRT-surgery interval of 35 ± 16 days. A multiple linear regression model was generated to assess demographic, clinicopathologic, and treatment characteristics associated with the preRT-surgery interval. A Kaplan-Meier survival analysis was then conducted, stratified by the preRT-surgery interval, to assess survival over 10 years. Finally, a multivariate Cox regression analysis model was constructed to further evaluate the association between the preRT-surgery interval and overall survival, adjusted for demographic, clinicopathologic, and treatment characteristics.

Results: A longer preRT-surgery interval was associated with higher age (β = 0.002 per year [95% CI 0.0 to 0.004]; p = 0.026), tumor location in the pelvis (compared with the lower extremity; β = 0.15 [95% CI 0.082 to 0.22]; p < 0.001), and malignant peripheral nerve sheath tumor subtype (compared with undifferentiated pleomorphic sarcoma; β = 0.17 [95% CI 0.044 to 0.29]; p = 0.008). A shorter preRT-surgery interval was associated with higher facility volume (β = -0.002 per case [95% CI -0.003 to -0.002]; p = 0.026) and higher tumor stage (compared with Stage I; β = -0.066 [95% CI -0.13 to -0.006]; p = 0.03 for Stage II; β = -0.12 [95% CI -0.17 to -0.065]; p < 0.001 for Stage III). The 5-year overall survival rates were similar across all preRT-surgery interval groups: less than 3 weeks (66% [95% CI 60 to 72]), 3 to 4 weeks (65% [95% CI 60 to 71]), 4 to 5 weeks (65% [95% CI 60 to 71]), 5 to 6 weeks (66% [95% CI 60 to 72]), 6 to 7 weeks (63% [95% CI 54 to 72]), 7 to 9 weeks (66% [95% CI 58 to 74]), and more than 9 weeks (59% [95% CI 48 to 69]). Over 10 years, no difference in overall survival was observed when stratified by the preRT-surgery interval (p = 0.74). After controlling for potentially confounding variables, including age, sex, Charlson/Deyo comorbidity score, histology, tumor size, stage and surgery type, the preRT-surgery interval was not associated with survival (hazard ratio = 1 per day [95% CI 1 to 1]; p = 0.88).

Conclusion: With the numbers available, this study demonstrates that a delay in surgery up to 120 days after radiation is not associated with poorer survival. Therefore, clinicians may be able to delay surgery to minimize the risks of wound complications and modifiable comorbidities without affecting overall survival.Level of Evidence Level III, therapeutic study.
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http://dx.doi.org/10.1097/CORR.0000000000001287DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7899587PMC
March 2021
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