Journal of Pediatric Orthopaedics最新文献

Background: This study aims to report on the acetabular indices of walking age children following successful DDH treatment with Pavlik harness and investigate risk factors for residual acetabular dysplasia (RAD).

Methods: We retrospectively reviewed the data for children treated for DDH at a single centre between 2015 and 2020. Acetabular indices (AI) measured on pelvic radiographs taken at 2- and 4-year follow-up visits were referenced against age-matched and sex-matched normal data. Values ≥90th percentile were considered to represent RAD.

Results: A total of 305 children with 470 hips were suitable for inclusion. The mean age at treatment initiation was 7.0±4.5 weeks and mean treatment duration was 15.9±4.3 weeks. Overall, 27% and 19% of hips were found to have RAD at 2- (n=448) and 4-year (n=206) follow-up, respectively. The χ 2 test for independence demonstrated that the difference in the proportion of hips with RAD at both time points was significant ( P =0.032). Patients with RAD at 2 years were found to have been treated for longer ( P =0.028) and had lower alpha angles on final ultrasound assessment ( P <0.001). Patients with RAD at 4 years were older at initiation of treatment ( P =0.041), had lower alpha angles on final ultrasound assessment ( P <0.001) and were more likely to have had RAD at 2 years ( P <0.001). Multivariate analysis identified lower alpha angles on final ultrasound to be predictive for RAD at 2 years ( P =0.011), and presence of RAD at 2 years to be predictive for RAD at 4 years ( P <0.001).

Conclusions: The risk of RAD beyond walking age in children successfully treated with Pavlik harness is not negligible. However, we observed that a significant proportion of children with RAD at 2-year follow-up had spontaneously improved without any intervention. This data suggests that routine long-term radiologic follow-up of children treated with Pavlik harness is necessary, and surgical intervention to address RAD should be delayed until at least 4 years of age.

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

Background: Pediatric diaphyseal femoral fracture (PDFF) is one of the most common injuries requiring hospitalization. Elastic stable intramedullary nailing (ESIN) is commonly used for PDFFs in ages 5 to 11. The optimal treatment method for length unstable PDFF is a subject of ongoing debate. This study aimed to compare clinical, radiographic, and pedobarographic outcomes of ESIN between length stable and unstable PDFF.

Methods: We retrospectively reviewed patients undergoing ESIN treatment for isolated PDFF between 2016 and 2021. Exclusion criteria were (1) history of ipsilateral or contralateral lower extremity fractures, (2) highly comminuted or segmental fractures, (3) body weight >50 kg, and (4) comorbidities affecting bone quality, range of motion, or neurologic status. The patients were divided into 2 groups according to length stability. Clinical, radiographic, and pedobarographic data were then assessed to compare groups.

Results: Twenty-five patients were included (17 length stable and 8 length unstable PDFF) with a mean age of 73.6±17.8 months. There was no significant difference between groups in age, side of injury, body weight, follow-up duration, and nail-canal diameter ratio. Mean deformity in the fracture site in the early postoperative x-rays was not significantly different between groups ( P =0.661). After a mean follow-up of 27.8±14.2 months (range, 12-67), there was no significant difference in mechanical axis deviation, distal femur joint orientation angle, or limb-length discrepancy in both groups. The pedobarographic assessment revealed that the length unstable group had a significantly higher external foot progression angle in the injured extremity (9.8°±6.9° vs. 1.3°±5.6°, P =0.031). However, the length stable group had no significant difference in the foot progression angle (4.9°±5° vs. 3°±4.3°, P =0.326). There was no significant difference in either group for other pedobarographic parameters.

Conclusion: ESIN is a safe and effective option for length-unstable PDFF, yet attention should be paid to the rotational alignment. Although significant external rotation deformity occurs in length-unstable PDFF, it has no implications for the other pedobarographic parameters.

Level of evidence: Level IV.

