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Purpose: The purpose of this prospective study was to assess and compare clinical outcomes for patients with bilateral tarsal coalitions who had at least one coalition treated with surgical excision. Method: Patients were identified prospectively and agreed to participate. Data was collected prior to surgery, and again after surgery for up to 2 years. Comparisons of patients with unilateral disease to bilateral disease as well as unilateral excision to bilateral staggered and bilateral concomitant excision was done. Results: Initial cohort included 55 patients with 70 feet containing a tarsal coalition. 30 patients with 45 feet had bilateral tarsal coalition excision during the study period. Post-operative outcomes were considerably improved from preoperative outcomes. Five bilateral patients had concomitant excision, and ten had staggered surgery. There was no difference in outcome from patients with unilateral disease when compared to bilateral disease. There was no difference in patients with bilateral disease who had only one side excised compared to those that had both sides excised, and there was no difference in outcome for patients with staggered surgery compared to those with concomitant surgery. Conclusions: Patients with bilateral tarsal coalition show improvement in their outcomes in a similar fashion to those with unilateral disease. Concomitant surgical outcomes are comparable to staggered outcomes in this group, although the series is small.

Background: Challenges remain in determining which displaced supracondylar humerus fractures are safe to postpone surgical treatment until daylight hours. The purpose of this study is to determine which characteristics can be identified to guide the timing of treatment of supracondylar humerus fractures. Methods: 225 completely displaced Gartland extension type 3/4 supracondylar humerus fractures in healthy patients that presented between 6 am and 7 am were identified. Data were collected retrospectively. Data analysis included univariate, multivariable logistic regression and classification and regression tree analysis. Results: 5% (78/225) underwent surgical treatment the night they presented, while 65% (147/225) were treated the next day. Overall complication rate was 6%, with no difference based on timing of surgery. 12% (28/225) presented with a motor nerve injury, while 6% (14/225) a “pink pulseless” extremity. Statistical analysis found the most reliable radiographic predictor to be the maximum displacement on the anterior–posterior or lateral view. Classification and regression tree analysis developed a clinical algorithm; patients with a “pink pulseless” extremity or motor nerve injury were recommended for surgery overnight, while those with an anterior–posterior or lateral view Conclusion: This study provides guidance on the timing of treatment for displaced supracondylar humerus fractures that present overnight. We provide a simple algorithm with three key clinical predictors for timing of treatment: presence of a “pink pulseless” arm, presence of a motor nerve injury, and displacement of any cortex by at least 25 mm (anterior–posterior or lateral view). This provides a step forward to help practitioners make safer evidenced-based timing decisions for their patients. Level of evidence: Prognostic Study, Level II.

Purpose The presence of a clubfoot is often found prenatally and some families seek counselling with a specialist. The purpose of this study was to compare the parental anxiety levels in families that: a) knew prenatally and had prenatal counselling; b) knew prenatally but did not seek prenatal counselling; and c) did not know until after delivery. Methods This prospective cohort study evaluated the anxiety of parents as they presented to the paediatric orthopaedic clinic with their newborn with a foot disorder (prior to the diagnostic confirmation of clubfoot). Each family filled out the ‘Pre-visit orthopaedic surgeon questionnaire’ and then after the initial visit with the orthopaedic surgeon (confirming the clubfoot diagnosis) the family filled out the ‘Immediately post-visit orthopaedic surgeon questionnaire’. Through these questionnaires, anxiety level was assessed prior to meeting postnatally with the paediatric orthopaedic specialist, as well as after the meeting and compared across groups. Results A total of 121 parents completed questionnaires: 71% (86/121) confirmed clubfoot; 69% of families (59/86) received prenatal counselling (Group A); 16% (14/86) knew prenatally but had no counselling (Group B); and 15% (13/86) found out at birth (Group C). There was no difference in anxiety levels across groups before (p = 0.78) or after (p = 0.57) meeting with the paediatric orthopaedic surgeon; however, overall anxiety reduced significantly (p < 0.001). Conclusion We found no difference in the anxiety levels of across the three groups. Prenatal counselling for parents of children with likely clubfoot may not decrease parental anxiety, but nonetheless is very appreciated by the families who receive it. Level of Evidence Prognostic Level II

