Journal of Pediatric Orthopaedics最新文献

Background: Differentiating lateral ankle avulsion fractures from subfibular ossicles in pediatric ankle sprains remains diagnostically challenging with conventional radiography. This study evaluates a novel dynamic ultrasonography technique for reliable differentiation, offering clinicians a rapid, accurate diagnostic tool.

Methods: We collected radiographic and dynamic ultrasound imaging data from 95 children with lateral ankle sprains, all of whom underwent examination using the novel dynamic ultrasonographic technique. Four observers with varying levels of clinical experience evaluated the images. Each observer made diagnoses based on radiographs alone and then in combination with dynamic ultrasound images. Interobserver reliability was assessed using the multirater free-marginal kappa, while intraobserver reliability was evaluated using the linear weighted kappa. The changes in diagnoses of the observers after the addition of dynamic ultrasound images were collected and analyzed.

Results: The study of 95 cases identified 5% (5/95) subfibular ossicles, 16% (15/95) distal fibular avulsion fractures, 4% (4/95) lateral process talus fractures, and 75% (71/95) radiographically negative cases. Among the 24 radiographically positive cases, initial interobserver agreement for distinguishing subfibular ossicles from avulsion fractures was slight (κ=0.33) using radiographs alone, which improved to excellent (κ=0.89) with dynamic ultrasound images. Ultrasound prompted diagnostic changes in 26% of cases (6.25 cases) from subfibular ossicles to avulsion fractures, and 6% (1.5 cases) from avulsion fractures to subfibular ossicles.

Conclusion: The dynamic ultrasonographic technique accurately differentiates between lateral ankle avulsion fractures and subfibular ossicles in pediatric lateral ankle sprains. This dynamic ultrasound technology can also be used to assess the stability of lateral ankle bone fragments, providing valuable information for treatment planning.

Level of evidence: Level III-diagnostic study.

Background: Multidirectional instability (MDI) of the shoulder is a complex condition with a high rate of recurrence after surgical intervention in the younger population. This study was undertaken to determine the best treatment strategy for adolescent patients who fail their index surgical capsulorrhaphy.

Methods: Patients managed surgically over a 6-year period for MDI at a pediatric facility with 2 years minimum follow-up were evaluated via demographics, arthroscopic findings, and patient-reported outcomes (PROs): qDASH (short form Disabilities Arm, Shoulder, and Hand), PASS (Pediatric and Adolescent Shoulder Survey), and SANE (Single Assessment Numerical Evaluation). Treatment failure was defined as the need for a revision procedure, a PASS score less than 85, or a SANE score less than 75. Three cohorts were developed for comparison: successful, and unsuccessful (those electing a revision surgery, and those without a revision surgery).

Results: A total of 27 patients (34 total shoulders) with a mean age 16.1±2.0 years (70% female) were identified who met criteria with a mean overall follow-up duration of 6.3±2.4 years. 50% (17/34) had a failed initial procedure with 5 electing to undergo revision surgery. The successful cohort mean qDASH 1.3±2.3, PASS 94.7±3.8, and SANE 92.8±6.7 scores were better than the unsuccessful cohorts ( P <0.001), who had similar mean outcome scores ( P >0.2) between revision and no revision cohorts, respectively: qDASH (12.4±5.9 vs. 13.6±11), PASS (74.7±12.0 vs. 71.8±23.8), and SANE (74.3±8.2 vs. 65.6±25.0). However, 1/5 (20%) of the revision cohort did achieve acceptable PROs after the revision surgery.

Conclusions: A revision surgery following failed index MDI procedure does not appear to improve patient-reported outcome scores for all adolescents. Surgeons should counsel patients and families on the potential outcomes of the primary and/or revision surgery for this condition to improve the shared decision-making process. Future study into risk factors for failure, improved patient selection criteria, and even utilization of open techniques is warranted for adolescents with MDI and involuntary instability of their shoulders.

Level of evidence: Level III-comparative study.

Lam Qua, a Chinese artist, was commissioned by Dr Peter Parker, a medical missionary, to paint portraits of patients attending the Canton Hospital with tumors and deformities. Among numerous such portraits painted by Lam Qua, one is of an adolescent boy with severe deformities of the right lower limb associated with extensive scarring. The possible causes of such scarring are discussed. The fact that appropriate measures adopted while treating major wounds of the limbs can prevent deformities from developing is emphasized.

