James H Beaty’s research while affiliated with Le Bonheur Children's Hospital and other places

Background: Although proximal femoral locking compression plates (PF-LCP) have been used with increasing frequency in the fixation of proximal femoral fractures in the pediatric population, there is a lack of literature regarding their use. The purpose of this study was to examine the failure rates of PF-LCP fixation in comparison to other accepted fixation methods within a pediatric population. Methods: Retrospective review identified consecutive children treated for proximal femoral fractures from September, 2008 to February, 2019, who had a minimum follow-up of 12 weeks. Patient charts and radiographs were reviewed, and demographic information was compiled. In the case of failures, timing and method of failure were documented. Results: Sixty-four proximal femoral fractures (61 children) were studied. The average age at the time of presentation was 10.4 years. Twenty-six fractures were treated with PF-LCPs and 38 with other fixation methods (compression hip screws, rigid locked intramedullary nailing, cannulated screws, or a combination of hip screw side plate and intramedullary nailing). Failure occurred in four of the 26 fractures treated with locking compression plating (15.4%), compared to none of the 38 treated with other fixation types (p<0.05). Conclusions: This study demonstrates an increased risk of failure in proximal femoral fractures treated with locking compression plates (12.9%) compared to 0% other fixation methods (no failures). As a result of this study, we no longer use locked plating systems for pediatric femoral neck fractures at our institution.

Purpose: Fracture stability is important in choosing the optimal treatment for pediatric femoral fractures, although there is no consensus for characterizing a fracture as "stable" or "unstable." The authors sought to measure interobserver and intraobserver reliability in classifying femoral fracture stability and examined the relationship between fracture ratio and perceived fracture stability and morphology. Methods: Fracture ratios were calculated from anteroposterior and lateral radiographs from 65 children aged 5 to 12 years, who were treated for femoral shaft fractures at a level 1 pediatric trauma center. Deidentified radiographs were placed into a PowerPoint presentation in random order and were shown to six fellowship-trained pediatric orthopaedic surgeons at two time points 4 months apart. Raters classified stability as "stable/unstable" and morphology as "spiral/ oblique/transverse." Cohen and Fleiss kappa (k) values were calculated to determine intraobserver and interobserver reliability. Generalized linear modeling was used to compare FR to rater fracture stability and morphology. Results: The mean k for fracture stability for all raters was 0.68 (strong intraobserver agreement). The k for fracture stability during round 1 was 0.53 (67.7% moderate interobserver agreement). The k for fracture stability during round 2 was 0.68 (75.4% strong interobserver agreement). The mean k for fracture morphology for all raters was 0.79 (strong intraobserver agreement). The k for fracture morphology during round 1 was 0.38 (15.4% fair agreement). The k for fracture morphology during round 2 was 0.46 (24.6% moderate agreement). The average anteroposterior fracture ratio in fractures deemed stable was 1.32 compared with 1.78 in unstable fractures (P < 0.001). The average lateral fracture Volume 4, Number 2, May 2022 2 Copyright © 2022 JPOSNA® www.jposna.org ratio in stable fractures was 1.34 compared with 2.10 in unstable fractures (P < 0.001). Average anteroposterior and lateral fracture ratios were highest in spiral fractures and lowest in transverse fractures (P < 0.003). Conclusions: Raters demonstrated strong intraobserver and interobserver agreement in classifying radiographic femoral fracture stability. Anteroposterior and lateral fracture ratios were significantly higher in unstable fractures. Level of Evidence: Level III Key Concepts: • This study sought to measure intraobserver and interobserver reliability in determining pediatric femoral fracture morphology and stability. • The authors also were interested in seeing if an objective measurement, the fracture ratio (FR), could accurately predict fracture morphology and stability. • A strong intraobserver agreement in defining both fracture stability and morphology was found.

Orthopaedists are typically skilled diagnosticians as orthopedic training involves frequent evaluation of radiographs, but even a seasoned orthopedist has the potential to miss certain anomalies on radiographic images. Misdiagnosis can lead to morbidity, malunion, increased need for surgical procedures, or osteonecrosis of a large joint. “RAMBO” lesions, or radiographic anomalies missed by orthopaedists, are a subset of traumatic pediatric injuries that can be missed by an orthopaedist. These include transphyseal fracture of the distal humerus, Monteggia injury, entrapped medial epicondyle fracture of the elbow, hip dislocation with incongruous hip after reduction, and lower extremity ipsilateral second fractures. Radiographs of skeletally immature patients offer additional challenges in interpretation as many providers may be unfamiliar with the radiographic anatomy of younger patients. Understanding the characteristics of pediatric radiographs and a high index of clinical suspicion help prevent missing certain subtleties on radiographs. The purpose of this article is to review a few key traumatic pediatric radiographic anomalies missed by orthopaedists, deemed RAMBO lesions, with the aims of further educating highly skilled orthopaedic surgeons and preventing radiographic anomalies from being missed.