Background: Pediatric patients with isolated femoral diaphyseal fractures are difficult to assess for nonaccidental trauma (NAT). The purpose of this study was to determine (1) if there are any demographic features of isolated femoral diaphyseal fractures associated with suspected NAT and (2) if there are clinical signs associated with isolated femoral diaphyseal fractures associated with suspected NAT.

Methods: All patients with femoral diaphyseal fractures from January 2010 to June 2018 were reviewed. We included patients younger than 4 years old with isolated femoral diaphyseal fractures. We excluded patients 4 years old and older, polytraumas, motor vehicle collisions, and patients with altered bone biology. Diagnosis of suspected NAT was determined by review of a documented social work assessment. We recorded fracture characteristics including location along femur as well as fracture pattern and presence of associated findings on NAT workup including the presence of retinal hemorrhage, subdural hematoma, evidence of prior fracture, or cutaneous lesions. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of these associated findings were calculated.

Results: Totally, 144 patients met the inclusion criteria. Social work was consulted on 50 patients (35%). Suspected NAT was diagnosed in 27 patients (19%). The average age of patients with suspected NAT was 0.82 and 2.25 years in patients without NAT ( P <0.01). The rate and type of skin lesions present on exam were not different between the 2 groups. Patients with suspected NAT had no findings of retinal hemorrhage or subdural hematoma, but 5 of 27 patients (19%) had evidence of prior fracture on skeletal survey. The sensitivities of retinal hemorrhage, subdural, and skeletal survey were 0%, 0%, and 19% and the specificities of all were 100%. The NPVs were 39%, 27%, and 63%, respectively. The PPV of skeletal survey was 100%. Since there were no patients in this study with positive findings of retinal hemorrhage or subdural hematoma, the PPV for these could not be assessed.

Conclusions: In the current study, signs of NAT such as skin lesions, retinal hemorrhage, subdural hematoma, and evidence of prior fracture on skeletal survey may not be helpful to diagnosis suspected NAT in patients with an isolated femoral diaphyseal fracture.

Level of evidence: Level III-diagnostic study.

Background: Spasticity of the elbow flexors causes a dynamic and/or static elbow flexion deformity. This position interferes with the functional use of the hand, is aesthetically unpleasant and can cause problems with hygiene and comfort. A lengthening procedure of elbow flexor muscles can improve elbow posture and range of motion. However, causal spasticity is not addressed directly. Selective neurectomy of the musculocutaneous nerve has a direct effect on underlying spasticity but is not sufficient when contracture is present. In this study, we examine the long-term results of a combined surgical approach: a release procedure of the elbow flexors and selective neurectomy of the musculocutaneous nerve.

Methods: A retrospective study of 14 patients with spastic flexion deformity of the elbow was performed. After a mean follow-up of 52.6 months (SD 33, range 12 to 113), the results of the combined surgical approach were evaluated. Spontaneous position of the elbow and active and passive range of motion were assesses using goniometry. Spasticity was assessed using the Modified Ashworth Scale. Function of the affected upper limb before and after surgery was assessed by the House functional classification. Patient and caretaker's satisfaction were assessed using a visual analogue scale.

Results: The mean decrease of passive elbow extension deficit was 34 degrees (SD 21.3, P <0.05). Active elbow extension increased with a mean of 41 degrees (SD 16.5, P <0.05). Spontaneous position elbow flexion decreased by a mean of 40 degrees (SD 21.1, P <0.05).The Modified Ashworth score decreased significantly ( P <0.05) from 3.27 (range 1 to 4) preoperatively to 0.64 (range 0 to 4) postoperatively.The difference between the House score preoperatively and postoperatively was not significant ( P =0.180). Mean patient satisfaction was 8.2/10 (SD 2.7, range 2 to 10) and mean caregiver satisfaction was 7.1/10 (SD 2.7, range 1 to 10).

Conclusion: A combined surgical approach to elbow flexion deformity in the form of a lengthening procedure and selective neurectomy of the elbow flexors result in a significant and sustained improvement of the spontaneous position, active and passive elbow extension and elbow flexor spasticity and high patient and caregiver satisfaction.

