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.

A large number of surgical techniques have been described to prevent recurrent patellofemoral instability in the pediatric population, including both proximal and distal realignment procedures. The wide variety of treatment options highlights the lack of agreement as to the best surgical approach. However, when a comprehensive exam and workup are paired with a surgical plan to address each of the identified abnormalities, outcomes are predictably good. Patellar instability is a common knee disorder in the skeletally immature patient that presents a unique set of challenges. Rates of re-dislocation in pediatric and adolescent patients are higher than in their adult counterparts. Careful consideration of the physeal and apophyseal anatomy is essential in these patients. While the majority of primary patellar instability events can be treated conservatively, multiple events often require surgical intervention.

Objectives: Patient-reported outcomes (PRO) assessing health-related quality of life (HRQoL) are important outcome measures, especially in Legg-Calvé-Perthes disease (LCPD) where symptoms (pain and limping), activity restrictions, and treatments vary depending on the stage of the disease. The purpose of this study was to investigate the validity of the Patient-reported Outcomes Measurement Information System (PROMIS) for measuring HRQoL of patients with LCPD in various stages of the disease. Methods: This is a multicenter validity study. Patients with LCPD between 4 and 18 years old were included and classified into modified Waldenström stages of disease: Early (1 or 2A), Late (2B or 3), or Healed (4). Seven PROMIS domains were collected, including Pain Interference, Fatigue, Mobility, Depression, Anger, Anxiety, and Peer Relationships. Convergent, discriminant, and known group validity was determined. Results: A total of 190 patients were included (mean age: 10.4±3.1 y). All 7 domains showed the worst scores in patients in the Early stage (known group validity). Within each domain, all domains positively correlated to each other (convergent validity). Patients who reported more anxiety, depression, and anger were associated with decreased mobility and increased fatigue and pain. Peer relationships had no to weak associations with other domains (discriminant validity). Conclusions: PROMIS has construct validity in measuring the HRQoL of patients in different stages of LCPD, suggesting that PROMIS has potential to serve as a patient-reported outcome tool for this population. Level of Evidence: Diagnostic level III study.

Background: Patients with limited health literacy require online educational materials to be written below a sixth grade level for optimal understanding. We assessed the quality, accuracy, and readability of online materials for Kienböck disease (KD). Methods: “Kienbock’s Disease” and “Lunate Avacular Necrosis” were entered into 3 search engines. The first 25 Web sites from each search were collected. Quality was assessed via a custom grading rubric, accuracy by 2 residents and a fellow, and readability by Flesch-Kincaid grade level (FKGL) and New Dale-Chall test. Web sites were stratified according to the search term, FKGL, order of appearance, and authorship type. Results: A total of 38 unique Web sites were included, of which 22 were assigned to “KD” and 16 to “Lunate Avascular Necrosis.” The average quality score out of 30, accuracy score out of 12, and FKGL for all Web sites were 13.3 ± 7.3, 10.4 ± 1.9, and 10.5 ± 1.4, respectively. Web sites assigned to the term “Kienbock’s Disease” had a significantly higher FKGL. Web sites of higher FKGL had significantly worse accuracy scores. Order of appearance had no influence. Physician specialty societies (PSS) had a significantly lower FKGL than Web sites of other authorship types. Conclusions: Despite concerted efforts by national organizations, the readability of online patient materials is above the recommended level for KD. Patients with limited health literacy will be most affected by this reality. Until readability improves, patients should continue to consult their physicians when uncertain and prioritize Web sites that are easier to read and produced by PSS.

