Journal of Pediatric Orthopaedics最新文献

Background: To evaluate the efficacy of the Ponseti method in the treatment of idiopathic congenital clubfoot (CCF) in a public health service, during 2 distinct periods, focusing on the impact of orthosis type (ankle-foot orthosis and abduction orthosis).

Methods: This retrospective longitudinal cohort study analyzed medical records of 552 patients (842 feet) with CCF treated with the Ponseti method at a single hospital. Individuals were categorized into 2 groups: group 1 (2009 to 2017), which used an ankle-foot orthosis (AFO) after casts; and group 2 (2017 to 2021), which used an abduction orthosis (AO). Outcomes evaluated included relapse rates, residual deformities, and functional results using the modified Laaveg-Ponseti scale. The χ 2 tests and Student and Welch t tests were used to assess statistical significance.

Results: The mean follow-up period was 10.3 years for group 1 and 5.3 years for group 2. Significant differences were observed between the groups ( P <0.05). Group 1 (AFO) showed higher rates of relapse (71.9% vs. 31.2%) and residual deformities (58.8% vs. 32.6%) compared with group 2 (AO). Functional outcomes were also superior in group 2, with 81.8% achieving good/excellent results on the modified Laaveg-Ponseti scale, compared with 69.3% in group 1. Family adherence was lower in group 2 (16.5% nonadherence) compared with group 1 (10.5% nonadherence) and was related to higher relapse, yet overall outcomes were better.

Conclusion: The Ponseti method is effective for treating CCF, with superior results when an abduction orthosis is used. This highlights the importance of appropriate orthosis selection and continuous family support in public health services.

Level of evidence: Level III-retrospective comparative study.

Background: Ectrodactyly (cleft foot) is a rare congenital deformity characterized by central ray deficiency. Surgical intervention is considered for pain, shoe-wear difficulty, callosities, or cosmetic concerns. This multicenter study evaluates indications, surgical strategies, radiographic correction, and incorporates intra- and inter-rater reliability testing of the Blauth and Abraham classification systems.

Methods: A retrospective multicenter review was conducted of patients with ectrodactyly treated operatively between 2010 and 2022. Demographic, clinical, and radiographic data were collected, including preoperative shoe-wear difficulty, pain, and cosmesis concerns. Surgical indications, operative strategies, complications, revisions, and long-term outcomes were analyzed. Radiographic outcomes included forefoot splay angle and splay index.

Results: Sixty-six patients (101 feet) underwent surgical intervention for ectrodactyly of the foot at a mean age of 5.8±4.5 years, with a mean follow-up of 3.7±3.5 years. Shoe-wear difficulty was the most common indication for surgery (79 feet, 82%), followed by pain (51 feet, 53%), calluses or skin complaints (25 feet, 26%), and/or cosmetic concerns (10 feet, 10%). Approximately 68% of procedures were performed for Blauth type II to IV deformities. Initial surgeries included 16 soft-tissue-only, 23 bony procedures, and 59 combined approaches. Common techniques included forefoot narrowing osteotomies (32%), soft-tissue cleft closure (30%), and ray excision (11%). Eight feet (8%) underwent revision due to recurrent deformity. Radiographs demonstrated significant improvements in forefoot splay angle (36.14 to 21.39 degrees, P <0.001) and splay index (1.88 to 1.69, P <0.001).

Conclusion: Operative management of foot ectrodactyly provides favorable radiographic outcomes. Combined bony and soft-tissue strategies were most common, yielding significant radiographic correction with low revision rates. As the largest multicenter series on cleft foot reconstruction, this study highlights considerable management heterogeneity across centers and underscores the need for an indication-based classification system that integrates radiographic severity with patient-centered concerns to guide surgical decision-making and standardize care.

Level of evidence: Level III.

Background: Residual equinus is an important indicator for deciding the need for tenotomy and checking for recurrence of clubfoot deformity. This study aims to validate a novel, radiologic marker-the Talar Index-for objective assessment of residual equinus in clubfoot.

Methods: A cross-sectional observational study was conducted on infants with idiopathic clubfoot treated using the Ponseti protocol, assessed just before percutaneous Achilles tenotomy. The validity of the talar index was tested against the unaffected feet. A positive talar index was defined as the presence of residual equinus. Receiver operating characteristic (ROC) analysis and logistic regression were performed between positive talar index and lateral tibiocalcaneal angle and sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. Interobserver and intraobserver reliability of the talar index was assessed using Cohen's kappa.

