Yoram Hemo

Intra- and interobserver reliability analysis of digital radiographic measurements for pediatric orthopedic parameters using a novel PACS integrated computer software program

BackgroundThe between-observer reliability of repeated anatomic assessments in pediatric orthopedics relies on the precise definition of bony landmarks for measuring angles, indexes, and lengths of joints, limbs, and spine. We have analyzed intra- and interobserver reliability with a new digital measurement system (TraumaCad Wizard™).MethodsFive pediatric orthopedic surgeons measured 50 digital radiographs on three separate days using the TraumaCad system. There were 10 anterior–posterior (AP) pelvic views from developmental dysplasia of the hip (DDH) patients, 10 AP pelvic views from cerebral palsy (CP) patients, 10 AP standing view of the lower limb radiographs from leg length discrepancy (LLD) patients, and 10 AP and 10 lateral spine X-rays from scoliosis patients. All standing view of the lower limb radiographs were calibrated by the software to allow for accurate length measurements, using as reference a 1-inch metal ball placed at the level of the bone. Each observer performed 540 measurements (totaling 2,700). We estimated intra- and interobserver standard deviations for measurements in all categories by specialists and nonspecialists. The intraclass correlation coefficient (ICC) summarized the overall accuracy and precision of the measurement process relative to subject variation. We examined whether the relative accuracy of a measurement is adversely affected by the number of bony landmarks required for making the measurement.ResultsThe overall ICC was >0.74 for 13 out of 18 measurements. Accuracy of the acetabular index for DDH was greater than for CP and relatively low for the center–edge angle in CP. Accuracy for bone length was better than for joint angulations in LLD and for the Cobb angle in AP views compared to lateral views for scoliosis. There were no clinically important biases, and most of the differences between specialists and nonspecialists were nonsignificant. The correlation between the results according to the number of bony landmarks that needed to be identified was also nonsignificant.ConclusionsDigital measurements with the TraumaCad system are reliable in terms of intra- and interobserver variability, making it a useful method for the analysis of pathology on radiographs in pediatric orthopedics.

Are Gait Indices Sensitive Enough to Reflect the Effect of Ankle Foot Orthosis on Gait Impairment in Cerebral Palsy Diplegic Patients

Background: Neuromuscular impairments may compromise gait function in patients with cerebral palsy (CP). As such, ambulatory children with CP often use ankle foot orthosis (AFO) to facilitate and optimize their ability to walk. The aim of this study was to evaluate whether the different gait indices, the Gillette Gait Index (GGI), the Gait Deviation Index (GDI), and the Gait Profile Score (GPS), reflect the improved gait that was previously shown using AFO. Methods: A retrospective analysis of 53 studies on children with spastic diplegic CP. All had undergone a comprehensive gait study and were analyzed while walking, both barefoot and with their braces, in the same session. Kinematic and temporal spatial data were determined and summarized by 3 methods: GPS, GDI, and GGI. Results: Significant differences were found between the barefoot condition and the AFO conditions for temporal and kinematic parameters: changes in GGI, GDI, and GPS were not statistically significant, with an improvement of 9.33% in GGI (P=0.448) and no change in GDI and GPS. Conclusions: The use of AFO in diplegic CP children caused a statistically significant improvement in temporal and kinematic parameters. Interestingly, it was found that this improvement was not reflected by GGI, GDI, or GPS. These findings might suggest that gait indices, as outcome measures, may sometimes not reflect all the effects of specific interventions. Level of Evidence: Level III—retrospective study.

Growth and development of tarsal and metatarsal bones in successfully treated congenital idiopathic clubfoot: early radiographic study.

Fifteen cases of unilateral clubfoot treated according to Ponsetis technique had the talocalcaneal angles on the anteroposterior and lateral views and the size of the talus, calcaneus, I–V metatarsus measured on radiographs of both feet that were taken at a mean age of 15.2 months (range 8–23). The measurements of talocalcaneal angles and size of the talus, calcaneus, and I, II, and III metatarsi were significantly smaller on the affected side, whereas the values for the IV and V metatarsi were similar on both sides. Clubfoot deformity involves all structures of the foot, but intrinsic compressive forces on the small hindfoot bones induce measurable reduction in their size and spatial orientation. This effect is seen early on the medial but not the lateral long tubular forefoot bones.