Journal of Pediatric Orthopaedics最新文献

Introduction: Legg-Calvé-Perthes disease (LCPD) often causes residual deformities, typically manifesting as an ellipsoidal femoral head shape. This condition arises from initial bone collapse and necrosis, inhibiting growth at the anterosuperior femoral head and resulting in asymmetric growth. The aim of this study is to assess the effectiveness of selective hemiepiphysiodesis in improving femoral head sphericity in patients with LCPD with previous onset of ovalization.

Methods: We compared 71 hips undergoing prophylactic selective hemiepiphysiodesis (surgical group) against 86 hips managed nonsurgically (control group). Radiographic evaluations were performed at 3 time points (3 y after disease onset, 5 y after disease onset, and skeletal maturity) to assess disease progression and intervention effects, measuring the ellipsoidal index (EI), the Reimer migration index (RMI), and the articulotrochanteric distance (ATD), with classifications according to the Herring scale and final sphericity assessments.

Results: Both cohorts were initially comparable in terms of age at onset, sex, and degree of deformity, showing similar EI, Herring classifications, and RMI ( P >0.05). At T2, significant improvements were observed in the EI, RMI, and ATD in the surgical group compared with the control group. At skeletal maturity, the surgical group demonstrated significantly improved sphericity across all 3 indices ( P <0.05), confirming the effectiveness of selective hemiepiphysiodesis in halting and partially reversing the ovalization process. The sphericity deviation score was significantly lower in the operated group (28±12) compared with the control group (43±28), the EI improved to 1.68±0.25 in the operated group from 2.11±0.33 in the controls, and the RMI showed a marked improvement (24.0±8.1) compared with controls (32.4±7.3).

Conclusions: Growth modulation by selective hemiepiphysiodesis effectively disrupts the progression of femoral head ovalization and enhances sphericity. This intervention presents a viable option for mitigating the ellipsoidal process in patients with LCPD, suggesting a significant potential to improve long-term outcomes by addressing early signs of deformity.

Level of evidence: Level III-retrospective cohort study.

Background: Magnetic resonance (MR) bone imaging may reduce radiation exposure compared with computed tomography (CT) in staging lumbar spondylolysis. This study aimed to validate the consistency between MR bone imaging and CT.

Methods: We retrospectively investigated short tau inversion recovery (STIR), MR bone imaging, and CT scans of patients diagnosed with lumbar spondylolysis who underwent MRI and CT scans within 2 weeks between November 2021 and March 2023.We identified 190 fractures in 968 pars interarticularis of 105 patients. MR bone imaging was based on Siemens 3 Tesla T1-weighted volumetric interpolated breath-hold imaging (T1 VIBE). The CT-based staging and T1 VIBE-based staging were matched [incomplete fracture, complete fracture, gap of ≥2 mm (gap)].

Results: For fracture detection with CT as a reference, the respective sensitivity, specificity, and accuracy were 94%, 99%, and 99% for incomplete fracture, 74%, 100%, and 98% for complete fracture, 81%, 99%, and 99% for gap, and 97%, 100%, and 100% for any fracture. When we assessed 62 pars with complete fracture or a gap, the rates were 91%, 100%, and 99%, respectively. In staging 190 fractures with CT as a reference, the respective sensitivity, specificity, and accuracy were 94%, 91%, and 93% for incomplete fracture, 74%, 96%, and 91% for complete fracture, 81%, 96%, and 95% for gap, and 97%, 100%, and 97% for any fracture. The respective values were 91%, 98%, and 96% for complete fracture combined with gap. Of 153 pedicles with high signal change on STIR, 10 showed no fracture line, 110 showed incomplete fracture lines, 30 showed complete fracture lines, and 3 showed a gap on T1 VIBE, compared with 5, 109, 39, and 0, respectively, on CT.

Conclusions: The T1 VIBE sequence is highly accurate, although it has some limitations in fracture detection. T1 VIBE can be used clinically in conjunction with STIR and may replace CT in determining the treatment strategy for lumbar spondylolysis, resulting in reduced medical radiation exposure to pediatric patients.

Level of evidence: Level III diagnostic study.

Objective: This study aimed to evaluate the current trends and practices in medial patellofemoral ligament reconstruction (MPFL-R) among pediatric and adolescent patients in South America.

