Journal of Pediatric Orthopaedics最新文献

Background: The Shilla technique offers direct apical control and allows continuous cranial and caudal guided growth in early-onset scoliosis (EOS), eliminating the need for repeated surgeries. For cases where bipolar growth is not feasible, we developed a modified "unipolar" Shilla technique, allowing for asymmetric growth modulation with fusion at the opposite end. This study examines the feasibility and effectiveness of this approach in a complex EOS population.

Methods: We conducted a retrospective review of all Shilla cases performed by 3 surgeons over 11 years at a single institution. We identified patients treated with the unipolar Shilla technique and collected socio-clinical variables, radiographic parameters, and growth metrics. "Rod slide" was measured to determine intra-Shilla construct growth.

Results: Thirteen patients treated with unipolar Shilla were identified. The mean major coronal curve decreased from 69 degrees preoperatively to 19 degrees postoperatively. Thoracic height (T1 to T12) increased from 17.5 to 21.9 cm, and T1 to S1 height from 26.8 to 34.0 cm. Rod slide in those with complete follow-up averaged 9.6 mm, and all patients had more than 5 mm of Shilla growth. Overall, there was one unplanned return to OR due to discomfort from a prominent rod, which was trimmed.

Conclusions: The unipolar Shilla technique provided excellent correction of severe spinal deformities with minimal complications. Although growth was modest in most cases, this technique is potentially beneficial for patients requiring definitive apical control with limited growth potential or those who may have difficulty with follow-up.

Level of evidence: Level IV-retrospective case series.

Background: Navigation-assisted spine surgery has become widely used in adult patients with studies demonstrating improved outcomes. This remains poorly studied in pediatric patients. This study examines the impact of navigation on complication rates in pediatric idiopathic scoliosis surgery.

Methods: A national insurance database, Pearldiver, a national insurance database with claims from Medicare, private insurance, cash pay, and Medicaid Advantage, identified pediatric patients (<21 y old) with idiopathic scoliosis who underwent posterior spine fusion with ≥2 years of follow-up. Patients were divided into navigated and non-navigated cohorts. A multivariable logistic regression identified risk factors for instrumentation revision, and cohorts were matched 1:2 based on significant variables. The primary outcome was instrumentation revision at 6 months, 2 years, and 10 years postoperatively. Secondary outcomes were postoperative neurological deficit and surgical site infection.

Results: Of 15,917 patients, 1599 had navigated and 14,318 had non-navigated surgery. Decreased age and male sex were associated with a revision risk. After cohort matching (4747 total: 1585 navigated, 3162 non-navigated), navigated cases had significantly lower revision rates: 1.1%, 2.7%, and 3.8% vs. 2.1%, 4.4%, and 6.3% ( P <0.05). Surgical site infection was significantly lower in navigated cases at 2 years (6.4% vs. 4.2%) and 10 years (8.3% vs. 4.7%) ( P <0.001). The overall rate of postoperative neurological deficit was 2.1% and 2.6% for navigated and non-navigated cases ( P >0.05).

Conclusions: This largest study to date on navigation in pediatric scoliosis surgery demonstrates significantly lower instrumentation revision and infection rates in navigated procedures compared with non-navigated cases.

Level of evidence: Level III.

Background: Pelvic incidence-lumbar lordosis (PI-LL) mismatch is a validated marker of sagittal balance that correlates with pain and HRQoL in adult spinal deformity. The purpose of this study was to investigate whether there is an association between a normal postoperative pelvic incidence-lumbar lordosis (PI-LL) relationship and pain improvement at 2 years following PSF for SK.

Methods: SK patients who underwent PSF and reached 2 years postoperative were identified in a multicenter registry. Patients with anterior release, prior spine surgery, neuromuscular comorbidity, or posttraumatic/postlaminectomy kyphosis were excluded. A normal PI-LL relationship (<10° difference; either correction of mismatch OR maintenance of normal) was determined at 2 years. Improvement in pain was defined as a 2-year postoperative increase in SRS-22 pain score of more than or equal to the minimal clinically important difference.

Results: Of the 91 patients who were eligible, 50 (16.2±1.6 y/o, 68% male) had radiographic and health-related quality of life (HRQoL) data available for analysis. Preoperative and 2-year postoperative major kyphosis were 74±11° and 48±9°, respectively. The average pain score was 3.9 [interquartile range (IQR): 3.4 to 4.4] at preoperative and 4.4 (IQR: 4.0 to 5.0) at 2-year postoperative ( P =0.002). Only 4 (8%) patients had normal PI-LL at preoperative, increasing to 19 (38%) patients at 2 years postoperative. In those with normal postoperative PI-LL, 68% (N=13) had improvement in pain, compared with 42% (N=13) in those with PI-LL mismatch ( P =0.069). Patients with normal postoperative PI-LL had an increased likelihood of pain improvement by 1.63 (95% CI=0.98, 2.73) times when compared with those with PI-LL mismatch ( P =0.062).