Metatarsal fractures account for a significant proportion of foot injuries, representing 35% of all foot fractures and 5% to 6% of all skeletal injuries, with an estimated incidence of 6.7/10 000 people. 5,28,41,42 These injuries are more common in females (2:1) in the general population, although in the athletic population, they are seen most commonly in males. 28,37,41,42 Patients in their second through fifth decade of life most commonly sustain metatarsal fractures, with a mean age of 42.28 Most metatarsal fractures occur by low-energy trauma, although they can also occur from penetrating trauma.28 Anatomically, the metatarsals fall into 3 groups: first, fifth, and central metatarsals. In a population study investigating metatarsal fractures, fifth metatarsal fractures occurred most commonly, followed by middle metatarsals and the first metatarsal. 28Although most first and fifth metatarsal fractures are isolated fractures, multiple metatarsal fractures often occur in contiguous bones. If a fracture is identified in a single metatarsal, the orthopedist must closely inspect adjacent metatarsals and joints, especially the Lisfranc articulation.28 Stress fractures can also occur in metatarsals, most commonly in the second metatarsal but also not uncommonly in the third and fifth metatarsal. They are seen typically in women with osteoporosis and athletes with repetitive stress injuries, which includes groups as diverse as ballet dancers and military recruits. 36The appropriate and successful management of these fractures requires knowledge of the anatomy, pathophysiology, and treatments for each of the metatarsal fracture groups. Unfortunately, outcomes are generally less predictable in patients with risk factors such as obesity and diabetes.5 This review focuses on acute metatarsal fractures, with only a cursory discussion of stress fractures and Lisfranc injuries. First and Central MetatarsalsFractures involving the first and central (second through fourth) metatarsals can vary significantly, including stress and acute traumatic fractures. First metatarsal fractures are not as common as central metatarsal fractures. 28 There is a 60% rate of contiguous fractures when patients sustain fractures involving the central metatarsals. 28 AnatomyFirst Metatarsal. The first metatarsal is larger than the lesser 4 metatarsals. Distally, there is the transmetatarsal ligament in the first webspace. The resting position of the first tarsometatarsal joint is supported by a capsule containing strong, thick ligaments. The first metatarsal base is the site of attachment for 2 powerful muscles, tibialis anterior and peroneus longus. The first metatarsal head overlies the 2 sesamoid bones, which provides 2 of the 6 contact points of the forefoot and allows the first ray to support up to 40% of the forefoot weight. The blood supply is primarily from a single nutrient artery with secondary epiphyseal and metaphyseal arteries.Central Metatarsals. The central metatarsals have significant ligamentous structures that link each bone to ...

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Background: Early-onset scoliosis (EOS) is a complex, heterogeneous condition involving multiple etiologies, genetic associations, and treatment plans. In 2014, Williams and colleagues proposed a classification system of EOS (C-EOS) that categorizes patients by etiology, Cobb angle, and kyphosis. Shortly after, Smith and colleagues validated a classification system to report complications of growth-friendly spine instrumentation. Severity refers to the level of care and urgency required to treat the complication, and can be classified as device-related or disease-related complications. The purpose of this study was to investigate if C-EOS can be used as a reliable predictor of Smith complications to better risk stratify these young, surgical patients. Methods: This study queried retrospective data from a large multicenter registry with regard to growth-friendly spine instrumentation in the EOS population. One-hundred sixteen patients were included in final data analysis to investigate the outcomes of their growth-friendly procedures according to the Smith complication classification system. Results: There were 245 Smith complications distributed among 116 patients included in this study (2.1 complications per patient). The majority of the complications were device related requiring at least one unplanned trip to the operating room (Smith Device Complication IIA or IIB; 111 complications). There were no complications that caused abandonment of growth-friendly instrumentation (Smith Complication III) and no mortalities (Smith Complication IV). The most severely affected EOS group was the hyperkyphotic syndromic group with a major curve angle >50 degrees (S3+), with 3.4 complications per patient. The least affect EOS group was the hyperkyphotic congenital group with a major curve angle between 20 and 50 degrees, with 0.3 complications per patient. Conclusions: The C-EOS simplifies a complex pathology and the Smith complication classification scheme creates a language to discuss treatment of known complications of growth-friendly spine surgery. Although there is an association between more advanced C-EOS and Smith complications, there does not appear to be a correlation that can satisfy a risk stratification at this time. Level of Evidence: Level II.