Journal of Pediatric Orthopaedics最新文献

Background: Clubfoot is the most common congenital abnormality of the lower extremity. The widely accepted Ponseti casting method includes a series of manipulations and casts often followed by Achilles tenotomy then use of a foot abduction orthosis. Some evidence suggests initiation of casting within a week of age improves outcomes but access to care and socioeconomic factors can impact timing of casting initiation. This study evaluates differences in clinical outcomes, demographic variables, and Child Opportunity Index (COI) between patients who initiated treatment before and after 4 weeks of age.

Methods: This was a retrospective study on patients with idiopathic clubfoot treated with the Ponseti method at a tertiary care center between 2011 and 2023. Patients were categorized into 2 groups by age at initial cast: early treatment (<4 wk) and late treatment (≥4 wk to 6 mo). Demographic and clinical data were collected, including treatment outcomes and bracing issues, and COI scores were recorded.

Results: Seventy-eight patients were included: 60 in the early group (92 feet) and 18 in the late group (25 feet). Groups differed significantly by age at initiation of casting ( P =<0.001). There were no significant differences in other demographic characteristics or insurance type. Patients in the late group were more likely to experience non-skin-related bracing issues ( P =0.047). No significant differences were found in other clinical or bracing outcomes. Patients in the late group were more likely to have a low/very low total COI ( P =0.008). There were no significant differences in domain-specific COI scores (health, socioeconomic, education).

Conclusions: Clubfoot patients who initiated treatment ≥4 weeks had a lower total COI, indicating that socioeconomic factors may be associated with delayed treatment. Although patients in the late group experienced more non-skin-related bracing issues, there were no significant differences in other clinical outcomes when compared with those treated at <4 weeks of age. These findings may alleviate pressure to initiate treatment by the first week of life when there are barriers to accessing care that can be overcome within a month and highlight the need for providers to consider socioeconomic profiles in treatment planning.

Level of evidence: This was a retrospective cohort study comparing 2 methods of treatment between 2 patient groups, making it a level III therapeutic study.

Background: Legg-Calvé-Perthes disease (LCPD) is a pediatric hip disorder characterized by idiopathic avascular necrosis of the femoral head. Although its etiology remains unclear, frequent observations of short stature and delayed skeletal maturation have suggested disturbance of systemic growth regulation, particularly involving the growth hormone (GH)/insulin-like growth factor-1 (IGF-1) axis. This study evaluates the impact of GH deficiency (GHD) and timing of GH therapy (GHT) on radiographic progression and femoral head morphology in LCPD.

Methods: We conducted a retrospective review of 10 patients (11 hips) with GHD and LCPD treated at a single institution. Patients were stratified into 2 cohorts: group A (n=5), diagnosed with GHD and initiated on GHT before LCPD onset, and group B (n=5, 6 hips), diagnosed and treated during LCPD. Each case was matched 1:2 to controls without GHD based on sex, age at diagnosis, stage, and treatment. Radiographic staging and outcomes were assessed using Waldenström and Stulberg classifications. Growth parameters and treatment-related complications were also recorded.

Results: Group A exhibited disease stage duration and femoral head outcomes similar to matched controls. In contrast, group B experienced significantly prolonged fragmentation (1.8 vs. 0.8 y of matched controls, P =0.008) and reossification stages (5.8 vs. 3.9 y, P =0.006), along with worse femoral head sphericity (Stulberg I/II in 0% vs. 67%, P =0.013). Notably, all group B patients had growth deceleration (growth velocity <5 cm/y) before GHD diagnosis. GHT was well tolerated in all cases, with no orthopaedic complications.

Conclusions: GHD diagnosed and treated during LCPD was associated with prolonged fragmentation and reossification stages and poorer femoral head morphology. In contrast, patients with GHD treated before LCPD onset demonstrated outcomes similar to matched controls. These findings underscore the potential relevance of the GH/IGF-1 axis in LCPD. Orthopaedic clinicians should maintain vigilance for endocrinopathies in LCPD patients with growth deceleration (growth velocity <5 cm/y) and delayed bone age, as early endocrine referral and treatment may improve outcomes.

Level of evidence: Level III.

Background: Talocalcaneal coalition is a common tarsal coalition, but incomplete ossification in children often leads to underdiagnosis using traditional radiographic signs like the "C sign" and "talar beak." Ultrasonography, which is radiation-free and detects unossified cartilage, has not been studied for pediatric talocalcaneal coalition. This study evaluates the accuracy and reliability of ultrasonography versus radiography in diagnosing suspected pediatric talocalcaneal coalition.

Methods: Eighty-six suspected talocalcaneal coalitions underwent ultrasonography, radiography, and 3-dimensional CT scanning. Three pediatric orthopaedic surgeons assessed ultrasound results and radiographic signs ("C sign" and "talar beak") for interobserver and intraobserver reliability. Using CT as the diagnostic standard, the sensitivity, specificity, positive predictive value, and negative predictive value of ultrasonography and radiographic signs were evaluated.

