Journal of Pediatric Orthopaedics最新文献

Background: Current literature lacks comprehensive documentation on the burden placed on patient families managing spica casts for extended periods. Various complications associated with spica casts further intensify these challenges. To address this gap, our study aims to assess the lived experiences of families caring for children undergoing treatment for developmental dysplasia of the hip (DDH) with a hip spica cast.

Methods: A comprehensive survey was designed to gather caregiver perspectives on various orthotic treatments for DDH. The survey consisted of both Likert statements and open-ended questions to provide a holistic understanding of caregiver experiences. This anonymous survey was distributed online through REDCap to the Global Hip Dysplasia Registry (GHDR) network, reaching participants through mailing lists, social media groups, and clinic visits at the authors' respective institutions. Targeting an international audience, the survey engaged parents and caregivers of pediatric patients treated with different orthoses, including harnesses, braces, and spica casts. The lived experiences of families managing hip spica casts were analyzed as a distinct subset of the broader data set.

Results: A total of 140 respondents reported experience with a spica cast. Caregivers consistently reported concerns about restrictions on outings and daily activities while their child wore the spica cast. Hygiene issues, such as challenges with bathing and keeping the cast clean without getting it wet, were also prevalent. In addition, caregivers faced difficulties with cuddling and holding their children, although they emphasized that bonding remained intact. Many caregivers expressed feeling inadequately informed about spica casts, underscoring the need for improved education and support.

Conclusions: While hip spica casts were acknowledged as an effective treatment for postsurgical DDH, caregivers expressed overall dissatisfaction due to challenges related to convenience, hygiene, bonding, and other daily caregiving difficulties.

Level of evidence/clinical relevance: Understanding the lived experiences of families caring for children undergoing treatment for DDH with a hip spica cast can illuminate challenges and inform strategies for improved patient care and support. The findings from this investigation provide valuable insights that will be instrumental in refining the design of hip spica casts and enhancing education and support for caregivers, ultimately shaping future advancements in the treatment of DDH.

Introduction: Pediatric orthopaedic surgeries for complex hip and spine conditions, particularly in children with cerebral palsy, are associated with high complication rates. Malnutrition, common in this population, contributes to poor wound healing, infections, and prolonged recovery. Despite its impact, definitions and assessments of malnutrition remain inconsistent. Posterior spinal fusion and hip reconstruction carry complication rates over 50%. While interest in nutritional optimization is growing, no standardized approach exists, especially in pediatric orthopaedic populations. The purpose of this study was to evaluate the existing literature on perioperative nutritional assessment and optimization of pediatric patients undergoing complex hip and spine surgery.

Methods: We conducted a PRISMA-compliant systematic review of MEDLINE, Embase, and Cochrane databases in April 2025. Inclusion criteria were studies on patients 21 years or younger undergoing hip or spine surgery that reported perioperative nutritional status or interventions alongside clinical outcomes. Eligible study designs included RCTs, cohort studies, and case series (>10 patients). Data were independently extracted and study quality assessed using the Newcastle-Ottawa Scale (NOS).

Results: Out of 371 studies, 23 met the inclusion criteria. Eighteen were retrospective cohorts, 1 prospective cohort, 2 cross-sectional, and 2 case-control studies. Fifteen were high quality (NOS ≥7). Thirteen studies (57%) examined laboratory-based markers; 10 (43%) assessed nutritional interventions or classifications. Common outcomes included wound complications (48%), respiratory complications (26%), LOS/readmissions (26%), and patient-reported outcomes (17%). Laboratory findings were inconsistent, though transferrin <200 mg/dL was linked to respiratory risk. BMI-based metrics better predicted complications, especially in those who were underweight or experiencing >10% weight loss. Enhanced recovery after surgery (ERAS) protocols improved LOS, pain, and IL-6 levels, while routine nutrition assessments showed no clear benefit.

Conclusion: While isolated laboratory values are inconsistent predictors, underweight status and weight loss are more reliable indicators of risk. ERAS protocols incorporating nutritional strategies may improve outcomes, although more pediatric-focused data are needed. The lack of standardized malnutrition definitions across studies limits comparability. Future research should establish uniform nutritional screening practices and evaluate specific interventions in high-risk pediatric orthopaedic populations. Despite limitations in study heterogeneity and small sample sizes, this review supports integrating structured perioperative nutrition into care pathways.

