Journal of Pediatric Orthopaedics最新文献

Background: Axial imaging is typically obtained following operative reduction of developmental dysplasia of the hip (DDH) to confirm a concentric reduction. Although the utility of axial imaging has been studied following the index reduction, its value following spica cast exchange remains unclear.

Methods: This single-center study included all children 2 years or younger with idiopathic DDH who underwent closed or open reduction between 2012 and 2023. Patients with concurrent osteotomies or dysplasia secondary to syndromic/neuromuscular causes were excluded. Institutional protocol during this period consisted of 3 months of immobilization with a spica cast exchange at 6 weeks for all closed or medial open reductions. Axial imaging (CT or MRI) was typically obtained after both the index procedure and cast exchange to confirm reduction. A retrospective review was conducted to assess how often axial imaging directly altered clinical management, defined as an unplanned return to the operating room or a documented change in management based on imaging findings per the treating surgeon's notes. Minimum follow-up was 1 year. Descriptive statistics were used to summarize patient characteristics and arthrogram findings.

Results: The cohort included 91 patients (124 hips): 92 (74%) hips underwent closed reduction, and 32 (26%) underwent open reduction. The median age at index reduction was 7.7 months, with 52% (n=47/91) above 6 months old. Of those with preoperative radiographs (n=98), most hips were IHDI grade 3 (29%, n=27) or 4 (39%, n=38). Axial imaging changed management in 3% of hips after the index reduction (4/92 closed reductions, 0/32 open reductions). Among 124 hips receiving axial imaging at cast exchange (92=MRI, 32=CT), only 1 hip was dislocated (<1%). Analysis of a separate cohort of 12 hips that did not receive axial imaging at cast exchange suggests that an adequate arthrogram (no medial dye pool and deep concentric reduction) is sufficient to confirm reduction.

Conclusions: Axial imaging at the time of spica cast exchange rarely alters clinical management and should not be routinely obtained unless otherwise indicated by a concerning intraoperative arthrogram.

Level of evidence: Level IV-retrospective case series.

Background: Pink pulseless hand (PPH) is a critical condition in pediatric Gartland type III supracondylar humeral fractures, raising concerns about neurovascular injury. While watchful waiting is often recommended, most cases do not require surgical intervention; however, some eventually require open procedures, and there remains a risk of missed cases. Intraoperative duplex ultrasonography (DUS) allows real-time neurovascular assessment; however, its intraoperative application remains unclear. The aim of this study was to describe the detailed methodology and clinical outcomes of intraoperative DUS in pediatric supracondylar fractures with PPH.

Methods: This retrospective observational study included 10 pediatric patients with PPH due to Gartland type III supracondylar fractures, treated at 2 referral hospitals in Japan between 2018 and 2024. After closed reduction and percutaneous pinning, intraoperative DUS was used to assess brachial artery blood flow and the continuity of the median, radial, and ulnar nerves. The primary outcomes were the necessity of an open procedure and postoperative neurovascular recovery.

Results: DUS confirmed intraoperative brachial arterial blood flow in 8 of 10 patients. Two patients required open procedures: one due to arterial spasm and the other due to arterial kinking, both of which resolved without requiring vascular repair. Three patients had median nerve palsy, and 1 patient had anterior interosseous nerve palsy. No neurovascular entrapment was observed, and nerve continuity was intact in all cases. Postoperatively, the radial pulse of all cases returned within 3 days, and all nerve palsy resolved within 6 weeks. Based on the Flynn criteria, all patients achieved excellent functional and cosmetic outcomes at 6 months.

Conclusion: Intraoperative DUS is a noninvasive and effective tool for real-time neurovascular assessment in Gartland type III supracondylar fractures with PPH. Its use should be considered in facilities with intraoperative ultrasonography, as it may optimize surgical decision-making by reducing unnecessary open procedures while ensuring optimal neurovascular outcomes.

Level of evidence: Level IV.

Background: The aims of this study were to assess the differences in preoperative Scoliosis Research Society 22r (SRS-22r) questionnaire scores, two-year postoperative SRS-22r scores, and the change in SRS-22r scores from preoperatively to two years postoperatively between patients with idiopathic scoliosis (IS) undergoing spinal fusion with instrumentation (PSFI) who were vitamin D sufficient and vitamin D deficient preoperatively.

Methods: This was a retrospective review of patients with juvenile and adolescent IS aged 11 to 20 years who underwent PSFI from 2018 to 2022 with a minimum of 2-year follow-up. Patients with vitamin D levels <30 ng/mL were considered deficient and repleted with vitamin D3 800 to 2000 international units (IU) daily or 50,000 IU weekly. Variables were compared between vitamin D deficient and sufficient groups with Wilcoxon or two‑sample t tests. Linear regression was used to assess the relationship between preoperative major curve and vitamin D levels.

