Journal of Pediatric Orthopaedics最新文献

Background: Increasingly, professional societies and accrediting bodies in orthopaedic surgery recognize the role of case minimum requirements to assess and enhance fellowship training. This study analyzes targets for case minimum requirements during Accreditation Council for Graduate Medical Education (ACGME)-accredited pediatric orthopaedic surgery fellowship training.

Methods: This was a cross-sectional study of ACGME-accredited pediatric orthopaedic surgery fellows who graduated between 2018 and 2024. Means, SDs, and percentiles for recorded case volumes were calculated across ACGME-defined case categories. Variability was defined as the fold-difference between the 90th and 10th percentiles of case volume. Potential targets for case minimum requirements were identified through sensitivity analyses.

Results: There were 258 ACGME-accredited pediatric orthopaedic surgery fellows included in this study. Mean annual case volume increased over the study period (254.9±70 to 285.2±82, P =0.456). The most frequently reported cases were in spine deformity (19%), foot and ankle deformity (16%), hip reconstruction (13%), and limb deformity (12%). Variability in total reported case volume was 2.0 and was greatest in clubfoot (78.4), soft tissue: transfer, lengthen, release (15.4), and treatment of infection (10.6). The 10th and 30th percentiles of fellows reported 18 and 26 hip reconstruction cases, 17 and 30 foot and ankle deformity cases, 14 and 23 limb deformity cases, 12 and 25 spine deformity cases, 11 and 19 trauma lower limb cases, and 8 and 14 trauma upper limb cases before graduation, respectively.

Conclusions: Case volumes of recently graduated fellows may help inform future case minimum requirements for ACGME-accredited pediatric orthopaedic surgery fellowship training. Future investigation is needed to refine proposed targets for case minimum requirements through elucidation of surgical learning curves and other clinical competency metrics.

Clinical relevance: Case minimum requirements may facilitate operative training during pediatric orthopaedic surgery fellowship training and promote greater standardization across programs. Case minimum requirements may also promote clinical competency assessments and patient safety in pediatric orthopaedic surgery.

Introduction: The influence of the first assistant's training level on outcomes of orthopaedic surgery in children with cerebral palsy (CP) remains unknown. As such, this study aims to evaluate the effects of first assistant training level (resident vs. fellow) on perioperative and postoperative outcomes following proximal femoral varus derotational osteotomy (VDRO) in children with CP.

Methods: Pediatric patients (age <18 y) with CP who underwent VDRO by a single fellowship-trained pediatric orthopaedic surgeon between 2017 and 2021 were retrospectively reviewed. Patients with a minimum of 2-year follow-up were included. Demographic data, training level of first assistant, and perioperative surgical characteristics (operative time, operating room time, estimated blood loss, length of stay, and peri- and postoperative complications) were recorded. Acute complications (≤ 90 d postoperatively) included medical complications, surgical site infection (SSI), peri-prosthetic fractures, emergency department visits, hospital readmission, and revision surgery. Long-term complications (>90 d postoperatively) included delayed/nonunion, re-subluxation, SSI, symptomatic hardware, and revision surgery. Preoperative and minimum 1-year postoperative migration percentages (MPs) were collected. t tests, χ 2 test, and Fisher exact test were used to detect differences between complication rates and outcomes between resident-assisted (group A) and fellow-assisted (group B) cases.

Results: Sixty-nine patients were included for analysis (group A: 27; group B: 42). Demographic data, medical comorbidities, and surgical complexity were comparable between groups. Perioperative surgical characteristics, acute complications, and long-term complications were equivalent between groups ( P >0.05). Minimum 1-year postoperative MPs were lower in group A than group B (1% vs. 7.5%, P <0.001). No patients had MP≥40% at 1-year postoperatively in either group.

Conclusion: Despite the high surgical and medical complexity of osseous hip reconstructions for children with CP, postoperative outcomes are not impacted by the first assistant's training level. While postoperative MPs were slightly lower for patients in the resident-assisted group, these differences were not clinically significant, and 1-year radiographic outcomes were comparable. Resident surgeons should be encouraged to participate in VDRO cases, and families should be reassured that resident participation will not negatively affect outcomes.

Background: Pediatric fractures are common injuries, and the increasing prevalence of neuropsychiatric conditions like ADHD, autism, anxiety, and depression may complicate postoperative outcomes. Understanding how these diagnoses affect surgical recovery is essential for optimizing care in this vulnerable population.

Methods: This study analyzed data from the 2019 and 2022 Kids Inpatient Database. Children undergoing common nonspine orthopedic procedures were identified and matched one-to-one by age, sex, ethnicity, and severity of illness. Primary outcomes included postoperative complications, such as infection and mechanical implant failures; secondary outcomes were length of stay and total hospital charges. Logistic regression models were used to adjust for potential confounders.