Methods: A cross-sectional web-based survey consisting of 21 questions, Supplemental Digital Content 1, http://links.lww.com/BPO/A960 was distributed to members affiliated with 4 pediatric orthopaedic societies from Argentina, Brazil, Chile, and Colombia. The survey collected data on demographics, patient selection criteria, surgical preferences, graft choice, fixation methods, and use of adjunctive procedures. Descriptive statistics (mean and SD) were calculated for continuous variables and frequencies. Percentages were calculated to summarize qualitative data.

Results: A total of 132 completed surveys were collected, with the following distribution: Argentina (11.4%), Brazil (61.4%), Colombia (10.6%), and Chile (16.7%). Sixty percent of the participants had been in practice for more than 10 years. Most surgeons (84.8%) favored autografts, with semitendinous (54.5%) and quadriceps tendons (41.7%) being the most common choices. Preferences for femoral fixation included suture anchors (41.7%) and interference screws (37.9%), whereas patellar fixation preferences included suture anchors (48.5%), periosteum-based (36.4%), and patellar tunnels, (15.2%). There were diverse practices in distal realignment techniques and variable indications and approaches for derotation osteotomy in patients with femoral anteversion across the surveyed countries. Most surgeons (55.3%) preferred staging-guided growth and MPFL-R for skeletally immature patients with significant genu valgum. A common trend identified was the limited experience with trochleoplasty techniques.

Conclusions: This survey revealed substantial variability in MPFL-R practices among pediatric orthopaedic surgeons in South America. These findings underscore the need for standardized guidelines and further research to optimize surgical outcomes in pediatric and adolescent patients. Understanding regional differences can inform future collaborative efforts to develop best practices and improve patient care in this population.

Level of evidence: Level V.

Background: Musculoskeletal infections (MSKIs), including osteomyelitis and pyogenic arthritis, present significant health risks in pediatric populations. This study evaluates the risks of septic deep vein thrombosis (DVT), intensive care unit (ICU) admission, and mortality in children diagnosed with lower extremity MSKIs, with a focus on methicillin-resistant Staphylococcus aureus (MRSA) infections.

Methods: This retrospective cohort study from a multi-institutional database included 38,023 pediatric patients diagnosed with lower extremity MSKIs. Incidence and risk factors for DVT, ICU admission, and mortality were collected. Comparisons were made between age groups and MRSA versus non-MRSA infections. The association between CRP levels and outcomes was also examined. Multivariable logistic regression models were utilized.

Results: The mean age of the cohort was 8.49 years. Overall, 1.52% of patients developed septic DVT, 0.49% required ICU admission, and 0.48% died. Patients with MRSA had significantly higher risks of DVT (RR 4.89, P <0.001) and mortality (RR 3.57, P <0.001) compared with those without MRSA. CRP levels were also markedly higher in MRSA patients ( P <0.001). When comparing age groups, those <12 years had a higher risk of ICU admission (RR 2.03, P <0.001), whereas the 12 to 18 age group had a higher risk of DVT (RR 0.71, P <0.001). Among patients with DVT, the mortality risk was significantly increased (RR 5.18, P <0.001). MRSA patients with DVT had the highest mortality risk (RR 5.38, P <0.001) and elevated CRP levels ( P <0.001).

Conclusions: Reporting the largest series of children with lower extremity MSKI, our study found increased risk of DVT, ICU admission, and mortality in pediatric patients with MRSA. MRSA patients with septic DVT had significantly higher level of CRP than those without DVT (100.95 mg/L vs. 61.59 mg/L, P <0.001). MRSA infections with septic DVT had the highest rate of mortality (7.24%). Clinicians should consider proactive screening and aggressive management strategies for septic DVT in the at-risk population, especially in patients with high CRP.

Level of evidence: Prognostic level III.

Background: Increased femoral anteversion is a common problem in children, but the condition usually normalizes spontaneously over time. There is limited knowledge of the long-term consequences of persistently increased anteversion. The purpose of this study was to analyse the long-term functional complaints of untreated adults with idiopathic increased anteversion compared with a control group.

Methods: Study participants were recruited from our institutional register of increased femoral anteversion during the period 1975 to 2008. Inclusion criteria were anteversion angle ≥30 degrees and no other disorders affecting the lower limbs. Outcome measures were the HAGOS and KOOS questionnaires, radiographic signs of osteoarthritis, and clinical examination. A control group of 24 healthy individuals was examined with the same methods.