Background: Tibial deficiency (TD) is a rare congenital condition with an incidence of 5 to 21/million live births. While femoral and fibular deficiencies are more commonly recognized and frequently co-occur, associated femoral, hip, and pelvic (FHP) anomalies in TD remain under-characterized. Treatment options for TD include the use of orthotics, amputation with prosthetic management, and limb reconstruction. The presence of additional ipsilateral lower extremity anomalies and their impact on management are unknown. This study aims to characterize FHP anomalies in TD patients and assess their impact on treatment decisions.

Methods: A retrospective review was conducted on TD patients seen at seven tertiary surgical facilities between 2004 and 2022. Demographic data, radiographic findings, anomalies, and treatment details were collected and analyzed. TD was classified using the Jones classification when possible.

Results: A total of 492 patients with 650 tibial-deficient limbs were included. FHP anomalies were identified in 19% of limbs, with femoral anomalies most common (13%), followed by hip anomalies (8%) and pelvic anomalies (1%). The majority (72%) of FHP anomalies occurred with Jones type 1 TD. Treatment modifications for limbs with these anomalies were required in 50%, primarily additional procedures, treatment/surgery for the additional leg length loss, or a change in the level of prosthesis.

Conclusions: FHP anomalies occur in 19% of limbs with TD. They necessitate additional treatment or a change in treatment plan for 9% of all TD limbs, and 50% of TD limbs with FHP anomalies. Further studies are needed to explore the functional outcomes for these patients with femoral, hip, and pelvic anomalies seen in conjunction with ipsilateral tibial deficiency and the impact on factors such as mobility and prosthesis selection.

Level of evidence: Level III.

Background: Allergic diseases are common in children and are risk factors for infections following orthopaedic surgery. However, their association with infection risk following knee surgery in pediatric populations is unknown. This study compared the risks of postoperative infection in children with and without a history of allergic disease (eczema [atopic dermatitis] or asthma) who underwent common orthopaedic sports knee surgeries.

Methods: A retrospective cohort study was conducted using the TriNetX database. Patients aged 10 to 18 who underwent anterior cruciate ligament (ACL) reconstruction (ACLR) or meniscal surgery, including meniscectomy, meniscal repair, and meniscal transplant, were organized into separate cohorts based on prior history of asthma or eczema and matched based on demographics and comorbidities. Outcomes were 90-day postoperative superficial soft tissue infection (SSTI), deep soft tissue infection (DSTI), sepsis, wound complication, pneumonia, urinary tract infection (UTI), and emergency department (ED) visit risks. Tests of significance (alpha=0.05) were performed, and risk ratios (RRs) with 95% confidence intervals were calculated.

Results: Patients with allergic diseases were more likely to be African American and obese. The risks of SSTI (1.3% vs. 0.4%; RR=3.182; P =0.0004) and sepsis (0.4% vs. 0%; P =0.002) in ACLR patients, and risks of SSTI (1.0% vs. 0.3%; RR=3.2; P =0.0007) and pneumonia (0.4% vs. 0%; P =0.0005) in meniscus surgery patients, were higher in patients with a history of eczema than without. Asthma was associated with a greater likelihood of SSTI (1.1% vs. 0.5%; RR=2.067; P =0.02) and sepsis (0.4% vs. 0%; P =0.002) in patients undergoing ACLR but not meniscus surgery. Prior diagnosis of either disease was associated with increased risk for ED visits following both ACLR and meniscus surgery. No significant differences in risk rates were noted between cohorts for DSTI, wound complications, and UTI.

Conclusions: Although overall risks were low, there were significantly greater risks of SSTI and ED visits following common knee sports surgeries in pediatric patients with a history of allergic disease than in those without.

Level of evidence: Level III.

Background: Rett syndrome (RS) is a rare neurodevelopmental disorder often associated with progressive scoliosis requiring treatment. Surgical interventions include magnetically controlled growing rods (MCGR) to allow spinal growth in younger patients or posterior spinal fusion (PSF) for definitive curve correction and stability. There is limited literature on outcomes of growth-friendly surgical treatment in RS patients with scoliosis.

Methods: This multicenter retrospective review included RS patients with scoliosis treated with MCGR or primary PSF with minimum 2-year follow-up. Demographics, radiographic measures, surgical data, complications, unplanned returns to the operating room, and EOSQ-24 scores were recorded pre- and postindex surgery.

