Journal of Pediatric Orthopaedics最新文献

Background: Guided growth of the proximal femur, a minimally invasive procedure for coxa valga, shows promising short-term outcomes in cerebral palsy (CP). However, as it alters physis growth, existing studies lack comprehensive long-term analysis until skeletal maturity.

Methods: This retrospective study included children with spastic CP who underwent proximal femur-guided growth surgery between 2012 and 2017, followed until physeal closure. Radiographic measurements included head-shaft angle (HSA), Hilgenreiner-epiphyseal angle (HEA), acetabular index (AI), Reimer's migration percentage (MP), and α angle. Outcomes were compared between ambulatory/nonambulatory (GMFCS I-III/IV, V) and with/without soft tissue release. Factors associated with earlier physeal closure and femoral head deformity were analyzed.

Results: Among 29 patients (53 hips) with guided growth studied at skeletal maturity, 4 patients (6 hips, 11.3%) experienced procedure failure and required varus osteotomy due to severe deformities. It was more common in GMFCS IV-V patients (27.3%, 3/11) than in GMFCS I-III (5.6%, 1/18). In the remaining 25 patients (47 hips), 7 hips (14.9%) received concomitant pelvic osteotomy with AI and MP evaluated separately. All radiographic parameters improved significantly (P<0.001). Epiphysis grew off the screw in 25 hips (53.2%), requiring reinsertion in 19 (40.4%), with a higher rate in nonambulatory children (73.3% vs. 25%, P=0.002). Changes of the parameters showed no difference between ambulatory/nonambulatory (GMFCS I-III/IV, V) and with/without soft tissue release. The cumulative duration of screw crossing the physis was a key factor for earlier closure (P<0.001) and correlated with increased α angle (P=0.039).

Conclusion: Guided growth successfully improved outcomes in both ambulatory and nonambulatory groups, although less effective in severe dysplasia. This minimally invasive procedure has some concerns, including the epiphysis growing off the screw, reinsertion need, earlier physeal closure, and femoral head deformity.

Level of evidence: Level IV, therapeutic study.

Objective: Wide awake local anesthesia no tourniquet (WALANT) techniques are increasingly utilized for hand surgeries in adults, given the clinical benefits to patients, reduced environmental waste during surgery, and lower costs to the health care system. This technique is not widely employed for pediatric hand surgeries given concerns for parental and patient anxiety, noncompliance during surgery, and tolerance of administration of local anesthesia. Select patients undergoing amenable procedures can potentially benefit from this method and enjoy the lower morbidities and costs that adult patients enjoy. It was hypothesized that WALANT technique would be safe, efficient, and feasible in a pediatric cohort.

Methods: A retrospective chart review of all 223 upper extremity surgeries performed by a single surgeon at a pediatric hospital and its surgery center was performed. Patients aged 7 to 20 years scheduled for local anesthesia without monitored anesthesia care were included. These patients were not instructed to fast before their procedure. Patient demographics, surgical and recovery room times, pain scores, and complications were recorded.

Results: Eighty-six patients underwent surgery under local anesthesia and were compared with 76 patients undergoing similar surgeries under general anesthesia. Both soft tissue and bony surgeries were included. The WALANT group had both significantly shorter average length of surgery and time spent in recovery compared with the general anesthesia group, translating into significant cost savings. Lower pain scores and fewer narcotic prescriptions were noted. There were no conversions to any type of monitored anesthesia care, nor cancellations due to inability to tolerate administration of local. No difference in infection rates or other complications were noted between groups.

Conclusions: WALANT is safe, efficient, and feasible in a pediatric hospital for a variety of surgeries. Expanding this technique for use in select children allows patients, their families, and the health care system to enjoy the clinical, financial, and environmental benefits of WALANT surgery.

Level of evidence: Level III-retrospective comparative study.

Background: Pediatric acute septic arthritis necessitates urgent identification and treatment to avoid irreversible joint damage if not recognized and treated in a timely manner. Many centers routinely obtain both aerobic and anaerobic cultures for the purpose of pathogen identification; however, the yield of anaerobic culture results has been called into question. The goal of this study was to determine the positivity rate of anaerobic cultures collected intraoperatively in pediatric patients with clinically diagnosed septic arthritis.

