Journal of Childrens Orthopaedics最新文献

Purpose: To identify clinical and radiographic risk factors associated with hip redislocation in children with cerebral palsy (CP) who underwent surgical treatment for hip dislocation.

Methods: This multicenter retrospective study included children with CP who underwent reconstructive osteotomy for hip dislocation and were followed until triradiate cartilage closure. Demographic, clinical, and radiographic variables were evaluated. Univariate and multivariate logistic regression analyses were performed to identify independent risk factors for redislocation. Additionally, a classification and regression tree (CART) model was developed to stratify redislocation risk.

Results: Hip redislocation occurred in 25 of 115 hips (21.7%). Redislocation was significantly more frequent in hips treated with femoral osteotomy alone (40%) compared to combined femoral and pelvic osteotomies (16.7%), (p = 0.026). Multivariate analysis identified younger age at surgery (Odds ratio (OR) = 0.981, p = 0.010), higher postoperative Sharp's angle (OR = 1.082, p = 0.034), and lower postoperative Mose hip ratio (MHR) (OR = 0.007, p = 0.033) as independent predictors of redislocation. Radiographic ratios, including medial joint space to cranial joint space (MJS/CJS) and MJS to maximum capital femoral epiphysis diameter (MJS/MCFED), were also significantly higher in redislocated hips. The CART model classified patients into high- and low-risk groups based on surgical age ≤76 months, postoperative Sharp's angle ≥48°, and MHR < 0.69.

Conclusions: Younger surgical age, insufficient correction as indicated by a higher postoperative Sharp angle and lower MHR were independently associated with hip redislocation in CP patients undergoing surgery. MJS/CJS and MJS/MCFED ratios were also associated with redislocation, indicating incomplete reduction.

Significance of study: This study presents a clinically applicable decision-tree model to predict redislocation risk after CP hip reconstruction using radiographic parameters.

Level of evidence: Level III, multicenter retrospective study.

Purpose: Clavicle injuries are among the most common pediatric injuries. This study aimed to identify the 50 most cited articles on pediatric and adolescent clavicle injuries, characterize their publication trends, and assess the correlation between citation metrics and study quality.

Methods: A bibliometric analysis was performed using Web of Science and Scopus databases, identifying the 50 most cited articles on pediatric and adolescent clavicle injuries. Data extracted included citation counts, citation density, study design, level of evidence, and publication characteristics. Methodological quality was assessed using the modified Coleman Methodology Score (mCMS) and Methodological Index for Non-Randomized Studies (MINORS), where applicable. Correlations between citation metrics and quality scores were evaluated using Spearman correlation.

Results: Among the 50 most cited articles published between 1984 and 2019, the majority (70%) were published in the last decade and in Journal of Pediatric Orthopaedics (38%). Most studies originated from the United States (74%). The mean citation count was 31.9 ± 19.7, with a citation density of 2.6 ± 1.4 citations/year. Level 4 evidence predominated (73%), with no level 1 studies identified. The average mCMS and MINORS scores were 40.1 and 13.1, respectively. No significant correlation was found between citation rank and methodological quality scores, although citation rank was significantly correlated with citation density (r _s = -0.66, p < 0.001).

Conclusions: The most cited studies on pediatric clavicle injuries are predominantly low-level evidence and retrospective in nature. Citation frequency was not associated with methodological quality, suggesting that article influence is often driven by historical context, novelty, or foundational relevance rather than study rigor.

Purpose: The risk of implant-associated infection (IAI) is occasionally cited as an indication for routine removal of orthopaedic implants in children, but evidence is lacking. This study aimed at exploring the frequency of microbial colonization of paediatric orthopaedic implants by sonication, a gold standard for diagnosing IAI.

Methods: Data of all patients aged <18 years at index implantation who underwent implant removal over a 34-month period at a single institution were retrospectively reviewed. Sonication culture results were classified according to microbial growth as negative (no/non-significant growth) or positive (significant growth/colonization). Descriptive statistics were performed, correlations were analysed via crosstabs and univariate ANOVA (p < 0.05).

Results: One hundred and twenty-nine sonicated devices from 63 patients were included. Mean patient age at implantation was 9.8 years (standard deviation (SD) 3.4; range 3.0-15.6), mean implant in situ time was 2.2 years (SD 1.5; range 0.6-8.8). In all, 63 tension band plates, 35 locking screw plates, 26 cannulated screws, 3 intramedullary nails and 2 K-wires were evaluated. In total, 128/129 (99%) of implant sites were asymptomatic. Sonication fluid cultures of 24/128 (19%) implants from 21 asymptomatic patients showed non-significant growth of pathogens mainly related to the human skin microbiome, suggesting contamination.

