Journal of Pediatric Orthopaedics最新文献

Background: Outcomes of arthroscopic management of bony Bankart (BB) lesions may result in higher reinjury rates, revision surgeries, and return-to-sport outcomes compared with adolescent patients with no bony Bankart (NBB) lesions.

Methods: Adolescent patients undergoing arthroscopic stabilization (2010 to 2023) with a minimum of 2 years follow-up were categorized into BB and NBB cohorts based on MRI and intraoperative findings. Preinjury glenoid diameter was estimated using a best-fit circle technique. Data collected included demographics, injury details, surgical techniques, and surgical outcomes. Patient-reported outcomes were assessed using single assessment numeric evaluation (SANE), pediatric/adolescent shoulder survey (PASS), and quick Disabilities of the Arm Shoulder and Hand (qDASH) scores.

Results: Fifty patients were analyzed (25 BB, 25 NBB), with mean age 16.9±0.9 years (BB) and 16.6±1.0 years (NBB) (P=0.32), and overall mean follow-up 4.2 years. BB was associated with males (P=0.02) and collision mechanisms of injury (P=0.02). BB utilized more suture anchors (6.0±1.2 vs. 4.9±1.4) (P=0.005). Preinjury glenoid diameter was larger in the BB (29.9±2.6 vs. 26.2±2.3 mm) (P<0.001). Mean sagittal width of the BB fragment measured 5.7±1.5 mm (range: 3 to 10 mm) and represented a mean glenoid bone loss of 18.9%±4.5%. Surgery failure rates (32% BB vs. 32% NBB), revision surgery rates (12% BB vs. 4% NBB), and return to sport rates (88% BB vs. 80% NBB) were not significantly different. SANE scores were higher with BB (91.2±9.9 vs. 85.2±12.8) (P=0.03), yet no differences were found in PASS and qDASH outcomes.

Conclusions: BB was associated with larger glenoid diameters, male sex, and collision injuries, but outcomes did not appear to vary when compared with NBB shoulders, refuting the hypothesis that bony Bankart shoulders would have poorer short-term to mid-term outcomes over time compared with those with only soft-tissue injury. Recurrent instability and revision surgery rates remain high in this youthful population regardless of the presence of a bony Bankart-associated anterior instability.

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.

Background: Managing femur fractures in pediatric patients with neuromuscular (NM) disease poses challenges due to joint contractures, spasticity, and low bone density, with fractures often occurring from minimal trauma. Treatment decisions entail navigating multiple potential complications. This study aimed to evaluate treatment outcomes of patients with NM disease who sustained femur fractures.

Methods: A retrospective analysis of 139 femur fractures in 106 pediatric NM patients over a 10-year period was conducted. Radiographic, clinical, demographic, and treatment data were collected. Malunion criteria included >2 cm shortening, frontal plane angulation >10 degrees, or sagittal plane angulation >30 degrees. Patients with insufficient follow-up were excluded.

Results: The majority of patients were treated conservatively (65% of femurs). The overall complication rate was 59.3% in the conservatively treated group and 62.5% in the surgically treated group. The most common complication observed was malunion (38%). Fifty-eight patients had more than one fracture, 95% being wheelchair users. Nonambulatory status, prior femoral surgery, spasticity, and anticonvulsant use were potential contributors to fracture risk and complications.

Conclusions: Conservative versus surgical treatment of pediatric femur fractures in NM patients have similar complication rates. Surgical management was noted to have a lower rate of malunion but a higher risk of skin or wound complication, refracture, and unplanned return to the OR. Further studies are needed to assess how patients are affected by malunion to inform shared decision-making in this complex population.

Level of evidence: Level IV.

Background: Spinal navigation has been widely adopted in adult spine surgery. The purpose of this study was to characterize the use of navigation in pediatric spinal deformity surgery.

Methods: This was a retrospective cohort study. The NSQIP Pediatric database years 2016 to 2022 were used. We included patients 17 years or younger of age that received posterior spinal fusion for deformity. Our primary outcome of interest was the proportion of cases using navigation over time. Our secondary outcomes included the proportion of cases using navigation based on age (under 9 y, 10 to 17 y), etiology (idiopathic scoliosis, neuromuscular scoliosis, syndromic scoliosis, congenital scoliosis, and kyphosis), sex, surgical specialty, number of surgical levels, previous spinal surgery, and pelvic instrumentation. Rates of allogeneic transfusion, postoperative neurological injury, deep surgical site infection, and operative time were compared between the 2 groups over time. Descriptive statistics and χ2 tests were used for analysis. Adoption curves over time were created for the entire cohort and for each etiology.