Results: In a cohort of 86 suspected pediatric talocalcaneal coalitions, the mean age was 12.3 years. The interobserver reliability for the "C sign" was moderate (κ=0.55), while the interobserver reliability for ultrasonography was almost perfect (κ=0.87). Using 3-dimensional CT scanning as the diagnostic standard, the specificity and sensitivity of the "C sign" for diagnosing talocalcaneal coalition in children were 86% and 54%, respectively. Ultrasonography demonstrated a sensitivity of 96% and a specificity of 98%. The "talar beak" had only 3 true positives and 25 false negatives, resulting in a sensitivity of 11%, which was statistically significant ( P <0.001).

Conclusions: The "C sign" is useful but less accurate than ultrasonography for diagnosing suspected pediatric talocalcaneal coalition, while the "talar beak" is unsuitable due to low sensitivity. Ultrasonography can accurately detect pediatric talocalcaneal coalition, even in unossified cases. Compared with radiography, ultrasonography is more suitable for diagnosing suspected pediatric talocalcaneal coalition.

Level of evidence: Level III-diagnostic study.

Background: Intraoperative neurophysiological monitoring (IONM) is essential for detecting potential neurological injury during scoliosis surgery, but obtaining recordable baseline signals can be challenging in neuromuscular scoliosis (NMS) patients. Absent baseline IONM signals, characterized by unattainable initial IONM responses despite technical and anesthetic optimization, present significant challenges to intraoperative neurological assessment and surgical risk stratification. This study aims to identify predictive factors for absent baseline IONM signals in pediatric NMS patients and establish a clinically applicable risk prediction model.

Methods: This retrospective study initially identified 118 nonambulatory NMS patients under 18 years old who underwent spinopelvic fusion between 2013 and 2022. All patients received standardized total intravenous anesthesia (TIVA) protocol to optimize signal acquisition. After excluding 3 patients with spinal cord injuries, 115 patients were analyzed. Multimodality IONM, including somatosensory evoked potentials (SSEPs) and transcranial electrical motor evoked potentials (TcMEPs) was attempted in all cases. Clinical data and radiographic measurements were analyzed to determine predictive factors for absent baseline IONM signal. ROC curve analysis and logistic regression were used to determine optimal thresholds and predictive factors for absent baseline IONM signals.

Results: Thirty-eight (33%) had absent baseline lower extremity IONM signals. Cerebral palsy (CP) was the most significant predictive factor [odds ratio (OR): 9.615, P <0.001], with 53.1% of CP patients having absent baseline IONM signals. Within the CP cohort, Gross Motor Function Classification System (GMFCS) level V (OR: 11.501, P =0.028) and body height <128.5 cm (OR: 4.097, P =0.044) were significant risk factors. Three patients developed new-onset urinary incontinence postoperatively, though the relationship to IONM status remains undetermined.

Conclusion: Severe CP and shorter stature significantly increase the risk of absent baseline IONM signals in pediatric NMS patients. These findings inform preoperative risk assessment, enhance patient-specific surgical planning, and suggest the need for alternative monitoring approaches in high-risk cases. Such early identification of monitoring challenges can improve surgical preparation, consent processes, and ultimately patient care in this vulnerable population.

Level of evidence: Level III.

Background: Differentiating lateral ankle avulsion fractures from subfibular ossicles in pediatric ankle sprains remains diagnostically challenging with conventional radiography. This study evaluates a novel dynamic ultrasonography technique for reliable differentiation, offering clinicians a rapid, accurate diagnostic tool.

Methods: We collected radiographic and dynamic ultrasound imaging data from 95 children with lateral ankle sprains, all of whom underwent examination using the novel dynamic ultrasonographic technique. Four observers with varying levels of clinical experience evaluated the images. Each observer made diagnoses based on radiographs alone and then in combination with dynamic ultrasound images. Interobserver reliability was assessed using the multirater free-marginal kappa, while intraobserver reliability was evaluated using the linear weighted kappa. The changes in diagnoses of the observers after the addition of dynamic ultrasound images were collected and analyzed.

Results: The study of 95 cases identified 5% (5/95) subfibular ossicles, 16% (15/95) distal fibular avulsion fractures, 4% (4/95) lateral process talus fractures, and 75% (71/95) radiographically negative cases. Among the 24 radiographically positive cases, initial interobserver agreement for distinguishing subfibular ossicles from avulsion fractures was slight (κ=0.33) using radiographs alone, which improved to excellent (κ=0.89) with dynamic ultrasound images. Ultrasound prompted diagnostic changes in 26% of cases (6.25 cases) from subfibular ossicles to avulsion fractures, and 6% (1.5 cases) from avulsion fractures to subfibular ossicles.

