Junichi Tamai

Access to care for the adolescent anterior cruciate ligament patient with Medicaid versus private insurance.

Purpose: To determine the potential impact of type of health insurance on access to outpatient orthopaedic care for an adolescent patient with an acute anterior cruciate ligament (ACL) tear. Methods: The offices of 42 orthopaedic surgeons in the Greater Cincinnati area, to include Ohio, Indiana, and Kentucky were contacted on 2 separate occasions describing a fictitious 14-year-old male with an acute ACL tear. The 2 calls were separated by a period of 2 to 4 weeks. The independent variable was the patient’s insurance status, reported as either Medicaid or private insurance. Statistical comparison of the rates of successful appointment scheduling was performed through the Fisher exact test. Results: Thirty-eight of 42 Orthopaedic surgery practices (90%) offered the privately insured 14-year-old ACL patient an appointment within 2 weeks, while only 6 of 42 (14%) offered the Medicaid patient such an appointment. The difference in these rates was statistically significant (P<0.0001) with the odds of getting an appointment with private insurance being 57 times higher than that with Medicaid (95% confidence interval: 12.87, 288.62). Conclusions: Access to orthopaedic care for children on Medicaid continues to be a problem in the United States. Previous pediatric studies have documented that the reason for these discrepancies in access are related primarily to Medicaid reimbursement rates (approximately 23% of private insurance). Ours is the first study to show that these same limitations exist for teenagers with acute knee injuries likely to require surgery.

Nonoperative treatment of both-bone forearm shaft fractures in children: predictors of early radiographic failure.

Background Forearm shaft fractures are the third most common fracture in children. Although closed reduction and casting is the preferred treatment; outcomes remain variable. The purpose of this study was to identify factors associated with failure of nonoperative treatment for pediatric complete forearm shaft fractures and to explore the time frame in which failure is likely. Methods Male patients less than 18 years and female patients less than 17 years of age, who were treated for a complete both-bone forearm shaft fracture between January 2005 and January 2008, were included. A pediatric orthopaedic surgeon evaluated all radiographs to confirm the diagnosis. Fractures were classified as proximal, middle, or distal, based one-third division of the shaft. Thresholds for maximum acceptable angulation for male patients <10 years and female patients <8 years were as follows: 10 degrees for proximal-third, 15 degrees for middle-third, 20 degrees for distal-third fractures; for female patients ≥8 years and male patients ≥10 years, up to 10 degrees was considered acceptable at all the levels. Angulation was measured at initial presentation and at weekly intervals for 4 weeks post fracture. Anteroposterior measurements accounted for the natural bow of the radius. Multivariable logistical regression was performed to identify predictors of failure. Results Of the 321 patients identified, 282 underwent closed reduction and casting. The average age of patients was 8.5 years, 63% were male. Fifty-one percent of patients exceeded angulation criteria within the follow-up period. Of those who failed, 55% failed by the end of the first week, and 95% failed by 3 weeks. Odds of failure was greatest in patients ≥10 years (odds ratio (OR)=2.79; confidence interval (CI) 95, 1.47-5.29), those with proximal radius fractures (OR=6.81; CI95, 3.28-14.14), and those with initial ulna angulations <15 degrees (OR=2.94; CI95, 1.49-5.83). Conclusions Children with 10 years of age or older, with proximal-third radius fractures, and ulna angulation <15 degrees seem to be at highest risk for failure when treated nonoperatively for both-bone forearm fractures. As the majority of failures occur early, early surgical decision-making is encouraged. Level of Evidence Prognostic Level II.

Complications of elastic stable intramedullary nailing in pediatric fracture management: AAOS exhibit selection.

