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Pediatric medial malleolus fractures are commonly Salter-Harris (SH) type III or IV fractures of the distal tibia and are associated with a risk of physeal bar formation and subsequent growth disturbance. The purpose of this study was to determine the incidence of physeal bar formation following pediatric medial malleolus fracture and evaluate for patient and fracture characteristics predictive of physeal bar formation. Seventy-eight consecutive pediatric patients during a 6-year period who had either an isolated medial malleolar or a bimalleolar ankle fracture were retrospectively reviewed. Forty-one of 78 patients had greater than 3 months of radiographic follow-up and comprised the study population. Medical records were reviewed for demographic information, mechanism of injury, treatment, and need for further surgery. Radiographs were reviewed to assess for initial fracture displacement, adequacy of fracture reduction, SH type, percentage of the physeal disruption from the fracture, and physeal bar formation. Twenty-two of 41 patients (53.7%) developed a physeal bar. The mean time to diagnosis of physeal bar was 4.9 months (range, 1.6–11.8 months). Twenty-seven percent (6 of 22) of bars were diagnosed at greater than 6 months from injury. Adequacy of reduction was predictive of physeal bar formation, although all patients were reduced to within 2 mm. The mean residual displacement of patients with a bar was 1.2 mm compared with 0.8 mm for those without a bar (P=.03). Because the bar formation rate is greater than 50% on radiographs, routine radiographic assessment of all pediatric medial malleolar fractures should continue for at least 12 months after injury. [Orthopedics. 202x;4x(x):xx–xx.]

Category: Other; Midfoot/Forefoot Introduction/Purpose: While evaluation of an underlying neurologic disorder in children with cavovarus foot deformity (CVD) is of great importance, no standardized method of neurologic assessment exists. Moreover, the yield of commonly employed diagnostic measures remains unstudied. This study aims to compare the diagnostic yield of traditional methods of neurologic assessment for patients CVD of unknown etiology to a more advanced diagnostic algorithm. Methods: An IRB-approved retrospective review of patients presenting to a single pediatric tertiary care center for bilateral or unilateral CVD was performed over a 19-year period. Patients with a known etiology for their deformity or preexisting neurologic or syndromic diagnoses were excluded. Neurologic evaluation of all remaining patients was conducted by a pediatric neurologist using one of two diagnostic algorithms. The traditional diagnostic algorithm (TDA) consisted of clinical examination, MRI of the brain and spinal cord and/or EMG/NCV. The advanced diagnostic algorithm (ADA) Included all components of the TDA in addition to genetic testing, and/or muscle/nerve biopsy and/or repeat EMG/NCV testing when initial workup remained negative. These diagnostic algorithms were compared regarding determination of an underlying etiology for CVD. Results: 108 patients (average age 9.7 years) were included. 96 were assessed via the TDA which detected an underlying neurologic diagnosis in 56 (58%). 15 had central neurologic disease, 35 had peripheral neuropathies and 6 had combined central/peripheral neuropathology. Of the 40 patients in whom no diagnosis was made using the TDA, 21 were further assessed using the ADA revealing a diagnosis in 15 (71%), thereby increasing the diagnostic yield to 71/77 patients (92%) when the ADA was incorporated and 71/96 (74%) overall. Moreover, 23 of 41 patients (56%) diagnosed with an unspecified polyneuropathy by TDA received a more specific diagnosis via the ADA. Definitive diagnosis was achieved solely by genetic testing without the TDA in 12 patients, 75% of whom had variants of Charcot-Marie-Tooth disease. Conclusion: Neurologic etiology remains undetected in 42% of children with CVD using solely neuroaxis imaging and electrodiagnostic testing. Determination of an underlying neurologic cause for deformity can be increased by over 30% through the incorporation of genetic testing and other components of the ADA.

