Journal of Pediatric Orthopaedics-Part B最新文献

Patients with bone sarcomas increasingly choose limb salvage. This can lead to issues with limb length discrepancy (LLD) for the skeletally immature. We synthesize management options into an algorithm and report our results. Patients with bone sarcomas involving any location from the femoral diaphysis to the tibial diaphysis 12 years or younger were reviewed. Our clinical pathway prescribed patients with metadiaphyseal lesions to intercalary allograft reconstruction, epiphyseal lesions and less than 5 cm expected LLD to osteoarticular allograft and patients with more than 5 cm expected LLD to extendable prosthesis. Twenty patients met inclusion criteria: 11 with osteoarticular allografts, 5 with extendable prostheses and 4 with intercalary allografts; median age 11.5 years; median follow-up 8.2 years; and final median LLD 1.6 cm. Five patients had contralateral epiphysiodesis, two patients underwent contralateral femoral shortening and a median of 6 (range 4-8) lengthenings were performed for extendable prostheses. Four patients had residual LLD over 3 cm. There were 13 revisions in 8 patients and 2 amputations. Limb-salvage in paediatric bone sarcoma of the knee can be managed with multiple techniques producing satisfactory results in regards to LLD. Careful pre-operative planning and shared decision making is a requisite given the high rate of secondary procedures for both LLD and reconstructive failures. Level of evidence: Level III Retrospective Comparative Study.

Cerebral palsy (CP) in upper limb produces functional, aesthetic and hygienic issues, and is not always amenable to surgical procedures. We are reporting a single-center, long follow-up experience with tendon transfer in wrist and forearm CP. The CP cases who had undergone tendon transfer in hand, wrist and forearm in a 14-year period were evaluated for change in motion, function and cosmetic appearance and also assessed by Manual Ability Classification System (MACS), and Dash (Disability of Arm, Shoulder, Hand) scores. Forty-two spastic CP patients with a mean age of 19.81 (10-34 years, SD: 5.36) years with a mean follow-up of 5.5 (2-14) years, entered the study. 24 cases were GMFCS I or II and 18 were III or IV. Supination beyond neutral was seen in 48.5%, and improvement in MACS scores in all the cases. Improved 'grasp' and 'release' and keyboard use was seen in 50%, 71% and 87% respectively. The satisfaction from appearance and improved function of 83-96% correlated positively with GMFSC, MACS and DASH scores. Noticeable improvement in personal hygienic care was seen in only 52% of cases. Tendon transfer in well-selected spastic upper extremity CP cases results in long-time improved function, and limb appearance - correlating with initial GMFCS and MACS scores.

Pelvic osteotomies are essential to approximate widened symphysis pubis in the exstrophy-epispadias complex, yet it is unknown which osteotomy type has the greatest effect on pelvic volume. We therefore used virtual surgery to study pelvic volume change with anterior, oblique, and posterior iliac osteotomies. Preoperative CT scans of two cloacal and one classic bladder exstrophy patients were used. Simulations were free-hand or constrained to keep minimal strain in the sacrospinous SSL and sacrotuberous STL ligaments. Changes in inter-pubic distance, pelvic volume, SSL and STL strains were measured. Mean pelvic volume decreased by 10% with free hand compared to 23% with constrained simulations ( P  = 0.171) and decreased by 7% with posterior, 17% with diagonal and 26% with horizontal osteotomies ( P  = 0.193). SSL and STL were strained by 20% and 26%, respectively, with free-hand simulations. A statistically significant moderate positive correlation was found between the decrease in inter-pubic distance and reduction in pelvic volume (r = 0.6, P  = 0.004). Mean pelvic volume decreased 0.05, 0.37 and 0.62% for each mm of pubic symphysis approximation with posterior, diagonal and horizontal osteotomies, respectively. Differences in effect on pelvic volume were identified between the osteotomies using virtual surgery which predicted residual diastasis in actual cloacal exstrophy surgical reconstructions. Oblique osteotomies are a compromise, avoiding difficulties with posterior osteotomies and excessive pelvic volume reduction with horizontal osteotomies. Understanding how osteotomy type affects pelvic morphology with virtual surgery may be an effective adjunct to pre-operative planning in exstrophy spectrum.