Results: Fifty-eight patients (46 females) with a mean age of 46.2 years were included in the AV group. The mean anteversion angle was of 40.2 degrees in the anteversion group and 20.6 degrees in the controls. The mean external foot progression angle was 0.5 degrees in the anteversion group and 4.6 degrees in the controls ( P <0.001). The anteversion group scored significantly worse than the control group in 5 out of 6 HAGOS subscales: Pain ( P =0.032), Symptoms ( P =0.041), Sport/Rec ( P =0.001), PA ( P =0.036), and QOL ( P =0.001). The KOOS subscale Symptoms was the only subscale with a worse score in the AV group ( P =0.006). Only 1 patient in the anteversion group had hip osteoarthritis.

Conclusions: Untreated adults with idiopathic increased femoral AV at a mean age of 46 years experienced more hip pain and limitations in participation in physical activities and sports compared with healthy individuals, but the limitations were mostly small to moderate and would hardly influence the present strict indications for surgical correction in children.

Level of evidence: Level II-prospective comparative study.

Background: Fractures involving the medial humeral epicondyle are common but no consensus on the best treatment approach exists. Casting alone and open reduction with internal fixation (ORIF) both provide reliable healing, although there is limited evidence to support either approach. This study surveyed surgeons treatment preferences for pediatric medial epicondyle fractures (MEF) and willingness to randomize between casting and ORIF. We hypothesized that low consensus exists in the preferred treatment approach (casting vs. ORIF).

Methods: An online survey was emailed in 2017 to members of the Pediatric Orthopaedic Society of North America (POSNA). Demographic information regarding orthopaedic surgeon practice experience and setting, in addition to opinions regarding MEF treatment, were collected. Seven patient cases were presented to assess the surgeon's preferred treatment approach and willingness to randomize treatment.

Results: The survey was completed by 322 POSNA members (∼25% of membership). Respondents were well-represented by POSNA with 55.7% <9, 23.8% 10 to 19, and 20.5% ≥20 years in practice. Most respondents were from an academic setting (77.4%), taught residents (83.3%), and treated primarily pediatric patients (91.6%). Years of experience significantly influenced both their treatment preferences and willingness to randomize, while practice setting only influenced the latter. Factors that influenced treatment approach included chronological/skeletal age (64.2%), known elbow dislocation (74.1%), neurovascular status (65.3%), and the amount of fragment displacement (80.4%). Displacement contributed to the treatment decision with 1.1% opting to operate at any displacement, 2.7% at >2 mm, 24.6% at >5 mm, 27.7% at >10 mm, and 43.9% choosing to analyze factors beyond displacement. Immobilization length varied between the treatments with 63.6% recommending immobilization of ≥4 weeks for casting and 81.9% recommending immobilization of ≤2 weeks for ORIF. The greatest consensus (87%) for ORIF was found in a 14-year-old with a fracture fragment displaced >10 mm, with no elbow dislocation and in the nondominant arm, neurovascularly intact. The lowest consensus (50.9% recommending ORIF) was in an 11-year-old with a fracture fragment displaced >10 mm, with no elbow dislocation and in the nondominant arm, neurovascularly intact. For these cases, 48% and 60% of surgeons were willing to randomize treatment, respectively. For the 7 cases overall, a mean of 58% (range: 48% to 63%) of respondents were willing to randomize treatment.

Conclusion: A lack of standardization exists for the preferred treatment approach for pediatric MEF. The decision to pursue casting or ORIF appears multifactorial. Roughly half of the respondents would be willing to randomize the treatment of these injuries.

Background: Trauma centers may utilize fracture clinics primarily staffed by advanced practice clinicians (APC) for management of basic fractures that typically require few visits. It is unclear if provider continuity is important in these brief health care encounters. The purpose of this study was to determine the association between continuity of care and patient satisfaction scores in APC-run urgent/fracture clinics.

Methods: This was a retrospective IRB-approved study at a pediatric tertiary-care Level-1 trauma hospital. We reviewed prospectively collected Press Ganey data from 2021 to 2023 for acute injury/fracture patients seen in a pediatric orthopaedic fracture clinic, which is APC-staffed and physician-supervised. Demographic and clinical data were collected along with the results of 4 Press Ganey patient satisfaction survey items ( recommend provider , teamwork , recommend practice , overall rating ). Univariate and multivariable models were conducted to determine independent predictors of patient satisfaction, including the effect of continuity of care.

Results: A total of 230 follow-up encounters were reviewed. Median age was 11 years (range, 0 to 17). The majority of patients were male (59%), White (75%), with a very high child opportunity index (72%). Patients who saw the same provider at follow-up had a higher proportion of top-box ratings compared with those who saw a different provider for 3 of 4 outcomes: 88% versus 76% for staff teamwork ( P =0.04), 94% versus 78% for recommend practice ( P =0.003), and 93% versus 76% for overall rating of care ( P =0.003). After adjusting for consistency of care, location, age, sex , child opportunity index, injury region, and geographical distance from clinic, the odds of receiving a top-box rating for recommend practice were 4.7 times higher ( P =0.004) and 3.8 times higher for overall rating ( P =0.002) for patients with continuity of care-provider.