Abstract Purpose This article prospectively examines the functional outcome measures following management of vascular insult secondary to paediatric supracondylar humerus fractures (SCHFX) using validated outcome measures. Methods The three-year, prospective, IRB-approved study consecutively enrolled operative SCHFX patients. Clinical data included presence and symmetry of the radial pulse in injured and uninjured extremities, Doppler examination of non-palpable (NP) pulses and perfusion status of the hand. Pediatric Outcomes Data Collection Instruments (PODCI) and the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) Measures were used to assess functional outcome at final follow-up. Multiple regression analysis was used to determine the relationship between the presence of a vascular abnormality and functional outcome while controlling for other injury parameters. Results A total of 146/752 enrolled patients (mean age 6.8 years; range 2 years to 13 years) completed functional outcome measures at final follow-up. Of these, 20 (14%) patients had abnormal vascular exams at presentation: nine (6%) with palpable asymmetric pulse and 11 (7.5%) with NP pulse. Of those with NP pulses, nine/11 (6%) were Dopplerable and two (1.5%) lacked identifiable Doppler signal. Patients with a symmetric, palpable pulse demonstrated better PODCI pain and comfort scores (95.2 versus 85.2) (p < 0.0001), and QuickDASH scores (10.9 versus 21.6) (p < 0.007) compared to those with any abnormal vascular examination. Patients with palpable pulses, regardless of symmetry, demonstrated ­significantly higher PODCI pain and comfort scores (94.6 versus 84.7) (p < 0.003) than NP pulses. Conclusions In children with operative SCHFX, an abnormal vascular examination at presentation is predictive of poorer outcomes in pain and upper extremity function. A palpable pulse, versus NP, is predictive of better pain and comfort at final follow-up. Level of evidence II

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: Correction of juvenile bunion deformities has historically been fraught with high recurrence rates leading to dissatisfaction among patients and surgeons alike. It is now recognized that these historically poor results have likely been due to a failure to correct the elevated distal articular metatarsal angle (DMAA) encountered in the vast majority of juvenile bunions. Though preoperative planning for deformity correction hinges on plain radiographic measurement of the DMAA, accuracy of this measurement in the juvenile population has not been studied. The purpose of this study is to compare plain radiographic measurements of the DMAA to in-vivo DMAA measurement. Methods: This is an IRB-approved retrospective r¬eview of prospectively enrolled patients over a 4-year period at single pediatric institution who underwent a scarf osteotomy for management of a juvenile bunion deformity. Children with neurologic disorders, autoimmune disease, congenital foot or extremity deformities, or history of prior ankle or foot surgery were excluded. Pre-operative DMAA was measured on standardized weight-bearing foot radiographs. In-vivo DMAA goniometric measurement was made at the time of surgery following capsulotomy and direct visualization of the articular surface of the metatarsal head. A Pearson’s correlation coefficient was calculated to assess the relationship between radiographic and in-vivo measurements. Results: 19 feet in 20 patients with an average age at surgery of 15.9 years (range 13.1 -17.9 years) met inclusion criteria. Radiographic DMMA averaged 25.2o (range 7o - 32o) and intra-operative DMAA averaged 18.1o (range 5o - 69o). Pearson correlation coefficient revealed no correlation between radiographic and in-vivo DMAA measurements (r=0.186, p=0.45). Repeat analysis after removing three outliers with very high in-vivo DMAA measurements (greater than 40o) also showed no correlation between radiographic and anatomic DMAA measurements (r=0.051, p=0.85). As the in-vivo DMAA increased, radiographic measurements were more likely to underrepresent the true degree of deformity present (Figure 1). Conclusion: Plain radiographic DMAA measurements do not correlate to actual articular deformity in children with juvenile bunions. Moreover, as the degree of in-vivo DMAA increases, radiographic assessment is increasingly likely to underrepresent the extent of deformity correction required to achieve a normal DMAA intra-operatively. Surgeons should therefore not rely solely on plain radiography for preoperative planning or to assess adequacy of surgical correction of the juvenile bunion deformity. This is of particular importance for those performing minimally invasive bunion surgery as neither the amount of desired correction nor the surgical correction achieved can be reliably determined using plain radiography alone.

