Journal of Pediatric Orthopaedics-Part B最新文献

Level of evidence: Level IV - prognostic, retrospective case series.

Supracondylar humerus fractures comprise of a major part in pediatric trauma cases. They result from a fall on an outstretched hand. The rotational components of Gartland type III fractures if not corrected appropriately can lead to cubitus varus (gun stock deformity). The surgeon's aim while fixing this fracture is to achieve reduction and stable fixation without a residual deformity. The rotational component is difficult to correct owing to factors like severe swelling, obesity, entrapment of soft tissue, and pull of muscles. This study aimed to demonstrate the use of a proximal fragment Kirschner wire as a joystick to correct the rotational displacement in Gartland type III pediatric supracondylar humerus fractures. We proposed a method of using a lateral 3 mm. Kirschner wire as a joystick by inserting 1-1.5 cm proximal to the fracture and correct the rotational malalignment. The children were followed up for 1 year after surgery and evaluated with Flynn criteria. Amongst 18 type III supracondylar fractures, the average flexion was 146.8° in the 24-week follow-up period. The Flynn criteria showed 14 (77.78%) had excellent outcomes, three (16.66%) had good outcomes, and one (5.56%) had fair outcomes. Patients having obesity, severe edema, rotatory displacement, difficult or inadequate reduction by traction, and manipulation alone using a Kirschner wire in the proximal fragment as a joystick to reduce the fracture is a time-saving, cost-effective, simple, and reproducible technique with an excellent cosmetic and functional outcome without significant complications.

The proximal humerus is a common site for pediatric malignant bone tumors, often necessitating complex surgical approaches when the tumor extends into the glenohumeral joint. Limb-salvage techniques like clavicula pro humero (CPH) reconstruction aim to balance limb function with oncological safety. However, nonunion and functional limitations remain significant challenges. This study evaluates whether adding a vascularized fibular graft (VFG) reduces nonunion in CPH reconstructions following proximal humeral tumor resection. A retrospective review of six pediatric patients (mean age 12 years) treated between 2006 and 2021 for malignant bone tumors in the proximal humerus was performed. All underwent CPH reconstruction combined with a VFG. Primary outcomes included nonunion rates, time to bone healing, and complications like infections and fractures. Secondary outcomes assessed morbidity related to fibular graft harvesting, including lower limb alignment and peroneal nerve injury. Of the six patients, four (66%) experienced proximal nonunion, all requiring revision surgery. The average time to proximal union (21 months) was significantly longer than distal union (11.5 months; P  < 0.05). Fibular graft complications included transient common peroneal nerve deficiency in two cases (33%). No infections or local tumor recurrences were observed during follow-up. VFG improves distal junction consolidation, but provides limited benefit for proximal union. This may be influenced by factors such as the length of the harvested clavicle or the vascularization quality of the clavicular graft.

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.

T-condylar fractures of the distal humerus are rare pediatric injuries. There is no consensus regarding ideal management and clinical outcomes for these injuries. The current review was planned to comprehensively review existing evidence regarding these rare pediatric fractures. A literature search was performed to identify the articles on pediatric T-condylar distal humerus fractures (1950-2024). Patient data was categorized under two groups: groups A (≤8 years old) and B (9-18 years). Finally, 32 articles were reviewed. Groups A and B included 25 and 148 patients, respectively. A majority of patients were males (72.3%) in both groups. 100% and 95.3% (141) of patients in groups A and B, respectively, were managed surgically [closed/open reduction and internal fixation (CR/ORIF)]. IF was predominantly done using Kirschner wire (K-wire) in group A. In group B, IF was performed using plate/screw/K-wire. There was no significant difference in complication rates between the groups [3/10 and 39/62 complications were observed in groups A and B, respectively; Mantel-Haenszel odds ratio:0.33 (95% confidence interval (CI): 0.09-1.14; Z = 1.75, P = 0.08; Chi-square = 3.23, P = 0.66; I2 = 0%)]. 87.5% in group A and 91.8% in group B had excellent; and good to excellent outcomes, respectively. The final elbow range of motion was significantly higher in group A (vs. group B; mean difference:13.91°; 95% CI: 6.93°-20.89°; test of overall effect: z = 3.91, P < 0.0001). Surgical management (i.e. ORIF) is the preferred intervention in pediatric T-condylar fractures. K-wire fixation is the most common operative technique. Overall complication rate is 58.3% (irrespective of age and treatment). Postinjury stiffness is more common in older children (>8 years).

