Journal of Pediatric Orthopaedics最新文献

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.

Background: Arthrogryposis multiplex congenita patients' functional abilities vary greatly, depending on the disease severity and treatment. This study aimed to identify and describe associations among physical impairments and long-term functional outcomes of adults with arthrogryposis.

Methods: We interviewed 42 adult patients ( M =37 y, SD=12; range 20 to 74; 50% men) with arthrogryposis who were treated between 1988 and 2019 at a pediatric rehabilitation center or major adjacent general hospital. We evaluated their function and quality of life with the Physical Activity Scale for Individuals with Physical Disabilities (PASIPD); Disabilities of the Arm, Shoulder, and Hand (Quick-DASH); and Short Form 36 Health Survey (SF-36) and compared variables using the Fisher exact and Mann-Whitney tests.

Results: Participants were more likely than the general population to have graduate degrees and lower physical function, but rated their quality of life as similar. Despite high rates of musculoskeletal pain in the back (60%), hip (50%), shoulder-elbow (25%), and wrist (58%), only 2 participants reported regularly using pain medication. Over 83% had upper-limb involvement; upper-extremity and lower-extremity symptoms limited upper-extremity function. Upper limb function was correlated with shoulder, elbow and wrist symptoms but also with hip, knee and foot symptoms (Quick-DASH; P <0.05). General dysfunction was correlated with shoulder, spine, hip, and foot symptoms (PASIPD; P <0.05). Shoulder and spine symptoms had a grave effect on mobility. Participants who had spine surgery reported better upper-limb function than patients who did not (Quick-DASH; P <0.05).

Conclusion: We found a significant discrepancy between the participants' high quality of life and education levels and their limited mobility and social, physical, and upper-extremity function and high rates of symptoms. Pain management and social rehabilitation remain major aims for this population. Upper-extremity function was not only correlated with upper-extremity joint symptoms but also with lower-extremity joint dysfunction and appears to improve with spine surgery. It is possible that improved posture or seating position will enhance the functional position of the upper extremity. The ramifications of surgery and the correlation between extremity function should be further examined.

Level of evidence: Level 4.

Background: Lyme disease is the most common vector-borne disease in United States children. It was traditionally thought to be limited to the Northeast and upper Midwest due to the prevalence of tick and deer vectors in these regions. We hypothesize that as Lyme disease cases in children continue to increase throughout the country, nontraditional regions such as the Midwest and South may have an increased rate of Lyme disease compared with the Northeast region.

Methods: The Pediatric Health Information System (PHIS) database was queried for patients 19.0 years or younger who were treated for Lyme disease between 2004 and 2019 through Emergency Department and in-patient records using ICD coding. Data from 49 pediatric hospitals was included and the centers were split into 4 regions based on geographic location. The data was separated into 2 time periods: 2004 to 2014 and 2015 to 2019. Slopes were compared using a general linear model with interaction to determine if annual rates of Lyme disease were statistically different between the 2 time periods. The data was then split by geographic region and again the annual rate of Lyme disease was compared between the 4 regions. A P -value <0.008 was considered significant to adjust for multiple comparisons.

Results: Between 2004 and 2019, 7,572 cases of Lyme disease were reported with a mean age of 9.5 years (range: 0.08 to 19.00 y) and 58% male. From 2004 to 2019, there was an annual increase of 46.5 cases. When separated by region from 2004 to 2019, the Midwest had a higher increased annual rate of Lyme disease (30.7 additional cases/year) compared with the Northeast (10.0 additional cases/y), the South (3.6 additional cases/y), and the West (2.2 additional cases/y).

Conclusions: Lyme disease continues to show an increased rate across the United States. The annual increase in cases in the Midwest was significantly higher than the other regions from 2004 to 2019. There does appear to be a significant regional spread, particularly in the Midwest. Awareness of the increased rate and spread of Lyme disease across the US is crucial in helping to identify national and regional strategies to diagnose and treat this disease in children.

Level of evidence: Level IV.