Background: An area of enlargement of the metaphyseal socket around the epiphyseal tubercle, termed the peritubercle lucency sign, has recently been introduced as a possible predictor of contralateral slipped capital femoral epiphysis in patients with previous unilateral slipped capital femoral epiphysis. This study aimed to assess intraobserver and interobserver reliability for detecting the presence or absence of the peritubercle lucency sign. Methods: Thirty-five radiographs were presented to 6 fellowship-trained pediatric orthopaedic surgeons on 2 separate occasions 30 days apart, ensuring that the images were shown in a different order on the second exposure. Both times the reviewers recorded whether the peritubercle lucency sign was present or absent in each of the radiographs. Statistical analysis was performed to determine the intraobserver and interobserver reliability. Results: In the intraobserver analysis, percent agreement between the first and second time the radiographs were reviewed varied between 62.9% and 85.7%, for an average intraobserver agreement of 74.8%. κ values for the 6 reviewers varied between 0.34 and 0.716, with an average intraobserver κ value of 0.508. The interobserver percent agreement was 40.0% for the first time the radiographs were reviewed, 42.9% the second time, and the overall interobserver percent agreement was 29%. The interobserver κ value was 0.44 the first time the radiographs were reviewed, 0.45 the second time, and the overall interobserver κ value was 0.45. Discussion: On the basis of our findings, the peritubercle lucency has modest intraobserver and interobserver reliability at best and should be used with other currently used factors, such as age, presence of endocrinopathy, status of triradiate cartilage, posterior sloping angle, and modified Oxford score, in determining the need for prophylactic pinning. Further refinement of the definition of the peritubercle lucency sign may be needed to improve agreement and reliability of the sign. Level of evidence: Level III-prognostic study.

Children's femoral shaft fractures are commonly treated with flexible intramedullary nailing after closed or open reduction, but there is little information concerning indications for open reduction. The purpose of this study was to determine radiographic and clinical features likely to lead to open reduction before flexible intramedullary nailing. Record review identified 158 femoral shaft fractures treated with flexible intramedullary nailing. In addition to patient demographics and mechanism of injury, data obtained included surgeon name, estimated blood loss, type of reduction, type and diameter of nail, type of operating table, the use of percutaneous reduction techniques or supplemental casting, time to and duration of surgery, total time in operating room, and time to union. Fracture ratios were calculated based on established radiographic protocol. Of 158 fractures, 141 were treated with closed reduction and 17 with open reduction. The anteroposterior fracture index (1.3 ± 0.4, P = 0.0007), surgeon (P = 0.002), and flattop operating table (0.05) were associated with open reduction. Smaller lateral diameter of bone at the fracture site, transverse fracture, and surgeon were all found to be independent risk factors for open reduction; patient characteristics, including age, sex, and BMI, did not seem to influence the choice of open reduction. Fractures with a lower fracture index or pattern resembling a transverse fracture rather than oblique or spiral had an increased risk of converting to an open reduction. Surgeon preference and use of flattop tables also had a significant influence on how the fracture was treated.

Background A 2006 study from our institution found a 10-fold increase in pediatric community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) osteoarticular infections over a 5-year period and found that these patients had a higher complication rate and required more surgical debridements than those with methicillin-sensitive Staphylococcus aureus (MSSA) infections. Clinical experience since that time has suggested that these trends may have continued. Our investigation sought to evaluate the evolving nature of these infections since the previous publication. Methods The records of all patients treated at our institution for acute hematogenous septic arthritis and osteomyelitis between January 2005 and December 2011 were reviewed for demographic, diagnostic, clinical, and radiographic data. Results Of the 240 patients who met the inclusion criteria, 100 were diagnosed with CA-MRSA infections, 51 had MSSA infections, and 75 had no identifiable pathogen. Group A streptococcus (GAS), group B streptococcus (GBS), Streptococcus pneumoniae , and Salmonella were together responsible for 14 infections. The overall infection incidence was 4.29 cases per 1000 hospital admissions. The mean age of CA-MRSA patients was 6.4 yr, compared to 8.9 yr for MSSA patients ( P =0.002). There was no significant difference in admission laboratory values, surgical procedures, or long-term complications for CA-MRSA and MSSA infections. Subperiosteal abscess was evident in 51% and 45% of CA-MRSA and MSSA patients, respectively. Surgical intervention was required in 87% of CA-MRSA patients and 84% of MSSA patients. Deep vein thrombosis was identified in 12 CA-MRSA patients, five of whom subsequently developed septic pulmonary emboli. Eight CA-MRSA patients developed chronic osteomyelitis, as did one MSSA patient. Intramuscular abscesses were seen in nine CA-MRSA patients and four MSSA patients. Empiric antibiotic therapy consisted primarily of clindamycin or vancomycin and was tailored according to microbial sensitivities. Conclusions Contrary to trends identified in an earlier publication, the annual frequency of CA-MRSA infections has stabilized at roughly 40% of all cases. Our data suggest that MSSA infections have become more virulent because these patients now have similar rates of complications and operative interventions to patients with CA-MRSA infections. Level of Evidence Prognostic level II study (retrospective).