Pediatric forearm fractures of the radius and ulna are common. Previous literature suggests that conservatively managed mid-shaft radius and ulna forearm fractures have a remanipulation rate of 10-70%. The purpose of this study is to compare the re-displacement rate of closed displaced mid-shaft both-bone forearm fractures (BBFF) in children treated with closed reduction and casting with a loop and sling applied proximal to the fracture site (Rang method) compared with a standard sling. A retrospective review was performed of 42 patients under the age of 14 with BBFF treated over a 4-year period. The average patient age was 7 years. Data analyzed included demographics, mechanism of injury, presence of a pulse, presence of nerve injury, incidence of compartment syndrome, sling type, loss of reduction, remanipulation, and need for surgical fixation. Loss of reduction was defined as a final number of >15° angulation if age <10 years old and >10° angulation if >10 years old. Fifteen patients (36%) were treated with the Rang method. Twenty-seven patients (64%) were given a standard sling. Only one patient (7%) managed with the Rang method lost reduction, whereas 17/27 patients (63%) given a regular sling lost reduction and required remanipulation ( P  = 0.0004). Treatment of a BBFF in a child aged <14 years typically involves closed reduction and casting. The 'Rang' method of placing a loop and attached sling proximal to the fracture site is a casting pearl that helps to minimize fracture redisplacement.

Pirani scoring system is one of the most commonly used tools to assess the initial deformity, monitor the treatment progression, and identify relapse in clubfoot. The method has been demonstrated to correlate well with the sequential correction of deformity for children under age 1 year. We conducted a study to examine the interobserver reliability of Pirani scores in children of walking-age. The retrospective study focused on children >1 year age with idiopathic clubfoot presenting for primary treatment. The Pirani scores at presentation charted by pediatric orthopedic consultant and orthopedic registrars were compared and the intergroup reliability calculated using Cohen's kappa. Thirty-five feet in 22 clubfoot children (13 bilateral) were analyzed. The mean child's age was 3.9 years. The mean Pirani score for the consultant was 3.2 and for the registrars was 3.6. The overall reliability of Pirani score was 0.3 ('fair'). The highest reliability was calculated for the head of talus (0.55), rigid equinus (0.48), and lateral border (0.44) (moderate). A lower kappa was recorded for medial crease (0.28), posterior crease (0.34), and empty heel (0.4). The registrars graded the clubfoot deformity in the walking-age child as more severe compared to the consultant. The mean Pirani scores for medial and posterior crease subcomponents were low. Contrary to the common perception, empty heel manifested even in this age group. Looking to the statistics of 'fair' reliability of Pirani score for older child, further research is warranted to develop more reliable scores for assessment and treatment of clubfoot.

Surgical options for relapsed clubfoot include repeat heel cord lengthening or posterior release for recurrent equinus, and anterior tibialis tendon transfer (ATT) for residual dynamic supination deformity. Some studies have suggested that these procedures be performed in isolation to allow for early range of motion after intra-articular surgery. This study was performed to examine clinical and radiographic outcomes comparing two surgical methods, simultaneous ATT with posterior release (ATT/PR) vs ATT performed in isolation (ATT(i)), for the management of recurrent clubfoot deformity. Patients who underwent ATT(i) and ATT/PR for relapsed clubfoot deformity after initial Ponseti casting, were 2-20 years old at time of surgery, and had postoperative range of motion (ROM) data, pedobarographic data, and radiographic results with minimal follow-up of 1 year were included. A total of 49 patients (69 feet) were reviewed. Mean age at time of surgery was 4.4 (SD 1.73) years. Of the 69 feet, 27 received ATT(i) and 42 received ATT/PR. No difference in the ROM outcome of ankle dorsiflexion was found between ATT(i) vs ATT/PR at a mean of 5.8 years follow-up. In patients undergoing ATT(i), there was a mild increase in lateral loading of the foot compared to those feet having ATT/PR. Follow up radiographic results for both groups were in the normal range, with less residual radiographic equinus in the ATT/PR group. ATT(i) or ATT performed along with intra-articular posterior capsular release offers comparable short-term outcomes. Level of evidence. This study was a retrospective case series, Level IV.

Calcaneonavicular (CNC) and talocalcaneal coalitions (TCC) account for most tarsal coalitions. Plain radiographs are typically sufficient to diagnose CNC, while computed tomography (CT) scans are often required to diagnose TCC. The standard of care for all coalitions includes a CT to characterize the coalition and identify additional coalitions. Multiple ipsilateral coalitions are rare and literature on the topic is limited. While the role of routine CT in TCC is well-established, the benefits of routine CT in CNC are less clear. A retrospective review of medical records and plain radiographs of patients less than 20 years of age who underwent tarsal coalition resection at our institution from 2006 to 2021 was performed. Patients received preoperative foot XRs and CT scans. We evaluated demographics, surgical data, and whether the diagnosis was made with XR or CT. In multiple coexisting coalitions, special consideration was placed on whether CT modified treatment plans. The study population consisted of 76 patients. 55 (100%) of CNC were diagnosed on XR compared to 11 (52.4%) of TCC. CT was necessary to diagnose in 10 (47.6%) of the TCC patients. CT identified additional coalitions in two (2.6%) patients. The treatment plan was affected by CT findings in one (1.3%) patient. The rate of clinically significant multiple ipsilateral tarsal coalitions is extremely low in our patient population. The utility of CT scan remains important in diagnosing TCC that cannot be seen on XR but is suspected clinically. Patients with XR diagnosis and consistent clinical presentation of CNC are unlikely to benefit from routine CT. Modifying the standard of care would decrease cost, time, and radiation exposure. Level of evidence: Level IV.