Results: A total of 70 feet (49 affected and 21 unaffected) were evaluated. The talar index correctly identified residual equinus in 94.3% of feet, with a sensitivity of 95.9% and specificity of 90.5%. There was a strong association between a positive talar index and increased tibiocalcaneal angle (AUC: 0.929, P=0.001). Sensitivity, specificity, PPV, and NPV of the positive talar index were found to be 84%, 90.5%, 77.9%, and 93.4%, respectively. Logistic regression showed a significant model fit (P<0.001, R²=0.82). Inter (κ=0.84) observer and intra (κ=0.97) observer reliability was excellent.

Conclusion: The talar index is a valid, reliable, and easily interpretable radiologic marker for assessing residual equinus in clubfoot. Its simplicity and high diagnostic accuracy make it particularly suitable for routine clinical use, including in resource-limited and high-volume settings.

Level of evidence: Level III.

Background: This study aimed to evaluate the impact of socioeconomic status (SES), as measured by Child Opportunity Index (COI) 3.0 and insurance type, on access to orthopaedic care among pediatric patients with osteochondral defects (OCDe) of the knee. A secondary aim was to determine whether delays in care were associated with differences in lesion severity or return-to-sport (RTS) outcomes.

Methods: We conducted a retrospective cohort study of 109 patients aged 21 years or younger who underwent surgery for knee OCDe between 2012 and 2023 at a tertiary academic center. Demographic and clinical variables were extracted from the chart review. The time interval between injury to diagnosis was categorized as prompt (30 d or fewer) or delayed (more than 30 d). COI 3.0 scores, including total and domain-specific scores for education, health, and SES, were assigned using patient zip codes and stratified into quintiles. χ2 and the Fisher exact tests were used to assess associations between SES indicators and time to care.

Results: The cohort (mean age 16.1±2.6 y) was predominantly male (64.2%), Spanish/Hispanic/Latino (52.6%), and publicly insured (62.0%), with 75.2% residing in low or very low total COI neighborhoods. Neither insurance type nor COI scores were associated with delayed care. There were also no significant differences in lesion size, ligament injury, or RTS outcomes between prompt and delayed groups at an average follow-up of ∼1.5 years.

Conclusions: In this predominantly minority and socioeconomically disadvantaged cohort, neither lower COI scores nor public insurance were associated with delayed orthopaedic care for OCDe of the knee. Delays in care did not impact lesion severity or short-term RTS outcomes. Institutional and community-level factors may have mitigated traditional barriers to access in this safety-net pediatric setting.

Level of evidence: Level III.

Introduction: Though numerous studies have assessed the function of idiopathic clubfeet (CF) treated by the Ponseti method, few studies have assessed alterations in the unaffected foot of patients with unilateral CF imparted by Ponseti bracing. The purpose of this study was to identify pedobarographic differences in the unaffected foot of patients with unilateral CF treated with the Ponseti abduction brace and to determine if those differences persist over time.

Methods: Patients with unilateral CF who were treated during infancy by either the Ponseti method or the French Physiotherapy method (PT) were prospectively followed until the age of 16 years. Following correction, those treated by the Ponseti method used an abduction brace 23 hours a day for 3 months, followed by nighttime brace wear until at least 2 years of age (Braced). Those treated with the PT method had a custom unilateral orthosis fitted only to the affected foot during the maintenance phase of treatment (Unbraced). Pedobarographic assessment of the unaffected foot was collected longitudinally at 2, 5, 10, and 16 years of age. Nonparametric Mann-Whitney U tests were used to compare plantar contact area (CA%), mean force (MF%), and contact time (CT%) between groups.

Results: Forty-three patients (18 Braced and 25 Unbraced) underwent pedobarographic assessment at all time intervals. Braced patients demonstrated significantly higher MF% and CT% in the medial and lateral midfoot at 2 years of age. These differences, however, were resolved by age 5, with no difference in plantar pressures between groups at 16 years or younger.

Discussion: Abduction bracing of the unaffected foot in patients with unilateral CF deformity results in measurable increases in midfoot MF% and CT% during the brace phase of treatment. This indicates that bracing does impart an increased pes planus posture of the unaffected foot; however, these changes are transient and are expected to resolve after brace discontinuation. This information should reassure parents of unilateral CF patients concerned about the effects of abduction bracing on the unaffected foot.

Level of evidence: Therapeutic Level II.

Background: Coronal-plane knee deformities, both genu varum and genu valgum, are common in pediatric orthopaedics and can be effectively managed in skeletally immature patients with guided growth techniques. Among these, percutaneous epiphysiodesis using transphyseal screws (PETS) and tension band plates (TBP) are widely used, yet their comparative effectiveness remains debated.

Methods: A comprehensive search of PubMed, Embase, and Web of Science (January 2004 to January 2025) identified 603 studies. After applying the inclusion criteria, 13 studies (8 noncomparative and 5 comparative) were included in the analysis. Risk of bias was assessed using the ROBINS-I tool, and study quality was evaluated using the MINORS criteria. A frequentist random-effects meta-analysis was conducted to compare correction rates of mechanical lateral distal femoral angle (mLDFA), medial proximal tibial angle (MPTA), and mechanical axis deviation (MAD).

