Journal of Childrens Orthopaedics最新文献

Purpose: Radial neck fractures in children are rare, representing less than 1% of all pediatric fractures. While conservative treatments are often sufficient, displaced fractures may require closed or open reduction. The Metaizeau technique is widely accepted for closed reduction and internal fixation. This study aims to assess the long-term functional and radiological outcomes of this technique and identify any complications that may arise.

Methods: This retrospective study analyzed 22 pediatric patients treated with the Metaizeau technique for proximal radius fractures between 2005 and 2018. Data on demographics, preoperative radiographs, and postoperative complications were reviewed. Outcomes were evaluated using radiographic and functional measures, including grip strength, the Mayo elbow performance score (MEPS), and the Tibone and Stolz classification.

Results: The mean age at the time of injury was 9.9 years, with a mean follow-up period of 139 months (range: 72-213 months). Patients were classified as Judet type 3 (n = 9), type 4a (n = 9), or type 4b (n = 4). The functional outcomes showed a mean MEPS score of 99 (range: 90-100), with 86% of patients achieving excellent results according to the Tibone and Stolz classification. Excellent outcomes were recorded in 100% of type 3, 77.7% of type 4a, and 75% of type 4b cases. Documented complications included one case of radioulnar synostosis and two cases of heterotopic ossification.

Conclusions: The Metaizeau technique represents an efficacious treatment option for pediatric radial neck fractures, offering favorable long-term functional and radiological outcomes with a low complication rate. Long-term follow-up data further support the reliability of this technique.

Types of studies: Level IV.

Purpose: To evaluate the effect of vitamin D on the speed and quality of pediatric fracture healing.

Methods: A 4-year prospective study of healthy children with shaft fractures of the forearm bones (treated with minimally invasive osteosynthesis) or femur (treated by traction or by minimally invasive osteosynthesis). All children had their vitamin D levels examined four times-at the time of the injury, 1, 3, and 5 months after the injury. Also, all children underwent radiograph follow-ups (same time as blood tests) to evaluate fracture healing. Children were, in the beginning, blindly divided into two similarly sized groups-one group was orally administered cholecalciferol throughout the follow-up, the second group was not, and we compared those groups.

Results: Altogether, 63 children were included in the study-36 supplemented and 27 non-supplemented. In supplemented children, the vitamin D levels increased statistically significantly during the follow-up period, in contrast to the non-supplemented group. The fracture healing on radiographs was also statistically significantly faster and better in the supplemented group. When we divided children according to fracture type, we observed statistically significantly better fracture healing in children with forearm fractures in the supplemented group for the whole study period. In children with femoral fractures, the healing in the supplemented group was statistically significantly better after 3 months; however, after 1 and 5 months, the difference was not statistically significant.

Conclusions: Based on our results, we recommend vitamin D testing and administration for children treated for forearm and femoral fractures.

Level of evidence: Level I.

Purpose: This study aimed to compare the clinical and radiographic outcomes of traction to assist reduction in patients with late-detected developmental dislocation of the hip using the Petit-Morel technique versus the Bryant overhead traction technique, and to compare the clinical and radiographic outcomes of these two traction techniques with immediate closed reduction.

Methods: A comprehensive systematic search of the MEDLINE/PubMed, EMBASE, and Web of Science databases was performed to identify relevant studies. Studies on Petit-Morel and overhead traction techniques and immediate closed reduction were then screened, selected, and data collected; included studies were assessed using the Methodological Index for Non-Randomized Studies criteria.

Results: In total, 22 studies met the inclusion criteria. The Petit-Morel group had a successful reduction rate of 87% while the overhead traction group had a successful reduction rate of 67.1%, and the immediate closed reduction group had a successful reduction rate of 78.4% (Petit-Morel versus overhead traction, p < 0.001; overhead traction versus immediate closed reduction, p < 0.001, Petit-Morel versus immediate closed reduction, p = 0.021). The Petit-Morel group had an overall avascular necrosis rate of 2.7%, compared to 10.6% for overhead traction and 21.5% for immediate closed reduction (Petit-Morel versus overhead traction, p = 0.001; Petit-Morel versus immediate closed reduction, p < 0.001; overhead traction versus immediate closed reduction, p < 0.001). The Petit-Morel group achieved a satisfaction rate of 86.4% according to the Severin classification, as compared to 71.2% in the overhead traction group and 76.4% in the immediate closed reduction group (Petit-Morel versus overhead traction, p < 0.001; Petit-Morel versus immediate closed reduction, p = 0.018; overhead traction versus immediate closed reduction, p = 0.195).

Conclusion: Petit-Morel and overhead traction techniques did not outperform immediate closed reduction in terms of redislocation rates, and radiological satisfaction, the Petit-Morel technique, has lower clinically significant avascular necrosis rates than overhead traction and immediate closed reduction.