Category: Midfoot/Forefoot; Hindfoot Introduction/Purpose: The purpose of this study was to use pedobarography and patient reported outcome measures (PROs) to determine if obese adolescents with flexible flatfoot deformity (FFD) have more severe alterations in dynamic plantar pressures than patients with FFD who fall within normal BMI percentiles (wnBMI), and if such alterations affect pain and activity. Methods: A retrospective review of patients aged 10 to 18 years with non-syndromic symptomatic FFD enrolled in a prospective IRB approved registry, was performed. Overweight (BMI≥ 85%) patients were compared to wnBMI patients with regard to dynamic plantar pressure measures and PRO scores. Pedobarograph foot data were subdivided into regions: medial/lateral - hindfoot, midfoot and forefoot. Plantar pressure variables were normalized to account for differences in foot size, body weight and walking speed. Contact area was normalized by the total foot (CA%), maximum force by body weight (MF%) and contact time by total time of the roll over process (CT%). Two foot-specific PROs were assessed including the Foot and Ankle Outcome Score (FAOS) and the Oxford Ankle Foot Measure for Children (OxAFQ-C). Results: Of the 48 adolescents studied, 27(56%) were overweight and 21(44%) were wnBMI. After normalization of the data, overweight patients had significantly greater medial midfoot MF%, while CT% was increased across the medial and lateral midfoot and hindfoot regions (Table 1). Significant correlations were made between BMI percentile and MF% in the medial midfoot (r = 0.39, p = 0.006), CT% in the medial (r=0.52, p< 0.001 and CT% lateral (r=0.55, p< 0.001) midfoot. There were no significant differences between the overweight and wnBMI cohorts for CA% or any PRO pain or activity sub-scores. No significant correlations were made between pedobarograph parameters and PRO sub-scores. Conclusion: Although obese adolescents with FFD exhibit greater forces and greater time spent during the rollover process in the medial midfoot than patients with wnBMI, they do not report worse pain or disability. While it seems intuitive that increased body weight would be associated with higher levels of pain in adolescents with FFD, this does not seem to be the case. Though significant increases in plantar force and contact time were found in the obese adolescents, this did not result in greater discomfort or functional limitation. It, therefore, cannot be concluded that BMI alone is a differentiating factor in FFD symptomatology.

Category: Other Introduction/Purpose: The purpose of this study is to compare rates of recurrent toe-walking following operative intervention between idiopathic toe walkers and toe walkers with associated sensory processing/autism spectrum disorders. Methods: An IRB-approved retrospective review of patients at a single pediatric institution who underwent surgical treatment for toe-walking over a 12-year period was conducted. Children with peripheral or central neurologic disorders, muscle disorders, congenital foot/extremity deformities, prior ankle/foot surgery, and those not managed with an isolated triceps surae procedure were excluded. The remaining patients were divided into those with idiopathic toe-walking (ITW Group) and those with toe- walking associated with sensory processing/autism spectrum disorders (SPD Group). Recurrence of toe walking and need for additional surgery for recurrence were compared between cohorts. Recurrence rates and subsequent operations were assessed for each group. Multivariate regression and Fischer exact test were used to evaluate differences in group characteristics. Results: 106 patients met inclusion criteria. 29 patients (27%) had an associated sensory processing disorder, the remaining 77 patients comprised the ITW group. There were no differences between groups in length of follow-up (p=0.08) or type of initial surgery performed (p=0.48). The SPD group contained a significantly greater percentage of males (75% vs 56%, p=0.01) and were younger at the age of index surgery (8.5 vs 10 years, p=0.03). At an average follow-up time of 1.2 years, 11 patients (10%) developed clinical recurrence, of whom, 4 underwent a subsequent intervention. The SPD group had significantly higher rates of recurrence than idiopathic toe walkers (24% vs 5%, p=0.009). Multivariate regression analysis demonstrated that an underlying sensory processing disorder was an independent predictor of recurrence (p=0.018, OR=7.5). Conclusion: Clinical recurrence following the surgical treatment of toe-walking is over seven times greater in children with autism spectrum and/or other sensory processing disorders than idiopathic counterparts.