The aim of this study was to determine the factors that may predict failure of closed reduction and casting of diaphyseal forearm fractures in children. Demographic and radiographic data of children with closed reduction and casting of these fractures in the emergency department were evaluated. Of 174 patients with adequate follow-up to union, 19 (11%) required a repeat procedure. Risk factors for repeat reduction included translation of 50% or more in any plane, age more than 9 years, complete fracture of the radius, and follow-up angulation of the radius more than 15° on lateral radiographs or of the ulna more than 10° on anteroposterior radiographs.

To compare clinical and radiographic outcomes of medial epicondylar fractures treated operatively to those treated nonoperatively, 30 patients with 31 fractures were divided into three groups: (a) nondisplaced, six treated nonoperatively; (b) incarcerated fragment, four with operative treatment; and (c) displaced but not incarcerated, 21 fractures, 14 treated operatively and seven nonoperatively. Clinical outcomes were assessed with follow-up examination and the Japanese Orthopaedic Association elbow assessment score. Average elbow scores were 98 in nondisplaced fractures, 94 with an incarcerated fragment, 95 in displaced fractures treated operatively, and 94 in displaced fractures treated nonoperatively. The only nonunion was in a fracture with an incarcerated fragment. Both operative and nonoperative treatment produced good outcome scores in displaced but not incarcerated fractures, but radiographic deformity and instability were more frequent in those treated nonoperatively.

The options for treating femoral fractures in children and adolescents have evolved over the last 2 decades to include a variety of nonoperative and operative methods. The purpose of this study was to identify changes in the types of treatment for pediatric femoral fractures in the United States from 1997 to 2012. From discharge estimates for 1997, 2000, 2003, 2006, 2009, and 2012 in the Kids' Inpatient Database, data were extracted using the International Classification of Diseases, 9th revision, and Clinical Modification for pediatric femoral fracture treatments. Patients included were 0 to 17 years old and were categorized into 5 age groups: younger than 1, 1 to 4, 5 to 9, 10 to 14, and 15 to 17 years. A total of 74,483 estimated discharges were recorded for pediatric patients with femoral fractures in the database for years 1997, 2000, 2003, 2006, 2009, and 2012. A total of 12,986 pediatric femoral fractures were estimated for 1997 and 9813 for 2012, which was statistically different (P<0.0001). Significantly fewer fractures were treated with closed reduction alone in 2012 than in 1997 in age groups 5 to 9, 10 to 14, and 15 to 17 years. Children aged 5 to 9 had more frequent open reduction and internal fixation in 2012 than in 1997, whereas adolescents aged 15 to 17 had less frequent open reduction and internal fixation in 2012 than in 1997. Although the number of femoral shaft fractures overall has decreased, the frequency of operative treatment has increased significantly in patients 5 to 9 years of age. Knowledge of these trends can guide educational efforts and resource allocation, but further study is necessary to determine procedure-specific (eg, nailing, plating, external fixation) trends and their clinical and economic impacts. Level III-case series.

Systematic review of the literature was done to determine (1) the frequency and type of associated injuries, (2) frequency of concomitant Osgood-Schlatter disease, (3) methods of treatment, (4) functional and radiologic outcomes according to fracture type, and (5) complications of tibial tubercle fractures in pediatric patients. A systematic review of the English literature from 1970 to 2013 included 23 eligible articles reporting 336 fractures with a mean follow-up of 33.56 months (range, 5.7 to 115 mo). Fractures were classified by a comprehensive system that included characteristics of previous systems. Clinical outcomes were assessed by a qualitative scale (excellent/fair/poor), the rate of return to preinjury activity, and knee range of motion. Rate of fracture healing, associated injuries (patellar/quadriceps tendon avulsion and meniscal tears), compartment syndrome, and complications were also recorded. Mean age at surgery was 14.6 years and the most common fracture reported was type III (50.6%). The overall associated injury rate was 4.1%, most common in type III fractures (4.7%). Compartment syndrome was present in 3.57% of cases. Open reduction and internal fixation were done in 98% of surgical cases. Rates of return to preinjury activity and knee range of motion were 98%, regardless of the type of fracture. Fracture consolidation was achieved in 99.4% of cases. Overall complication rate was 28.3%; removal of an implant because of bursitis (55.8%) was most common. Tenderness/prominence (17.9%) and refracture (6.3%) were also common. Treatment of tibial tubercle fractures in adolescents produced good clinical and radiologic results regardless of fracture type, which was more related to potential complications. Fractures with intra-articular involvement tended to present with more associated injuries and to have fair functional outcomes, suggesting that advanced imaging may be justified with these fractures. Complications could be more common than expected without a significant effect on final outcome. Finally, there is a need for longer follow-up to determine long-term outcomes. Level III-systematic review of level III/IV studies.