Journal of Pediatric Orthopaedics最新文献

Background: Single-event multilevel surgery (SEMLS) has been accepted as the standard of care for the surgical treatment of children with cerebral palsy (CP). However, little has been studied on the effect of dual-attending surgeons in SEMLS. The aim of this study was to compare the effect of single versus dual-attending surgeons on resource utilization and postoperative outcomes in children with CP undergoing SEMLS.

Methods: A total of 70 patients with CP or CP-like conditions, who were <20 years old, and who underwent SEMLS at a single institution, were identified. Bivariate comparisons were conducted using Student's t tests, Mann-Whitney U tests, and chi-squared tests. Stratified analyses were conducted within patient characteristic subgroups to compare operative outcomes within groups. Multivariable regression analyses were used to assess differences across surgeon cohorts while controlling for potential confounding factors.

Results: Patients were stratified into single versus dual surgeon cohorts (n=40 vs. n=30, respectively). No significant differences were noted with respect to age, sex, race, BMI, GMFCS level, or ASA level between groups. A higher proportion of patients with a seizure history (67% vs. 38%; P =0.03) and revision procedures (33% vs. 3%, respectively; P =0.001) were found in the dual surgeon cohort. Bivariate analysis demonstrated that operative times in the dual surgeon cohort were significantly decreased in GMFCS level IV/V patients (269.6 ± 46.7 vs. 356 ± 103.4 min; P =0.002) and patients undergoing hip reconstruction procedures (270.6 ± 53.2 vs. 337.4 ± 85.8 min; P =0.007). A significant decrease in total blood loss (20% in hip reconstruction patients, P =0.036, 25% in GMFCS IV/V patients, P =0.049) and OR costs (16% in GMFCS level IV/V patients, P =0.008) was also observed. Moreover, multivariable analysis found that dual surgeon procedures had a 50-minute average reduction in operative time ( P =0.005); no differences were noted in complication rates, unplanned clinic visits, or re-operation rates.

Conclusions: A 2-surgeon team for SEMLS can significantly decrease operative time, total blood loss, and OR costs-particularly for hip reconstruction and higher GMFCS level patients.

Level of evidence: Level III.

Introduction: In treating early-onset scoliosis (EOS), pediatric orthopaedic surgeons and families must often choose between growth-friendly interventions such as magnetically controlled growing rods (MCGR) and early definitive posterior spinal fusion (PSF). While each strategy has associated pros and cons, little is understood about the specific preferences of patients' families. Addressing potential nuances in these preferences is crucial for meaningful shared decision-making (SDM). To better understand the factors influencing family decisions, we conducted a choice-based conjoint (CBC) analysis to explore parents' preferences for PSF and MCGR as treatment options.

Methods: A survey was developed using Sawtooth Software (Lighthouse Studio version 9.2.0) to gather demographic information and preferences on surgical scenarios via CBC analysis. Anonymous participants, recruited via the Prolific crowdsourcing platform, qualified if they were US residents over 18 years of age with children aged 8 to 9. Data analysis involved the Hierarchical Bayes (HB) method to determine the desirability of 5 surgical attributes: curve correction, increase in spinal height, total number of surgeries, duration of treatment, and chance of complications.

Results: The study included 432 participants who prioritized the likelihood of complications (relative importance value of 37), followed by total number of surgeries (22), curve correction (21), spine height (12), and treatment duration (8). Female participants and those with daughters assigned significantly higher importance to the treatment's total number of surgeries ( P <0.05). Simulator analysis showed that 86.6% of participants would hypothetically prefer PSF, while only 13.4% would opt for growing rods based on the modeled participant choices.

Conclusions: This CBC analysis suggests that parents of children with EOS requiring surgical intervention would prioritize complication minimization, reduction in total surgical procedures, and effective curve correction, demonstrating a marked preference for PSF. Notably, the sex of both the child and the parent influenced attribute preferences. These findings exemplify the utility of CBC analysis in orthopaedic care, allowing for a deeper understanding of family preferences and enhancing SDM by providing the ability to align surgical recommendations with specific family priorities.

Level of evidence: Level III.