Background: Genu valgum and genu varum have various causes; however, the cause in some children remains unknown, leading to a diagnosis of idiopathic angular deformity. In this study, we investigated whether vitamin D deficiency could lead to idiopathic knee angular deformity in the absence of typical radiographic findings of rickets by examining serum markers in affected children and controls.

Methods: In this prospective cross-sectional comparative study, we evaluated 38 children aged 7 to 14 years with genu valgum or varum without medical conditions or radiographic findings affecting lower limb alignment and 29 controls. Laboratory parameters and the prevalence of vitamin D deficiency (serum 25-hydroxyvitamin D level <20 ng/mL) or hyperparathyroidism [serum parathyroid hormone (PTH) level >60 pg/mL] were compared between the 2 groups. The prevalence of angular deformities was compared among the groups based on the presence of vitamin D deficiency and hyperparathyroidism. Binary logistic regression analysis was used to calculate the odds ratios (ORs) for angular deformities based on vitamin D deficiency and hyperparathyroidism.

Results: The mean serum 25-hydroxyvitamin D levels did not significantly differ between the angular deformity (16.7±6.1 ng/mL) and control groups (19.9±7.1 ng/mL) ( P =0.055). However, vitamin D deficiency was more prevalent in the angular deformity group than in the control group (79% vs. 48%, P =0.009). Angular deformities were more prevalent in children with both vitamin D deficiency and hyperparathyroidism than in those without these conditions [11/13 (85%) vs. 5/18 (28%), P =0.012]. The logistic regression analysis-adjusted for age, sex, and weight-showed a higher risk of angular deformity in children with both vitamin D deficiency and hyperparathyroidism (OR: 9.86, 95% CI: 1.36-71.47, P =0.024), but not in children with vitamin D deficiency alone.

Conclusions: Isolated vitamin D deficiency without other laboratory abnormalities or radiographic findings of rickets did not lead to knee angular deformity. However, in cases in which vitamin D deficiency elevates PTH levels, idiopathic genu valgum or genu varum might be observed.

Level of evidence: Level III-prognostic study.

Background: Current literature lacks comprehensive documentation on the burden placed on patient families managing spica casts for extended periods. Various complications associated with spica casts further intensify these challenges. To address this gap, our study aims to assess the lived experiences of families caring for children undergoing treatment for developmental dysplasia of the hip (DDH) with a hip spica cast.

Methods: A comprehensive survey was designed to gather caregiver perspectives on various orthotic treatments for DDH. The survey consisted of both Likert statements and open-ended questions to provide a holistic understanding of caregiver experiences. This anonymous survey was distributed online through REDCap to the Global Hip Dysplasia Registry (GHDR) network, reaching participants through mailing lists, social media groups, and clinic visits at the authors' respective institutions. Targeting an international audience, the survey engaged parents and caregivers of pediatric patients treated with different orthoses, including harnesses, braces, and spica casts. The lived experiences of families managing hip spica casts were analyzed as a distinct subset of the broader data set.

Results: A total of 140 respondents reported experience with a spica cast. Caregivers consistently reported concerns about restrictions on outings and daily activities while their child wore the spica cast. Hygiene issues, such as challenges with bathing and keeping the cast clean without getting it wet, were also prevalent. In addition, caregivers faced difficulties with cuddling and holding their children, although they emphasized that bonding remained intact. Many caregivers expressed feeling inadequately informed about spica casts, underscoring the need for improved education and support.

Conclusions: While hip spica casts were acknowledged as an effective treatment for postsurgical DDH, caregivers expressed overall dissatisfaction due to challenges related to convenience, hygiene, bonding, and other daily caregiving difficulties.

Level of evidence/clinical relevance: Understanding the lived experiences of families caring for children undergoing treatment for DDH with a hip spica cast can illuminate challenges and inform strategies for improved patient care and support. The findings from this investigation provide valuable insights that will be instrumental in refining the design of hip spica casts and enhancing education and support for caregivers, ultimately shaping future advancements in the treatment of DDH.