Results: Forty-seven patients were included. Twenty-five patients (53%) were vitamin D deficient. The mean preoperative vitamin D levels were 21±6 ng/mL in the deficient group and 41±14 ng/mL in the sufficient group (P<0.001). Pre-operatively, vitamin D deficient patients had lower SRS‑22r function scores than sufficient patients (4.4 vs. 4.6; P=0.020), while two-year postoperative scores were similar. When comparing preoperative to postoperative subdomains, function, management, pain and self-image scores all improved in the vitamin D deficient group, while management and self-image scores improved in the vitamin D sufficient group. Linear regression demonstrated a weak inverse relationship between vitamin D levels and preoperative major curve size (β=-0.178; r=-0.35; P=0.016).

Conclusions: In patients undergoing PSFI for IS, vitamin D deficient patients had lower preoperative SRS-22r function scores compared with vitamin D sufficient patients. After perioperative repletion and PSFI, vitamin D deficient patients experienced improvement in their function score and achieved similar 2-year postoperative SRS-22r function scores compared with sufficient patients. Our findings strongly support preoperative vitamin D screening and perioperative vitamin D repletion in IS patients undergoing PSFI.

Level of evidence: Level III-retrospective case control study.

Background and aim: Temporary distal medial tibial hemiepiphysiodesis (DMTH) is used to correct pediatric ankle valgus. This review evaluated the radiographic correction achieved, the durability of alignment after implant removal, and safety outcomes.

Methods: PubMed, Ovid MEDLINE, and Embase were searched, and 17 retrospective studies (549 patients and 800 ankles) met the inclusion criteria. Pooled outcome measures included the lateral distal tibial angle (LDTA), tibiotalar angle (TTA), tibiotalar tilt (TT), correction rate, complication rate, and rebound.

Results: Preoperative pooled means were TT 13.8, LDTA 78.4, and TTA 76.2 degrees. The pooled radiographic outcomes demonstrated substantial correction, with TT, LDTA, and TTA improving to 0.6, 87.6, and 86.4 degrees, respectively, and the alignment remained largely preserved after implant removal, with corresponding values of TT 3.3, LDTA 85.5, and TTA 85.4 degrees. The overall correction occurred at an average rate of 0.6 degrees per month over a mean duration of 18.6 months before implant removal. Rebound averaged 0.3 degrees/month. Complications were reported in 56 of 508 ankles (11.0%) among the studies that provided complication data, and reoperations were required in 15 of 386 ankles (3.9%) among those reporting reoperation outcomes, most of which were hardware-related.

Conclusion: DMTH provides consistent correction toward physiological alignment, with modest rebound and low reoperation rates. Heterogeneity and the retrospective design limit generalizability. Standardized outcomes and comparative trials are needed.

Level of evidence: Level III-therapeutic.

Background: Few studies have directly compared plate fixation and screw fixation in treating pediatric femoral neck fractures. The present systematic review compared the postoperative outcomes associated with these 2 fixation methods.

Methods: The PubMed, EMBASE, Cochrane Library, and Google Scholar databases were searched for articles reporting the outcomes of using plate fixation and screw fixation to treat femoral neck fractures in pediatric populations. Surgical outcomes were evaluated in terms of functional assessments and postoperative complications.

Results: This review included 31 studies involving 950 pediatric femoral neck fracture cases. The Ratliff criteria for functional assessments were comparable between the plate fixation and screw fixation groups. Plate fixation showed a reduced incidence of postoperative avascular necrosis and premature physeal closure compared with screw fixation. In addition, the incidence of coxa vara was slightly higher in the plate fixation group, although the nonunion and leg length discrepancy rates were similar between the screw fixation and plate fixation groups. Moreover, the results of subgroup analyses indicated that plate fixation reduced the risk of avascular necrosis and leg length discrepancy in patients with Delbet III/IV fractures and displaced fractures than screw fixation was.

Conclusion: Plate fixation may be a superior option because it showed a reduced risk of postoperative avascular necrosis and premature physeal closure, particularly in patients with Delbet type III/IV or displaced fractures.

Level of evidence: Level III-systematic review of retrospective comparative studies and case series.

Background: Treatment options for early-onset scoliosis (EOS) are confounded by the risks associated with intervention at a younger age. Spinal instrumentation must be considered carefully due to potentially adverse effects to the spine, chest wall, and lungs. Posterior spinal fusion before subsequent growth can also lead to the crankshaft phenomenon. With the recent increasing interest in delaying spinal fusion, we aim to determine trends in patient age selection at a single definitive (termed "one and done") fusion for EOS.

Methods: We identified 791 patients from 2005 to 2022 who met the inclusion criteria (age 5 y or younger, single definitive fusion, and complete data). Patients who underwent a hemivertebrae resection with limited fusion were not included. Multiple linear regression was performed with date of fusion as the independent variable and age at definitive fusion as the dependent variable. Our regression included race and sex to control for their effects as confounders. We repeated this analysis with groups separated by scoliosis etiology and sex. Coefficients with P<0.05 were considered significant.