Background: Pediatric pelvic ring fractures are different in biomechanics and anatomy compared with adults. Existing classification systems are insufficient in assessing the mechanical stability of these fractures due to a variety of reasons, leading to a potential underestimation of the injury severity, resulting in suboptimal treatment with the risk of long-term dysfunctions. This study aims to address this problem by comprehensively describing a cohort of patients with pediatric pelvic fractures, identifying specific pediatric pelvic fractures and patterns.

Methods: A retrospective cohort selection of pediatric patients with a pelvic fracture treated in a major level 1 trauma center between 2001 and 2021 was conducted. Fracture patterns were classified using existing systems (Tile, Young and Burgess, Torode and Zieg), with additional parameters such as skeletal maturity considered. In addition, the incidence of specific pediatric fracture characteristics was reviewed.

Results: The CT scans of 68 children were reviewed. The median age was 15.5 years, with a majority being female (53%). Traffic accidents were the primary mechanism of injury (65%). Most fractures were classified as Tile type B2 (53%) and Young & Burgess LC3 (32%). SI-joint avulsion fractures were frequently seen (n=14, 21%), predominantly in children with a mature pelvis (n=10, 71%). A significant proportion of fractures did not fit conventional classifications, with little difference between skeletally mature and immature patients (73% vs. 75%).

Conclusions: A large portion of skeletally mature and immature patients cannot be classified according to the currently existing classifications, highlighting the need for a tailored pediatric classification system. APC2-like fracture patterns had a high incidence of SI-joint avulsion fractures, so purely ligamentous APC-fracture patterns are, in our experience, very rare in children. In addition, a previously undescribed fracture pattern (ped-LC3) was identified. Future research is necessary to grasp the full concept of skeletal maturation on the biomechanics and distribution of forces in the pediatric pelvis.

Level of evidence: Level III.

Introduction: When surgical treatment is indicated, closed reduction with elastic stable intramedullary nailing (ESIN) is a widely accepted technique for managing both-bone forearm fractures in children. However, the optimal postoperative protocol-particularly the necessity and duration of immobilization-remains a matter of debate.

Objective: This study aims to compare complication rates in patients with both-bone forearm fractures treated with ESIN, with or without postoperative splint immobilization.

Methods: This retrospective study included 137 patients with displaced and unstable both-bone forearm shaft fractures who underwent surgical treatment with ESIN at our Department of Pediatric Surgery, Orthopedics, and Traumatology between January 2020 and August 2022. Postoperative immobilization was decided individually by the operating surgeon. Data collected included fracture etiology, healing time, complications, and final clinical outcomes.

Results: Eighty-one patients were treated with postoperative splint immobilization, while 56 patients did not receive immobilization. There was no significant difference in bone healing time between the 2 groups. However, the complication rate was higher in the splinted group (16%) compared with the nonsplinted group (5.4%). In addition, open fractures and the need for open reduction were significantly associated with an increased risk of complications. No differences were observed between the groups in terms of QuickDASH scores.

Conclusion: Postoperative splint immobilization does not appear to be necessary to achieve satisfactory outcomes following ESIN treatment of both-bone forearm fractures in pediatric patients. It does not influence bone healing time or functional recovery and may be associated with a higher risk of complications. Open fractures and the requirement for open reduction are additional factors associated with increased complication rates.

Level of evidence: Level III-retrospective comparative study.

Introduction: Talocalcaneal coalition (TCC) is one of the most common tarsal coalitions in children. However, current classifications of TCC are limited and focus on histologic or morphologic features without clinical correlation or therapeutic guidance. Moreover, no classification system specifically designed for pediatric populations. We hypothesize that the novel classification system will be clinically relevant, reliable, and easy to use for pediatric TCC management.

Methods: A total of 43 patients (58 feet) with pediatric TCC confirmed by 3-dimensional CT scans were included in this study. All cases were classified according to the novel classification system: type I (middle facet TCC), type II (posterior facet TCC), and type III (extra-articular TCC). Three pediatric orthopaedic surgeons with varying levels of experience independently classified the 58 cases to assess interobserver agreement. For all patients, we documented the hindfoot alignment (valgus, varus, or neutral), presence of pain, peroneal muscle spasm, tarsal tunnel syndrome, treatment strategies, surgical duration, preoperative and postoperative AOFAS and VAS scores, and complications.