BACKGROUND: Reduction of variations may streamline healthcare delivery, improve patient outcomes, and minimize cost. The purpose of this study was to characterize variations in surgical rates and hospital costs for treatment of pediatric distal radius fractures (DRFs) using Pediatric Health Information System (PHIS) database. METHODS: The PHIS database was queried from 2009-2013 for DRFs in patients 4-18 years of age. Patients who underwent surgical treatment with internal fixation were identified using surgical CPT codes and/or ICD-9 procedure codes. 25 children’s hospitals were included. Surgical rates and hospital costs were modeled. Rates were adjusted and standardized for gender, age, presence of other diagnoses, and year. RESULTS: The aggregate rate of surgery for treatment of DRF was 2.65% and for open surgery was 0.81%. The standardized surgical rates for the 25 hospitals ranged widely, from 1.45% to 13.8% and for open surgical treatment from 0.51% to 4.27%. Six of the 25 hospitals had rates significantly higher than the aggregate for surgical treatment. Standardized hospital costs per patient ranged from $361 to $1,088 (2013 US dollars) across the hospitals with fairly uniform distribution. CONCLUSIONS: In the United States, there is great variability in practice and hospital costs of treatment of distal radius fractures. Further characterization of the root causes of these variations, and the effect, if any, on patient outcomes, is needed to improve value delivery in pediatric orthopaedic care. Level of Evidence: II

Purpose To compare two common surgical techniques of epiphysiodesis: drill/curettage epiphysiodesis (PDED) versus cross screw epiphysiodesis (PETS). The hypothesis is that the two techniques have similar efficacy but demonstrate differences in length of hospital stay (LOS), time to return to activity and complication rates. Methods A retrospective review of growing children and adolescents less than 18 years old who required an epiphysiodesis with leg-length discrepancy (LLD) of 2 cm to 6 cm with minimum two years of follow-up was conducted. Characteristics including age at surgery, gender, epiphysiodesis location, side, operative time, LOS and hardware removal were compared across treatment groups. LLD, expected growth remaining (EGR) and bone age were determined preoperatively and at most-recent visit. The correction ratio (change in EGR) was calculated along with a 95% confidence interval (CI) to assess if correction in leg length was achieved. Results A total of 115 patients underwent epiphysiodesis in the femur (53%), tibia (24%) or a combination (24%). The cohort was 47% male, with a mean age of 12.6 years (7.7 to 17.7) at surgery. Median follow-up was 3.7 years (2.0 to 12.7). In all, 23 patients underwent PETS and 92 patients had PDED. Both treatment groups achieved expected LLD correction. There was no significant difference in median operative time, complication rates or LOS. PETS patients returned to activity at a mean 1.4 months (interquartile range (IQR) 0.7 to 2.1) while PDED patients returned at a mean 2.4 months (IQR 1.7 to 3) (p < 0.001). Conclusion Effectiveness in achieving expected correction, LOS and operative time are similar between screw and drill/curettage epiphysiodesis. Patients undergoing PETS demonstrated a faster return to baseline activity than patients with PDED. Level of Evidence III

Purpose Treatment of idiopathic clubfoot with the Ponseti method is now standard, but predicting relapse can be difficult. Most experts recommend bracing to the age of four years, but this can be challenging for families, and may not be necessary in all patients. The purpose of this study is to compare patterns of bracing and age of relapse to help determine if predictable patterns exist. Methods The 70 patients with idiopathic clubfoot treated initially with the Ponseti technique who had relapse of their clubfoot were identified. Relapse was defined as a return to casting or surgery due to recurrent deformity. Data collected included demographics, treatment and brace adherence. Patients who sustained initial relapse before the age of two years were compared with those who sustained initial relapse after the age of two years. Results In total 56% (39/70) had their initial relapse prior to age two years while 44% (31/70) were after age two years. Of the patients who relapsed prior to the age of two years, 28% (11/39) were adherent with bracing while 72% were non-­adherent. For patients who initially relapsed after age two, 74% (23/31) were adherent with bracing while 26% were non-adherent (p < 0.001). Of those who had initial ­relapse ­prior to age two, a subsequent relapse was seen in 69% (27/39). Conclusion Patients with idiopathic clubfoot who experienced recurrence prior to age two years are significantly more likely to be non-adherent with bracing than those who sustain recurrence after age two. After initial relapse prior to age two, bracing adherence does not affect likelihood of subsequent recurrence.

OBJECTIVES: Pediatric pain management has rapidly changed over the last 2 decades. In this study, we describe the changing practices and adverse events (AEs) related to patient-controlled analgesia (PCA) and/or nurse-controlled analgesia (NCA) over a 22-year period. METHODS: After institutional review board approval, retrospective data from a single tertiary-care pediatric hospital were collected between 1994 and 2016. Subgroup analyses were done for surgical and medical case patients. We reported the number of times that PCA and/or NCA was ordered annually, the median and interquartile ranges for age, PCA and/or NCA duration and length of stay, and AE frequencies. RESULTS: Over 22 years, 32 338 PCAs and/or NCAs were ordered in this institution. Morphine and hydromorphone were used most commonly. Between 1994 and 2006, initial orders for PCA and/or NCA increased 2.5-fold. After 2007, initial orders for PCA and/or NCA rapidly decreased; after 2013, the decrease continued at a slower rate, with a total of 1007 orders in 2016. This decrease occurred despite increased hospital admissions and surgeries. Between 2007 and 2012, peripheral nerve blocks rapidly increased (10-fold). After 2002, 146 AEs were reported (1.0%). Of those, 50.5% were nonintercepted, and 20.6% were intercepted AEs; 5.5% and 6.2% were preventable and nonpreventable AEs, respectively. CONCLUSIONS: PCA and/or NCA usage continues to be common in pediatric patients, although usage has declined and stabilized in the setting of other emerging methods of analgesia and increases in the number of minimally invasive surgical procedures. The overall rate of AEs was extremely low. However, improvements to eliminate all errors are needed, especially with medications with a great risk of harm (such as opioids).