The Bado III Monteggia lesion is an uncommon fracture in children. Radial head dislocation can occur due to intra- or extra-articular fractures of the olecranon. In extra-articular ulnar fractures, heterogeneous operative methods are proposed in different case reports. The objective of this study is to determine if closed reduction of the ulnar fracture, either without osteosynthesis or by using TEN, is a safe treatment option. In a multicenter study, we retrospectively analyzed 26 children who were treated for an extra-articular proximal metaphyseal ulnar fracture with dislocation of the radial head. These patients underwent a follow-up examination after an average of four years. The investigation included a physical examination, visualization of the elbow anatomy, and specifically, the radial head retention in the joint by ultrasound. Of the 26 patients, 18 were treated by closed reduction and intramedullary osteosynthesis (TEN), 7 were treated by closed reduction and cast immobilization without osteosynthesis, and 1 child was treated by open reduction of the ulna and plate osteosynthesis. In the follow-up examination, 25 children showed an excellent outcome, as well as inapparent sonography. Although this is a retrospective study with different types of treatment, closed reduction of the ulna with or without osteosynthesis appears to be effective. We believe that the correct primary reduction is the key to an excellent long-term outcome. Regarding the invasiveness of the treatment, reduction without or with TEN osteosynthesis should be the preferred approach in extra-articular pediatric Bado III fractures.

Pediatric humerus lateral condyle fractures (PHLCF) are one of the most common fractures among children. PHLCF is approximately 20% of all pediatric elbow fractures. Among the treatment modalities are: nonoperative treatment with splinting, closed reduction with percutaneous K-wire fixation (CRPP), and open reduction with K-wire fixation (ORIF). We aimed to evaluate radiological, functional, and clinical outcomes of Jakob type 2 PHLCF treated either with CRPP or ORIF. We hypothesized that CRPP may be as safe and effective as ORIF for Jakob type 2 PHLCF. In this retrospective study, we included patients with Jakob type 2 PHLCF operatively treated in a single center. Patients with multiple fractures or open fractures were excluded from the study. 69 patients between ages 2 and 12 were included and they were divided into two groups. Group 1 included the patients treated with CRPP, whereas Group 2 included the patients treated with ORIF. Demographical, radiological, clinical, and functional parameters were evaluated. Average duration of surgery ( P < 0.001), initial displacement ( P = 0.014), and duration of admission ( P < 0.001) were significantly less in group 1. Group 2 had significantly higher percentage of left-sided injury than group 1 ( P = 0.038). Average varus deformity score was significantly higher in group 1 ( P = 0.014). CRPP was associated with shorter duration of surgery and hospital stay. Functional, clinical, and radiological outcomes were identified similar between CRPP and ORIF for Jakob type 2 PHLCF. CRPP may be as safe and effective as ORIF for Jakob type 2 PHLCF.

This study aimed to emphasize the effectiveness of using intraoperative neuromonitoring (IONM) in preventing possible nerve damage in Sprengel's deformity surgery. Eighteen patients who underwent Woodward surgery accompanied by neuromonitoring due to Sprengel's deformity were included in the study. Demographic information of the patients and their clinical and cosmetic results before and after surgery were recorded. Complications that occurred during and after the surgery were recorded. Of the 18 patients who underwent surgery, 12 were female and 6 were male. The mean age of the patients was 4.4 (2-8). The mean shoulder abduction angle of the patients was 84.4 (65-105) degrees before the surgery and 151.1 (125-175) degrees in the first year after the surgery. The mean Cavendish score of the patients was 3.6 (3-4) before the surgery and 1.1 (1-2) in the first year after the surgery. In one patient, there was a decrease in IONM motor-evoked potency signals during the reduction of the intraoperative scapula. Considering some loss of correction in the deformity, the scapula was detected at the point where there was no loss of signals. No patients developed wound problems or infections. In this study, it was determined that the use of neuromonitoring was effective in preventing brachial plexus damage, even if this complication was minimal in patients operated on due to Sprengel's deformity.

Flexible intramedullary nail (FIN) fixation of pediatric femur fractures is a popular method of fixation in children. Typical immobilization options include spica casting, long leg cast, knee immobilizers, or no immobilization and the decision to use each is usually left to surgeon preference. Our primary aim is to evaluate whether different postoperative immobilization status influences outcomes, namely radiographic alignment at the time of healing. A retrospective chart review was conducted of all patients with femur fractures treated with FIN fixation at a pediatric hospital from April 2018 through July 2022. Postoperative immobilization protocols were recorded and separated into two groups, patients who were immobilized (IMM) and patients who were not immobilized (NoIMM). Radiographs were evaluated for fracture alignment immediately following surgery and at the time of healing. Patients demographic, fracture, and postoperative clinical characteristics were compared between the two groups (NoIMM vs. IMM). A total of 41 patients were treated for diaphyseal femur fractures with FINs at our institution during the study period. No significant difference was observed in alignment at healing. Our results suggest that either immobilization or no immobilization after flexible intramedullary nailing of pediatric femoral shaft fractures are viable options when postoperative immobilization status is left to the surgeon's discretion.