Methods: Patients with a clinical diagnosis of septic arthritis were extracted from a search of musculoskeletal infections at a large tertiary care pediatric hospital from 2007 to 2021. Cultures obtained from the operating room or through arthrocentesis were examined.

Results: We identified 470 cases of pediatric septic arthritis of which only 3 cultures were positive (0.6%) for anaerobic organisms. All cases involved a single isolate. The anaerobic bacteria that were detected included 1 facultative anaerobe, 1 strict anaerobe, and 1 relatively aerotolerant anaerobe. Four aerobic organisms grew on the anaerobic cultures. Three of the false positives also grew on aerobic culture media, whereas 1 aerobic specimen grew explicitly on anaerobic media. Neither the facultative anaerobe nor the aerotolerant anaerobe grew on aerobic culture media.

Conclusions: Over a 14-year period, only 0.6% (3 cases) of septic arthritis cases yielded positive anaerobic cultures that were not able to be cultured on aerobic media. As such, an anaerobic culture was more likely to culture a bacterium that would have also been cultured on aerobic media. In addition, a true positive anaerobic culture that would not have been diagnosed on aerobic cultures only occurs about once every 5 years at our institution. If one were to decide against obtaining anaerobic cultures, they would only miss 3 infections out of almost 500 (0.6%), and antibiotics would only have changed 0.6% of the time. These results suggest that routinely obtaining anaerobic cultures may be of limited value in pediatric septic arthritis. The false-positive rate of anaerobic labs exceeds that of true-positive cases. These results provide actionable opportunity to help guide clinician decision-making in a more cost-effective and efficient management of pediatric septic arthritis.

Level of evidence: IV.

Objective: Artificial intelligence (AI) chatbots, including chat generative pretrained transformer (ChatGPT) and Google Gemini, have significantly increased access to medical information. However, in pediatric orthopaedics, no study has evaluated the accuracy of AI chatbots compared with evidence-based recommendations, including the American Academy of Orthopaedic Surgeons clinical practice guidelines (AAOS CPGs). The aims of this study were to compare responses by ChatGPT-4.0, ChatGPT-3.5, and Google Gemini with AAOS CPG recommendations on pediatric supracondylar humerus and diaphyseal femur fractures regarding accuracy, supplementary and incomplete response patterns, and readability.

Methods: ChatGPT-4.0, ChatGPT-3.5, and Google Gemini were prompted by questions created from 13 evidence-based recommendations (6 from the 2011 AAOS CPG on pediatric supracondylar humerus fractures; 7 from the 2020 AAOS CPG on pediatric diaphyseal femur fractures). Responses were anonymized and independently evaluated by 2 pediatric orthopaedic attending surgeons. Supplementary responses were, in addition, evaluated on whether no, some, or many modifications were necessary. Readability metrics (response length, Flesch-Kincaid reading level, Flesch Reading Ease, Gunning Fog Index) were compared. Cohen Kappa interrater reliability (κ) was calculated. χ 2 analyses and single-factor analysis of variance were utilized to compare categorical and continuous variables, respectively. Statistical significance was set with P <0.05.

Results: ChatGPT-4.0, ChatGPT-3.5, and Google Gemini were accurate in 11/13, 9/13, and 11/13, supplementary in 13/13, 11/13, and 13/13, and incomplete in 3/13, 4/13, and 4/13 recommendations, respectively. Of 37 supplementary responses, 17 (45.9%), 19 (51.4%), and 1 (2.7%) required no, some, and many modifications, respectively. There were no significant differences in accuracy ( P = 0.533), supplementary responses ( P = 0.121), necessary modifications ( P = 0.580), and incomplete responses ( P = 0.881). Overall κ was moderate at 0.55. ChatGPT-3.5 provided shorter responses ( P = 0.002), but Google Gemini was more readable in terms of Flesch-Kincaid Grade Level ( P = 0.002), Flesch Reading Ease ( P < 0.001), and Gunning Fog Index ( P = 0.021).

