Journal of Pediatric Orthopaedics最新文献

Background: Meniscal injuries frequently accompany acute anterior cruciate ligament (ACL) tears, creating clinical dilemmas regarding optimal surgical timing. While delayed reconstruction increases risks of progressive meniscal damage, early intervention may interrupt natural healing capacity in the adolescent population. This study examines relationships between surgical timing, detailed tear characteristics, and meniscal healing patterns in adolescent ACL injuries.

Methods: A retrospective cohort analysis of 55 adolescent patients (mean age: 14.9±1.9 y, range: 11.9 to 18; 63.6% male) undergoing arthroscopic ACL reconstruction (2015 to 2024) compared preoperative MRI findings with intraoperative meniscal evaluations. Individual meniscal tears (n=64) were characterized by anatomic location and morphologic configuration. Meniscal healing (absence of arthroscopically visible tears previously seen on MRI) was the primary outcome. Secondary analyses examined healing rates by location and surgical timing as a continuous variable. Multivariate logistic regression identified independent predictors.

Results: Among 64 individual tears, 29 (45.3%) demonstrated spontaneous healing. Continuous timing analysis revealed healed tears averaged earlier surgery at 169.8±78.4 days versus persistent tears at 203.4±89.2 days (difference: 33.6 d, P =0.021). Medial meniscal tears showed significantly higher healing rates than lateral tears (60.0% vs. 27.6%, P =0.006). Multivariate analysis identified 3 independent predictors: medial location (OR: 3.9, 95% CI: 1.5-10.1, P =0.005), earlier surgical timing per day (OR: 0.994, 95% CI: 0.989-0.999, P =0.021), and posterior horn location (OR: 2.8, 95% CI: 1.1-7.2, P =0.031). Six new tears were identified at surgery (10.9% rate), with 5 occurring in patients with delayed surgery (>120 d from injury).

Conclusion: This analysis demonstrates significant associations between surgical timing and meniscal healing in adolescent ACL injuries, with each day of delay associated with a 0.6% reduction in healing odds. These preliminary findings require validation in larger prospective studies before influencing treatment decisions but may inform patient counseling regarding expected outcomes.

Level of evidence: Level III-retrospective cohort study.

Background: Anterior vertebral body tethering (AVBT) is a promising fusionless alternative for treating idiopathic scoliosis; however, limited data exist on the learning curve for this procedure. Previous studies are limited by single-center and short-term complication data. This multicenter study assesses the learning curve by evaluating improvements in operative characteristics over time and radiographic measurements up to 2 years postoperatively.

Methods: As recorded from a multicenter registry, surgeons with ≥10 index AVBT procedures for patients with idiopathic scoliosis aged 16 years and below were included. Relationships between case number and multiple surgical variables were determined using Pearson correlation and linear regression testing. For identification of an inflection point, consecutive cases were plotted against operative time per level and fitted with a locally weighted scatterplot smoothing curve. Independent samples t test and χ 2 test were used to compare outcomes between cases before and after the inflection point. Outcomes of interest included demographic, surgical, and radiographic information at the baseline, immediate postoperative, and 2-year timepointswhere available.

Results: Eight surgeons and 325 index AVBT patients met the inclusion criteria. Inverse relationships were identified between case number and estimated blood loss, operative time, anesthesia time, and fluoroscopic time per level ( P < 0.005). The inflection point was identified at 15 cases. Operative time, anesthesia time, and fluoroscopy time per level were greater in the first 15 cases compared with those after ( P < 0.05). There were no significant differences in demographic variables, intraoperative complications, or length of stay between the early and late cases. Greater correction in the major coronal curve, minor coronal curve, and coronal balance occurred in the cases performed after the inflection point ( P < 0.05).

Conclusions: AVBT is a safe alternative to posterior spinal fusion and demonstrates a predictable improvement in surgical performance over time. Large improvements can be expected during the first 15 AVBT cases performed with minimal differences in complications.

Level of evidence: Level III.