Level of evidence: Level III.

Background: Metal implants are increasingly used in children for trauma and deformity correction. This review outlines the current knowledge on the types of metals used and explores reasons for removal and the potential for long-term health issues of metal implants.

Methods: The literature pertaining to these aspects was studied and summarised in this review.

Results: Types of metals used have evolved as well as the development of children-specific implants. Improvements in deformity correction are measurable with likely improved outcomes and reduced health costs. Indications for metal implant removal following successful treatment remain ill-defined; however, the risks of removal are known with a minimum 6% complication rate. Health costs could be reduced by around 6% by judicious decisions to leave metal in place. Implant removal should only be encouraged in the presence of infection, mechanical failure or symptoms that are truly attributable to the implant. In the domain of spinal implants, there is evidence of significant metal ion release, most notably titanium which remains elevated to many times baseline levels beyond 2 years. The detection of titanium at low levels requires special techniques. The long-term health effects on patients and/or their offspring are not well defined, although well described in animal models.

Conclusion: The risks of metal removal are significant. Clinicians need to be aware of potential health risks in the use of metal implants and the potential for covert toxicity effects in children especially with their long life ahead. There is a need for greater awareness of metal alloy composition and implant design to minimise risks.

Level of evidence: Level V.

Purpose: Diagnostics and treatment pathways for developmental dysplasia of the hip are highly variable in clinical practice. Recently, two national guidelines were developed in the Netherlands, providing a uniform protocol for the diagnosis and treatment of developmental dysplasia of the hip in children under the age of 1 year. The aim of this survey study was to assess whether diagnostic and treatment strategies have changed amongst paediatric orthopaedic surgeons in the Netherlands compared to a similar survey study in 2011, after the introduction of the guidelines.

Methods: A web-based online questionnaire was developed and shared amongst the members of the Dutch Paediatric Orthopaedic Society. The questions concerned the diagnosis and treatment of developmental dysplasia of the hip, ranging from mildly dysplastic to dislocated hips, in children under the age of 1 year. We used a questionnaire similar to the previous study and evaluated the results.

Results: Thirty-four participants completed the survey. Regarding diagnosis and follow-up, ultrasonography was generally applied for children younger than 6 months, while radiography was more frequently used for children aged 6-12 months. In 2011, radiography was more widely applied in all age groups. Initial treatment for dysplastic, stable hips was mostly active monitoring, while this was generally a rigid splint in 2011. For dislocated unstable hips, the first step in treatment was generally the Pavlik harness, as in 2011.

Conclusion: The diagnostic and treatment pathways of developmental dysplasia of the hip in children under the age of 1 year seem to have partially changed amongst Dutch paediatric orthopaedic surgeons compared to 2011, after the publication of new guidelines.

Purpose: The study aimed to compare the clinical and radiologic results of in situ pinning and modified Dunn procedure methods in stable-moderate slipped capital femoral epiphyses surgery.

Methods: Slipped capital femoral epiphyses cases between January 2000 and December 2022 were retrospectively analyzed. Stable and moderate cases treated with in situ pinning or modified Dunn procedure and those with a follow-up period longer than 1 year were included. Two groups were formed: the in situ pinning group and the modified Dunn procedure group. Radiologically, postoperative alpha angle, Southwick angle, avascular necrosis, and osteoarthritis rates were compared. Clinically, Harris Hip Score and Merle d'Aubigné score were compared. Total complications were evaluated.

Results: The in situ pinning group consisted of 28 patients and the modified Dunn procedure group consisted of 17 patients. The groups were similar in terms of age, gender, affected side, body mass index, Fahey/O'Brien Classification, preoperative slip angles, and follow-up time. Operation time was shorter in the in situ pinning group (p < 0.001). Postoperative Southwick and alpha angle were lower in the modified Dunn procedure group (p < 0.001). In clinical outcomes, Merle d'Aubigné and Harris Hip Score were higher in the in situ pinning group (p = 0.013, p = 0.005, respectively). The rate of avascular necrosis was higher in the modified Dunn procedure group (p = 0.048). There was no difference between the groups in terms of total complications and osteoarthritis.

Conclusions: In situ pinning has an advantage over the modified Dunn procedure in the treatment of stable-moderate slipped capital femoral epiphyses due to shorter operative time, better clinical outcomes, and fewer avascular necrosis rates. Although Southwick and alpha angle measurements were found to be higher after in situ pinning compared to the modified Dunn procedure, this does not constitute a significant disadvantage in terms of osteoarthritis development in the mid-term.

Level of evidence: Level III, case-control study.

Purpose: The purpose of this study was to define how different force environments by neuromuscular diagnosis (hypertonic versus hypotonic) impact the growth and morphology of the proximal femoral and acetabular regions relative to typically developing children.