Results: There were 37,594 patients in this study. Navigation was used in 3219 (8.6%) cases. The proportion of cases with navigation use has increased from 2016 to 2022 (2016: 2.0% vs. 2022: 15.6%, P<0.001). There was no significant difference in the proportion of cases performed with navigation between patients 9 years or younger and patients 10 to 17 years (P=0.39). Patients with a diagnosis of kyphosis had a higher rate of navigation use (10.2%, P=0.03). There was a higher rate of navigation use in surgeries with more surgical levels (≤6 levels: 7.5%, 7 to 12 levels: 8.2%, ≥13 levels: 9.4%, P<0.001). There was no significant difference in patients who had previous spinal surgery (P=0.567). Cases with pelvic instrumentation had a higher rate of navigation use (12.8% vs. 8.1%, P<0.001). Navigation was used in 17.7% of cases performed by pediatric neurosurgery compared with 8.3% of cases performed by pediatric orthopaedic surgery (P<0.001). Navigated cases had a lower rate of allogeneic transfusion (P<0.001) and longer operative time (P<0.001).

Conclusion: Use of spinal navigation has increased over time. Several patient and surgical factors are associated with higher rates of navigation use.

Level of evidence: Level III.

Introduction: Tibial shaft fractures are common in the pediatric population. As patients approach skeletal maturity, rigid intramedullary nailing of these fractures is a potentially advantageous option, allowing rigid fixation and earlier mobilization and weight-bearing. However, potential injury to the open proximal tibial physis in patients with remaining growth remains a concern. This study sought to determine the rate of growth disturbance following rigid, transphyseal tibial nailing of tibial shaft fractures in patients with open physes.

Methods: This was a retrospective study of skeletally immature patients who were treated with transphyseal nailing of a tibial shaft fracture. Included patients had at least 1 year of growth remaining, as determined by the Modified Fels Skeletal Maturity System, and at least 1 year of follow-up. Growth disturbance was determined by a change in posterior tibial slope or medial proximal tibial angle on radiographs obtained at the time of injury as compared with radiographs at final follow-up.

Results: A total of 20 patients were included in the study. The mean chronological age of the cohort was 14.5 years (SD=1.47, range: 12 to 17 y) at the time of injury. The mean skeletal age at the time of injury in female patients was 12.6 years (SD=0.4, range: 12.0 to 13.0) and in males, 14.4 years (SD=0.7, range: 12.5 to 15.0). The cohort had a mean of 1.51 years of growth remaining (SD=0.6, range: 1 to 3.5 y). There was no significant change in the mean posterior tibial slope or medial proximal tibial angle between injury and final radiographs (P=0.467, 0.906, respectively). Two patients developed a decrease in posterior tibial slope angle (flattening of slope) of greater than 3 degrees (3.9 and 6.7 degrees).

Conclusions: Rigid transphyseal nailing of pediatric tibial shaft fractures in patients with open physes who are approaching maturity remains a safe treatment option; however, when more than 1 year of growth remains, surgeons must carefully monitor patients for the development of angular deformity at the knee.

Background: After successful treatment of developmental dysplasia of the hip (DDH) with a Pavlik harness, controversy exists about whether it's best to continue harness use for an additional "weaning" period or simply terminate treatment. The purpose of this randomized controlled trial (RCT) was to compare radiographic outcomes between patients with stable hip dysplasia who were weaned (W) or not weaned (NW) after Pavlik harness treatment.

Methods: This was a single-center RCT of infants with stable ultrasonographic dysplasia in whom a Pavlik harness was initiated at <3 months of age. After 23 hours/day of harness treatment and normalization of ultrasound indices, patients were randomized into W or NW groups. W patients continued harness use for an additional 4 to 6 weeks, progressively decreasing daily use. Primary outcome was acetabular index (AI) on AP radiographs of the pelvis at 6 months of age. Secondary outcomes were number of hips with AI ≥ 30 degrees at 6 months (our threshold for prescribing part-time abduction bracing for residual dysplasia) and AI at 1 year of age.

Results: Seventy-two patients (36 W, 36 NW) met inclusion criteria. There were no differences between W and NW cohorts in age at Pavlik initiation or baseline alpha angle or percent femoral head coverage. At time of ultrasonographic normalization, there was no significant difference in mean time spent in the harness between W and NW cohorts (35.0 vs. 34.9 d, P=0.84). At 6 months, mean AI was significantly lower in the W cohort (24.8±3.9 deg.) compared with the NW cohort (26.9±3.4 deg.) (P=0.02). Fewer braces were prescribed for residual dysplasia at 6 months in the W versus NW cohort (17% vs. 22%), but this was not statistically significant (P=0.56). AI at 1 year of age was not significantly different between groups (W 24.6±3.4 deg.; NW 25.3±2.3 deg., P=0.84) but this likely was affected by the use of additional bracing.

Conclusions: A Pavlik weaning protocol resulted in improved AI at 6 months of age versus immediate termination of treatment. At 1 year, AI was not significantly different between W and NW cohorts, likely due to the use of additional part-time bracing in those who were dysplastic at 6 months.

Level of evidence: Level I-randomized controlled trial.