Purpose: To compare two common surgical techniques of epiphysiodesis: drill/curettage epiphysiodesis versus cross screw epiphysiodesis. The study hypothesis is that these two techniques have similar efficacy, but demonstrate differences in hospital stay and complication rates. Methods: Between 2004 and 2012 a retrospective review of patients 0- 18 years of age who required an epiphysiodesis to correct a leg length discrepancy (LLD) of 2-6 cm with minimum 2 year follow up were identified. Only cases with screw (S) or drill/curettage (D) epiphysiodesis technique …

Clubfoot, a common major structural malformation, develops early in gestation. Epidemiologic studies have identified higher risks among boys, first-born children, and babies with a family history of clubfoot, but studies of risks associated with maternal exposures are lacking. We conducted the first large-scale, population-based, case-control study of clubfoot with detailed information on maternal medication use in pregnancy. Study subjects were ascertained from birth defect registries in Massachusetts, New York, and North Carolina during 2007-2011. Cases were 646 mothers of children with clubfoot without other major structural malformations (i.e., isolated clubfoot); controls were mothers of 2,037 children born without major malformations. Mothers were interviewed within 12 months of delivery about medication use, including product, timing, and frequency. Odds ratios were estimated for exposure to 27 medications in pregnancy months 2-4 after adjustment for study site, infant sex, first-born status, body mass index (weight (kg)/height (m)(2)), and smoking. Odds ratios were less than 1.20 for 14 of the medications; of the remainder, most odds ratios were only slightly elevated (range, 1.21-1.66), with wide confidence intervals. The use of antiviral drugs was more common in clubfoot cases than in controls (odds ratio = 4.22, 95% confidence interval: 1.52, 11.73). Most of these results are new findings and require confirmation in other studies.

Objective Routine prenatal ultrasound has often resulted in the early detection of musculoskeletal disorders. The purpose of this study was to determine which socioeconomic factors are associated with prenatal detection of clubfoot.

Objectives: Orthopaedists often speculate how weather and school schedule may influence pediatric orthopedic trauma volume, but few studies have examined this. This study aims to determine: how do weather patterns, day, month, season and public school schedule influence the daily frequency of pediatric orthopedic trauma consults and admissions? Methods: With IRB approval, orthopedic trauma data from a level 1 pediatric trauma center, including number of daily orthopedic trauma consults and admissions, were collected from July 2009 to March 2012. Historical weather data (high temperatures, precipitation and hours of daylight), along with local public school schedule data were collected for the same time period. Univariate and multivariate regression models were used to show the average number of orthopedic trauma consults and admissions as a function of weather and temporal variables. Results: High temperature, precipitation, month and day of the week significantly affected the number of daily consults and admissions. The number of consults and admissions increased by 1% for each degree increase in temperature (p=0.001 and p Conclusion: Pediatric orthopedic trauma consultations and admissions are highly linked to temperature and precipitation, as well as day of the week and time of year.

Introduction : Tibia fractures are common in pediatric patients and time necessary to return to normal function may be underappreciated. The purpose of this study was to assess functional recovery in pediatric patients who sustain tibia fractures, utilizing the Pediatrics Outcome Data Collection Instrument (PODCI), in order to provide evidence-based information on post-injury functional limitations and anticipated recovery times. Methods : 84patients (out of 264 eligible patients, response rate 32%) age 1.5-18 years treated for a tibia fracture at a large children's hospital between 1/07 and 4/08 completed a PODCI questionnaire at 6 and 12 months post-injury. PODCI questionnaires were compared to previously reportednormal controls using Student's t-test in six categories. Results : At 6 months after injury, the Sports functioning PODCI score was significantly less than healthy controls in both the parent reports for adolescent (mean 88.71 versus 95.4) and adolescent self-report (mean 90.44 versus 97.1); these showed no difference at 12 months. Discussion : For adolescents who sustain fractures of the tibia, there remains a negative impact on their sports functioning after 6 months that resolves by 12 months. Physicians can counsel their patients that although they may be limited in their sports function for some time after injury, it is anticipated that this will resolve by one year from the time of injury. Level of Evidence : Level II.