Elastic stable intramedullary nailing (ESIN) for pediatric fracture management has gained increasing popularity since its introduction in the late 1970s. Relatively few modifications have been made to the original technique in the last forty years, which illustrates the sound biomechanical principles and simplicity of the technique. Jean-Paul Metaizeau, the originator of the technique, pointed out that poor results after ESIN were typically due to incorrect constructs, incorrect indications, and insufficient surgeon training1. The initial (1977 to 1980) indications for ESIN were limited to pediatric patients with multiple injuries or head trauma in whom cast or traction treatment was not practical. Later, its use was extended to all diaphyseal fractures of long bones in children. With widespread acceptance, the indications have been further expanded to metaphyseal fractures, comminuted fractures, pathologic fractures, and fractures of smaller bones (including clavicular, supracondylar humeral, and metacarpal fractures). ESIN was introduced in the United States in 19972. The literature is replete with reports of the clinical success of ESIN, but reports related to its complications are scarce. The aim of this manuscript was to review the common complications related to ESIN and provide technical pearls to manage and avoid complications. The principle of ESIN involves balanced nailing (i.e., use of two flexible nails of the same diameter to provide elasticity and stability in opposite directions at the fracture site). This principle is different from the principle of the Ender nail, which is based on maximal filling of the medullary canal3. To achieve balanced nailing when two nails are used, the apex of curvature of each nail should be at the fracture site. To achieve this, both nails should have the curvature of the letter “C” if they are inserted from opposite sides of the bone, or one nail should have …

Limitations of the radiocapitellar line for assessment of pediatric elbow radiographs.

Background The radiocapitellar line (RCL) is recommended for evaluating radiocapitellar alignment in skeletally immature elbows, yet its parameters have not been clearly defined. This study systematically assesses the RCL relationship in normal elbows, investigating the impacts of radiographic view, choice of anatomic landmarks, patient age, forearm position, and observer bias on the manner in which the RCL intersects the capitellum. Methods On radiographs of 20 normal elbows (age range, 1 to 8 y), 3 pediatric orthopaedic surgeons, blinded to clinical history, drew lines (RCLs) on anteroposterior and lateral projections, along the radial shaft and neck, and with and without the capitellum visible. Line placement was repeated 2 weeks later. The relationship of each RCL to the capitellum was assessed continuously using the perpendicular distance to the center of the capitellum, normalized to capitellar width [line-capitellar distance (LCD)], and categorically as passing through the middle third, outer two-thirds, or outside the capitellum. Results Of the 480 RCLs drawn, 23 (5%) missed the capitellum and 224 (47%) missed the middle third. More radial neck than shaft lines intersected the middle third on both anteroposterior and lateral views (P<0.05, Fisher exact test), with the lowest LCD values for neck lines on the lateral view (P<0.05, analysis of variance (ANOVA)). More RCLs intersected the middle third when the capitellum was visible than when it was obscured (P=0.03, Fisher exact test), suggesting an effect of observer bias. Patient age correlated inversely with LCD (P<0.001). The angle between the neck and shaft lines correlated positively with LCD (P<0.001), suggesting an impact of forearm rotation position. Intraobserver and interobserver reliability was moderate-to-substantial (&kgr;=0.40-0.75). Conclusions The RCL best defines normal radiocapitellar alignment when the line is drawn along the radial neck on the lateral view, although this relationship is affected by bias, patient age, and forearm rotation position. The RCL does not reliably intersect the middle third of the capitellum, arguing against its sufficiency for assessing precise radiocapitellar alignment. Level of Evidence Diagnostic Level 3.

Interobserver and intraobserver reliability of the modified waldenström classification system for staging of legg-calvé-perthes disease

