Journal of Pediatric Orthopaedics最新文献

Background: The Early-Onset Scoliosis Self-Report Questionnaire (EOSQ-SELF) is a recently developed tool designed to assess health-related quality of life (HRQoL) in children with early-onset scoliosis (EOS). It complements the existing EOSQ-24, which relies on parental proxy reporting. While the EOSQ-SELF has demonstrated reliability in English, Chinese, and Turkish populations, it has yet to be validated for Spanish-speaking patients. This study aimed to translate, culturally adapt, and validate the EOSQ-SELF for use in Spanish-speaking children with EOS.

Methods: A multicenter, prospective validation study was conducted in Puerto Rico from August to November 2024. Participants aged 8 to 18 years with EOS were recruited during routine follow-up visits, regardless of treatment stage. The EOSQ-SELF underwent a rigorous translation and cultural adaptation process, including forward-backward translation and expert panel review. Reliability was evaluated using internal consistency metrics. Content and construct validity were assessed through expert and patient feedback, nonparametric tests, and multiple linear regression.

Results: The final Spanish EOSQ-SELF showed no significant semantic or cultural issues following expert and patient feedback. A total of 42 patients (mean age 10.3±2.4 y; 64% female) were included. The instrument demonstrated excellent internal consistency (Cronbach's α=0.91), with item-total correlations ranging from 0.34 to 0.75. Discriminant validity was confirmed in 75% of domain comparisons, although overlap was observed between "Transfer" and "Pain." Ceiling effects were most prominent in the "Relationships" domain (78%), while the lowest ceiling effect was found in "Pain and Discomfort" (30%).

Conclusions: The Spanish EOSQ-SELF is a reliable and valid instrument for measuring self-reported HRQoL in Spanish-speaking children with EOS. Despite some ceiling effects in high-functioning domains, the tool remains clinically and scientifically useful for this population.

Level of evidence: Level II-prognostic.

Background: Multiple distraction strategies to mitigate pain and distress during and after hospital procedures and surgery have become widely accepted and used in multimodal pain management in children. One such mode of nonpharmacological intervention and distraction is the application of cast art. There is a paucity of literature investigating the effect that cast art may have on a child's perception of pain. The purpose of this study was to investigate pain reporting and management trends in children undergoing supracondylar humerus fracture (SCHFx) surgery and immobilized postoperatively in a cast with applied custom illustrated cartoon art compared with a plain cast/no-art group.

Methods: Children who underwent closed reduction with percutaneous pinning (CRPP) of SCHFx were identified through retrospective chart review. Children were divided into 2 cohorts: those who received cast art and those who did not. Postoperative Visual Analog Scale (VAS), Face, Legs, Activity, Cry, Consolability scale (FLACC), and pain medication administration were recorded. Data were compared using χ 2 , ANOVA, and Man-Whitney U tests to determine significance set as P <0.05.

Results: Demographics and fracture type based on the Gartland fracture classification were similar between groups. The cast art group had significantly lower VAS ( P =0.009) and FLACC ( P =0.004) scores, required less acetaminophen ( P =0.048), ibuprofen ( P =0.014), and 4 times less children requiring postoperative narcotics ( P =0.003) compared with the no art group. The average (+/- SD) surgery time differed between the art and no art groups (24.6+/-8.4 min vs. 20.1+/-5.6 min, P =0.012). Similarly, the average (+/- SD) anesthesia time differed between the art and no art groups (59.9+/-19.4 min vs. 49.9+/-9.9 min, P =0.01).

Conclusion: Children undergoing CRPP for SCHFx fracture were found to have lower pain scores (VAS and FLACC) on the medical-surgical floor postoperatively and had decreased floor analgesic requirements lending evidence that cast art may be an adjunctive distraction strategy to mitigate pain and distress following SCHFx surgery in children.

Level of evidence: Level III-retrospective comparative study.

Background: Many pediatric injuries can be diagnosed with one radiograph. Because of health care costs and radiation risks, provider prudence while ordering radiographs is crucial. Although clinical guidelines like Ottawa Ankle Rules (OAR) and Ottawa Knee Rules (OKR) exist, the decision to order radiographs often bypasses clinical judgment. The purpose of this study was to conduct a review of the radiographic practices of providers.

Methods: This was a retrospective cohort of 179 pediatric patients with an extremity injury. Detailed chart review was performed on patients regarding demographics, HPI, physical exam, radiographs, and follow-up. Primary outcomes included radiographs and their relationship to the physical examination. Specifically, knee, ankle, and foot complaints were examined in relation to OAR and OKR. Predictor variables included age, sex, ordering provider, and location of presentation.