Level of evidence: Case series, level IV.

Background: The induced membrane technique is now widely used for pediatric diaphyseal bone loss due to various etiologies. Although consolidation rates remain satisfactory, complications, and healing delays may occur requiring additional procedures. We studied a series of induced membrane bone reconstructions in which the second stage included an embedded endomembranous non vascularized fibular shaft, in addition to iliac bone grafts. The purpose of this study was to analyze the results in terms of bone consolidation and complications.

Methods: This is a retrospective comparative and multicentric study of 32 children with large bone loss treated with the induced membrane reconstruction technique. Patients were divided into 2 groups according to the graft used during the second stage. The first group (G1) of 16 patients had a nonvascularized fibula embedded inside the membrane in addition with the corticocancellous grafts from the iliac crest. The second group (G2) of 16 patients underwent reconstruction using the original technique, with iliac crest graft only.

Results: The 2 groups were similar in terms of etiologies of bone loss and follow-up (mean: 44 mo for G1 and 49 mo for G2). Mean bone losses were 15.4 cm (range: 2 to 25; SD: 5.6) for G1 and 10.6 cm (range: 3 to 19; SD: 5.2) for G2. In the first group, all patients healed primarily, with a mean time of 5.9 months (range: 4 to 8; SD: 1.6). In the second group, 2 of 16 patients did not healed; for the others 14, healing mean time was 6.9 months (range: 3 to 12; SD: 2.7). The short-term and long-term complications rates were 38% to 19% for G1 and 50% to 31% for G2, respectively. Regarding the donor site, the fibulas reconstructed spontaneously with a mean time of 4.8 months (range: 3 to 6; SD: 1.2).

Conclusions: The integration of a nonvascularized fibula during the second stage of the induced membrane technique appears to improve the consolidation rate in the pediatric population.

Level of evidence: Level III-Retrospective comparative study.

Background: Osteochondromas are benign osseous lesions often excised for pain, growth abnormalities, and aesthetic concerns. While characteristic clinical and radiographic features leave little diagnostic ambiguity in most cases of osteochondroma, pathologic analysis to confirm the diagnosis and screen for malignancy is routinely performed following surgical excision. The purpose of this study was to determine the clinical and economic value of routine pathologic analysis after osteochondroma excision in a pediatric population.

Methods: A retrospective review of clinical records from 2 pediatric orthopaedic hospitals (St. Louis Children's Hospital and Shriner's Hospital for Children, St. Louis) identified 426 osteochondroma lesions surgically resected from 201 patients. Patients with solitary and multiple lesions were included. Clinical, radiographic, and surgical data were recorded for each resection surgery. Pathologic reports were evaluated. Costs incurred for routine pathologic assessment was also noted.

Results: Totally, 132 patients were treated with surgical resection of a solitary osteochondroma lesion, while an additional 291 lesions were resected from 69 patients with multiple lesions. Average age at the time of surgical resection was 13.0 years (2.1 to 17.9). The most common anatomic locations of excised lesions included the distal femur (110, 25.8%), proximal tibia/fibula (95, 22.3%), and distal radius/ulna (58, 13.6%). All resected specimens were sent for pathologic analysis. The average size of the resected lesions was 19.9 mm 3 (0.02 to 385.0 mm 3 ). In all cases, the histologic diagnosis confirmed benign osteochondroma. The total charges of pathologic analysis including processing and interpretation fees was ∼$755.00 for each lesion assessed, for a total cohort charge of $321,630.

Conclusion: We propose that in most cases of pediatric osteochondroma excision procedures, postoperative histologic analysis is not strictly indicated as it rarely, if ever, alters diagnosis or management. We suggest using a "gross only" analysis in these cases. However, we do believe that with preoperative diagnostic ambiguity, or if patients present with concerning features such as rapidly expansile lesions or cortical destruction, have axial skeleton or pelvic involvement, or enlarged cartilaginous caps, full histologic evaluation of the excised lesions will continue to be prudent.