Conclusion: The dynamic ultrasonographic technique accurately differentiates between lateral ankle avulsion fractures and subfibular ossicles in pediatric lateral ankle sprains. This dynamic ultrasound technology can also be used to assess the stability of lateral ankle bone fragments, providing valuable information for treatment planning.

Level of evidence: Level III-diagnostic study.

Background: Multidirectional instability (MDI) of the shoulder is a complex condition with a high rate of recurrence after surgical intervention in the younger population. This study was undertaken to determine the best treatment strategy for adolescent patients who fail their index surgical capsulorrhaphy.

Methods: Patients managed surgically over a 6-year period for MDI at a pediatric facility with 2 years minimum follow-up were evaluated via demographics, arthroscopic findings, and patient-reported outcomes (PROs): qDASH (short form Disabilities Arm, Shoulder, and Hand), PASS (Pediatric and Adolescent Shoulder Survey), and SANE (Single Assessment Numerical Evaluation). Treatment failure was defined as the need for a revision procedure, a PASS score less than 85, or a SANE score less than 75. Three cohorts were developed for comparison: successful, and unsuccessful (those electing a revision surgery, and those without a revision surgery).

Results: A total of 27 patients (34 total shoulders) with a mean age 16.1±2.0 years (70% female) were identified who met criteria with a mean overall follow-up duration of 6.3±2.4 years. 50% (17/34) had a failed initial procedure with 5 electing to undergo revision surgery. The successful cohort mean qDASH 1.3±2.3, PASS 94.7±3.8, and SANE 92.8±6.7 scores were better than the unsuccessful cohorts ( P <0.001), who had similar mean outcome scores ( P >0.2) between revision and no revision cohorts, respectively: qDASH (12.4±5.9 vs. 13.6±11), PASS (74.7±12.0 vs. 71.8±23.8), and SANE (74.3±8.2 vs. 65.6±25.0). However, 1/5 (20%) of the revision cohort did achieve acceptable PROs after the revision surgery.

Conclusions: A revision surgery following failed index MDI procedure does not appear to improve patient-reported outcome scores for all adolescents. Surgeons should counsel patients and families on the potential outcomes of the primary and/or revision surgery for this condition to improve the shared decision-making process. Future study into risk factors for failure, improved patient selection criteria, and even utilization of open techniques is warranted for adolescents with MDI and involuntary instability of their shoulders.

Level of evidence: Level III-comparative study.

Lam Qua, a Chinese artist, was commissioned by Dr Peter Parker, a medical missionary, to paint portraits of patients attending the Canton Hospital with tumors and deformities. Among numerous such portraits painted by Lam Qua, one is of an adolescent boy with severe deformities of the right lower limb associated with extensive scarring. The possible causes of such scarring are discussed. The fact that appropriate measures adopted while treating major wounds of the limbs can prevent deformities from developing is emphasized.

Background: Genu valgum and genu varum have various causes; however, the cause in some children remains unknown, leading to a diagnosis of idiopathic angular deformity. In this study, we investigated whether vitamin D deficiency could lead to idiopathic knee angular deformity in the absence of typical radiographic findings of rickets by examining serum markers in affected children and controls.

Methods: In this prospective cross-sectional comparative study, we evaluated 38 children aged 7 to 14 years with genu valgum or varum without medical conditions or radiographic findings affecting lower limb alignment and 29 controls. Laboratory parameters and the prevalence of vitamin D deficiency (serum 25-hydroxyvitamin D level <20 ng/mL) or hyperparathyroidism [serum parathyroid hormone (PTH) level >60 pg/mL] were compared between the 2 groups. The prevalence of angular deformities was compared among the groups based on the presence of vitamin D deficiency and hyperparathyroidism. Binary logistic regression analysis was used to calculate the odds ratios (ORs) for angular deformities based on vitamin D deficiency and hyperparathyroidism.

Results: The mean serum 25-hydroxyvitamin D levels did not significantly differ between the angular deformity (16.7±6.1 ng/mL) and control groups (19.9±7.1 ng/mL) ( P =0.055). However, vitamin D deficiency was more prevalent in the angular deformity group than in the control group (79% vs. 48%, P =0.009). Angular deformities were more prevalent in children with both vitamin D deficiency and hyperparathyroidism than in those without these conditions [11/13 (85%) vs. 5/18 (28%), P =0.012]. The logistic regression analysis-adjusted for age, sex, and weight-showed a higher risk of angular deformity in children with both vitamin D deficiency and hyperparathyroidism (OR: 9.86, 95% CI: 1.36-71.47, P =0.024), but not in children with vitamin D deficiency alone.

Conclusions: Isolated vitamin D deficiency without other laboratory abnormalities or radiographic findings of rickets did not lead to knee angular deformity. However, in cases in which vitamin D deficiency elevates PTH levels, idiopathic genu valgum or genu varum might be observed.

Level of evidence: Level III-prognostic study.