Introduction: Pediatric orthopaedic surgeries for complex hip and spine conditions, particularly in children with cerebral palsy, are associated with high complication rates. Malnutrition, common in this population, contributes to poor wound healing, infections, and prolonged recovery. Despite its impact, definitions and assessments of malnutrition remain inconsistent. Posterior spinal fusion and hip reconstruction carry complication rates over 50%. While interest in nutritional optimization is growing, no standardized approach exists, especially in pediatric orthopaedic populations. The purpose of this study was to evaluate the existing literature on perioperative nutritional assessment and optimization of pediatric patients undergoing complex hip and spine surgery.

Methods: We conducted a PRISMA-compliant systematic review of MEDLINE, Embase, and Cochrane databases in April 2025. Inclusion criteria were studies on patients 21 years or younger undergoing hip or spine surgery that reported perioperative nutritional status or interventions alongside clinical outcomes. Eligible study designs included RCTs, cohort studies, and case series (>10 patients). Data were independently extracted and study quality assessed using the Newcastle-Ottawa Scale (NOS).

Results: Out of 371 studies, 23 met the inclusion criteria. Eighteen were retrospective cohorts, 1 prospective cohort, 2 cross-sectional, and 2 case-control studies. Fifteen were high quality (NOS ≥7). Thirteen studies (57%) examined laboratory-based markers; 10 (43%) assessed nutritional interventions or classifications. Common outcomes included wound complications (48%), respiratory complications (26%), LOS/readmissions (26%), and patient-reported outcomes (17%). Laboratory findings were inconsistent, though transferrin <200 mg/dL was linked to respiratory risk. BMI-based metrics better predicted complications, especially in those who were underweight or experiencing >10% weight loss. Enhanced recovery after surgery (ERAS) protocols improved LOS, pain, and IL-6 levels, while routine nutrition assessments showed no clear benefit.

Conclusion: While isolated laboratory values are inconsistent predictors, underweight status and weight loss are more reliable indicators of risk. ERAS protocols incorporating nutritional strategies may improve outcomes, although more pediatric-focused data are needed. The lack of standardized malnutrition definitions across studies limits comparability. Future research should establish uniform nutritional screening practices and evaluate specific interventions in high-risk pediatric orthopaedic populations. Despite limitations in study heterogeneity and small sample sizes, this review supports integrating structured perioperative nutrition into care pathways.

Background: Rett syndrome (RS) is a rare neurodevelopmental disorder often associated with progressive scoliosis requiring treatment. Surgical interventions include magnetically controlled growing rods (MCGR) to allow spinal growth in younger patients or posterior spinal fusion (PSF) for definitive curve correction and stability. There is limited literature on outcomes of growth-friendly surgical treatment in RS patients with scoliosis.

Methods: This multicenter retrospective review included RS patients with scoliosis treated with MCGR or primary PSF with minimum 2-year follow-up. Demographics, radiographic measures, surgical data, complications, unplanned returns to the operating room, and EOSQ-24 scores were recorded pre- and postindex surgery.

Results: The study included 15 females with Rett syndrome. Five patients had MCGR and 10 underwent PSF. The mean age of the MCGR group was 8.5 years (range: 7.6 to 9.2) and the PSF group was 12.8 years (range: 10.1 to 17.7). Mean preindex major curve magnitude was similar between the MCGR and PSF patients [75 (range: 67 to 91) vs. 80 degrees (range: 53 to 116)]. At final follow-up, the PSF group achieved greater major curve correction than the MCGR group [35 (range: 21 to 58) vs. 42 degrees (range: 26 to 59)]. The MCGR group had greater mean preindex maximum kyphosis [71 (range: 53 to 89) vs. 57 degrees (range: 18 to 96)] but mean maximum kyphosis at final follow-up was similar between the MCGR and PSF patients [54 (range: 42 to 86) vs. 50 degrees (range 18 to 78)]. Mean preindex T1-T12 and T1-S1 lengths were shorter in the MCGR patients [T1-T12: 16.6 cm (range 13.8 to 19.7) vs. 19.4 cm (range: 14.8 to 23.2); T1-S1: 28.6 cm (range: 25.2 to 33.0) vs. 31.0 cm (range: 22.3 to 37.7)]. Final mean T1-T12 lengths were 22.2 cm (range: 19.8 to 25.4) for the MCGR group and 23.8 cm (range: 20.3 to 26.9) for the PSF group; mean T1-S1 lengths were 35.3 cm (range 31.9 to 40.8) and 36.9 cm (range: 32.3 to 42.6), respectively. There was one complication per group. One MCGR patient had acute respiratory failure requiring prolonged hospitalization, and one PSF patient had a wound infection requiring surgical intervention and antibiotics. MCGR patients showed declines in more EOSQ-24 domains than PSF patients between preindex surgery and last follow-up.