Introduction: Syndromic polydactyly is often associated with an increased cancer risk. However, limited data exist regarding nonsyndromic polydactyly and its associated risk of subsequent malignancy. Therefore, our purpose was to investigate differences in rates of both malignant and benign neoplasms among pediatric patients diagnosed with nonsyndromic polydactyly compared with matched controls.

Methods: The TriNetX US Collaborative Network database was queried using ICD-9 and ICD-10 codes to identify patients aged 10 and younger diagnosed with any form of polydactyly. Patients were then divided into 2 cohorts depending on their history of polydactyly. These cohorts were propensity-matched based on age, sex, race, ethnicity, and congenital malformation syndromes associated with both polydactyly and malignancy. Subsequent rates of cancer were compared between patients with and without polydactyly.

Results: A total of 9,266,353 patients aged 10 and younger were identified, of which 16,478 (0.18%) were diagnosed with polydactyly. After 1:1 propensity matching, both cohorts included 14,361 patients. Mean follow-up was 73 months for the polydactyly cohort and 78 months for the control cohort. Overall, the polydactyly cohort had a significantly increased rate of any neoplasm (3.3% vs. 2.6%) and benign neoplasms (2.6% vs. 2.2%) compared with the control cohort. There was no significant difference between rates of malignant neoplasms between cohorts. In contrast, when analyzing site-specific cancer risk between cohorts, malignant neoplasms of bone or cartilage (0% vs. 0.1%) as well as breast (0% vs. 0.1%) were significantly higher in the control cohort compared with the polydactyly cohort. However, there were no significant differences between cohorts among rates of alternative site-specific cancers, including digestive, respiratory or intrathoracic, skin, mesothelial or soft tissue, urinary tract, central nervous system (CNS), thyroid or endocrine, neuroendocrine, lymphoid, and lip, oral cavity, or pharynx. Furthermore, after stratifying follow-up time periods, no significant differences were appreciated between polydactyly and control cohorts in rates of all neoplasms, malignant neoplasms, and benign neoplasms at follow-up <1 year, between 1 and 5 years, and >5 years.

Conclusions: Nonsyndromic polydactyly seems to be associated with increased rates of neoplasms, particularly benign neoplasms. However, site-specific cancers of bone, cartilage, and breast were significantly decreased in polydactyly patients. Although our large study further investigates this complex relationship, further studies are needed to elucidate polydactyly and its cancer implications.

Level of evidence: Retrospective cohort study, level of evidence III.

Background: Fixed knee flexion deformity in skeletally immature patients with cerebral palsy (CP) is a common contributor to mobility impairment. Established techniques for guided growth using metal implants are associated with symptomatic hardware. This study provides early results following anterior distal femur hemi-epiphysiodesis (ADFHE) with a novel technique utilizing suture anchor-based nonmetallic implants.

Methods: We reviewed a consecutive series of skeletally immature patients with CP treated for fixed knee flexion contracture with ADFHE using this novel technique between April 2021 and March 2023 at a single tertiary care hospital. All surgeries were performed by a single board-certified pediatric orthopaedic surgeon. Age at surgery, ambulatory status, Gross Motor Function Classification System (GMFCS) level, concurrent lower extremity surgery, and preoperative and postoperative knee flexion contracture (degrees) were collected. Time to resolution of contracture (months) and correction rate (degrees/month) were calculated for each knee. All patients were followed for a minimum of 6 months postoperatively (or until full correction). Descriptive statistics and time-to-event analysis were performed.

Results: Twenty-one patients were included, of whom 19 underwent bilateral correction (N=40 knees); 14 patients (26 knees) were ambulatory, and 7 patients (14 knees) were non-ambulatory. Six patients were classified as GMFCS level II (29%), 8 level III (38%), 6 level IV (29%), and 1 as level V (5%). In the ambulatory patients, preoperative knee flexion contracture measured 12.9±6.6°. Final postoperative contracture measured 1.69±4.16°. Correction occurred at a rate of 2.0°/month over 11.9±10.2 months. In the non-ambulatory patients, preoperative knee flexion contracture measured 24.6±17.4°. Final postoperative knee flexion contracture measured 13.2±12.3°. Correction occurred at a rate of 1.6°/month over 13.5±0.3 months. Correction rate ( P =0.71) and time-to-resolution of contracture ( P =0.91) did not differ significantly based on ambulatory status. There were no complications or symptomatic hardware necessitating removal.