Results: The study included 15 females with Rett syndrome. Five patients had MCGR and 10 underwent PSF. The mean age of the MCGR group was 8.5 years (range: 7.6 to 9.2) and the PSF group was 12.8 years (range: 10.1 to 17.7). Mean preindex major curve magnitude was similar between the MCGR and PSF patients [75 (range: 67 to 91) vs. 80 degrees (range: 53 to 116)]. At final follow-up, the PSF group achieved greater major curve correction than the MCGR group [35 (range: 21 to 58) vs. 42 degrees (range: 26 to 59)]. The MCGR group had greater mean preindex maximum kyphosis [71 (range: 53 to 89) vs. 57 degrees (range: 18 to 96)] but mean maximum kyphosis at final follow-up was similar between the MCGR and PSF patients [54 (range: 42 to 86) vs. 50 degrees (range 18 to 78)]. Mean preindex T1-T12 and T1-S1 lengths were shorter in the MCGR patients [T1-T12: 16.6 cm (range 13.8 to 19.7) vs. 19.4 cm (range: 14.8 to 23.2); T1-S1: 28.6 cm (range: 25.2 to 33.0) vs. 31.0 cm (range: 22.3 to 37.7)]. Final mean T1-T12 lengths were 22.2 cm (range: 19.8 to 25.4) for the MCGR group and 23.8 cm (range: 20.3 to 26.9) for the PSF group; mean T1-S1 lengths were 35.3 cm (range 31.9 to 40.8) and 36.9 cm (range: 32.3 to 42.6), respectively. There was one complication per group. One MCGR patient had acute respiratory failure requiring prolonged hospitalization, and one PSF patient had a wound infection requiring surgical intervention and antibiotics. MCGR patients showed declines in more EOSQ-24 domains than PSF patients between preindex surgery and last follow-up.

Conclusions: Both MCGR and PSF effectively control scoliosis in RS patients. PSF provides superior coronal curve correction, while MCGR promotes spinal growth. The impact of spinal surgery on quality of life warrants further investigation. Larger studies are needed to validate these results and guide individualized treatment for this unique population.

Level of evidence: Therapeutic level IV.

Background: The Early-Onset Scoliosis Self-Report Questionnaire (EOSQ-SELF) is a recently developed tool designed to assess health-related quality of life (HRQoL) in children with early-onset scoliosis (EOS). It complements the existing EOSQ-24, which relies on parental proxy reporting. While the EOSQ-SELF has demonstrated reliability in English, Chinese, and Turkish populations, it has yet to be validated for Spanish-speaking patients. This study aimed to translate, culturally adapt, and validate the EOSQ-SELF for use in Spanish-speaking children with EOS.

Methods: A multicenter, prospective validation study was conducted in Puerto Rico from August to November 2024. Participants aged 8 to 18 years with EOS were recruited during routine follow-up visits, regardless of treatment stage. The EOSQ-SELF underwent a rigorous translation and cultural adaptation process, including forward-backward translation and expert panel review. Reliability was evaluated using internal consistency metrics. Content and construct validity were assessed through expert and patient feedback, nonparametric tests, and multiple linear regression.

Results: The final Spanish EOSQ-SELF showed no significant semantic or cultural issues following expert and patient feedback. A total of 42 patients (mean age 10.3±2.4 y; 64% female) were included. The instrument demonstrated excellent internal consistency (Cronbach's α=0.91), with item-total correlations ranging from 0.34 to 0.75. Discriminant validity was confirmed in 75% of domain comparisons, although overlap was observed between "Transfer" and "Pain." Ceiling effects were most prominent in the "Relationships" domain (78%), while the lowest ceiling effect was found in "Pain and Discomfort" (30%).

Conclusions: The Spanish EOSQ-SELF is a reliable and valid instrument for measuring self-reported HRQoL in Spanish-speaking children with EOS. Despite some ceiling effects in high-functioning domains, the tool remains clinically and scientifically useful for this population.

Level of evidence: Level II-prognostic.

Background: Multiple distraction strategies to mitigate pain and distress during and after hospital procedures and surgery have become widely accepted and used in multimodal pain management in children. One such mode of nonpharmacological intervention and distraction is the application of cast art. There is a paucity of literature investigating the effect that cast art may have on a child's perception of pain. The purpose of this study was to investigate pain reporting and management trends in children undergoing supracondylar humerus fracture (SCHFx) surgery and immobilized postoperatively in a cast with applied custom illustrated cartoon art compared with a plain cast/no-art group.

Methods: Children who underwent closed reduction with percutaneous pinning (CRPP) of SCHFx were identified through retrospective chart review. Children were divided into 2 cohorts: those who received cast art and those who did not. Postoperative Visual Analog Scale (VAS), Face, Legs, Activity, Cry, Consolability scale (FLACC), and pain medication administration were recorded. Data were compared using χ 2 , ANOVA, and Man-Whitney U tests to determine significance set as P <0.05.