Patients with idiopathic clubfoot are considered at increased risk for having developmental dysplasia of the hips (DDH). However, the studies showing this association have been relatively small. Many clinicians who treat idiopathic clubfoot routinely screen the hips of these patients with ultrasound or radiograph due to the concerns of increased risk of DDH. We evaluated a large clubfoot population to determine the risk of DDH and compare this to a population of children without clubfoot. We also evaluated if the clubfoot patients found to have DDH would have been discovered by standard DDH screening.We identified infants in 3 states (MA, NY, NC), who were reported to each state's birth defects registry as having a clubfoot. A second cohort of infants without clubfoot was also identified as a control group. Mothers of these children were contacted to be included in the study, and a computer-assisted telephone interview was administered by one of the study nurses, including questions about treatment of DDH. The child's median age at interview was 7 months. Mothers of clubfoot cases were also contacted for follow-up at mean age of 3.3 years.Families of 677 patients with clubfoot and 2037 controls were interviewed. A total of 5/677 (0.74%) patients with clubfoot and 5/2037 (0.25%) controls reported having their infant treated with a brace or harness for hip problems (P=0.134). Of the patients with clubfoot, 2 of them did not need treatment for their DDH and 2 would have been discovered by standard hip screening. Follow-up study at 3.3 years of age found no serious late hip dysplasia.Treatment of DDH was uncommon in all children; the higher proportion in infants with clubfoot was not statistically different than controls. Of the patients with clubfoot and DDH, standard hip screening would have been appropriate and others did not need treatment. These data suggest that routine hip ultrasound or radiographic screening of idiopathic clubfoot patients is not necessary unless indicated by the standard infant hip screening.Level 3 study.

Clubfoot is a common structural malformation, occurring in approximately 1/1,000 live births. Previous studies of sociodemographic and pregnancy-related risk factors have been inconsistent, with the exception of the strong male preponderance and association with primiparity. Hypotheses for clubfoot pathogenesis include fetal constraint, Mendelian-inheritance, and vascular disruption, but its etiology remains elusive. We conducted a population-based case-control study of clubfoot in North Carolina, Massachusetts, and New York from 2007 to 2011. Mothers of 677 clubfoot cases and 2,037 non-malformed controls were interviewed within 1 year of delivery about socio-demographic and reproductive factors. Cases and controls were compared for child's sex, maternal age, education, cohabitation status, race/ethnicity, state, gravidity, parity, body mass index (BMI), and these pregnancy-related conditions: oligohydramnios, breech delivery, bicornuate uterus, plural birth, early amniocentesis (

Background: The United States Preventive Services Task Force recently determined that they could not recommend any screening strategies for developmental dysplasia of the hip. Disparate findings in the literature and treatment-related problems have led to confusion about whether or not to screen for this disorder. The purpose of the present study was to determine, with use of expected-value decision analysis, which of the following three strategies leads to the best chance of having a non-arthritic hip by the age of sixty years: (1) no screening for developmental dysplasia of the hip, (2) universal screening of newborns with both physical examination and ultrasonography, or (3) universal screening with physical examination but only selective use of ultrasonography for neonates considered to be at high risk. Methods: Developmental dysplasia of the hip, avascular necrosis, and the treatment algorithm were carefully defined. The outcome was determined as the probability of any neonate having a non-arthritic hip through the age of sixty years. A decision tree was then built with decision nodes as described above, and chance node probabilities were determined from a thorough review of the literature. Foldback analysis and sensitivity analyses were performed. Results: The expected value of a favorable hip outcome was 0.9590 for the strategy of screening all neonates with physical examination and selective use of ultrasonography, 0.9586 for screening all neonates with physical examination and ultrasonography, and 0.9578 for no screening. A lower expected value implies a greater risk for the development of osteoarthritis as a result of developmental dysplasia of the hip or avascular necrosis; thus, the optimum strategy was selective screening. This model was robust to sensitivity analysis, except when the rate of missed dysplasia rose as high as 4/1000 or the rate of treated hip subluxation/dislocation was the same; then, the optimum strategy was to screen all neonates with both physical examination and ultrasonography. Conclusions: Our decision analytic model indicated that the optimum strategy, associated with the highest probability of having a non-arthritic hip at the age of sixty years, was to screen all neonates for hip dysplasia with a physical examination and to use ultrasonography selectively for infants who are at high risk. Additional data on the costs and cost-effectiveness of these screening policies are needed to guide policy recommendations. Level of Evidence: Economic and decision analysis Level II. See Instructions to Authors for a complete description of levels of evidence.