Level of evidence: Level IV-case series.

Background: The Putti sign, a common deformity and complaint in children with brachial plexus birth injury (BPBI), stems from a glenohumeral (GH) abduction contracture. Despite recent clinical studies offering insights into this deformity, none have explored the prevalence of the Putti sign or its correlation with GH abduction contractures.

Methods: We conducted a prospective analysis of 238 patients (median age 7.5 years; range, 4.1-16.2) with residual BPBI seen in the clinic from December 2019 to December 2022. Epidemiological data, including demographics, palsy levels, modified Mallet scale sum, surgical history, and presence/absence of the Putti sign and glenohumeral adduction angle (GHADD), were collected. Patients were categorized into 4 age groups: 0 to 5 years (n=67), 6 to 10 years (n=102), 11 to 15 years (n=53), and 16 years and older (n=16). Results were expressed as medians (minimum-maximum), with frequency comparisons done using Pearson's chi-square analysis. Mann-Whitney U and Kruskal-Wallis tests were used for quantitative variable comparison, and receiver operating characteristic (ROC) analysis determined the threshold GHADD angle for Putti sign appearance.

Results: Main findings included: (1) 27% of patients with residual BPBI exhibited the Putti sign, (2) confirmed correlation between the Putti sign and GH adduction contractures, (3) Putti sign manifestation with GHADD angle measuring less than -5° because to abduction contracture, and (4) association between this deformity and reduced activities requiring external rotation. No significant differences in Putti sign prevalence were found across age groups.

Conclusions: Our study underscores the common occurrence of the Putti sign in children with residual BPBI. It is important to note that we highlight its functional significance beyond cosmetic concerns. Contrary to prior literature, our analysis reveals functional impairment associated with the Putti sign. Although no age-based differences in Putti sign prevalence were observed, patients aged 0 to 5 years and 11 to 15 years showed more severe glenohumeral abduction contractures, possibly due to growth spurts.

Level of evidence: Diagnosis IV.

Introduction: The Ponseti serial casting method is the method of choice in treating children with congenital clubfeet. The arthrogrypotic clubfoot has traditionally been considered challenging to treat, with higher rates of recurrence and the need for more corrective surgeries. However, initial reports have found promising results in using the Ponseti method to treat arthrogrypotic feet. This study aims to compare the outcomes of idiopathic versus arthrogrypotic clubfeet following initial treatment with the Ponseti serial casting method.

Methods: A retrospective review of medical records from a single institution was conducted. Data was collected from children ages 0 to 18 with idiopathic or arthrogrypotic clubfoot treated from 2002 to 2022 with Ponseti-style serial casting with a minimum 2-year follow-up. Recurrence was defined as the need for additional casting or subsequent surgeries following initial correction. Data was collected on relevant patient demographics, previous treatment, casting records, Achilles tenotomies, and surgical treatments.

Results: A total of 352 patients (546 feet) met inclusion criteria. In all, 334 idiopathic and 18 arthrogrypotic patients were analyzed with an average follow-up duration of 3.4 and 4.2 years, respectively. Twelve patients had distal arthrogryposis, and 6 had amyoplasia. In all, 93.4% of idiopathic and 72.2% of arthrogrypotic patients successfully achieved correction with Ponseti casting and Achilles tenotomy. Recurrence rates were significantly higher in the arthrogrypotic group at 83.3% compared with 44.6% in the idiopathic group ( P =0.001). A posterior or posterior medial release was performed in 35.0% of idiopathic and 66.7% arthrogrypotic feet.

Conclusions: We report the largest series of arthrogrypotic clubfeet treated by Ponseti casting to the best of our knowledge. In contrast to earlier reports, our investigation underscores that while the Ponseti method may be able to secure initial correction in arthrogrypotic clubfeet, on average, at a 3-year follow-up, the prognosis is less favorable. These patients exhibit higher recurrence and often require operative treatment. Notably, a posterior medial release may eventually be needed in up to 6 of 10 patients.

