Journal of Pediatric Orthopaedics-Part B最新文献

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.

Rett syndrome, a neurodevelopmental disorder primarily affecting females, presents unique challenges in managing associated scoliosis. This study aims to evaluate the efficacy and challenges of posterior spinal fusion (PSF) in Rett syndrome patients by analyzing postoperative complications. A retrospective cohort study was conducted using a large national database. We included Rett syndrome patients aged 10-18 years who underwent PSF between 2010 and 2020. Outcomes such as medical and surgical complications, emergency department visits, readmissions, mortality, and reoperation rates up to 5 years were compared with a matched neuromuscular scoliosis (NMS) group. The study identified 195 Rett syndrome patients and 973 NMS patients. Post-surgery, Rett syndrome patients showed a significantly higher incidence of pneumothorax (56.9%, P  < 0.001), respiratory failure (24.6%, P  = 0.013), and pneumonia (26.2%, P  < 0.001). Additionally, ileus (7.2%, P  = 0.041), acute kidney injury (14.9%, P  = 0.029), and urinary tract infections (14.9%, P  < 0.001) were also significantly more frequent in the Rett syndrome group. Rett syndrome group also had higher rates of transfusion (11.3%, P  = 0.004). Interestingly, the incidence of pseudarthrosis, implant complications, junctional failures, and the necessity for reoperation did not significantly differ at postoperative year 2. Mid-term follow-up showed that the reoperation rates over a 5-year period did not significantly differ between the Rett syndrome and NMS groups. Rett syndrome is associated with increased immediate postoperative complications, necessitating tailored preoperative planning, and intensive postoperative care. Despite these challenges, the mid-term surgical outcomes are comparable to those in NMS patients.

Level of evidence: This study is a retrospective case series, as it involves a review of clinical outcomes from a defined group of patients over a specific time period. According to the criteria, this study would be classified as Level III evidence.

Pediatricians and general practitioners are involved in the newborn screening for developmental dysplasia of the hip. They often rely on the quality of the ultrasound (US) examination to make diagnostic and therapeutic decisions. Therefore, the professional must be able to assess its quality. The aim of our work is to present a new system to evaluate the quality of a neonatal hip US and to assess the effectiveness and reproducibility of this tool among professionals involved in the evaluation of the neonatal hip but not experts in the radiological examination of hip US. In a 15-min training session, 135 professionals involved in neonatal hip US screening with limited or no experience in evaluating the quality of hip US were taught to recognize the basic landmarks of hip US using evocative descriptions (Christmas ball) despite the technical terms. Before and after training, participants were given a test of 10 hip US images presented in random order and asked to identify incorrect images. One hundred thirty-five physicians participated in the study. In the first and second evaluation, participants answered 1.46 ± 2.49 and 8.64 ± 1.51 questions correctly on average ( P  < 0.05); analysis of the individual questions showed a significant improvement ( P  < 0.05) for all questions. A simple and relatively quick training tool can help professionals with little or no experience in interpreting neonatal hip US to understand when a hip US exam has been performed incorrectly and improve their diagnostic and therapeutic decisions. Level of evidence: III.

Hip dislocation is a common and severe complication in children with cerebral palsy (CP), significantly affecting their quality of life. In cases of unilateral hip dislocation, there is ongoing debate regarding the choice between unilateral versus bilateral reconstructive surgeries. This study explores an alternative approach that combines unilateral hip reconstruction surgery with contralateral Proximal Femoral Guided Growth (PFGG) as a potential solution. A retrospective observational study was conducted at a pediatric neuro-orthopedic referral center from 2019 to 2022, including children who underwent hip reconstruction surgery and contralateral PFGG. The minimum follow-up period was 2 years. Collected data included demographic, clinical, and surgical details, radiological parameters, as well as complications. Eleven patients (six females and five males) with varying levels of functional impairment (2 Gross Motor Function Classification System level III, 4 level IV, and 5 level V) were included. The median age at surgery was 7.7 years (range: 4.9-11 years), with a median follow-up period of 29.6 months (range: 24.1-55.6 months). Significant improvements were observed in all parameters for the reconstructed hip and in several parameters for the PFGG-treated hip, particularly migration percentage, head-shaft angle, and Hilgenreiner epiphyseal angle (P < 0.05). Reconstructed hips had significantly more complications than those treated with PFGG(13 versus 2, P < 0.001). Combining hip reconstruction surgery with contralateral PFGG offers a promising alternative to traditional bilateral reconstructive procedures when managing unilateral hip dislocation in CP patients. This approach not only addresses the immediate hip dislocation but also prevents future contralateral hip displacement within the same surgical session, while minimizing complication rates. Further studies are needed to validate these findings and establish comprehensive guidelines for this surgical strategy. Level of evidence: Level IV, case series.

Opioids are the mainstay of pain management in scoliosis surgery. We hypothesized that in adolescent idiopathic scoliosis (AIS) patients undergoing posterior spinal fusion (PSF) surgery, perioperative intravenous (IV) lidocaine would reduce postoperative opioid requirement and pain scores. In this retrospective observational before-and-after study, we identified AIS patients who underwent single-stage PSF at a tertiary university hospital from 2020 to 2022. All patients received total intravenous anesthesia. The Lidocaine group received a bolus of 1.5 mg/kg IV lidocaine prior to induction, followed by infusion at 2 mg/kg/h. At wound closure, the rate was reduced to 1 mg/kg/h and continued for 30 min in recovery. All patients received patient-controlled analgesia (PCA) morphine postoperatively. The primary outcome was total morphine consumption in the first 24 h. The secondary outcome was mean pain scores over 48 h using a numerical rating scale. We included 115 patients: 59 in the Usual Care group and 56 in the Lidocaine group. Postoperative morphine use in the first 24 h showed no significant difference (Lidocaine: 13.5 ± 8.9 mg vs Usual Care: 13.9 ± 10.6 mg; P  = 0.821). The cumulative morphine milligram equivalents per kilogram bodyweight at 48 h was 0.43 mg/kg. Mean pain scores were higher in the Lidocaine group in the first 48 h (4.25 ± 0.37 vs 3.67 ± 1.46; P  = 0.03). Perioperative IV lidocaine administered as an analgesic adjunct for AIS surgery did not reduce postoperative morphine requirement. Although pain scores were statistically higher in patients receiving intravenous lidocaine, the difference was minimal and lacked clinical significance.