Conclusion: Improvements are observed in both PI-LL measures and pain scores following PSF for SK at 2 years postoperatively. Patients with normal PI-LL postoperatively (corrected or maintained) had an increased likelihood of pain improvement.

Level of evidence: Level III-retrospective case-control study.

Introduction: Madelung deformity is a rare wrist condition characterized by progressive angular deformity secondary to asymmetric premature closure of the distal volar-ulnar radial physis. Standardized treatment guidelines remain lacking. This study aimed to evaluate clinical and radiologic outcomes following different surgical strategies and to identify key parameters to guide surgical decision-making.

Methods: A retrospective review was performed on 74 wrists in 41 patients treated between 1999 and 2023. Data collected included demographics, range of motion (ROM), and radiographic parameters: ulnar tilt (UT), lunate fossa angle (LFA), lunate subsidence (LS), and palmar carpal displacement (PCD), assessed preoperatively and postoperatively.

Results: Of 74 wrists, 56 (75.7%) underwent surgical treatment: 33 (44.6%) received Vickers ligament resection (VLR) at a mean age of 11.3 ± 2.5 years, and 23 (31.1%) underwent radial dome osteotomy (RDO) at 13.0 ± 1.9 years. RDO was indicated in patients presenting with marked ROM limitations (>20 degrees), LS ≥ 7.2 mm, and PCD ≥ 25.7 mm ( P  < 0.01). After VLR, radiologic parameters remained stable, while RDO significantly reduced PCD ( P = 0.0006); however, other radiographic changes were not statistically significant. Functional gains following RDO were limited, except for modest improvement in wrist extension. Reoperations were required in 12.1% of VLR and 17.4% of RDO cases, particularly when LS ≥ 6 mm and/or PCD ≥ 23 mm at baseline.

Conclusions: VLR performed in early skeletal maturity may stabilize deformity progression in mild cases. In contrast, patients with advanced deformity (LS ≥ 6 mm, PCD ≥ 23 mm, and significant ROM limitation) are better candidates for primary RDO. Radiologic correction does not consistently translate into functional recovery, emphasizing the need for individualized clinical-radiological assessment. This represents the largest single-center series to date and supports LS and PCD as key objective markers for surgical decision-making in Madelung deformity.

Level of evidence: Level IV-retrospective cohort study.

Background: Multiple Hereditary Exostoses (MHE) is an autosomal dominant, pediatric disorder characterized by the development of osteochondromas. These benign tumors can halt bone development and lead to pain, mobility issues, and growth abnormalities. MHE is male-predominant (1.5:1 male-to-female ratio), with males often displaying more acute symptoms. The underlying pathogenesis remains partially elucidated, and treatment primarily involves surgical intervention. Few studies address surgical statistics and question the assumed male predominance. This study seeks to provide an encompassing retrospective evaluation of MHE patients, emphasizing patient characteristics, surgical data, and sex discrepancies.

Methods: We examined 103 MHE-diagnosed patients treated at the University of Iowa Hospitals and Clinics from June 2008 to March 2023. Comprehensive chart reviews elucidated surgical data. Demographic and clinical data were collected through data extraction and chart review. Statistical methods included a 2-sample t test (age differences between sexes) and a 2-sample Poisson test (excision rates between sexes).

Results: The cohort consisted of 52 males and 51 females, indicating an equal sex distribution. Predominant excision sites included the distal femur (21.01%) and proximal tibia (19.33%). Significant sex differences were noted in surgical interventions: Males had a higher mean age of excision (23.30 y) than females (15.32 y) (95% CI: 11.48-19.16; P =0.03). Females exhibited a notably higher excision rate (CI: 1.17-2.00; P =0.001), with a ratio of 1.53 (female/male). Specifically, females had increased excisions at the foot/ankle (CI: 1.3-7.01; P =0.038) and hand/wrist (CI: 1.29-4.77; P =0.029).

Conclusion: Our findings deviate from the commonly accepted male predominance in MHE, revealing an even male-female distribution. The distal femur and proximal tibia were the chief excision sites. Males exhibited later excisions, potentially due to delayed growth plate closure. Interestingly, females had a higher surgery rate, especially in the foot/ankle and hand/wrist. This deviates from earlier research proposing males have higher lesion counts, suggesting a more intricate sex-specific disease manifestation. This discovery underscores the necessity for continued exploration of sex variances in MHE.