The amount of three-dimensional (3D) correction with apical sublaminar band (hybrid-SLB) technique has not been compared to all-pedicle screw instrumentation for adolescent idiopathic scoliosis (AIS) using detailed axial correction metrics or comparable rod types. Our purpose is to compare 3D improvement in AIS deformities following posterior spinal instrumentation and fusion (PSIF) with hybrid-SLB and segmental correction to all-pedicle screw correction. Patients ages 10-18 years with AIS who underwent PSIF between 2015 and 2022 and had preoperative and postoperative EOS imaging were included. Electronic medical records were reviewed for demographic, Lenke classification, operative technique, and 3D EOS data. Average changes in major and minor Cobb angle, axial rotation, thoracic kyphosis, and lumbar lordosis were compared. Ninety-five patients met inclusion criteria with 55 in the hybrid-SLB group (mean age 14.9 ± 1.9 years) and 40 in all-pedicle screw (mean age 14.7 ± 2.1 years). While all-pedicle screw demonstrated greater correction of major (45.7 ± 13.4 vs 37.9 ± 14.3 degrees; P = 0.008) and minor (28.7 ± 13.1 vs 17.8 ± 12.5 degrees; P = 0.001) Cobb angles, hybrid-SLB showed greater increase in T4-T12 kyphosis (13.3 ± 15.3 vs 5.6 ± 13.5 degrees; P = 0.01). Correction of T1-T12 kyphosis, axial rotation, and lumbar lordosis was similar between groups. 3D EOS analysis of AIS patients before and after PSIF revealed that all-pedicle screw constructs had greater overall coronal plane correction and hybrid-SLB had greater thoracic sagittal plane correction. Axial corrective abilities were similar. Hybrid-SLB may have advantages for correction of thoracic lordosis or hypokyphosis. Level of evidence: Level III, retrospective cohort study.

Femoral head reduction osteotomy (FHRO) was described to treat misshapen femoral head that is causing intraarticular hip pain. The published literature showed discrepancies in patient selection, surgical techniques, and decision to perform concurrent acetabular osteotomy. Very few studies used Standardized Outcome Measures (SOMs). This study aims to describe the technique of FHRO and report the results of our series of 22 patients using SOMs and compare them to former peer-reviewed articles. Twenty-two hips in 22 patients with hip pain caused by mishshapen femoral were treated with FHRO with or without triple pelvic osteotomy (TPO). Patients with poor hip range of motion and significant hip joint arthritis were excluded. The mean patient age was 15.8 (range, 9.2-23.9). Clinical results were reported using the HHS. Radiographical results were reported by comparing Lateral Center Edge Angle (LCEA), extrusion index, Tonnis angle, head size percent, sphericity index, and distance from tip of trochanter to center of femoral head. The mean follow-up was 3.2 years. Only 5 patients received TPO. The HHS showed statistical improvement from 62.0 to 81.6 (The median interquartile range 63.5-88.5). Five patients had HHS less than 70 at the latest follow up. All radiographic parameters except the Tonnis angle, showed statistically significant improvement. FHRO with or without pelvic osteotomy is a good salvage procedure for patients presenting with misshapen femoral head with intraarticular hip pain, who still have good preoperative ROM with no signs of hip arthritis. Level of evidence: IV.

This preliminary study investigated the efficacy and safety of bone marrow-derived mesenchymal stem cell transplantation in a piglet Legg-Calve-Perthes disease (LCPD) model. The LCPD model was induced in two Landrace piglets (6- and 7-week-old, weighing 12 and 17 kg, respectively) by ligaturing the femoral neck. In the first piglet, the natural LCPD course was observed. In the second piglet, 4 weeks after ligaturing the femoral neck, simple medium and medium containing 2.44 × 10 7 bone marrow-derived mesenchymal stem cells were transplanted into the right and left femoral heads after core decompression, respectively. Plain radiographs were obtained every 4 weeks, and the epiphyseal quotient was calculated by dividing the maximum epiphysis height by the maximum epiphysis diameter. The piglets were sacrificed at 14 weeks postoperatively. The femoral heads were extracted and evaluated grossly, pathologically, and by using computed tomography. The transplanted cell characteristics were evaluated using flow cytometry. Flattening of the epiphysis was observed in both femoral heads of the first piglet and only in the right hip of the second piglet. The epiphyseal quotients immediately and at 14 weeks postoperatively in the right femoral head of the second piglet were 0.40 and 0.14, respectively, while those of the left femoral head were 0.30 and 0.42, respectively. Hematoxylin and eosin staining did not reveal physeal bar or tumor cell formation. The transplanted cells were 99.2%, 65.9%, 18.2%, and 0.16% positive for CD44, CD105, CD29, and CD31, respectively. Core decompression combined with bone marrow-derived mesenchymal stem cell transplantation prevented epiphyseal collapse.