Conclusions: While AI chatbots provided responses with reasonable accuracy, most supplemental information required modification and had complex readability. Improvements are necessary before AI chatbots can be reliably used for patient education.

Level of evidence: Level IV.

Background: Tibial tubercle fractures (TTF) are uncommon injuries, comprising <3% of proximal tibial fractures. Rarely, they occur in conjunction with patellar tendon avulsion (PTA). We aimed to compare reoperation rates and short-term postoperative outcomes in patients with TTF versus combined injuries.

Methods: A retrospective review of patients presenting to a single tertiary pediatric hospital with a TTF who underwent open treatment and fixation of tibial tuberosity fractures was performed. Demographics, operative details, injury patterns, complications, and postoperative milestones were analyzed. Operative reports were reviewed to identify concomitant PTA. Outcomes analyzed included reoperation rates, weeks to full weight-bearing (FWB), full range of motion (FROM), and return to sport (RTS). Patients with <4 months of clinical follow-up were excluded from the analysis.

Results: We identified 117 fractures in 111 patients (mean age: 13.75 ± 1.27, 5% female). One-hundred and one fractures were isolated TTF and 16 were combined TTF with PTA. There was no significant difference in secondary surgery ( P =0.13) or complication rates ( P =0.20). The duration in the hinged knee brace was significantly higher in the combined injury group (12.95 wk) than in the isolated injury group (9.77 wk) ( P =0.0024). There was no significant difference in time to FWB ( P =0.25), FROM ( P =0.86) or time to RTS ( P =0.40).

Conclusion: No current postoperative guidelines exist for combined TTF and PTA. Our data suggest that combined injury can be largely managed similarly to isolated TTF. However, combined injuries may require a longer bracing period.

Level of evidence: Level II prognostic study.

Objective: Proximal junctional kyphosis (PJK) is a prevalent postoperative complication after posterior hemivertebra (HV) resection. Previous research has demonstrated a strong correlation between the development of PJK and reduced bone mineral density. The vertebral bone quality (VBQ) score, derived from magnetic resonance imaging, is considered a predictive and evaluative tool for bone mineral density. However, obtaining accurate magnetic resonance imaging signal intensity at the L1-L4 vertebrae is challenging in patients with HV. Consequently, a novel S1 VBQ score has been proposed, which exhibits high accuracy. This study aimed to evaluate the efficacy of S1 VBQ scores in predicting the incidence of PJK in these patients.

Methods: We conducted a retrospective analysis of patients diagnosed with HV who underwent posterior HV resection with transpedicular instrumentation at our department from 2010 to 2020. Comprehensive demographic and radiographic data were collected. To identify potential preoperative risk factors for the incidence of PJK, we utilized the least absolute shrinkage and selection operator method. Subsequently, a multivariate logistic regression model was constructed to evaluate the risk factors identified through the least absolute shrinkage and selection operator analysis. Cutoff values were determined through receiver operating characteristic analysis to assess the predictive value of the S1 VBQ score for PJK.

Results: A total of 88 patients met the inclusion criteria, with 14 patients (15.9%) developing PJK. Five potential risk factors were selected, including S1 VBQ scores, Risser sign, thoracic kyphosis, pelvic tilt, and proximal junctional angle. The multivariate logistic regression model demonstrated that the S1 VBQ score is an independent risk factor for predicting PJK. The area under the receiver operating characteristic curve (area under the curve) for S1 VBQ scores was 0.770 with an optimal threshold of 2.793 (sensitivity: 78.6%, specificity: 67.6%).

Conclusion: A higher S1 VBQ score is an independent risk factor for PJK, with a diagnostic accuracy of 77%. The S1 VBQ threshold of 2.793 was found to be effective in identifying PJK.

Level of evidence: Level III.