Conclusions: Sonication of implants removed from asymptomatic implant sites showed no significant microbial growth. Thus, the risk of IAI should be irrelevant for scheduling implant removal in children without signs and symptoms of infection.

Significance of study: This study investigates for the first time the role of sonication in non-spinal paediatric orthopaedics and provides important insights into the question of routine implant removal in children, providing a foundation for future research.

Background: The goal of treatment in early onset scoliosis patients is to control the deformity while allowing chest and spinal growth. However, management, either conservative or surgical, remains controversial and require further clinical evidence. The aim of this study was to determine best practice guidelines for the management of early onset scoliosis patients in Europe.

Methods: A Delphi approach was used among European experts to determine consensus in: (1) identification of progression risk factors, (2) clinical and radiographic evaluation, (3) conservative treatment, and (4) surgical management. Idiopathic and non-idiopathic groups were analyzed separately. Statements were only included in the final agreed consensus if at least 80% of respondents agreed with the statement.

Results: A total of 22 pediatric orthopedic surgeons completed the first and second surveys, and 21 the third. Out of open-ended questions included in the initial Delphi, 75 statements for 59 multiple-choice questions in the idiopathic group and 47 statements for the 44 multiple-choice questions for the non-idiopathic group were formed for the second round. Of the total 122 statements, 50 (40.9%) reached consensus, and 72 did not. Among the 72 statements re-evaluated in Round 3, consensus was reached on 69 (96%).

Conclusion: Early onset scoliosis represents a rare, heterogeneous, but life-threatening condition often associated with insufficient relevant evidence. Consensus is difficult to achieve (39.3% of the 122 statements), especially in the non-idiopathic group. However, 48 guidelines (33 for idiopathic and 15 for non-idiopathic) were provided by European experts to improve early onset scoliosis management.

Level of evidence: IV.

Purpose: Open reduction internal fixation of paediatric medial epicondyle (ME) fractures can be technically challenging. The pull of the common flexor origin, ulnar nerve proximity, narrow ideal screw trajectory and sometimes fragmented epicondyle piece can make reduction difficult and lead to complications. Concern for tenuous fixation can lead to longer immobilization, placing the elbow at risk of stiffness. We describe a modified technique for screw fixation of ME fractures, with the goal of reducing complications and improving the stability of fixation.

Methods: The modified technique includes insertion of a guidewire and pre-drilling for the screw prior to any fracture reduction, suture-assisted mobilization and control of the ME fragment, and conversion of the suture into a transosseous tension band to augment the screw fixation. A Retrospective chart review of 13 patients treated with this technique was undertaken to report early clinical and radiographic outcomes.

Results: The average age at surgery was 12 years (range: 6-15). The mean follow-up was 8 months (range: 1-17). There was 100% fracture union with an average time to union of 7 weeks (range: 4-13). All patients obtained a functional range of motion with median flexion of 140° and median extension of 0°. Five patients had screw removal during follow-up. One patient had symptomatic ulnar nerve instability that was addressed at screw removal. There were no other complications.

Conclusion: This technique improves ease of reduction and increases stability of fixation allowing earlier range of motion. This technique has provided reliable early results in our series of 13 patients.

Purpose: Patients with cerebral palsy commonly exhibit flexed knee gait. Hamstring lengthening is a common intervention, and the popliteal angle test (PAT) is widely used to assess hamstring tightness and guide surgical planning. This systematic review evaluated the role of the popliteal angle test in relation to surgical hamstring lengthening.

Methods: PubMed, Scopus, Web of Science, Embase, and Cochrane Library were searched from inception to January 29, 2025 for articles involving cerebral palsy, popliteal angle test, and hamstring lengthening.

Results: Thirty-one articles met the inclusion criteria. Outcomes were reported per patient or per limb, with Gross Motor Function Classification System level specified in 19 studies. Nineteen studies (61.3%) incorporated the popliteal angle test in preoperative assessments, 6 (19.4%) used it as the sole surgical determinant, and 4 (12.9%) applied it intraoperatively to guide additional hamstring lengthening. Twenty-seven studies reported pre- and postoperative popliteal angle test values; among the 21 providing statistical analyses, all showed significant postoperative improvement, although repeat procedures and longer follow-up failed to demonstrate sustained benefit. Kinematic data were reported in 20 studies, but analyses were mostly limited to sagittal knee flexion/extension during stance. Follow-up was reported in 24 studies, but durations rarely exceeded 2 years.