BACKGROUND The absence of a reliable classification system for Legg-Calvé-Perthes disease has contributed to difficulty in establishing consistent management strategies and in interpreting outcome studies. The purpose of this study was to assess interobserver and intraobserver reliability of the modified Waldenström classification system among a large and diverse group of pediatric orthopaedic surgeons. METHODS Twenty surgeons independently completed the first two rounds of staging: two assessments of forty deidentified radiographs of patients with Legg-Calvé-Perthes disease in various stages. Ten of the twenty surgeons completed another two rounds of staging after the addition of a second pair of radiographs in sequence. Kappa values were calculated within and between each of the rounds. RESULTS Interobserver kappa values for the classification for surveys 1, 2, 3, and 4 were 0.81, 0.82, 0.76, and 0.80, respectively (with 0.61 to 0.80 considered substantial agreement and 0.81 to 1.0, nearly perfect agreement). Intraobserver agreement for the classification was an average of 0.88 (range, 0.77 to 0.96) between surveys 1 and 2 and an average of 0.87 (range, 0.81 to 0.94) between surveys 3 and 4. CONCLUSIONS The modified Waldenström classification system for staging of Legg-Calvé-Perthes disease demonstrated substantial to almost perfect agreement between and within observers across multiple rounds of study. In doing so, the results of this study provide a foundation for future validation studies, in which the classification stage will be associated with clinical outcomes.

Ponseti method compared with soft-tissue release for the management of clubfoot: A meta-analysis study

AIM To compare the functional outcomes of patients who underwent open surgery vs Ponseti method for the management of idiopathic clubfoot and to determine whether correlations exist between functional outcome and radiographic measurements. METHODS A meta-analysis of the literature was conducted for studies concerning primary treatment of patients with idiopathic clubfoot. We searched PubMed Medline, EMBASE, and the Cochrane Library databases from January 1950 to October 2011. Meta-analyses were performed on outcomes from 12 studies. Pooled means, SDs, and sample sizes were either identified in the results or calculated based on the results of each study. RESULTS Overall, 835 treated idiopathic clubfeet in 516 patients were reviewed. The average follow-up was 15.7 years. Patients managed with Ponseti method did have a higher rate of excellent or good outcome than patients treated with open surgery (0.76 and 0.62, respectively), but not quite to the point of statistical significance (Q = 3.73, P = 0.053). Age at surgery was not correlated with the functional outcome for the surgically treated patients (r = -0.32, P = 0.68). A larger anteroposterior talocalcaneal angle was correlated with a higher rate of excellent or good outcomes (r = 0.80, P = 0.006). There were no other significant correlations between the functional and radiographic outcomes. CONCLUSION The Ponseti method should be considered the initial treatment of idiopathic clubfeet, and open surgery should be reserved for clubfeet that cannot be completely corrected.

Pediatric Triplane Ankle Fractures: Impact of Radiographs and Computed Tomography on Fracture Classification and Treatment Planning

BACKGROUND The purpose of this study was to compare the reliability of triplane fracture classification, displacement measurement, and treatment planning with the use of radiographs with and without computed tomography. METHODS One pediatric radiologist, one musculoskeletal radiologist, and three fellowship-trained pediatric orthopaedic surgeons rated a spectrum of twenty-five triplane fractures with use of radiographs alone and then with computed tomography scans on two separate occasions (two to four weeks apart). Raters classified the fracture pattern with use of the Rapariz classification system, measured the maximum intra-articular displacement, and drew the fracture on four outlines of the distal part of the tibia: one lateral view, one anteroposterior view, one axial view above the tibial physis, and one axial view below the physis. Reliability was assessed with kappa values and intraclass correlation coefficients. RESULTS The Rapariz triplane fracture classification had poor inter-rater reliability (a kappa of 0.17) and intra-rater reliability (a kappa of 0.31) with radiographs alone but moderate inter-rater reliability (a kappa of 0.41) and intra-rater reliability (a kappa of 0.54) with the addition of computed tomography. After reviewing computed tomography, raters changed the fracture pattern in 46% of ratings, the displacement from ≤2 mm to >2 mm in 39% of ratings, the treatment from nonoperative to operative in 27% of ratings, and either the orientation or number of screws in 41% of ratings. CONCLUSIONS Computed tomography had a definite impact on the fracture classification, displacement, and treatment plan, supporting its use as an adjunct to radiographs for the treatment of pediatric triplane fractures.