Results: A total of 22 type I, 9 type II, and 27 type III TCC cases were identified, with a mean age of 10.9 years. The new classification system demonstrated almost perfect interobserver agreement (kappa=0.90). Type I showed the highest valgus prevalence (59%, 13/22; P =0.004), type II predominant varus (67%, 6/9; P <0.001), and type III neutral alignment (52%, 14/27; P =0.515). Medial displacement calcaneal osteotomy was performed in 14% (3/21) of type I cases, and lateral displacement osteotomy in 42% (5/12) of type II and III cases. All types achieved significant AOFAS/VAS improvement. Type III TCC had the shortest operative time (52 min; P <0.001) and no complications.

Conclusion: We propose a novel classification system for pediatric TCC that is clinically relevant, reliable, and easy to use. Type I TCC is more often associated with hindfoot valgus, while type II TCC frequently presents with hindfoot varus. Types II and III TCC more commonly require lateral displacement calcaneal osteotomy for varus correction. Type III TCC showed the most favorable surgical outcomes, with the shortest operative times and lowest complication rates among all types.

Level of evidence: Level III-diagnostic study.

Introduction: Limb-length discrepancies (LLDs) have traditionally been treated with external fixators, but magnetically driven intramedullary nails (MILNs) are increasingly favored for improved comfort and reduced infection risk. This study compared intramedullary (IM) versus extramedullary (EM) lengthening nails in pediatric patients with narrow femoral canals to evaluate mechanical axis deviation, nail bending, tourniquet time, and complications.

Methods: A retrospective, single-center review was conducted of 75 pediatric patients who underwent femoral lengthening between 2015 and 2022, each with at least two years of follow-up. Patients received either an 8.5 mm IM nail or a 10.7/12.5 mm EM nail, combined with a solid, threaded IM nail for stability. Outcomes included preoperative and postoperative limb alignment (MAD, mLDFA, and mPDFA), IM nail bending, operative details (tourniquet time and blood loss), consolidation times, and complication rates classified according to the Cherkashin system.

Results: Forty-two patients were treated with EM nails and 33 with IM nails. Both groups achieved similar distraction amounts (4.7 ± 1.1 cm) and consolidation intervals (7 to 8 mo). However, the EM group demonstrated significantly greater postoperative MAD (12.9 ± 9.5 mm vs.  8.7 ± 7.3 mm, P  <0.05), higher nail bending (2 vs.  1.2 degrees, P <0.05), and longer tourniquet use. Overall complication rates were 69% (EM) and 60% (IM), with delayed union and soft tissue infection being the most frequent issues. Unplanned reoperations occurred in 21% of patients overall.

Conclusion: Both nail types correct limb‑length discrepancy, but extramedullary nails demand longer tourniquet times and have higher bending (of the IM component of the EM construct) and complication rates. Implant choice must suit patient factors and further comparative studies are warranted.

Background: Displaced femoral neck fractures in children are rare but carry significant risk for complications such as avascular necrosis (AVN), nonunion, and malunion. Although adult literature increasingly supports closed reduction when adequate alignment is achieved, the pediatric literature lacks consensus on optimal management. This study evaluates whether the quality of reduction, regardless of open or closed technique, predicts adverse outcomes in pediatric displaced femoral neck fractures.

Methods: We retrospectively reviewed 56 patients (ages 2 to 18) with displaced Delbet type II or III femoral neck fractures treated surgically at a single pediatric trauma center from 2000 to 2022. Fractures were classified radiographically, and the quality of postoperative reduction was assessed independently by 2 fellowship-trained orthopaedic surgeons. The primary outcome was a composite of adverse events including AVN, nonunion, malunion, fixation failure, SCFE, and infection. Survival analyses and Cox proportional hazard models were used to evaluate associations between reduction quality and outcomes.

Results: Anatomic reduction was achieved in 55% of patients and was more common after open reduction than closed reduction (71% vs. 29%, P=0.001). Patients with anatomic reductions had a significantly lower hazard of adverse events (HR: 0.21; 95% CI: 0.06-0.72; P=0.013) and longer event-free survival (RMST: 6.1 vs. 3.0 y, P=0.001). Type of reduction (open vs. closed) and preoperative radiographic parameters did not independently predict adverse outcomes. Early surgery (<12 h) did not show benefit and was associated with lower odds of achieving anatomic reduction.

