Journal of Pediatric Orthopaedics-Part B最新文献

Level of evidence: Level IV - case series.

This study reports the long-term outcomes of hamstring lengthening to treat flexed knee gait in children with ambulatory cerebral palsy (CP) after skeletal maturity. This retrospective longitudinal observational study used instrumented gait analysis (GA) <8 and >15 years old in children with bilateral CP. The primary variable was knee flexion in stance phase. Eighty children (160 limbs) were included; 49% were male, 51% female. Mean age at first GA was 6.0 (SD: 1.2) years and 19.6 (SD: 4.5) years at final GA. Mean follow-up was 13.7 (SD: 4.7) years. Children were classified as Gross Motor Function Classification System I-8, II-46 and III-26. Average Gross Motor Function Measure Dimension D was 72% (SD: 20%). Hamstring lengthenings occurred once in 82, twice in 54 and three times in 10 limbs. From initial to final GA, average knee flexion in stance was unchanged, 27.8° (SD: 14.8°) to final 27.0° (SD: 11.2°; P  = 0.54). Knee flexion at foot contact was 39.6° (SD: 13.0°), improving to final GA of 30.7° (SD: 10.6°; P  < 0.001). Initial gait deviation index was 65.8 (SD: 31.9), improving to final 78.9 (SD: 28.2; P  < 0.001). Older age, males and concomitant plantar flexor lengthening predicted change toward more flexed knee gait. Hamstring lengthening did not lead to back-kneeing gait at maturity while maintaining childhood stance phase knee flexion. A subgroup still developed significant flexed knee gait posture and may have benefited from more aggressive treatment options. This outcome may also be impacted by diverse functional levels, etiologies and treatments of flexed knee gait.

The diagnosis and treatment of developmental dysplasia of the hip (DDH) can be stressful for parents, often worsened by inadequate information. The primary aim of this study is to assess whether the information preferences of parents of children with DDH, identified in a prior single-center study, are generalizable across the Netherlands. A secondary aim is to compare these preferences with the perspectives of pediatric orthopedic surgeons. An online survey was conducted between September and November 2023 among parents of children with DDH and pediatric orthopedic surgeons in the Netherlands. Based on prior qualitative research, the survey included closed- and open-ended questions regarding the content, timing, and format of information delivery. A total of 177 parents and 20 pediatric orthopedic surgeons completed the survey. Median response scores were ≥7 across all questions, suggesting that previously identified parental preferences are applicable nationwide. Both parents and pediatric orthopedic surgeons emphasized the importance of accessible and understandable information to people at all levels of society. Parents strongly preferred reliable DDH-related information before diagnosis and valued resources they could revisit at home, such as websites or printed materials. However, parents showed minimal interest in a smartphone application, a preference that contrasted with pediatric orthopedic surgeons' perspectives. This nationwide study provides a comprehensive overview of the information preferences of parents in DDH care. Comparing these findings with the perspectives of pediatric orthopedic surgeons offers valuable insights for optimizing information delivery. This can help refine information delivery strategies, ultimately enhancing disease understanding, parental satisfaction, and treatment adherence.

The choice of upper-instrumented vertebrae (UIV) for posterior spinal fusion (PSF) constructs is influenced by guidelines where UIV is T4 or more cephalad. In a cohort of patients with adolescent idiopathic scoliosis (AIS) with thoracic curves, we sought to (a) compare postoperative shoulder balance for patients with UIV of T5-T6 versus T2-T4 and (b) evaluate curve and operative characteristics that lead to balance with a more caudal UIV. A single-institution AIS registry was queried for patients undergoing PSF from 2000 to 2017. Included were patients undergoing PSF for AIS, with Lenke 1 and 2 curves, and minimum 2-year follow-up. Shoulder balance was defined as: T1 tilt = 0 ± 5°, coracoid height difference (CHD) = 0 ± 1 cm. A total of 161 patients were included, mean follow-up was 47 months. Curves fused to T2-T4 had larger, stiffer preoperative proximal thoracic curves and were more likely to be classified as Lenke 2. Following PSF, there was no difference in final T1 tilt ( P  = 0.062) or final CHD ( P  = 0.176) between groups. Patients with a UIV of T5-T6 had shorter operative times ( P  < 0.001), less operative blood loss ( P  = 0.009), and similar complication rates ( P  = 0.344). In the T5-T6 cohort, 70.3% of patients achieved shoulder balance at the final follow-up. For thoracic AIS undergoing PSF, selecting a UIV of T5 or T6 can result in comparable postoperative shoulder balance in properly selected patients.