Results: Demographics and fracture type based on the Gartland fracture classification were similar between groups. The cast art group had significantly lower VAS ( P =0.009) and FLACC ( P =0.004) scores, required less acetaminophen ( P =0.048), ibuprofen ( P =0.014), and 4 times less children requiring postoperative narcotics ( P =0.003) compared with the no art group. The average (+/- SD) surgery time differed between the art and no art groups (24.6+/-8.4 min vs. 20.1+/-5.6 min, P =0.012). Similarly, the average (+/- SD) anesthesia time differed between the art and no art groups (59.9+/-19.4 min vs. 49.9+/-9.9 min, P =0.01).

Conclusion: Children undergoing CRPP for SCHFx fracture were found to have lower pain scores (VAS and FLACC) on the medical-surgical floor postoperatively and had decreased floor analgesic requirements lending evidence that cast art may be an adjunctive distraction strategy to mitigate pain and distress following SCHFx surgery in children.

Level of evidence: Level III-retrospective comparative study.

Background: Many pediatric injuries can be diagnosed with one radiograph. Because of health care costs and radiation risks, provider prudence while ordering radiographs is crucial. Although clinical guidelines like Ottawa Ankle Rules (OAR) and Ottawa Knee Rules (OKR) exist, the decision to order radiographs often bypasses clinical judgment. The purpose of this study was to conduct a review of the radiographic practices of providers.

Methods: This was a retrospective cohort of 179 pediatric patients with an extremity injury. Detailed chart review was performed on patients regarding demographics, HPI, physical exam, radiographs, and follow-up. Primary outcomes included radiographs and their relationship to the physical examination. Specifically, knee, ankle, and foot complaints were examined in relation to OAR and OKR. Predictor variables included age, sex, ordering provider, and location of presentation.

Results: At least one set of unnecessary radiographs was performed in 139 (86.3%) of 161 patients with documentation of physical examination. Decreased age was significantly associated with outcomes: unnecessary knee and foot radiographs per OAR and OKR, having completely negative radiographs, having unnecessary radiographs performed, and having zero radiographs indicated. Increased age was correlated with an increase in unnecessary radiographs ordered. Neither provider type nor location of triage showed significant outcomes.

Conclusions: There is a significant number of patients that are not receiving a proper screening before radiographic orders. Providers should return to physical examination and the utilization of clinical guidelines to best serve their patients, while understanding some of the ways that age may negatively impact their habits.

Level of evidence: Level III-retrospective diagnostic study.

Background: Avascular necrosis (AVN) is a known complication of slipped capital femoral epiphysis (SCFE) that can lead to poor long-term outcomes. Therefore, predicting the onset of AVN is crucial for effective management. While various preoperative methods have been proposed to predict AVN, none have demonstrated accurate prediction. This study aimed to assess the efficacy of preoperative perfusion magnetic resonance imaging (MRI) in accurately predicting the onset of AVN in patients with SCFE.

Methods: This study included 17 cases (18 hips) treated for SCFE at a single institution between January 2017 and April 2021. Preoperative factors such as stability (stable, unstable), gradual onset (acute, chronic, acute on chronic), slip severity (mild, moderate, severe), superior translation, bone scintigraphy results (HOT, COLD), and perfusion MRI findings were compared with the incidence of AVN. Perfusion MRI involved sequential imaging of the contrast-enhanced femoral head to generate time intensity curves, categorized as type A (similar enhancement on both sides), type B (delayed but stronger enhancement on the affected side), and type C (no enhancement on the affected side).

Results: AVN was observed in 4 out of 18 hips (22%). Among unstable hips, 4 out of 8 (50%) developed AVN, and superior translation averaged 20.8 ± 6.54 mm in 4 cases with AVN, and a statistically significant difference was observed in each factor. In terms of gradual onset, AVN occurred in 3 out of 7 acute cases (43%) and 1 out of 7 acute-on-chronic cases (14%). Regarding slip severity, AVN was found in 1 out of 7 moderate cases (14%) and 3 out of 9 severe cases (33%); there was no significant difference. AVN was observed in 4 out of 5 cases (80%) showing a COLD pattern on bone scintigraphy, and in all 4 cases (100%) classified as type C on perfusion MRI. Statistically significant differences were found for both imaging modalities.

Conclusions: Stability, superior translation, bone scintigraphy, and perfusion MRI in cases of SCFE may serve as effective predictors of future AVN.

Level of evidence: Level Ⅳ.