Conclusions: The use of suture anchor-based ADFHE technique for fixed knee flexion contracture is an effective technique in patients with CP, yielding results similar to those of historical techniques with a favorable complication profile.

Level of evidence: Level III.

Background: Guided growth offers a less invasive option for the treatment of Blount disease. Previous studies have found guided growth to be much less successful for individuals with more severe mechanical axis deviation (MAD). This study aims to assess the effectiveness and safety of guided growth systems for treating Blount disease in juvenile and adolescent patients with particular attention to patients presenting with severe deformities.

Methods: Patients were included if greater than 4 years of age and had undergone guided growth from January 2005 to September 2023. Treatment success was defined as final correction to MAD zone -1, 0, or +1 using only guided growth. Failure was defined as individuals who did not achieve correction to the above zones or those requiring osteotomy. Odds ratios were calculated for failure in patients with initial presentation in MAD zones -3 and -4. To further analyze our results, we also compared the treatment success rate of the 4-screw construct versus 2-screw construct, both of which are used at our institution.

Results: A total of 32 patients with 44 extremities were included in this study: 13 patients (41%) in the juvenile group, and 19 patients (59%) in the adolescent group. Overall, successful correction to MAD -1, 0, and +1 was 61%. Factors associated with failure were mean BMI 40.3 (±8.8) versus 33.5 (±9.3), ( P =0.034). The odds ratio of zone -3 and zone -4 deformity treatment failure were 1.64 (95% CI: 0.48-5.56) and 1.78 (95% CI: 0.51-6.17), respectively. The relative risk of 4-screw plate construct for treatment failure was 0.5 (95% CI: 0.21-1.19) while 2-screw plate construct carried a relative risk of 4.5 (95% CI: 0.579-35.6) for mechanical implant failure.

Conclusions: Our research demonstrates that moderate and severe varus deformity (zone -3 and -4) in children with Blount disease can be successfully treated by tension band plating, though the failure rate still remains high.

Level of evidence: Level III.

Introduction: Hurler syndrome is characterized by significant spinal abnormalities, including cervical instability, odontoid dysplasia, and spinal cord compression. Spinal compression and kyphosis at the cervicothoracic (C-T) junction are also observed but less commonly reported. The present study was conducted to determine the prevalence of C-T kyphosis and spinal cord compression at the C-T junction in patients with Hurler syndrome. In addition, we aimed to evaluate the significance of C-T kyphosis and spinal cord compression in these patients in terms of clinical symptoms or neuromonitoring changes in nonspine surgery.

Method: This retrospective case series examines patients with Hurler syndrome at a single pediatric institution from 2009 to 2023, with 47 included based on available spinal MRIs. Radiographic assessments included the C6-T4 kyphosis, maximal C-T kyphosis, and spinal cord compression using Kang grading for stenosis. Follow-up MRIs tracked changes in C-T kyphosis and new spinal cord compression. The value of C-T kyphosis associated with spinal cord compression (Kang grades 2 and 3) was determined using receiver operating characteristic (ROC) analysis. IONM data, including SSEP and TcMEP, were reviewed for significant changes during surgeries unrelated to the spine.

Results: This study involved 47 patients with an average age of 5 years and 57% male. Initial MRI showed a mean C-T kyphosis of 17 degrees, primarily affecting C7-T3. Follow-up MRIs revealed progressive C-T kyphosis and spinal cord compression. A C-T kyphosis >20 degrees was associated with Kang grade 2 spinal cord compression. IONM during nonspine surgeries identified significant changes in 3 patients. One patient developed postoperative paraplegia following hip surgery performed without IONM. A retrospective review of a prior airway MRI showed a C-T kyphosis of 49 degrees along with spinal canal stenosis.