Results: Among 4931 ADHD-matched pairs, patients with ADHD had longer mean hospital stays (5.07 vs. 4.69 d, P=0.041) and significantly increased risk of osteomyelitis (OR: 1.42, P=0.0017) and soft tissue infection (OR: 1.39, P=0.009). For 5673 anxiety-matched pairs, anxiety correlated with higher mean length of stay (7.16 vs. 5.54 d, P<0.01) and elevated odds of soft tissue infections (OR: 1.55, P<0.01), mechanical implant complications (OR: 1.28, P=0.036), and constipation (OR: 2.03, P<0.01). Depression (2950 matched pairs) was associated with longer stays (8.31 vs. 6.00 d, P<0.01) and greater risk of osteomyelitis (OR: 2.04, P<0.01). Among 2322 autism-matched pairs, autism did not significantly impact length of stay but increased pneumonia risk (OR: 1.76, P=0.025) and postoperative ileus (OR: 1.71, P=0.040).

Conclusion: These findings demonstrate the significant impact of neuropsychiatric comorbidities on pediatric orthopedic recovery. Behavioral factors, such as impulsivity or anxiety-driven movement avoidance, and physiological mechanisms, including altered immune function, may drive elevated complication rates. Tailored perioperative management, including mental health screening, specialized communication strategies, and enhanced caregiver support, could improve adherence and reduce morbidity for these patients. Further research should focus on targeted interventions, medication considerations, and strategies that foster cooperation among orthopedic, mental health, and rehabilitative services. Addressing these challenges can ultimately enhance the quality of care and reduce disparities for pediatric patients with coexisting orthopedic injuries and neuropsychiatric diagnoses.

Level of evidence: Level III-retrospective comparative study.

Background: Type IV Hereditary Sensory and Autonomic Neuropathy (HSAN IV) is an exceedingly rare autosomal recessive disease classically characterized by generalized loss of temperature/pain sensation, intellectual disability, and anhidrosis. HSAN IV patients are subject to repeated orthopaedic injuries and complications. There is some data on the clinical presentation, but limited data on the diagnostic and treatment challenges, and functional outcomes with HSAN IV.

Methods: This is a retrospective case series of 4 siblings with HSAN IV. Medical records were reviewed for data regarding presentation, diagnosis, and management. Functional outcomes were assessed using the Pediatric Outcomes Data Collection Instrument, with historical normative data used as a control. The 2 populations were evaluated with a Welch-modified 2-sample t test to explore the alternative hypothesis that HSAN IV patients are significantly functionally impaired.

Results: Our study included 4 siblings, 2 males and 2 females, aged 3, 8, 12, and 21 years, respectively. The average time to diagnosis was 53 months, and each diagnosis was confirmed through whole-exome sequencing. The challenges faced included delayed diagnosis, diverse clinical presentations, unestablished treatment guidelines, and unnecessary healthcare utilization before definitive diagnosis. The comparison of means between the normative population and the HSAN IV patients revealed a significant difference in sports/play ( T -score =-4.14, P =0.025) and global function ( T -score =-3.19, P =0.049) but no significant difference in upper extremity function ( P =0.216), transfer mobility ( P =0.164), pain/comfort ( P =0.955), and happiness ( P =0.995).

Conclusions: HSAN IV is a rare genetic condition with protean clinical manifestations that can result in significant deficits in play and global function. The clinical manifestations are varied, including multiple fractures, delayed/abnormal fracture healing, bone deformity, osteomyelitis, and various other non-orthopaedic manifestations. Whole-exome sequencing is a useful tool that, when combined with a high index of clinical suspicion, can expedite the diagnostic process for HSAN IV. Patients can benefit from earlier diagnosis and earlier access to education to prevent functional deterioration and repeat medical interventions.

Level of evidence: IV-case series.

Background: Supracondylar humerus fractures are common in children, often leading to malunion and cubitus varus. Corrective osteotomy techniques for cubitus varus include lateral closing-wedge, step-cut, dome, distraction osteogenesis, and computer-assisted multiplanar 3D osteotomies. This study seeks to determine the most effective corrective osteotomy technique for pediatric malunion of the supracondylar humerus through a systematic review, as there is currently no up-to-date review on this topic.

Methods: A literature search was conducted across the PubMed, EMBASE, ProQuest, Scopus, and Cochrane Library databases on April 2, 2023, following the PRISMA guidelines. Selected articles underwent a review process by 2 independent reviewers to reassess their eligibility based on predefined inclusion criteria. The quality and potential biases of each article were assessed utilizing the Newcastle-Ottawa Scale (NOS) for nonrandomized studies and the Cochrane Risk of Bias Tool for randomized studies.