Conclusions: Both MCGR and PSF effectively control scoliosis in RS patients. PSF provides superior coronal curve correction, while MCGR promotes spinal growth. The impact of spinal surgery on quality of life warrants further investigation. Larger studies are needed to validate these results and guide individualized treatment for this unique population.

Level of evidence: Therapeutic level IV.

Background: Tibial deficiency (TD) is a rare congenital condition with an incidence of 5 to 21/million live births. While femoral and fibular deficiencies are more commonly recognized and frequently co-occur, associated femoral, hip, and pelvic (FHP) anomalies in TD remain under-characterized. Treatment options for TD include the use of orthotics, amputation with prosthetic management, and limb reconstruction. The presence of additional ipsilateral lower extremity anomalies and their impact on management are unknown. This study aims to characterize FHP anomalies in TD patients and assess their impact on treatment decisions.

Methods: A retrospective review was conducted on TD patients seen at seven tertiary surgical facilities between 2004 and 2022. Demographic data, radiographic findings, anomalies, and treatment details were collected and analyzed. TD was classified using the Jones classification when possible.

Results: A total of 492 patients with 650 tibial-deficient limbs were included. FHP anomalies were identified in 19% of limbs, with femoral anomalies most common (13%), followed by hip anomalies (8%) and pelvic anomalies (1%). The majority (72%) of FHP anomalies occurred with Jones type 1 TD. Treatment modifications for limbs with these anomalies were required in 50%, primarily additional procedures, treatment/surgery for the additional leg length loss, or a change in the level of prosthesis.

Conclusions: FHP anomalies occur in 19% of limbs with TD. They necessitate additional treatment or a change in treatment plan for 9% of all TD limbs, and 50% of TD limbs with FHP anomalies. Further studies are needed to explore the functional outcomes for these patients with femoral, hip, and pelvic anomalies seen in conjunction with ipsilateral tibial deficiency and the impact on factors such as mobility and prosthesis selection.

Level of evidence: Level III.

Background: Allergic diseases are common in children and are risk factors for infections following orthopaedic surgery. However, their association with infection risk following knee surgery in pediatric populations is unknown. This study compared the risks of postoperative infection in children with and without a history of allergic disease (eczema [atopic dermatitis] or asthma) who underwent common orthopaedic sports knee surgeries.

Methods: A retrospective cohort study was conducted using the TriNetX database. Patients aged 10 to 18 who underwent anterior cruciate ligament (ACL) reconstruction (ACLR) or meniscal surgery, including meniscectomy, meniscal repair, and meniscal transplant, were organized into separate cohorts based on prior history of asthma or eczema and matched based on demographics and comorbidities. Outcomes were 90-day postoperative superficial soft tissue infection (SSTI), deep soft tissue infection (DSTI), sepsis, wound complication, pneumonia, urinary tract infection (UTI), and emergency department (ED) visit risks. Tests of significance (alpha=0.05) were performed, and risk ratios (RRs) with 95% confidence intervals were calculated.

Results: Patients with allergic diseases were more likely to be African American and obese. The risks of SSTI (1.3% vs. 0.4%; RR=3.182; P =0.0004) and sepsis (0.4% vs. 0%; P =0.002) in ACLR patients, and risks of SSTI (1.0% vs. 0.3%; RR=3.2; P =0.0007) and pneumonia (0.4% vs. 0%; P =0.0005) in meniscus surgery patients, were higher in patients with a history of eczema than without. Asthma was associated with a greater likelihood of SSTI (1.1% vs. 0.5%; RR=2.067; P =0.02) and sepsis (0.4% vs. 0%; P =0.002) in patients undergoing ACLR but not meniscus surgery. Prior diagnosis of either disease was associated with increased risk for ED visits following both ACLR and meniscus surgery. No significant differences in risk rates were noted between cohorts for DSTI, wound complications, and UTI.

Conclusions: Although overall risks were low, there were significantly greater risks of SSTI and ED visits following common knee sports surgeries in pediatric patients with a history of allergic disease than in those without.

Level of evidence: Level III.