Background: Because of the lack of symphyseal ligaments, pubic symphysis re-diastasis is the rule after iliac osteotomies for bladder exstrophy reconstruction. Progressive symphyseal diastasis may cause pelvic organ prolapse in females and penile retraction in males. This study assesses the results of tendon allograft symphyseal reconstruction for maintaining pubic approximation with iliac osteotomies in exstrophy repair.

Methods: Eleven consecutive patients had symphyseal reconstruction with delayed exstrophy repair, 7 classic bladder exstrophy, 2 cloacal exstrophy, and 2 exstrophy variants. There were 4 males and the average age at surgery was 14 months (9 to 20 mo). The average preoperative diastasis was 52 mm (43 to 79 mm). After pubic approximation with modified oblique iliac osteotomies, tendon allografts were looped subperiosteally around the pubic bones and through the obturator foramina, and reinforced by suturing anterior chondro-periosteal flaps. With the legs in a mermaid dressing, external fixators were kept for 3 to 4 weeks. All patients had preoperative pelvic computed tomography scans and pelvic x-rays before fixator removal and at the latest follow-up.

Results: All patients had successful urologic closure. The mean postoperative inter-pubic distance was 20.5 mm (8 to 29 mm). The mean postoperative follow-up was 10 months (4 to 19 mo). The mean inter-pubic distance at the latest follow-up was 21.6 mm (3 to 35 mm). We had maintained or even decreased inter-pubic distance in 9 out of 11 cases with the average postoperative interpubic distance of 19.3 mm compared with 18.9 mm at an average 11 months follow-up. In 2 patients, the inter-pubic distance increased from 25 and 26 mm postoperatively to 33 and 35 mm at 4 months follow-up.

Conclusion: The interpubic distance was stable or decreasing in 9 out of 11 patients with average follow-up of 11 months. Further reduction in the interpubic distance was observed due to bone formation medial to the pubic bones caused by the subperiosteal dissection. Longer-term follow-up is required to confirm stable pubic approximation.

Level of evidence: Level III.

Background: Proximal femoral varus osteotomy (PFVO) is commonly performed to improve femoral head containment and decrease deformity in Legg-Calve-Perthes disease (LCPD). Little is known about how PFVO impacts the quality of life after surgery. The purpose of this study was to determine the longitudinal changes to patient-reported physical, mental, and social health measures after PFVO.

Methods: This is a retrospective review of prospectively collected Patient-Reported Outcomes Measurement Information System (PROMIS) data from 20 patients with unilateral LCPD treated with a PFVO. We collected seven PROMIS measures (mobility, anxiety, fatigue, depressive symptoms, pain interference, anger, and peer relationships) before and approximately 1, 3, 8, 12, and 18 months after surgery. We compared PROMIS scores across different time points using repeated measures ANOVA and multiple pairwise comparisons with Tukey adjustment. The relationship between presurgery and postsurgery mental health scores was analyzed using a Spearman correlation.

Results: The mean age at PFVO was 8.2 ± 1.6 years. The mean length of follow-up was 17.0 ± 2.1 months. There was a significant improvement in the mobility score between preoperation and 12 months ( P =0.0031) and 18 months postoperation ( P <0.0001). Anxiety scores significantly improved from preoperation and 18 months postoperation ( P =0.0014). A significant reduction in the pain interference score between preoperation and 12 and 18 months postoperation ( P <0.0001) was observed. Peer relationships significantly improved from one month postoperatively to 18 months postoperation ( P =0.0355). Individual variations were also observed with some patients having elevated depressive symptoms and anxiety scores. Moderate correlations between preoperative and postoperative anxiety and depressive symptoms scores were observed.

Conclusions: PROMIS mobility, anxiety, pain interference, and peer relationship scores improved significantly after PFVO. While the mean anxiety, depressive symptoms, peer relationships, and anger scores were in normal ranges at each visit, individual variations with elevated anxiety and depressive symptom scores were observed. This new longitudinal PROMIS data will better inform patients and families about the quality of life and recovery experience after PFVO.

Level of evidence: Level IV-therapeutic study.