Results: At least one set of unnecessary radiographs was performed in 139 (86.3%) of 161 patients with documentation of physical examination. Decreased age was significantly associated with outcomes: unnecessary knee and foot radiographs per OAR and OKR, having completely negative radiographs, having unnecessary radiographs performed, and having zero radiographs indicated. Increased age was correlated with an increase in unnecessary radiographs ordered. Neither provider type nor location of triage showed significant outcomes.

Conclusions: There is a significant number of patients that are not receiving a proper screening before radiographic orders. Providers should return to physical examination and the utilization of clinical guidelines to best serve their patients, while understanding some of the ways that age may negatively impact their habits.

Level of evidence: Level III-retrospective diagnostic study.

Background: Avascular necrosis (AVN) is a known complication of slipped capital femoral epiphysis (SCFE) that can lead to poor long-term outcomes. Therefore, predicting the onset of AVN is crucial for effective management. While various preoperative methods have been proposed to predict AVN, none have demonstrated accurate prediction. This study aimed to assess the efficacy of preoperative perfusion magnetic resonance imaging (MRI) in accurately predicting the onset of AVN in patients with SCFE.

Methods: This study included 17 cases (18 hips) treated for SCFE at a single institution between January 2017 and April 2021. Preoperative factors such as stability (stable, unstable), gradual onset (acute, chronic, acute on chronic), slip severity (mild, moderate, severe), superior translation, bone scintigraphy results (HOT, COLD), and perfusion MRI findings were compared with the incidence of AVN. Perfusion MRI involved sequential imaging of the contrast-enhanced femoral head to generate time intensity curves, categorized as type A (similar enhancement on both sides), type B (delayed but stronger enhancement on the affected side), and type C (no enhancement on the affected side).

Results: AVN was observed in 4 out of 18 hips (22%). Among unstable hips, 4 out of 8 (50%) developed AVN, and superior translation averaged 20.8 ± 6.54 mm in 4 cases with AVN, and a statistically significant difference was observed in each factor. In terms of gradual onset, AVN occurred in 3 out of 7 acute cases (43%) and 1 out of 7 acute-on-chronic cases (14%). Regarding slip severity, AVN was found in 1 out of 7 moderate cases (14%) and 3 out of 9 severe cases (33%); there was no significant difference. AVN was observed in 4 out of 5 cases (80%) showing a COLD pattern on bone scintigraphy, and in all 4 cases (100%) classified as type C on perfusion MRI. Statistically significant differences were found for both imaging modalities.

Conclusions: Stability, superior translation, bone scintigraphy, and perfusion MRI in cases of SCFE may serve as effective predictors of future AVN.

Level of evidence: Level Ⅳ.

Background: Single-event multilevel surgery (SEMLS) has been accepted as the standard of care for the surgical treatment of children with cerebral palsy (CP). However, little has been studied on the effect of dual-attending surgeons in SEMLS. The aim of this study was to compare the effect of single versus dual-attending surgeons on resource utilization and postoperative outcomes in children with CP undergoing SEMLS.

Methods: A total of 70 patients with CP or CP-like conditions, who were <20 years old, and who underwent SEMLS at a single institution, were identified. Bivariate comparisons were conducted using Student's t tests, Mann-Whitney U tests, and chi-squared tests. Stratified analyses were conducted within patient characteristic subgroups to compare operative outcomes within groups. Multivariable regression analyses were used to assess differences across surgeon cohorts while controlling for potential confounding factors.

Results: Patients were stratified into single versus dual surgeon cohorts (n=40 vs. n=30, respectively). No significant differences were noted with respect to age, sex, race, BMI, GMFCS level, or ASA level between groups. A higher proportion of patients with a seizure history (67% vs. 38%; P =0.03) and revision procedures (33% vs. 3%, respectively; P =0.001) were found in the dual surgeon cohort. Bivariate analysis demonstrated that operative times in the dual surgeon cohort were significantly decreased in GMFCS level IV/V patients (269.6 ± 46.7 vs. 356 ± 103.4 min; P =0.002) and patients undergoing hip reconstruction procedures (270.6 ± 53.2 vs. 337.4 ± 85.8 min; P =0.007). A significant decrease in total blood loss (20% in hip reconstruction patients, P =0.036, 25% in GMFCS IV/V patients, P =0.049) and OR costs (16% in GMFCS level IV/V patients, P =0.008) was also observed. Moreover, multivariable analysis found that dual surgeon procedures had a 50-minute average reduction in operative time ( P =0.005); no differences were noted in complication rates, unplanned clinic visits, or re-operation rates.