In the treatment of paediatric limb disorders, the use of metal implants has been increasing over the last decades. Recent studies have addressed the decision of orthopaedic surgeons regarding the removal of implants after the treatment of fracture, and there is a growing consensus within the scientific community supporting the choice of not removing implants in children. This survey aimed to investigate the rationale behind the Italian orthopaedic community's decision regarding metal implant removal in paediatric patients. An electronic questionnaire was sent to all members of the Italian Paediatric Orthopaedic and Traumatology Society, Italian Orthopaedic and Traumatology Society, Italian Club of Osteosynthesis, and South Italy Society of Orthopaedic and Traumatology. The survey comprised 34 questions about hardware removal after the treatment of long bone fractures, epiphyseal growth plate injuries, slipped capital femoral epiphysis (SCFE), and flat foot. Of the 3500 orthopaedic surgeons who received the questionnaire, 5.5% responded. The leading indications for implant removal were the patient's intolerance, pain, ROM limitations, and hardware breakage. Removal of elastic nails for long bone fractures, cannulated screws for growth plate injuries, and SCFE and screws for arthroereisis for flat foot correction were analysed in detail. The consensus among Italian Orthopaedic Surgeons is to remove elastic nails and cannulated screws in cases of pain, intolerance, or breakage and to reduce further risks during patient growth. An increasing number of physicians, however, are endorsing and advocating the growing trend in the literature of not routinely removing the hardware.

Children and adolescents with metabolic bone disease present to the orthopedic surgeon with pain, fractures (which may be impending), and deformity. Different modalities of orthopedic management are available. Scant literature exists on the use of rigid intramedullary nailing in this population. This study sought to evaluate the utilization of this treatment modality in the pediatric cohort, focusing on indications, techniques, and outcomes of the procedures. A retrospective review was performed over an 11-year period at a single tertiary pediatric institution in the UK. Medical records and radiographs were reviewed. Preoperative surgical and medical management, time to bony union, and complications were specifically ascertained. Twenty-seven patients (63 lower limb segments) had rigid intramedullary nailing over the specified period. The majority of patients had an underlying diagnosis of osteogenesis imperfecta or fibrous dysplasia (including McCune Albright Syndrome). Surgical indications included acute fractures, prophylactic stabilization, previous nonunion and malunions, deformity correction, and limb lengthening. All fractures healed and deformity correction was successful. In one patient, delayed union occurred after deformity correction and was successfully treated with dynamization. Fractures healed faster than corrective osteotomies. Complications included implant prominence, cortical penetrance, and screw loosening. Nonunion occurred with limb lengthening in one patient. Rigid intramedullary nailing is a safe and effective method of treatment for lower limb fractures and deformities in children and adolescents. This technique is, therefore, recommended for patients with metabolic bone disease. However, care must be taken in preoperative surgical planning and a multidisciplinary approach should be utilized.

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.

Hemiepiphysiodesis using tension band plate and screws is a frequently used technique for the correction of lower extremity angular deformities. These implants are often left in place if patients have corrected their alignment on reaching skeletal maturity. There is little information regarding the rate of and reasons for subsequent removal of these deep implants. This retrospective case-control study included patients treated with hemiepiphysiodesis with tension band plate and screws at the distal femur and/or proximal tibia for idiopathic genu valgum and reached skeletal maturity with implants retained. Electronic medical records and radiographs were reviewed for patient characteristics and the need for subsequent removal of implants. Those who had implants removed were compared to those with implants not removed using Student's t-test for continuous variables and chi-square for categorical variables. Forty-six patients met inclusion criteria. Twenty-five of 46 patients (54%) underwent subsequent removal of deep implants, and all cases were due to symptoms related to the plate and screws. Factors associated with removal of deep implants included multiple vs. single rounds of hemiepiphysiodesis (76% vs. 43%, P = 0.02) and plates at the distal medial femur alone (P = 0.004). There were no differences between groups regarding sex, age at hemiepiphysiodesis, height, weight, and BMI. In conclusion, after skeletal maturity, there was a 54% rate of removal of symptomatic hemiepiphysiodesis implants. Factors associated with implant removal include repeat hemiepiphysiodesis and isolated distal medial femur plate position. This information can be used to guide patient and provider expectations as patients transition to adulthood.

This study aimed to summarize the clinical characteristics of acute epiphyseal osteomyelitis and acute metaphyseal osteomyelitis of long bones in children. Data of 43 children with acute osteomyelitis of long bones diagnosed and treated from November 2017 to January 2021 were retrospectively analyzed. Medical records, laboratory results, and MRI were reviewed. Surgical drainage of lesions was done to retrieve infective fluid and tissue for examination. There were 12 cases of metaphyseal and epiphysis involvement, including five boys and seven girls, aged from 1 to 12 years old, and the length of hospitalization was 21-45 days. There were six cases of distal femur, five cases of proximal tibia, and one case of distal humerus. The pathogenic microorganisms were methicillin-sensitive Staphylococcus aureus (MSSA) in six cases and methicillin-resistant Staphylococcus aureus (MRSA) in six cases. No complications were reported during the follow-up. Thirty-one cases of simple metaphyseal involvement, including 20 boys and 11 girls, aged 19 days to 12 years, and the length of hospitalization was 18-60 days. Twelve cases of distal femur, 11 cases of proximal tibia, three cases of distal humerus, two cases of proximal tibiofibular, two cases of proximal fibula, and one case of proximal ulna. The pathogenic microorganism was MSSA in 26 cases and MRSA in five cases. One patient with knee contracture during follow-up. Epiphyseal osteomyelitis is rare but can occur in older children. The prognosis is good with aggressive surgical treatment.