Level of evidence: Level IV-retrospective case series.

Background: Surgical interventions for congenital kyphosis (CK) in the growing child include posterior spinal fusions (PSF) with instrumentation and growth-friendly (GF) procedures. While GF approaches aim to preserve spinal growth, they may increase complications and unplanned reoperations (UPRORs). This study compares complications, UPRORs, and radiographic and patient-reported outcomes between PSF and GF approaches for CK.

Methods: An international, multicenter database for early-onset spinal deformity was queried to identify patients with CK who underwent primary operative management of the spinal deformity. The inclusion criteria were patients 9-years of age and younger with a preintervention sagittal kyphosis greater than their major coronal deformity, with the major coronal deformity being <35 degrees, and were followed up for at least 2-years postoperatively.

Results: A total of 54 patients (27 PSF; 27 GF) met the inclusion criteria with similar ages and follow-up periods. Preoperative and postoperative sagittal deformity was similar between groups. Both corrected sagittal deformity (PSF: -12 degrees, P =0.0182; GF: -25 degrees, P =0.0003) similarly postoperatively and at final follow-up. Preoperative and postoperative coronal deformity was also similar between groups, but PSF saw better corrections postoperatively (PSF: -6 degrees, GF: 1 degrees, P =0.0343). Coronal deformity correction was similar at final follow-up. T1-S1 length increased similarly for both groups at postoperative and final follow-up. Thirteen patients (41%) of the PSF group experienced complications compared with 36 patients (63%) in the GF group ( P =0.0048). Five patients (19%) in the PSF group experienced a UPROR compared with 14 patients (33%) in the GF group ( P =0.0470). The PSF group saw greater improvements in the EOSQ-24 general health domain (PSF: +23, GF: -6, P =0.0336), with all other scores being similar.

Conclusions: In this study, PSF patients had similar deformity correction and EOSQ-24 scores with fewer complications and UPRORs than GF patients. In addition, though GF aims to preserve spinal growth, T1-S1 growth overtime was similar between groups. Clinicians should weigh the risk and benefits of both approaches for each patient's unique CK deformity to optimize shared surgical decision-making.

Level of evidence: Level III.

Background: Controversy exists surrounding the necessity of capsular repair in patients undergoing hip arthroscopy. In adults, studies show capsulotomy decreases the hip joint's resistance to axial distraction, and capsular repair restores this resistance to native-state levels. However, no literature exists evaluating these distraction characteristics in pediatrics, particularly when utilizing a periportal approach. The purpose of this study is to assess whether periportal capsulotomy compromises the hip joint's resistance to axial distraction, and whether capsular repair can restore native state resistance in the pediatric population.

Methods: Patients undergoing primary hip arthroscopy for femoroacetabular impingement syndrome underwent intraoperative axial distraction testing. This was conducted in the native, capsulotomy, and repaired capsular states, using fluoroscopic imaging at 0-, 25-, 50-, 75-, and 100- lbs of applied traction. Comparisons were made between the various capsular states at different force intervals.

Results: Fifty hips were included for analysis with a mean age of 16.8±1.3 years. Relative to the native state, hips in the open capsulotomy state distracted to significantly greater distances at 25, 50, 75, and 100 lbs ( P <0.001). Once repaired, hips distracted to significantly lesser distances at 25, 50, 75, and 100 lbs compared with the capsulotomy state ( P ≤0.001). When comparing the repaired versus native states, repaired hips distracted more at 25 lbs ( P <0.001), distracted similarly at 50 lbs ( P =0.751), and significantly less at 75 and 100 lbs ( P <0.001).

Conclusion: This study provides the first in-vivo biomechanical data investigating intraoperative distraction in pediatric patients undergoing periportal capsulotomy with capsular repair. Despite minimizing iliofemoral ligament disruption with a periportal approach, the capsulotomy resulted in increased distraction compared with the native hip, with restoration of this resistance to distraction with capsular repair. To minimize the potential risk of iatrogenic hip instability after hip arthroscopy in pediatric patients, a capsular repair should be considered even when utilizing a periportal capsulotomy approach.

Level of evidence: Level III-case series.

Background: Lower extremity length discrepancy (LELD) is closely associated with spinal imbalances such as pelvic tilt and functional scoliosis. While existing studies have focused on LELD-induced coronal compensations, its impact on sagittal spinal balance remains poorly understood. The aim of the current study was to investigate the differential effects of LELD on coronal and sagittal spinal balance in adolescents with functional versus structural scoliosis.