Conclusions: The popliteal angle test remains widely used in the surgical assessment of flexed knee gait in cerebral palsy, but methodological heterogeneity limits comparability across studies. While postoperative improvements are common, they cannot be reliably correlated with gait outcomes. The main limitation lies in its use as the sole surgical or intraoperative determinant. Standardized protocols, integration with gait analysis, and long-term follow-up are needed to clarify its prognostic value.

Purpose: Compare functional, oncologic, and complication outcomes of distal femoral reconstruction after malignant tumor resection in children <12 years, in whom adult implants are unsuitable.

Methods: Preferred Reporting Items for Systematic Reviews and Meta-Analyses-guided systematic review and meta-analysis of PubMed, Embase, Scopus, Web of Science, and Cochrane (inception-January 1, 2025). Eligible studies reported outcomes for expandable or non-expandable prostheses, osteoarticular allograft, allograft-prosthetic composite, epiphyseal-preserving reconstruction, rotationplasty, arthrodesis, spacers, or amputation. Random-effects models pooled means/proportions; risk of bias was assessed using the Newcastle-Ottawa Scale; and certainty was assessed using GRADE.

Results: Forty-one studies (n = 1186) met criteria. Pooled mean Musculoskeletal Tumor Society was 24.9/30 (95% confidence interval, 23.9-25.9; I ² = 97%). Biological joint-preserving methods and rotationplasty tended to yield the highest function; arthrodesis and amputation were lower. Local recurrence was 5.2% (95% confidence interval, 3.3-7.1) without differences between techniques. Five-year overall survival was 81.6% (76.6-86.6); epiphyseal-preserving reached 93.3%, expandable prostheses 79.0% (contextual, not causal). Complications differed: expandable prostheses had reoperation rates of 57.2% and mechanical failure of 42.3%; osteoarticular allograft had a fracture rate of 27.4% and failure rate of 37.5%; allograft-prosthetic composite had a failure rate of 24.4% and nonunion rate of 13.5%; and arthrodesis had the fewest complications. Deep infection was 6.7%. GRADE certainty was as follows: high for local recurrence; moderate for 5-year survival and infection; and low for function and reoperation/failure (heterogeneity, retrospective design).

Conclusions: Reconstruction should be individualized, prioritizing function and complication risk; oncologic outcomes appear driven by tumor biology/systemic therapy. Heterogeneity and inconsistent failure definitions limited cross-technique comparisons and precluded pooled implant survival.

Significance of study: Our pooled estimates offer practical reference points for counseling families about function and complications across reconstruction options in children aged <12 years while highlighting priorities for standardized reporting and coordinated prospective research.

Purpose: X-linked hypophosphatemia is characterized by skeletal abnormalities, particularly lower limb angular deformities. Although burosumab has demonstrated short-term clinical improvements, its mid- to long-term effects on skeletal alignment remain underexplored. This study evaluated skeletal outcomes of burosumab therapy over 2 years, focusing on lower limb deformities.

Methods: We retrospectively analyzed 20 pediatric X-linked hypophosphatemia patients (10 boys and 10 girls) who initiated burosumab at a mean age of 7.5 ± 2.4 years. Rickets severity score, mechanical axis deviation, mechanical lateral distal femoral angle, medial proximal tibial angle, lateral distal tibial angle, and standing height were assessed at baseline, 12 months, and 24 months. Outcomes were analyzed using age-standardized z-scores.

Results: Rickets severity improved from the first year, with Rickets Severity Score decreasing from 3.5 ± 1.2 to 0.6 ± 0.5 at 24 months (mean change 2.9; 95% confidence interval 2.4-3.4). Lower limb alignment also improved: |z|-mechanical axis deviation decreased from 2.3 ± 1.6 to 1.0 ± 1.0 (change 1.3; 95% confidence interval 0.9-1.7), showing progressive correction from the first year. |z|-mechanical lateral distal femoral angle improved mainly at 24 months, decreasing from 2.7 ± 2.1 to 1.3 ± 1.2 (change 1.4; 95% confidence interval 0.8-2.0). |z|-medial proximal tibial angle and |z|-lateral distal tibial angle showed smaller overall changes (0.8 and 0.9, respectively), indicating modest tibial correction. Standing-height z-scores remained stable (-1.5 ± 0.8 to -1.3 ± 0.7), with no measurable change in growth over 2 years.

Conclusions: Burosumab therapy may improve skeletal deformities in pediatric X-linked hypophosphatemia. Early improvements in rickets severity were followed by gains in alignment, particularly mechanical axis deviation and mechanical lateral distal femoral angle, though standing height remained unaffected. Longer-term follow-up is required to confirm sustained skeletal benefits.

Level of evidence: Level IV.