Results: PETS was effective, with correction rates for mLDFA, MPTA, and MAD ranging from 0.64 to 1.3 ​degrees/month, 0.52 to 0.86 degrees/month, and 1.3 to 3 mm/month, respectively. The meta-analysis showed faster correction with PETS compared to TBP: mLDFA (θ=0.71; P=0.05), MPTA (θ=0.60; P=0.06), and MAD (θ=0.80; P=0.11), although statistical significance was not reached. A meta-analysis of correction speed of mLDFA (θ=0.43; P=0.17) and MPTA (θ=0.6; P=0.06) in idiopathic patients did not show a significant difference, although faster correction with PETS was again observed.

Conclusion: PETS is a reliable method for correcting coronal-plane deformities around the knee, with a tendency to achieve faster angular correction than TBP. Given the heterogeneity of included studies, further randomized controlled trials are needed to confirm these findings and guide implant choice based on patient-specific factors.

Level of evidence: Level III.

Background: Rigid intramedullary nail (RIMN) fixation is the standard treatment for tibial shaft fractures in adult patients. Recently, this technique has gained favor for usage in skeletally immature patients despite the required violation of the proximal tibial physis. The goal of this paper was to determine whether growth disturbance with resultant deformity could occur after RIMN treatment in patients with open physes.

Methods: A retrospective radiographic review was performed of all patients undergoing RIMN placement for acute tibia fractures at 3 level I Pediatric Trauma Centers between January 2012 and June 2022. Patients with an open proximal tibial physis and radiographic follow-up of at least 6 months were included. Intraoperative radiographs were analyzed to determine the immediate postoperative medial proximal tibial angle (MPTA) and posterior proximal tibial angle (PPTA), as well as the skeletal bone age utilizing the Abbreviated Modified Fels Knee System. The final radiographs were assessed for changes in the MPTA and PPTA.

Results: A total of 43 patients with an average chronological age of 14.5±1.3 years and skeletal age of 14.3±1.0 years met the inclusion criteria. There were a total of 37 males and 6 females with an average follow-up of 18.3±12.7 months. The average change in the MPTA was 1.0±0.9 degrees (P=0.566) with no patients having a change >3 degrees. The average change in the PPTA was a 2.3±3.8 degrees (P=0.007). Two patients progressed to a recurvatum deformity with 99 and 104 degrees of PPTA. With these 2 patients excluded, the average change in slope remained significant at 1.5±1.6 degrees (P=0.019).

Conclusion: The use of RIMN in skeletally immature adolescents can lead to a statistically significant, but most likely clinically insignificant change in the posterior slope. Yet, cases of recurvatum deformity can occur in the setting of this procedure. Though our series confirms RIMN are generally safe in treating tibial shaft fractures in skeletally immature adolescents, 2 cases demonstrate that a true risk of a subsequent sagittal deformity does exist.

Level of evidence: Level IV-retrospective case series.

Background: A critical component of patient care for osteogenesis imperfecta patients is understanding the development of union following fracture and osteotomy surgery. Studies evaluating the criteria of bony union in this population have varied. An objective standardized method for fracture healing was developed as the radiographic union score for tibial fractures (RUST), and subsequently revised to the modified RUST (mRUST). The RUST score has been shown to have excellent interobserver and intraobserver reliability in a single-center investigation in an OI population. The purpose of the study was to evaluate the mRUST reliability in a multicenter investigation.

Methods: Thirty OI patients with tibial fractures or osteotomy radiographs were identified. Nine observers from 3 institutions measured on 2 separate occasions. Four cortices were scored with the following classification: 1=no callus; 2=callus present; 3=bridging callus; and 4=remodeled, fracture not visible. The modified RUST score ranges from 4 to 16. Interclass and intraclass coefficients (ICC) of 95% CIs were used for interobserver and intraobserver reliabilities.

Results: Interobserver reliability ICC representing the interobserver reliability for the first and second scores was the following, respectively, 0.926 (0.864-0.962) and 0.915 (0.845-0.957). Three reviewers' intraobserver reliability for series 1 and series 2 measurements were 0.860 (0.707-0.934), 0.994 (0.986-0.997), and 0.974 (0.946-0.988).

Conclusions: Excellent interobserver and intraobserver reliability was demonstrated for the mRUST in the setting of OI bone, indicating the precision of the mRUST for OI tibia healing. Modified RUST application and routine use may help standardize the evaluation of osteotomy and fracture healing in the OI population with further work necessary for it to help make clinical decisions.

Level of evidence: Level III-retrospective study of nonconsecutive patients.