Results: This systematic review included 39 out of 754 articles, involving 863 patients who underwent various osteotomies. The patients were followed up for an average of 27.3 months, and data on range of motion, angle correction, and clinical outcomes were collected. Different assessment criteria were used for functional outcomes. Complications included infections, nerve injuries, reoperations, residual deformity, and absence of lateral condyle prominence. The systematic review revealed a shortage of randomized controlled trials (RCTs) due to challenges in randomization, surgical technique variations, and ethical considerations.

Conclusions: Various osteotomy techniques can be used to achieve favourable outcomes in cases of pediatric supracondylar malunion. These techniques include lateral closing wedge osteotomy, step-cut osteotomy, dome osteotomy, distraction osteogenesis, and multiplanar 3D osteotomy. Each osteotomy technique has its own advantages and disadvantages for specific outcomes. Lateral closing wedge osteotomy is recommended for patients with preoperative range of motion deficits. Step-cut osteotomy excels in correcting the humerus-elbow-wrist angle. A meta-analysis favoured the lateral closing wedge over the dome osteotomy for satisfactory outcomes.

Level of evidence: Level III.

Background: Planovalgus is a common foot deformity in children with cerebral palsy (CP). Orthopaedic surgery is widely established as an effective treatment for planovalgus deformity, but postoperative protocols vary without a clear rationale. Immediate weight bearing (WB) after planovalgus foot correction may accelerate recovery; however, concerns about complications cause reluctance. This study aimed to determine the prevalence of complications after planovalgus correction in children with CP with early WB versus non-WB (NWB).

Methods: This retrospective cohort study included ambulatory children (Gross Motor Function Classification System I to III) with CP and planovalgus foot deformity who underwent reconstructive surgery and pre- and postoperative gait analyses. Complications were defined in 3 timeframes: (1) short-term, within 6 months of surgery, by radiograph review for nonunion, hardware failure, or infection requiring return to surgery; (2) mid-term, at 1 to 3 years, by pedobarographic assessment; and (3) long-term, >3 years, by recurrence requiring surgical revision. Fisher's exact tests compared the prevalence of complications between the immediate WB and NWB groups. Regression analysis was used to evaluate the relationship between complications and child, surgical, and postoperative factors.

Results: One hundred thirty-five children with CP (Gross Motor Function Classification System I-12%, II-58%, III-30%) underwent 140 surgical events (224 feet) at age 12.7±2.8 years. Following surgery, 84% of children followed an immediate WB protocol; 16% were NWB for 6 weeks. The prevalence of short-term complications between the WB and NWB groups was not different (nonunion/hardware failure/infection: WB, 3%/1%/0%; NWB, 0%/3%/0%; P >0.9). No differences existed between groups in midterm correction status (undercorrected/corrected/overcorrected: WB, 31%/45%/24%; NWB, 32%/54%/14%; P >0.9). The prevalence of long-term recurrence necessitating surgery was not significantly different (WB/NWB, 3%/11%; 8.5±2.8 years postoperatively; P >0.9). WB status was not a significant predictor of correction status or long-term recurrence requiring revision ( P ≥0.11).

Conclusions: There were no significant differences in complications between groups who followed immediate WB versus NWB postoperative protocols. Immediate WB after planovalgus foot correction surgery should be encouraged in children with CP, as early WB may prevent disuse muscle weakness and promote recovery.

Level of evidence: Level III-retrospective cohort study.

Objective: Supracondylar humerus fracture is a common elbow injury sustained in the pediatric population. Percutaneous pinning, whether all lateral or medial-lateral, is the mainstay of operative management for these injuries. There has been much debate on the safety of medial-sided pinning, with the literature indicating that medial-sided pinning can lead to iatrogenic ulnar nerve injury. Thus, the goal of our study is to describe the rates of nerve injuries (radial, median, and ulnar), loss of reduction, and range of motion between all lateral and medial-lateral treatment groups.

Methods: Patients aged 1 to 18 years presenting at a pediatric hospital for a single, isolated supracondylar humerus fracture and treated with percutaneous pinning between 2018 and 2023 were reviewed. Patients with concurrent surgical treatment at the time of pinning, who presented with multiple injuries, had an open reduction, had an open fracture, or were lost to follow-up, were excluded. Age, sex, Gartland fracture classification, pinning method, nerve injury, range of motion, loss of reduction, and duration of follow-up were collected. Descriptive statistics were analyzed for variables of interest.