Conclusions: A 2-surgeon team for SEMLS can significantly decrease operative time, total blood loss, and OR costs-particularly for hip reconstruction and higher GMFCS level patients.

Level of evidence: Level III.

Introduction: In treating early-onset scoliosis (EOS), pediatric orthopaedic surgeons and families must often choose between growth-friendly interventions such as magnetically controlled growing rods (MCGR) and early definitive posterior spinal fusion (PSF). While each strategy has associated pros and cons, little is understood about the specific preferences of patients' families. Addressing potential nuances in these preferences is crucial for meaningful shared decision-making (SDM). To better understand the factors influencing family decisions, we conducted a choice-based conjoint (CBC) analysis to explore parents' preferences for PSF and MCGR as treatment options.

Methods: A survey was developed using Sawtooth Software (Lighthouse Studio version 9.2.0) to gather demographic information and preferences on surgical scenarios via CBC analysis. Anonymous participants, recruited via the Prolific crowdsourcing platform, qualified if they were US residents over 18 years of age with children aged 8 to 9. Data analysis involved the Hierarchical Bayes (HB) method to determine the desirability of 5 surgical attributes: curve correction, increase in spinal height, total number of surgeries, duration of treatment, and chance of complications.

Results: The study included 432 participants who prioritized the likelihood of complications (relative importance value of 37), followed by total number of surgeries (22), curve correction (21), spine height (12), and treatment duration (8). Female participants and those with daughters assigned significantly higher importance to the treatment's total number of surgeries ( P <0.05). Simulator analysis showed that 86.6% of participants would hypothetically prefer PSF, while only 13.4% would opt for growing rods based on the modeled participant choices.

Conclusions: This CBC analysis suggests that parents of children with EOS requiring surgical intervention would prioritize complication minimization, reduction in total surgical procedures, and effective curve correction, demonstrating a marked preference for PSF. Notably, the sex of both the child and the parent influenced attribute preferences. These findings exemplify the utility of CBC analysis in orthopaedic care, allowing for a deeper understanding of family preferences and enhancing SDM by providing the ability to align surgical recommendations with specific family priorities.

Level of evidence: Level III.

Background: Pediatric pelvic ring fractures are different in biomechanics and anatomy compared with adults. Existing classification systems are insufficient in assessing the mechanical stability of these fractures due to a variety of reasons, leading to a potential underestimation of the injury severity, resulting in suboptimal treatment with the risk of long-term dysfunctions. This study aims to address this problem by comprehensively describing a cohort of patients with pediatric pelvic fractures, identifying specific pediatric pelvic fractures and patterns.

Methods: A retrospective cohort selection of pediatric patients with a pelvic fracture treated in a major level 1 trauma center between 2001 and 2021 was conducted. Fracture patterns were classified using existing systems (Tile, Young and Burgess, Torode and Zieg), with additional parameters such as skeletal maturity considered. In addition, the incidence of specific pediatric fracture characteristics was reviewed.

Results: The CT scans of 68 children were reviewed. The median age was 15.5 years, with a majority being female (53%). Traffic accidents were the primary mechanism of injury (65%). Most fractures were classified as Tile type B2 (53%) and Young & Burgess LC3 (32%). SI-joint avulsion fractures were frequently seen (n=14, 21%), predominantly in children with a mature pelvis (n=10, 71%). A significant proportion of fractures did not fit conventional classifications, with little difference between skeletally mature and immature patients (73% vs. 75%).

Conclusions: A large portion of skeletally mature and immature patients cannot be classified according to the currently existing classifications, highlighting the need for a tailored pediatric classification system. APC2-like fracture patterns had a high incidence of SI-joint avulsion fractures, so purely ligamentous APC-fracture patterns are, in our experience, very rare in children. In addition, a previously undescribed fracture pattern (ped-LC3) was identified. Future research is necessary to grasp the full concept of skeletal maturation on the biomechanics and distribution of forces in the pediatric pelvis.

Level of evidence: Level III.

Introduction: When surgical treatment is indicated, closed reduction with elastic stable intramedullary nailing (ESIN) is a widely accepted technique for managing both-bone forearm fractures in children. However, the optimal postoperative protocol-particularly the necessity and duration of immobilization-remains a matter of debate.

Objective: This study aims to compare complication rates in patients with both-bone forearm fractures treated with ESIN, with or without postoperative splint immobilization.

Methods: This retrospective study included 137 patients with displaced and unstable both-bone forearm shaft fractures who underwent surgical treatment with ESIN at our Department of Pediatric Surgery, Orthopedics, and Traumatology between January 2020 and August 2022. Postoperative immobilization was decided individually by the operating surgeon. Data collected included fracture etiology, healing time, complications, and final clinical outcomes.