The Musculoskeletal Manifestations of the Coffin-lowry Syndrome

Coffin-Lowry syndrome (CLS) is a rare genetic disorder characterized by craniofacial abnormalities, mental retardation, short stature, and hypotonia. Patients with CLS may present with multiple musculoskeletal abnormalities. The purpose of this study was to identify and characterize the musculoskeletal findings in 10 patients with CLS. Eight patients presented with thoracolumbar kyphosis or kyphoscoliosis, with a mean Cobb angle of 45 degrees in the coronal plane and 31 degrees of thoracolumbar kyphosis. These may be progressive and difficult to treat, needing early surgical treatment. Close follow-up of the spinal deformities is strongly recommended to document progression. Sixty percent of the patients presented with bilateral flexible and painless planovalgus deformities. Hypoplasia of the ilium and hand deformities are common but do not seem to cause any functional problems. Observation is recommended for these asymptomatic hand, foot, and pelvic findings.

Hallux valgus interphalangeus deformity: A case series in the pediatric population

PURPOSE The objective of this report is to describe three cases (four feet) of hallux valgus interphalangeus deformity in the pediatric population. METHODS A retrospective review was completed to identify three patients (four feet) with a deformity consistent with hallux valgus interphalangeus. Patients were followed at regular intervals for a minimum of 6 months. Treatment modalities and clinical results were reviewed for all patients for this relatively rare entity in the skeletally immature population. RESULTS All patients in this report had a deformity that was not consistent with a traumatic etiology. Case number 1 had a significantly symptomatic deformity that failed conservative treatment, and eventually necessitated full surgical correction of the deformity. Symptom free unrestricted activity was obtained post-operatively, however final follow-up radiographs have demonstrated early changes consistent with arthritis. Case numbers 2 & 3 were relatively asymptomatic throughout their course of treatment, and responded well to non-operative intervention. CONCLUSION Based on these findings excision of the exostosis and soft-tissue realignment appears to be a reliable option for symptom relief for patients who present with a painful symptomatic hallux valgus interphalangeus deformity. However, the risk of degenerative changes following spur removal must be entertained prior to the procedure. On the contrary a pain free deformity that does not impact functionality of toe, or impair shoe ware may be treated successfully with conservative measures.

Spondylolisthesis: intraobserver and interobserver reliability with regard to the measurement of slip percentage.

Background Spondylolisthesis is often diagnosed and treated on the basis of measurements obtained from radiographs. Many physicians will perform surgery regardless of the patients symptoms above a specific slip percentage. However, current methods used to assess slip percentage are vague and lack appropriate standardization, leaving physicians to devise personal evaluation techniques. This study presents a defined method to calculate slip percentage that takes advantage of modern technology, is fast and simple to perform, and shows excellent intraobserver/interobserver reliability. Methods Four pediatric orthopaedic attendings each reviewed 30 radiographic cases of spondylolisthesis (grades 1 to 4) at the L5 to S1 level. The radiographs were measured twice through computer using PACS information management software with an interval of 2 days to 2 weeks between sessions. Using the PACS line tool, observers superimposed 6 lines onto each radiograph from which measurements were derived. The numerator in slip percentage (anterior displacement) was determined by 2 methods: the distance between a line outlining the posterior border of the sacrum and A: a line outlining the posterior border of L5 or B: a line parallel starting at the inferior, posterior corner of L5. The denominator in slip percent was determined by 2 methods. C: length of the inferior border L5 or D: length of the superior border of L5. This resulted in 4 different equations of slip percentage: A/C, A/D, B/C, and B/D. Analysis was performed using intraclass correlation coefficient. Results Slip percentage=A/D resulted in the highest intraclass correlation coefficient for both intraobserver and interobserver reliability (0.87 and 0.85, respectively). Slip percentage=B/C showed the poorest intraobserver reliability (0.69). Slip percentage=B/C and B/D had equally poor interobserver reliability (0.59). Conclusions Defining the numerator in slip percentage as the distance between a line outlining the posterior border of the sacrum and a line outlining the posterior border of L5 (A) results in the highest intraobserver/interobserver reliability. Defining the denominator in slip percentage as the length of the superior border of L5 (D) results in the highest intra/inter observer reliability. Level of Evidence Diagnostic level III.