Results: In the entire cohort, there was no significant change in the age at definitive fusion between 2005 and 2022 (coefficient=0.042, P=0.099). The mean age at fusion was 12.1 years. Of these, 167 (21.1%) cases had congenital scoliosis, 277 (35.0%) had idiopathic scoliosis, 191 (24.1%) had neuromuscular scoliosis, and 156 (19.7%) had syndromic scoliosis. Patients with idiopathic (-0.002, P=0.962), syndromic (-0.027, P=0.671), and neuromuscular (-0.005, P=0.924) EOS showed no significant change in the age at fusion. However, children with congenital EOS (0.171, P=0.006) and females (0.082, P=0.003) demonstrated a significant increase. On the basis of our regression models, the predicted age at definitive fusion increased from 10.6 years to 12.3 years in those with congenital EOS and from 11.4 to 12.1 years in females.

Conclusions: Over a 17-year study period, females and congenital EOS patients demonstrated significant increases in age at the time of definite fusion. There was no significant change for children with neuromuscular, idiopathic, or syndromic EOS over the same time frame. Further study is necessary to determine the nature of these disparities.

Background: In this study, we evaluate the frequency of trainee grants awarded to pediatric orthopaedic topics, their subsequent publication success, and the recipients' career trajectories post-training.

Methods: Research grants awarded by SRS (2020-2024), OREF (2012-2022), AONA (2000-2021), OTA (2012-2022), and POSNA (2014-2024) were obtained from their respective organizations. Only projects awarded to trainees (residents/fellows) and specific to pediatric orthopaedic topics were included. Projects were characterized by study type: (1) basic science, (2) biomechanical, (3) clinical, and (4) other. Univariable analysis was performed to determine the impact of the category of grant and grant amount on subsequent publication. Recipients were also evaluated on post-residency career trajectories, including academic position and specialization in pediatrics orthopaedics.

Results: A total of 1015 grants were analyzed, with a total of 55 (5%) that were awarded to trainees. Of these grants, 13% were basic science, 20% were biomechanical, 45% were clinical-based, and 22% were other types. At the time of data collection, 58% (n=32) were published. Project type was not associated with publication success. Of the 35 recipients who finished training at the time of analysis, 80% (n=28) of recipients held an academic position and 63% (n=22) had completed a pediatric orthopaedic fellowship.

Conclusions: Pediatric-specific trainee grants are associated with high publication rates. The majority of grant recipients pursue pediatric orthopaedic fellowships and continue in academic medicine. Compared with trauma resident research grants, pediatric grants are less available (397 vs. 55); however, recipients of pediatric grants are more likely to publish their grant (58% vs. 38%) and obtain academic positions following training (80% vs. 45%).

Level of evidence: Level III.

Background: In torsional malalignment syndrome (TMS), knee varus is observed when feet are neutral but disappears with external foot rotation. The underlying cause of this phenomenon-whether it results from visual alterations from limb rotation or reflects an additional structural abnormality in the lower extremity-along with the potential for simpler treatment options beyond rotational osteotomy, has not been previously investigated.

Methods: Eighteen subjects with TMS and ten control subjects had weight-bearing orthoroentgenograms and non-weight-bearing 3D CT scans of the lower limb. Mechanical lateral distal femoral angle (mLDFA) and medial proximal tibial angle (MPTA) were measured. Changes in the mechanical axis during femoral rotation were analyzed with 2D and 3D CT images processed with Adobe Photoshop and PowerPoint. Morphologies of the distal femur and proximal tibia were evaluated. Six subjects received guided growth with percutaneous epiphysiodesis transphyseal screws (PETS).

Results: TMS subjects showed significantly greater mLDFA and knee varus on weight-bearing radiographs, but not on 3D CT, indicating that weight-bearing contributes to the varus appearance. Although external rotation on 3D CT caused medial axis shift and mLDFA reduction in both groups, the degree of change in TMS subjects was similar to controls and insufficient to explain the pronounced varus, implying an additional structural abnormality. While femoral contours appeared normal, TMS subjects exhibited a significantly steeper posterior slope of the medial tibial plateau-averaging 7.0 degrees more than the lateral slope and also significantly steeper than in controls. In patients treated with PETS, the mean mLDFA improved from 90.2 to 88.1 degrees, and all reported cosmetic satisfaction, with no deterioration in LEFS or TLKSS scores.

Conclusions: A steeper posterior slope of the medial tibial plateau likely contributes to knee varus in TMS subjects when feet are neutral. Although PETS doesn't address the underlying rotational deformity, it improved coronal alignment and appearance in selected patients without functional compromise, offering a simple and cosmetically effective treatment alternative.

Level of evidence: Level III-diagnostic studies.