Journal of Childrens Orthopaedics最新文献

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.

Background: The one-bone forearm procedure has been considered as a potential treatment for severe forearm deformities. However, its primary limitation lies in the elevated risks of nonunion and infection. In order to enhance union rates, a technical modification was introduced, aiming not only to establish end-to-end radio-ulnar fixation but also to incorporate an additional overlay and fixation between the proximal and distal radius osteotomy stumps. This technique, initially applied in a heterogeneous patient population including individuals with neurological, tumoral, and congenital conditions, yielded promising results, achieving a consolidation rate of 100% and enabling supination corrections of up to 120°.

Methods: In this study, we present a retrospective cohort of 28 patients, with an average age of 9 years, all afflicted by forearm supination contracture exceeding 90° secondary to neonatal brachial plexus injury. These patients underwent treatment with the modified technique.

Results: The mean correction achieved in forearm rotation was 116°, and the average follow-up period extended to 43 months. Remarkably, all patients exhibited bone union within an average period of 6.6 weeks, without any complications.

Conclusion: Our findings underscore the efficacy of this modified technique, which enables substantial rotational corrections, boasts a high union rate, and maintains a low incidence of complications. This approach is particularly valuable for young patients suffering from neonatal brachial plexus injury with severe fixed supination deformities.

Case series level of evidence: IV.

Introduction: Down syndrome, or trisomy 21, is the most diagnosed chromosomal abnormality and is associated with multiple orthopedic concerns, including scoliosis. We sought to examine the surgical treatment of scoliosis associated with Down syndrome with an emphasis on specific complications in this population.

Methods: A retrospective review of 13 patients with Down syndrome who underwent surgical intervention for spinal deformity between 2000 and 2018 were identified. Postoperative complications were classified using the modified Clavien-Dindo-Sink system. Perioperative and final follow-up radiographic data were analyzed.

Results: The mean age at surgery was 14.2 years (11-19) with a mean follow-up of 3.6 years (0.4-6.2) at the time of data collection. Seven (54%) patients had postoperative complications, all related to wound healing. Three patients (23%) had major complications (Clavien-Dindo-Sink grade ≥3). These included one deep surgical site infection, one hematoma, and one seroma, all requiring surgical drainage. Four additional patients (31%) had minor complications (Clavien-Dindo-Sink grade ≤2).

Discussion: Surgical intervention for scoliosis in patients with Down syndrome is associated with high complication rates despite the use of more modern surgical techniques and implant types. Complications in this cohort primarily involved wound healing, whereas previous studies described high rates of postoperative implant failure, pseudoarthrosis, and significant curve progression, which were not experienced by the patients in this study. Although the etiology of wound-related complications is unknown, awareness of this risk may help surgeons optimize surgical technique, postoperative monitoring, and preoperative counseling of families.

Level of evidence: IV-single-institution retrospective case series.

Purpose: The management of odontoid fractures in adult patients has been widely described. However, there is sparse literature about this injury in the pediatric population. This study aimed to review published literature regarding the management and outcomes of pediatric odontoid fractures to develop a stepwise treatment algorithm.

Methods: A literature review was conducted using PRISMA guidelines on PubMed to identify studies between 1960 and 2023 that reported on the management and outcomes of odontoid fracture in pediatric patients. Studies were included if they were published in English and if their sample included at least four patients aged 0-18, minimum follow-up of 6 weeks, and outcomes for each patient clearly differentiated.

Results: In total, 15 studies including 125 pediatric patients with odontoid fractures were included. Treatment options varied from non-operative management with immobilization in rigid collars, halo vests, cervicothoracic orthosis, or soft collars to surgical management with fixation and/or arthrodesis. There were 73 patients initially treated nonoperatively, 47 initially treated surgically, 2 who healed with observation alone, and 3 who died acutely of concomitant injuries. The nonunion rate for nonoperative management was 5.5%. Surgery was successful, demonstrating bony union at final follow-up, in 94.6% of cases treated via a posterior approach and 85.7% of cases treated with an anterior approach.

Conclusions: Odontoid fractures must be considered in pediatric patients with cervical spine trauma. This is the largest literature review of pediatric odontoid fractures. Various management strategies exist and can be considered. The proposed algorithm offers an evidence-based framework for the management of pediatric odontoid fractures.

Purpose: The purpose of the study was to answer the following questions. What was functional results of pediatric patients receiving a short stem allograft-prosthesis composite of the proximal femur? What was complication rate and revision-free implant survival? Was it possible to preserve the bone stock of the proximal femur in pediatric patients?

Methods: We reviewed 10 pediatric patients treated with proximal femur resection for a primary bone tumor and reconstruction with short stem allograft-prosthesis composite, with at least 24 months follow-up. The median age was 9 years (4-13) at surgery. The mean resection length was 15 cm (6-29). In six cases, fixation was performed with a short plate positioned under the great trochanter while in four cases a long plate extended over the great trochanter was employed.

Results: Nine complications that required surgical revision were assessed in six patients (one wound dehiscence, two nonunions, two fractures, one acetabular wear, three hypometria), while allograft-prosthesis composite removal was required in three patients. The revision-free survival was 57% (95% confidence interval 33%-100%) at 5 and 10 years. The graft removal-free survival was 75% (95% confidence interval 50%-100%) at 5 and 10 years. The mean Musculo-Skeletal Tumor Society Score was 28 (20-30).

Conclusions: Allograft-prosthesis composites with short stem and compression plate represents an effective reconstructive option after proximal femur resection for primary bone tumors in growing patients, preserving bone stock. The use of a compression plate extended over the greater trochanter seemed to reduce failure rate.