Conclusions: Anatomic reduction, regardless of technique, is the strongest predictor of favorable outcomes after pediatric displaced femoral neck fracture. Open reduction should be pursued when closed methods fail to achieve anatomic alignment. Radiographic injury patterns and time to surgery were not independently predictive of adverse outcomes. These findings underscore the importance of prioritizing reduction quality to optimize long-term hip preservation in children.

Level of evidence: Level III-retrospective comparative study.

Purpose: To quantify the prevalence of neural axial abnormalities in congenital early-onset scoliosis (C-EOS) patients stratified by age group, correlate prevalence of treatment, and determine if a delay in MRIs affects outcomes.

Methods: A multicenter registry with data on 751 C-EOS patients was retrospectively reviewed, of which 659 patients were included. Data included demographics, pre-index major coronal curve, age at first MRI, intraspinal MRI findings, neurosurgical interventions and scoliosis fixation performed, intraoperative and postoperative complications, and unplanned return to the operating room (UPROR) for orthopaedic complications. Patients were divided into 2 cohorts utilizing age 3 as a cutoff. This age cutoff was selected based on an FDA warning of the potential neurocognitive effects of anesthesia used for MRIs in patients younger than 3 years. Spearman Rho correlations, independent t tests, and χ2 tests were used for statistical analysis.

Results: Patients were divided into 2 groups: first MRI younger than or equal to 3 years of age (n=277) and older than 3 years of age (n=382). One hundred thirty-three abnormal MRIs were identified (20%). There was no significant correlation between age at MRI and abnormal intraspinal findings (rs= -0.018, P=0.64). Among patients with abnormal MRIs, no correlation existed between age at MRI and UPROR. In this cohort, 23 neurosurgical procedures were performed and no significant difference was found in UPROR between groups (P=0.54). There were 3 neurologic complications in the younger than or equal to 3-year group and 0 in the older than 3-year group (P=0.07). No significant difference was found in mean pre-index major coronal curve (P=0.25).

Conclusions: The prevalence of neural axis abnormalities in C-EOS was 20%. There was no significant correlation between age at first MRI and the chance of an abnormal MRI. There were no significant differences in neurological complications and UPROR between the younger than or equal to 3-year and older than 3-year groups. Thus, in C-EOS, MRI may be cautiously deferred until after the age of 3 in patients with normal neurological examinations and radiological findings.

Background: Hip displacement (subluxation or dislocation) is common in children with cerebral palsy (CP), especially those who are nonambulatory. If unaddressed, this can cause pain, stiffness, hygiene difficulties, and seating imbalance. Progressive hip subluxation or dislocation often requires surgery, and further displacement after reconstruction may be described as "failure." There is currently no standardized definition of failure after the index procedure. This review aimed to identify published failure definitions and compile reported failure rates after index bony hip reconstruction.

Materials and methods: Following PRISMA guidelines, a systematic review was performed using PubMed, SCOPUS, and OVID databases (1990 to 2023). Exclusion criteria included soft tissue-only procedures, gait analysis-based outcomes, adults, non-CP syndromes, salvage or arthroplasty procedures, nonoperative management, unavailable full-text, non-English articles, novel techniques, radiographic or morphologic studies, or procedures without osteotomy. Studies without a definition of "failure" were excluded. Abstract review, full-text screening, and data extraction were performed by 2 authors, with a third adjudicating disagreements. Patient demographics, failure definitions and rates, and study quality were collected. Bias was assessed, and data were considered for pooled analysis.

Results: Of 630 abstracts, 27 studies were included. Failure rates ranged from 1.8% to 74% (mean 26.3%±17.4%). Definitions varied: Reimer Migration Percentage (MP) (63%) and revision surgery (48%) were most common. Other definitions included arthritis/hip pain (18.5%) and lateral center edge angle (18.5%). Significant heterogeneity in definitions, inclusion criteria, and follow-up, plus overlapping patient cohorts, precluded meta-analysis. The lowest rate (1.8%) reflected a single revision for painful instability. The highest (74%) came from a study defining failure as reoperation without MP. Two institutions contributed 6 publications.

Conclusions: There is no consistent definition of failure after bony hip reconstruction in CP, impeding comparison of techniques and outcomes. Children with CP are medically complex, and revision surgeries have significant implications. We advocate for a more uniform definition of failure following hip reconstruction in children with CP.

Level of evidence: Level III-systematic review of studies.