Conclusions: Continuity of APC care-provider has a positive impact on patient satisfaction in a pediatric fracture clinic, as patients who saw the same provider in successive follow-up visits. Demographic, geographic, and clinical factors had comparatively little effect on patient satisfaction. The provider remains a fundamental factor in patient experience.

Level of evidence: Level II.

Background/objectives: Lateral ankle injuries are common in pediatric populations. Avulsion fractures are a distinct injury involving bony disruption and may be underrecognized given their radiographically occult nature in skeletally immature patients. This study aims to compare the frequency, clinical presentation, and patient-reported outcomes (PROs) of lateral ankle avulsion fractures versus non-avulsion injuries in pediatric patients, with a focus on age-related differences.

Methods: Prospective cohort observational study conducted at a tertiary pediatric orthopedic/sports medicine practice. Patients aged 5 to 12 with a first lifetime lateral ankle injury within 30 days of the injury were consecutively enrolled, receiving clinical radiographs and research-based lateral ankle ultrasounds. Patients were classified into avulsion and non-avulsion groups based upon ultrasound findings, and additional comparisons were done between younger (age 5 to 10) and older (age 11 to 12) groups.

Results: Among 132 patients (mean age 9.95 (95% CI: 9.54-10.36), 56% younger group, 65% female), 44 avulsion fractures (33%) were identified. Avulsion fractures were significantly more common in the younger group (47%) than in the older group (16%) ( P <0.001). Swelling and bruising were more frequent in avulsion fractures ( P <0.001). Despite differences in injury type, initial presentation PROs did not differ.

Conclusions: Avulsion fractures account for one-third of pediatric lateral ankle injuries and are more frequent in younger children than older children, likely due to greater skeletal immaturity. Swelling and bruising may aid in accurate diagnosis. Longitudinal studies are needed to determine if these fractures lead to subfibular ossicles, which are associated with chronic pain and instability.

Level of evidence: Level II.

Background: Neuromuscular acetabular dysplasia is believed to be posterior in children with cerebral palsy (CP). While an anteroposterior (AP) pelvic radiograph is the current standard-of-care for CP hip surveillance, the 3-dimensional (3D) nature of the acetabulum makes accurate assessment difficult using 2-dimensional imaging (2D).

Methods: Over a 12-year period at a single tertiary care institution, a consecutive sample of 285 children with CP were retrospectively identified across Gross Motor Function Classification System Level (GMFCS) levels (age: 3 to 22 y, average: 9.3±3.5 years, 43% females). A cohort of age-matched and sex-matched children (n=285) without CP were used for comparison. Using a validated automatic segmentation and anatomy measurement program (Virtual Hip, Musculoskeletal Digital Innovation and Informatics Program, Boston's Children Hospital, Boston, MA), 3D hip models from 3-dimensional computed tomography (3D-CT) scans were developed to automatically measure acetabular index (AI) or acetabular angle (AA), and acetabular rim lateral extension (ARLE) from posterior (9 o'clock) to anterior (3 o'clock). AI/AA was also measured on corresponding radiographs. Mixed linear models were used to compare measurements around the clockface and between 3D-CT and radiographs (for AI and AA only). Linear regression investigated age-related changes.

Results: The acetabulum is significantly underdeveloped in both the posterior and anterior regions relative to the superior region in skeletally mature and immature patients with CP, as demonstrated by increasing AI ( P <0.05) and AA ( P <0.01)-and decreasing ARLE ( P <0.01)-at nearly all positions of the acetabulum clockface relative to 12 o'clock. Greater acetabular dysplasia correlated with increasing GMFCS level compared with our control cohort ( P <0.01). Finally, singular 2D radiographic measurements of AI and AA were only accurate for the most superior 12 o'clock position but significantly underestimated acetabular deficiency everywhere else ( P <0.05).

Conclusions: Severity of neuromuscular acetabular dysplasia is underestimated using plain radiographs. Using 3D-CT, acetabular deficiency is appreciated globally and worsens with increasing GMFCS level. Measuring the 3D ARLE for preoperative planning in neuromuscular acetabular dysplasia can provide more information than plain radiographic measurements.

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