Background: Orthopaedic surgical intervention in children with Charcot-Marie-Tooth (CMT) often includes triceps surae lengthening (TSL) and foot procedures to address instability and pain due to equinus and cavovarus deformities. These surgeries may unmask underlying weakness in this progressive disease causing increased calcaneal pitch and excessive dorsiflexion in terminal stance leading to crouch. The purpose of this study was to evaluate changes in ankle function during gait following TSL surgery in children with CMT.

Methods: Nineteen participants (11 male; age 12.8, SD 3.6 y) with CMT underwent gait analysis and clinical examination preoperatively and postoperatively to determine the outcomes of (1) triceps surae lengthening (TSL) and (2) plantar fascia release with bony foot surgery with or without TSL. TSL was performed in limbs with limited passive dorsiflexion range of motion (ROM) and decreased peak dorsiflexion in terminal stance, with gastrocnemius recession (GR) being preferred over tendo-Achilles lengthening (TAL) in cases with smaller dorsiflexion deficits. Passive dorsiflexion ROM, gait kinematics and kinetics, and foot posture index (FPI) were examined within and across surgical groups using linear mixed models.

Results: Dorsiflexion ROM, peak dorsiflexion in terminal stance and mid-swing, and peak nondimensional plantar flexor moment improved significantly after both GR (n=8 limbs) and TAL (n=11 limbs) ( P ≤0.02). After plantar fascia release with bony foot surgery (n=20 limbs), FPI changed significantly, indicating reduced cavovarus regardless of whether TSL was done ( P <0.05). Passive and dynamic dorsiflexion and ankle kinetics (moment and power) increased only when concomitant TSL was done ( P ≤0.04).

Conclusions: In patients with increased equinus due to reduced passive dorsiflexion range of motion, TSL is an effective surgery for reducing excessive equinus in terminal stance and mid-swing, decreasing toe-walking, and improving swing phase clearance. It can be combined with extensive foot surgery to correct cavovarus deformity without leading to excessive dorsiflexion in terminal stance and crouch gait. Clinical gait analysis is an important tool to help identify appropriate candidates for TSL based on the key indicator of peak dorsiflexion in terminal stance.

Level of evidence: Level IV.

Background: Prune belly syndrome (PBS) is a rare condition characterized by absence of abdominal musculature, cryptorchidism, and obstructive uropathy. The most common orthopaedic problem is scoliosis, yet no reports on growth-friendly surgical treatment of early-onset scoliosis (EOS) exist. Our purpose was to evaluate outcomes of distraction-based implants in children with PBS.

Methods: This was a multicenter retrospective review. Children with PBS treated with TGR, MCGR, or VEPTR with a minimum 2-year follow-up were identified. Demographics, radiographic/surgical data, complications, and unplanned returns to the operating room (UPROR) were collected. Quality of life was measured using EOSQ-24.

Results: Seven patients (100% male) were identified. The mean age at index surgery was 5.6 years. The mean length of follow-up was 4 years (range: 2 to 11 y). Implant types included MCGR (4 patients), TGR (2 patients), and VEPTR (1 patient). Two patients had pelvic fixation. The mean major curve magnitude was 87 degrees preindex, 47 degrees postindex, and 53 degrees at the last follow-up. Mean kyphosis was 55 degrees preindex, 25 degrees postindex, and 42 degrees at the most recent follow-up. Mean T1-T12 and T1-S1 lengths increased 4.4 and 4.8 cm, respectively, between preindex and last follow-up.Complications occurred in 3 patients. One patient had 3 TGR breakages resulting in 3 UPRORs to revise the rods and 1 superficial wound infection treated with antibiotics. Another patient was readmitted for respiratory failure after TGR lengthening and a third patient had a superficial infection manifested by incisional swelling after MCGR insertion that resolved with antibiotics. Two patients have undergone definitive fusion and 1 patient has retained his TGR definitively. The other patients are still undergoing rod lengthening.

Conclusions: Children with PBS can develop severe scoliosis at a young age. Distraction-based implants can successfully control scoliosis while allowing spinal growth. The complication rate is comparable to patients with idiopathic EOS treated with growth-friendly implants.

Level of evidence: Therapeutic level IV.