Results: Eighty-one patients were treated with postoperative splint immobilization, while 56 patients did not receive immobilization. There was no significant difference in bone healing time between the 2 groups. However, the complication rate was higher in the splinted group (16%) compared with the nonsplinted group (5.4%). In addition, open fractures and the need for open reduction were significantly associated with an increased risk of complications. No differences were observed between the groups in terms of QuickDASH scores.

Conclusion: Postoperative splint immobilization does not appear to be necessary to achieve satisfactory outcomes following ESIN treatment of both-bone forearm fractures in pediatric patients. It does not influence bone healing time or functional recovery and may be associated with a higher risk of complications. Open fractures and the requirement for open reduction are additional factors associated with increased complication rates.

Level of evidence: Level III-retrospective comparative study.

Introduction: Talocalcaneal coalition (TCC) is one of the most common tarsal coalitions in children. However, current classifications of TCC are limited and focus on histologic or morphologic features without clinical correlation or therapeutic guidance. Moreover, no classification system specifically designed for pediatric populations. We hypothesize that the novel classification system will be clinically relevant, reliable, and easy to use for pediatric TCC management.

Methods: A total of 43 patients (58 feet) with pediatric TCC confirmed by 3-dimensional CT scans were included in this study. All cases were classified according to the novel classification system: type I (middle facet TCC), type II (posterior facet TCC), and type III (extra-articular TCC). Three pediatric orthopaedic surgeons with varying levels of experience independently classified the 58 cases to assess interobserver agreement. For all patients, we documented the hindfoot alignment (valgus, varus, or neutral), presence of pain, peroneal muscle spasm, tarsal tunnel syndrome, treatment strategies, surgical duration, preoperative and postoperative AOFAS and VAS scores, and complications.

Results: A total of 22 type I, 9 type II, and 27 type III TCC cases were identified, with a mean age of 10.9 years. The new classification system demonstrated almost perfect interobserver agreement (kappa=0.90). Type I showed the highest valgus prevalence (59%, 13/22; P =0.004), type II predominant varus (67%, 6/9; P <0.001), and type III neutral alignment (52%, 14/27; P =0.515). Medial displacement calcaneal osteotomy was performed in 14% (3/21) of type I cases, and lateral displacement osteotomy in 42% (5/12) of type II and III cases. All types achieved significant AOFAS/VAS improvement. Type III TCC had the shortest operative time (52 min; P <0.001) and no complications.

Conclusion: We propose a novel classification system for pediatric TCC that is clinically relevant, reliable, and easy to use. Type I TCC is more often associated with hindfoot valgus, while type II TCC frequently presents with hindfoot varus. Types II and III TCC more commonly require lateral displacement calcaneal osteotomy for varus correction. Type III TCC showed the most favorable surgical outcomes, with the shortest operative times and lowest complication rates among all types.

Level of evidence: Level III-diagnostic study.

Introduction: Limb-length discrepancies (LLDs) have traditionally been treated with external fixators, but magnetically driven intramedullary nails (MILNs) are increasingly favored for improved comfort and reduced infection risk. This study compared intramedullary (IM) versus extramedullary (EM) lengthening nails in pediatric patients with narrow femoral canals to evaluate mechanical axis deviation, nail bending, tourniquet time, and complications.

Methods: A retrospective, single-center review was conducted of 75 pediatric patients who underwent femoral lengthening between 2015 and 2022, each with at least two years of follow-up. Patients received either an 8.5 mm IM nail or a 10.7/12.5 mm EM nail, combined with a solid, threaded IM nail for stability. Outcomes included preoperative and postoperative limb alignment (MAD, mLDFA, and mPDFA), IM nail bending, operative details (tourniquet time and blood loss), consolidation times, and complication rates classified according to the Cherkashin system.

Results: Forty-two patients were treated with EM nails and 33 with IM nails. Both groups achieved similar distraction amounts (4.7 ± 1.1 cm) and consolidation intervals (7 to 8 mo). However, the EM group demonstrated significantly greater postoperative MAD (12.9 ± 9.5 mm vs.  8.7 ± 7.3 mm, P  <0.05), higher nail bending (2 vs.  1.2 degrees, P <0.05), and longer tourniquet use. Overall complication rates were 69% (EM) and 60% (IM), with delayed union and soft tissue infection being the most frequent issues. Unplanned reoperations occurred in 21% of patients overall.

Conclusion: Both nail types correct limb‑length discrepancy, but extramedullary nails demand longer tourniquet times and have higher bending (of the IM component of the EM construct) and complication rates. Implant choice must suit patient factors and further comparative studies are warranted.