Acetabular retroversion (AR) alters load distribution across the hip and is more prevalent in pathologic conditions involving the hip. We hypothesized the abnormal orientation and mechanical changes may predispose certain individuals to stress injuries of the femoral neck. We retrospectively reviewed the anteroposterior (AP) pelvic radiographs of 54 patients (108 hips) treated for a femoral neck stress fracture (FNSF) and compared these radiographs with those for a control group of patients with normal pelvic radiographs. We determined presence of a crossover sign (COS), femoral neck abnormalities, and neck shaft angle. The prevalence of a positive COS was greater in patients with stress fractures than in the control subjects (31 of 54 [57%] versus 17 of 54 [31%], respectively) and higher than for control subjects reported in the literature. Thirteen patients had radiographic changes of the femoral neck consistent with femoroacetabular impingement (FAI). These radiographic abnormalities were seen more commonly in retroverted hips. A greater incidence of AR was noted in patients with FNSF. Potential implications include more aggressive screening of military recruits with AR and the new onset of hip pain. Finally, we present an algorithm we use to diagnose and treat these relatively rare FNSFs. Level of Evidence: Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Category: Other Introduction/Purpose: While transfer of the tibialis anterior tendon (TAT) to the lateral cuneiform (LC) following serial casting has been used for over 60 years to treat relapsed clubfoot deformity, modern methods of tendon fixation remain largely unstudied. Though interference screw fixation has the potential of obviate concerns of pressure necrosis and proper tendon tensioning associated with plantar button suspensory stabilization, a better understanding of LC morphology in young children is a necessary first step in assessing the viability of this fixation technique. The purpose of this investigation is therefore to define LC morphology in children aged 3-6 years. Methods: A retrospective radiographic review of 40 healthy pediatric feet aged 3-6 years who had either MRI or CT scans was performed at a single pediatric hospital. The length, width, and height of only the ossified portion of the LC were measured digitally using sagittal, coronal, and axial imaging. In addition, the maximal cross-sectional diameter of the TAT was measured at the level of the tibiotalar joint. Results: Average ossified LC width ranged from 8.5mm in the 3-year-old cohort to 10.3mm in 6-year-old children. While the average width increased with each year of age, ANOVA testing revealed no statistically significant difference in width between age groups (p=0.091). Average ossified LC length ranged from 13.5mm in the 3-year-old cohort to 18.3mm in 6-year-old children with statistically significant increases in all age groups separated by two or more years (p=0.017). the TAT to ossified LC width ratio ranged from 44% to 53% across age groups. (table 1). Conclusion: The dimensions of the LC ossification center are large enough to allow interference screw fixation in children 3 to 6 years of age.

Breast, prostate, renal, thyroid, and lung carcinomas commonly metastasize to bone. Managing skeletal metastatic disease can be complex. Pain is the most common presenting symptom and requires thorough radiographic and laboratory evaluation. If plain-film radiography is not sufficient for diagnosis, a bone scan may detect occult lesions. Patients with lytic skeletal metastases may be at risk for impending fracture. Destructive lesions in the proximal femur and hip area are particularly worrisome. High-risk patients require immediate referral to an orthopedic surgeon. Patients who are not at risk for impending fracture can be treated with a combination of radiotherapy and adjuvant drug therapy. Bisphosphonates diminish pain and prolong the time to significant skeletal complications.

Category: Hindfoot; Other Introduction/Purpose: Though resection and soft tissue interposition is the mainstay of surgical treatment for symptomatic calcaneonavicular coalitions (CNCs) that fail conservative treatment, some consternation exists as to balancing adequacy of resection with violation of adjacent talonavicular and calcaneocuboid (CC) articulations. As better understanding of nearby articular anatomy might be helpful in determining extent of resection, this study aims to identify differences in the anatomy of the CC articulation between feet with and without CNCs. Methods: A retrospective radiographic analysis of patients with symptomatic CNCs presenting to a single tertiary care pediatric hospital from 2010-2019 was performed. Patients without computed tomographic (CT) or magnetic resonance imaging (MRI) were excluded. Using either CT or MRI and standardized anatomic landmarks, the length and morphology of the calcaneal and cuboid articular surfaces were documented at the CC joint. When bilateral imaging was available in patients with a unilateral coalition, measurements were also made on the uninvolved side to provide a cohort of normal controls for comparison. Results: 81 CNCs in 55 patients were identified along with18 normal feet. Mean age was 11.7 years at the time of advanced imaging. In the coalition group, an accessory cuboid facet was identified articulating with the calcaneal portion of the coalition in 61/81 (75.3%) feet. The mean total length of the cuboid articular surface measured 28.6 mm (range, 22.4-34.9 mm). The average length of the accessory facet was 10.6 mm (range, 6.0-15.5 mm) while the length of the primary cuboid articulation with the calcaneus was 15.9 mm (range, 6.4-23.2 mm). Thus, the accessory facet comprised 37.2% of the cuboid articular surface in these patients. Patients without CNCs had a significantly larger primary cuboid articulation with the calcaneus of 21.6 mm (p<0.0001). An accessory cuboid facet was identified in only a single foot in the normal cohort. Conclusion: An accessory cuboid facet is present in over 75% of patients with CNCs and comprised nearly 40% of the proximal cuboid articular length. Moreover, significant differences in the shape of the cuboid portion of the CC joint were present in feet with and without CNCs. This information may be useful when planning the extent of CNC surgical resection as including the coalition side of the accessory articulation may have value in restoring hindfoot motion.