Results: A total of 406 pediatric patients were included. The average (SD) age at presentation was 5.7 (2.3) years, with 179 (44.1%) patients presenting with Type II fracture and 227 (55.9%) with Type III or IV. There were 131 (32.3%) patients treated with a medial-lateral pinning approach and 275 (67.7%) patients treated with an all-lateral pinning approach. Patients treated with a medial-lateral pinning experienced no new ulnar, radial, or median nerve injuries postoperatively. There was 1 (0.8%) patient with a loss of reduction, and 68.4% of patients with a medial pin had a full range of motion at their last follow-up. Patients treated with an all-lateral pinning approach experienced a new median nerve injury (n=1) and a new ulnar nerve injury (n=1) postoperatively. No patients with an all-lateral pinning approach had a loss of reduction, and 70.7% had a full range of motion at the last follow-up.

Conclusions: This study demonstrated no occurrence of an ulnar nerve injury while utilizing the medial entry pins in the treatment of supracondylar fractures. Strict adherence to surgical principles pertaining to medial entry pins is crucial to avoid ulnar nerve injury and should be included in orthopaedic surgeon's armamentarium when treating unstable supracondylar fractures.

Background: Serial casting is a safe and effective treatment for early-onset idiopathic scoliosis (I-EOS). However, its impact on a child's ability to walk has not been previously described. This study evaluates the influence of serial casting on ambulatory age in I-EOS patients.

Methods: A retrospective multicenter review was conducted on I-EOS patients who received their first casts before 18 months of age. Excluded were patients who were ambulatory at the first visit or had incomplete records. Data collected included sex, age at first visit and cast application, number of casts, precast/postcast coronal and kyphosis curves, age at final cast removal, total duration in cast, and age at first change in recorded ambulatory status. Patients were grouped by first recorded change in ambulatory status: ≤18 months, 19 to 24 months, and >24 months. Differences were assessed using ANOVA.

Results: Of the 203 patients, 148 were preambulatory at first visit. One hundred fourteen patients had sufficient documentation and of these, 30 ambulated by 18 months, 44 at 19 to 24 months, and 40 after 24 months. Significant differences were found in terms of sex ( P =0.012), precast major curve ( P =0.025), precast minor curve ( P =0.011), age at cast removal ( P =0.011), and casting duration ( P =0.007). Ambulators after 24 months had larger precast major curves compared with those at 19 to 24 months (47 vs. 36 degrees, P =0.019). Ambulators after 24 months also were older at age of cast removal (34 vs. 23 mo, P =0.008) and had longer casting duration (22 vs. 10 mo, P =0.007) versus ambulators at ≤18 months. No other statistical differences were observed.

Conclusion: In I-EOS patients treated with serial casting, delayed ambulators were more likely to be male, have greater magnitude initial major curves, a later age of cast removal, or longer total cast duration. There is an apparent association of casting with later ambulatory status; however, it is impossible to separate the impact of casting from the potential differences in underlying condition.

Level of evidence: Level III-retrospective chart review.

Background: Our aim is to investigate the association between soft tissue infection in the popliteal fossa and hamstring muscles to determine the risk of DVT formation in children with infections in the knee and posterior thigh.

Methods: This prospective cohort study (the Peterborough Paediatric Musculoskeletal Infection Study) has gathered data for 181 children aged 0 to 15 years with infection of their limbs or spine. Those with MRI evidence for infection of the popliteal fossa of the knee were identified, as well as those with thrombosis in the venous system.

Results: Popliteal fossa infection was present in 15 children (8% of the 181 in the entire study). Most were associated with septic arthritis of the knee (80%), but some were due to pyomyositis of the hamstrings or calf (20%). Venous thrombosis was noted in 1.1% of the entire 181 study group, but 13% of those with popliteal fossa infection, a 12-fold difference (Fisher exact test statistic 0.0064, P <0.01). One of those with a DVT died from pulmonary embolism a few hours after their MRI scan had been performed.

Conclusion: Thirteen percent of children with popliteal fossa infection had an associated DVT, so it may be an independent risk factor for thrombosis. To minimize the risk of DVT and its serious complications, we recommend that children presenting to the Emergency Department with pain in the knee, thigh or calf and raised inflammatory markers (CRP/ESR) suspicious for musculoskeletal infection should have their popliteal fossa examined, and if tender, an urgent Doppler ultrasound should be organised. On MRI, attention should be paid to the popliteal fossa on axial STIR images, and if oedema is present around the popliteal vessels, then prophylactic dose anticoagulation should be started, while those with a dilated popliteal vein on MRI should receive treatment dose anticoagulation.

Level of evidence: Level II. A lesser quality prospective study with patients enrolled at different points in their disease.