Conclusions: The manuscript sheds light on the intricate nature of C-T kyphosis in individuals with Hurler syndrome. While the clinical significance and optimal management of this condition are still under discussion, the study underscores the importance of evaluating C-T kyphosis to guide surgical planning and reduce the risk of spinal cord injury in affected patients.

Level of evidence: Case series, Level IV.

Background: Cast removal can be an anxiety-provoking medical procedure for children. Distraction emerges as the safest and most effective intervention to reduce anxiety. Although various distractions have been studied, none of them have proven simple and inexpensive enough to meet the needs of orthopaedic clinics. The present study aims to evaluate whether multimodal distraction incorporating music, drawings in a mirror, and finger puppets, can decrease children's anxiety during cast removal compared with standard of care.

Methods: A before and after quasi-experimental design was implemented with children aged 3 to 12 years old. The control group received standard care during cast removal, while the intervention group was offered distractions, including noise-cancelling headphones for music, finger puppets, and a mirror for drawing or observing the reflection of their healthy limb. Anxiety levels before, during, and after cast removal were assessed using the Children's Fear Scale (CFS) and the Faces, Legs, Activity, Cry and Consolability (FLACC) Scale. Parent and cast technician satisfaction was evaluated through homemade questionnaires and the Short Assessment of Patient Satisfaction (SAPS).

Results: One hundred two children participated in this study, with the first 51 assigned to the control group and the subsequent 51 to the intervention group. On the FLACC Scale, the median anxiety level was at 0 points in both groups at all 3 time points. On the CFS, the median anxiety level during cast removal was at 0.5 points for the intervention group and 1 point for the control group (P = 0.71). The level of anxiety was very low for both groups. Finally, 77% of parents indicated they would like their children to use distraction again.

Conclusion: The multimodal distraction presented in this study did not demonstrate a reduction in anxiety levels during cast removal in children compared with standard care provided at the institution. However, it provides a potentially more positive experience for children and is well accepted by the orthopaedic clinical team.

Level of evidence: Level II-prospective comparative study.

Purpose: The primary objective was to evaluate the incidence and risk factors for Meniscal Ramp Lesion (MRL), and secondarily, the rate of clinical failure, defined as the need for revision surgery for MRL at a minimum follow-up of 2 years.

Methods: A retrospective analysis of prospectively collected data was conducted on patients operated in our department, a tertiary referral center for pediatric knee surgery. All patients under the age of 18 who underwent primary or revision anterior cruciate ligament reconstruction (ACLR) between January 1, 2015, and December 31, 2018, were considered. Patients with congenital absence of the anterior cruciate ligament (ACL) or with <2 years of follow-up were excluded. This study involved 2 overlapping patient cohorts. The first, the overall ACLR cohort, included all pediatric patients who underwent ACLR with or without associated MRL. The second, the MRL cohort, included patients diagnosed intraoperatively with an MRL during ACLR within the same study period. In the overall ACLR cohort, the primary analysis evaluated the incidence of MRL and compared patients with and without MRL to identify potential risk factors. In the MRL cohort, a secondary analysis assessed the rate of subsequent surgery involving the posterior segment of the medial meniscus.

Results: In the overall ACLR cohort (n=216), the incidence of MRL was 25.9% (56 ramp lesions identified among 216 procedures). Initial knee trauma sustained during contact sports was identified as a risk factor for the development of MRL. A total of 56 patients were diagnosed with an MRL intraoperatively, of whom 3 were lost to follow-up, leaving 53 patients in the MRL cohort. As a result, 53 patients were included in the secondary analysis. Mean follow-up time was 55.5±20.4 months (range: 24.0 to 107.0 mo). Twelve patients (22.6%) were reoperated on the posterior segment of the medial meniscus, of which 5 patients (9.4%) had partial medial meniscectomy.

Conclusions: MRL have a significant prevalence during ACLR in children and adolescent patients, and participation in pivot contact sport appears to be a significant risk factor of developing MRL in this specific population. The overall secondary surgery rate on the medial meniscus after MRL repair was 22.6% in this cohort.

Level of evidence: Level IV-retrospective case series.