Methods: Children with cerebral palsy and spinal muscular atrophy were compared with typically developing children aged 6 months to 11 years. Routine pelvic radiographs were evaluated using measures of hip geometry for the proximal femur and acetabulum. The data were analyzed using general linear models to estimate the developmental patterns according to age and diagnosis.

Results: One hundred eighty-four children met the inclusion criteria: 58 spastic cerebral palsy Gross Motor Function Classification System I-V (263 hips), 32 spinal muscular atrophy (79 hips)), and 94 typically developing (187 hips) were included with a mean age of 4.9 ± 3.1 years. Using spinal muscular atrophy as a reference, significant differences in proximal femoral development included long thin versus short neck (p < 0.01) and round versus flat epiphysis (p = 0.001). A thin neck-wide epiphysis was found in spinal muscular atrophy versus thick neck-small epiphysis for typically developing (p < 0.05). The ratio of acetabular width to proximal femoral epiphysis width differed significantly for typically developing (p = 0.001) compared with cerebral palsy and spinal muscular atrophy. There was a negative correlation between migration percentage and acetabular width to epiphysis width in children with cerebral palsy, but no correlation in children with spinal muscular atrophy.

Conclusion: Hip geometry was impacted by the force environment experienced during growth. These findings emphasize the crucial roles of gross motor function, muscle tone, and strength differences in determining hip morphology.

Level of evidence: III, retrospective case control.

Purpose: This is the second phase in an investigation of the psychosocial impact of orthopedic surgery on adolescents. What are the core psychosocial factors that shape the experience of adolescent patients aged 11-18 who are undergoing orthopedic surgery?

Methods: Two 43-question surveys (preoperative and postoperative) were developed as modified versions of the survey used in phase 1. The preoperative survey was administered 2 weeks before surgery. The postoperative survey was administered 6 weeks later. Responses were collected from free-response and Likert-scale questions exploring patient-physician relationships, office visits/hospital stays, family, peers, academics, sports, and surgical expectations. The survey was administered prospectively to patients aged 11-18 undergoing limb lengthening/reconstruction, pediatric, spine, sports, or hand/upper extremity orthopedic surgery. In all, 135 patients were identified; 105 were enrolled and completed both surveys.

Results: There were some statistically significant changes in responses to questions regarding office visits/hospital stays, patient-physician relationships, friends/community, academic performance, and expectations for surgical experience throughout the perioperative period. There were no statistically significant changes in responses to questions regarding the role of parent/family and sports. There was no statistically significant difference between the female and male genders or between age groups in any of the domains. Overall statistical significance in this study did not consistently correlate to clinical significance.

Conclusion: Adolescents require psychosocial support from their surgeons, caregivers, and peers in addition to respect for their independence and personal needs.

Level of evidence: Level II.

Purpose: While children with hypermobility and/or ligamentous laxity due to coexisting connective tissue disorders might be expected to have worse outcomes after open reduction for hip dislocations, there is minimal prior research on this topic.

Methods: All open reduction surgeries for hip dislocations performed at a single urban, tertiary-care children's hospital from 2009 to 2023 were reviewed retrospectively. Those with connective tissue disorders secondary to a diagnosed syndrome or genetic disorder were included. Patients with <1 year of follow-up or hip instability in the setting of Trisomy 21 were excluded. Clinical and radiographic data was collected. Instances of re-dislocation, proximal femoral growth disturbance, residual acetabular dysplasia, and arthrofibrosis were recorded.

Results: Twenty-three hips (15 patients) were included. Mean age at the time of surgery was 19.6 months (Range: 8.2-36.0 months), and mean follow-up was 4.3 years. The most common connective tissue disorder condition included was Ehlers-Danlos syndrome (13%). A majority of open reductions were performed via an anterior approach (96%). Seven hips (30%) underwent a concomitant pelvic osteotomy without femoral osteotomy and seven hips (30%) underwent both pelvic and femoral osteotomies. Twenty-two hips (96%) were International Hip Dysplasia Institute grade 1 at the final follow-up. Re-dislocation occurred in four hips (17%); eight hips (35%) demonstrated residual acetabular dysplasia, five hips (22%) demonstrated proximal femoral growth disturbance, and nine hips (39%) developed stiffness postoperatively.

Conclusions: Patients with connective tissue disorders and ligamentous laxity have comparable rates of residual acetabular dysplasia, proximal femoral growth disturbance, and (surprisingly) stiffness as typical developmental dysplasia of the hip following open hip reduction surgery. Although the re-dislocation rate in the connective tissue disorders group was approximately 2-3 times higher, the difference did not reach statistical significance. Given that the study was limited by a low sample size, however, it is possible that the findings of no difference in residual acetabular dysplasia and proximal femoral growth disturbance were potentially due to a lack of power.

Level of evidence: IV.