Methods: A retrospective analysis of 211 patients was conducted. Participants were stratified into functional (n=165) or structural scoliosis (n=46) groups based on pelvic and lumbar correction with limb elevation. Radiographic parameters included coronal and sagittal measures. Statistical analyses compared groups and assessed correlations.

Results: Structural scoliosis exhibited significantly worse coronal imbalance (higher sacral obliquity, lumbar Cobb angle, and coronal balance distance; P <0.001) and greater sagittal vertical axis (SVA; P<0.05 ). LELD correlated with coronal parameters in functional scoliosis ( P <0.05) but not structural cases. Sagittal balance parameters (pelvic tilt, sacral slope) showed no LELD association, though SVA correlated with coronal imbalance only in functional scoliosis ( P <0.05). Roussouly's sagittal classification did not differ between groups.

Conclusions: LELD primarily drives compensatory coronal changes, with minimal sagittal impact. Structural scoliosis demonstrates worse coronal imbalance and elevated SVA, suggesting distinct compensatory mechanisms. Functional cases may benefit from LELD correction, while structural scoliosis requires sagittal evaluation during surgical planning. These findings highlight the importance of prioritizing coronal alignment in LELD-related scoliosis management.

Level of evidence: Level III.

Background: Firearm injuries are the leading cause of death among U.S. children, with increasing rates of both fatal and nonfatal injuries. While prior studies have described general epidemiologic trends, few have explored how injury intent is related to patterns of extremity injury in pediatric patients.

Methods: We conducted a retrospective review of pediatric patients (18 y or younger) presenting with firearm-related extremity injuries at a pediatric level I trauma center from January 1, 2018, to December 31, 2023. Demographic data, injury characteristics, and clinical outcomes were compared between assault-related and accidental injuries. Statistical analysis included χ 2 , the Fisher exact tests, and the Grubb test for statistical outliers, with significance set at P <0.05.

Results: A total of 230 patients were included, of whom 74.3% sustained assault-related injuries and 25.6% accidental injuries. Assault-related injuries primarily affected older African American males and were associated with higher injury severity scores, multisystem trauma, ICU admission, multiple gunshot wounds, and multiple extremity involvement. Accidental injuries were more common in younger patients and had higher rates of fractures (69.5% vs. 52.1%; P =0.02), orthopaedic consults (79.7% vs. 59.2%; P =0.0046), and surgical intervention (50.9% vs. 27.5%; P =0.001). A significant monthly spike in accidental injuries was noted in January ( P <0.05).

Conclusions: Injury intent is associated with patterns of extremity trauma following pediatric and adolescent firearm injury. While assault-related injuries are more systemically severe, accidental injuries often result in complex extremity trauma requiring operative care. The monthly spike of accidental injuries in January highlights an opportunity for targeted prevention efforts around firearm safety and storage.

Level of evidence: Level III.

Background: In medical research, a P -value of <0.05 is generally considered to indicate statistical significance and serve as the foundation from which clinical recommendations are made. However, the P -value is not immune to subjectivity and misinterpretation, introducing variability into study results. This can subsequently negatively impact patient care when used to support clinical recommendations or practice guidelines. This study sought to identify the frequency with which "trend" statements are used to describe nonstatistically significant results within recent pediatric orthopaedic literature.

Methods: An audit of all original research articles and meta-analyses published in 2024 across 4 major pediatric orthopaedic surgery journals was conducted to identify all instances of a trend statement (defined as a statement where a nonstatistically significant result was described as approaching or trending toward significance). Other data points collected included the location of the statement within the article, reporting of associated P -values, and the context of the statement. Editorials, commentaries, and literary reviews were excluded from consideration.

Results: A total of 21 of 451 (4.7%) articles evaluated in this study included at least one trend to describe a statistically nonsignificant value as approaching significance. Out of the 24 trend statements identified, half (n=12) explicitly acknowledged the lack of statistical significance. The average reported P -value was 0.0821, with most P -values falling between 0.05 and 0.10 (78.9%). Trend statements were most often found in the results section (66.7%) and used to describe a single statistical comparison. No articles provided a definition for the use of a trend statement.

Conclusions: Pediatric orthopaedic literature demonstrates a low percentage of trend statements to describe statistically nonsignificant results. These statements, while infrequent, may mislead readers and negatively influence clinical decision-making. Efforts to minimize their usage and provide explicit clarifications regarding statistical significance should continue, with leading journals playing a crucial role in setting the standard for future scholarly works.