Background: Recent animal studies have suggested that cartilage hypertrophy may occur in Legg-Calvé-Perthes disease (LCPD), potentially influencing femoral head morphology during containment treatment. We aimed to analyze cartilage hypertrophy in children with LCPD using magnetic resonance imaging (MRI) and assess its relationship with long-term femoral head outcomes.

Methods: Fifty-five patients with unilateral LCPD who underwent conservative containment treatment were evaluated. Cartilage thickness was measured in 10 distinct regions on coronal and sagittal MRI scans obtained during the early stage of the disease. Enlargement of the femoral head due to bone or cartilaginous components was also assessed. The relationships between clinical and radiologic variables, including age and the cartilage thickness ratio, and Stulberg classification at skeletal maturity, were analyzed.

Results: Femoral head enlargement was observed on the affected side compared with the normal side, primarily due to cartilage hypertrophy, whereas bony epiphyseal enlargement followed an age-dependent pattern on both sides. Cartilage hypertrophy occurred in multiple directions but was most pronounced in the lateral region. Onset age and horizontal cartilage hypertrophy emerged as independent prognostic indicators for the Stulberg classification. Severe deformities, defined as Stulberg class III or more, were observed in only 6% of children aged 7 years or younger with a cartilage thickness ratio of ≤3.7, whereas 83% of children aged 7 years or younger with a ratio >3.7 developed severe deformities.

Conclusion: Cartilage hypertrophy, frequently observed in early-stage LCPD, is associated with enlargement of the femoral head. The extent of horizontal hypertrophy and age at onset may serve as key prognostic indicators of femoral head deformity progression.

Level of evidence: Level III-study of nonconsecutive patients in diagnostic studies.

Background: Congenital muscular torticollis (CMT) with a sternocleidomastoid muscle (SCM) mass presents varying prognoses, yet early, quantifiable predictors of physical therapy (PT) outcomes remain inadequately defined. This study aimed to identify the predictors of PT outcomes and evaluate the clinical and ultrasonographic (US) features influencing PT duration in infants with CMT with an SCM mass.

Methods: In this prospective cohort study, 153 infants (30 ± 15 days old) with CMT and SCM mass were enrolled. Clinical evaluation and US measurements were performed at the initial visit and at 2, 4, 6, and 12 months of age. The primary outcome was favorable outcome versus unfavorable outcome. Unfavorable outcome was defined as surgery, PT >1 year without further improvement, or persistent cervical range-of-motion limitation >5 degrees. PT duration was analyzed among favorable outcome cases.

Results: Favorable outcome was achieved in 126 infants (82.4%), whereas 27 (17.6%) failed. >66% SCM length involvement was the strongest predictor of unfavorable outcome (92.6% in unfavorable vs. 45.2% in favorable; OR 15.23, P=0.010). Higher SCM thickness ratio at 2 months predicted unfavorable outcome (OR: 4.05, P=0.016). In the favorable outcome group, >66% length involvement was associated with significantly longer PT duration (B=0.201, P=0.004). Conversely, isolated sternal head involvement without clavicular head involvement was strongly associated with shorter PT duration (B=-0.229, P=0.008), and all such cases achieved favorable outcome.

Conclusions: Greater SCM length involvement (>66%) and higher 2-month thickness ratio independently predict unfavorable outcome, whereas isolated sternal head involvement predicts shorter therapy duration. Early US evaluation at 2 months provides robust prognostic information and may guide individualized PT strategies in infants with CMT.

Level of evidence: Level II.

Background: Simultaneous bilateral femur fractures (SBFFs) are an extremely rare type of injury, particularly among pediatric patients. Because of their infrequency, pediatric SBFFs are poorly characterized in the literature. Here, we review our center's experience with managing them. We hypothesized that such injuries were likely to be accompanied by additional traumatic injuries to other organ systems/parts of the body.

Methods: This retrospective, observational cohort study was conducted on all patients who underwent treatment for SBFFs at a freestanding, level I pediatric hospital between May 2008 and September 2022. Patients were excluded from the study if they were over age 18 or had bilateral femur fractures that occurred on separate occasions. Demographic data and details related to the patient's presenting injuries, hospital stay, and orthopaedic interventions were collected through chart review. Injury Severity Scores (ISS) were obtained from the trauma registry.

Results: A total of 17 patients were identified, most of whom were male, black, injured in a motor vehicle accident as unrestrained passengers, and had an associated injury to the head or neck at the time of presentation. Median age was 5.65 years (range: 0.93 to 16.84 y) while the median ISS was 14. Nearly half of the patients were admitted or transferred to the intensive care unit during hospitalization. One quarter of the patients required mechanical ventilation during the hospital stay, with 2 patients (12%) developing symptoms concerning for pulmonary fat embolism. No mortalities were observed following treatment of the femur fractures.

Conclusion: To date, this is the largest cohort of pediatric patients with simultaneous bilateral femur fractures that has been examined. More research into this topic should be carried out with larger sample sizes to further characterize the complication profile and long-term outcomes of this injury pattern.

Level of evidence: Level III.