Level of evidence: Level III-therapeutic studies-investigating the results of treatment.

Background: Computed tomography CT or magnetic resonance imaging (MRI) has been the most used imaging modality to assess hip reduction in developmental dysplasia of the hip (DDH) after open reduction (OR). In 2015, intraoperative 3D fluoroscopy (3D) was introduced at our center as an alternative to CT/MRI. 3D offers the advantage that if hip reduction is insufficient, it can be addressed at the time of surgery. The purpose of this study was to assess the efficacy of 3D in comparison to CT/MRI.

Methods: This was a single-centre, retrospective comparative study of two consecutive cohorts: those with OR and 3D between 2015 and 2017 and those with OR and CT/MRI between 2012 and 2014. Time to imaging, re-imaging, length of stay (LOS), re-operation, and redislocation or subluxation after cast removal were evaluated.

Results: Forty-two patients (46 hips) had 3D, and 30 patients (32 hips) had CT/MRI. Significant differences were found between groups in time to imaging, cast changes, and LOS. All 3D was intraoperative (46 hips), and only 69% (22 hips) of CT/MRI was on the day of surgery ( P <0.01). In the 3D group, 1 hip (2%) had a cast change under the same anesthetic, and 4 hips (13%) from CT/MRI had cast changes in subsequent surgery ( P =0.03). The mean LOS in days for 3D was 1.72 and 2.20 for CT/MRI ( P =0.03). There were no statistically significant differences between groups in further imaging and subluxations or re-dislocations at cast removal. Two hips (4%) in the 3D group had MRI, but with no further intervention ( P =0.51), and at cast removal, there were 3 subluxations in each group ( P =0.69) and 1 redislocation in the 3D group ( P =1.00).

Conclusions: Intraoperative 3D improved time to imaging, allowed for cast changes at surgery and had a shorter LOS. Moreover, there were no significant differences found in adverse outcomes between those who underwent 3D versus CT/MRI. 3D should thus be considered an effective alternative to CT/MRI for assessing hip reduction during OR for DDH.

Level of evidence: Diagnostic Study, level II.

Background: Triple pelvic osteotomy (TPO) is indicated when the anatomic and functional realignment of the hip joint is needed. Although the traditional approach for TPO involves a separate incision for ischial cut, there has been a trend for single-incision TPO in recent years. This study aims to compare the clinical and radiologic results of 2 different approaches.

Methods: Forty-two hips of 39 patients treated using TPO with a minimum of 24 months of follow-up were included in our cohort. Demographics, perioperative, and radiologic parameters were evaluated. Harris Hip Score and International Hip Outcome Tool were used for clinical evaluation.

Results: A single anterolateral incision approach was used in 18 hips (17 patients), whereas a 3-incision approach was used in 24 hips (22 patients). The mean follow-up was 4.7 years in the 3-incision group and 3.8 years in the single-incision group ( P =0.43), with mean surgery age at 8.7 years (range, 5.4 to 12) for single-incision and 9.7 years (range, 7.7 to 11.7) for 3e-incision ( P =0.22). There were no significant differences observed between the 2 groups concerning radiographic measurements, complications, and functional scores. The mean surgical time was 118.6 minutes in the single-incision group and 97.9 minutes in 3-incision group ( P =0.036). Mean intraoperative blood loss was 181.7 ml in the single-incision group and 243.4 ml in 3-incision group ( P =0.028). Three-incision group demonstrated significantly higher intraoperative blood loss, leading to lower hemoglobin values ( P =0.042).

Conclusion: The single-incision TPO demonstrated similar outcomes compared with the traditional 3-incision approach in terms of radiologic correction and functional improvement. The single-incision technique exhibited advantages such as reduced intraoperative blood loss and potential benefit of decreased pain due to fewer scars. However, it required a longer surgical time compared with the 3-incision approach. Surgeons should consider patient-specific factors and their expertise when selecting the most appropriate approach for each case.

Level of evidence: Level III-retrospective comparative series.