Journal of Childrens Orthopaedics最新文献

Back pain is a relatively common complaint in children and adolescents. The pediatric patient presenting with back pain can often be challenging, and there are many well-known organic diagnoses that should not be missed. In younger children, an organic cause of back pain can often be found. However, back pain in older children and adolescents is often "non-specific." The differential diagnosis of back pain in children includes neoplasms, developmental, and inflammatory conditions. Basic steps should include an in-depth anamnesis, a systematic physical examination, and standard spine radiographs (anteroposterior and lateral). Nevertheless, advanced diagnostic imaging and laboratory studies should be included when indicated to avoid missing or delaying a serious diagnosis. If other types of imaging tests are necessary (magnetic resonance imaging, computed tomography, bone scan, or single photon emission computed tomography), they should be guided by diagnostic suspicion.

Purpose: Pain in scoliosis is definitely a hot topic with growing popularity. The literature remains very controversial, with a pain prevalence ranging from 23% to 90%, but this can be explained by the great heterogeneity of the numerous series. The aim of this review was to report results from the literature regarding pain in relation to scoliosis regardless of the etiology.

Methods: A bibliographic search in Medline and Google database from 2003 to March 2023 was performed. Relevant literature was analyzed, summarized, and discussed based on authors' experience. A 1-year prospective series of adolescent idiopathic scoliosis patients was also included to compare with the existing literature.

Results: A total of 126 adolescent idiopathic scoliosis patients were included, with a mean preoperative Cobb angle of 64.5° (range, 45°-112°). Reported pain prevalence was 34.1%. Pain and no-pain groups were very different in their self-reported experience, with a very low mean visual analogue scale score of 0.5 (± 0.6) in the no pain group, while visual analogue scale averaged 5.6 (± 1.2) in the pain group (p < 0.001). No significant difference was found between groups regarding the most relevant demographic and radiological parameters.

Conclusion: Evidence-based literature on "scoliosis as a source of pain" remains ambiguous. There seems to be a consensus on the lack of direct relationship between deformity magnitude and back pain intensity. A comprehensive evaluation of the patient is therefore necessary before any treatment, including medical history, clinical examination, and relevant imaging for any child with scoliosis and back pain.

Level of evidence: Level VI.

Low back pain is a prevalent global musculoskeletal issue, with a lifetime prevalence ranging from 49% to 70% in adults. Traditionally associated with adults, recent field surveys indicate comparable prevalence rates in children and adolescents, challenging earlier assumptions. Non-specific low back pain, where the source cannot be identified through diagnostic imaging, accounts for about 80%-90% of cases. Studies have shown that over 80% of adolescents with low back pain exhibit no underlying pathology. The prevalence of low back pain in younger populations varies widely, influenced by study methodology, age, and pain types. Research suggests that back pain prevalence in adolescents increases with age, with a shift in attitudes considering it is not necessarily indicative of specific issues. Level of evidence: level V.

Background: Low back pain in childhood was underappreciated for a long time, but recent studies report higher prevalences, up to 70%. Two of the common causes are spondylolyis/spondylolisthesis and Scheuermann's disease. These disorders are relevant in a way they both cause significant back pain, and may disrupt the sagittal spinal balance.

Purpose: To present the current evidence on the diagnosis, natural history and treatment of these disorders with a special focus on sagittal spinal alignment.

Methods: This study is conducted as a literature review.

Results and conclusions: Spondylolysis and low-grade spondylolisthesis have a benign course and are typically treated conservatively. When pars repair is indicated, pedicle screw-based techniques achieve more than 90% fusion with acceptable complication rates. High-grade spondylolisthesis, however, is frequently progressive. Surgical treatment involves fusion, which can be done in situ or after reduction. Reduction is useful for "unbalanced" patients to acquire sagittal spinopelvic balance, and it is important to distinguish these patients. Despite lowering the risk for pseudoarthrosis, reduction brings a risk for neurologic complications. With re-operation rates as high as 40%, these patients definitely require careful preoperative planning. Scheuermann's disease generally causes back pain in addition to cosmetic discomfort during adolescence. If the kyphosis is lower than 60°, symptoms typically resolve into adulthood with conservative measures only. However, it must be kept in mind that these patients may experience problems with physical performance and have a lower quality of life even when the problem seems to have "resolved". Severe kyphosis and intractable back pain are the most frequently referred surgical indications, and surgery typically involves fusion. Proper utilization of osteotomies and proper selection of the upper and lower fusion levels are of utmost importance to prevent complications in these patients.

The growing spine differs from the adult spine in several ways. Although tumors and infections cause only a small percentage of pediatric back pain incidences, delayed proper diagnosis and treatment may be disastrous. Benign lesions, such as osteoid osteoma, osteoblastoma, and aneurysmal bone cyst in the spine, are predominant during the first two decades of life, whereas malignant bony spinal tumors are rare. In the pediatric population, malignant spine tumors include osteosarcoma, Ewing's sarcoma, lymphoma, and metastatic neuroblastoma. Infections of the growing spine are rare, with the incidence of discitis peaking in patients under the age of 5 years and that of vertebral osteomyelitis peaking in older children. Spondylodiscitis is often a benign, self-limiting condition with low potential for bone destruction. Conservative treatments, including bedrest, immobilization, and antibiotics, are usually sufficient. Spinal tuberculosis is a frequently observed form of skeletal tuberculosis, especially in developing countries. Indications for surgical treatment include neurologic deficit, spinal instability, progressive kyphosis, late-onset paraplegia, and advanced disease unresponsive to nonoperative treatment. Spinal tumors and infections should be considered potential diagnoses in cases with spinal pain unrelated to the child's activity, accompanied by fever, malaise, and weight loss. In spinal tumors, early diagnosis, fast and adequate multidisciplinary management, appropriate en bloc resection, and reconstruction improve local control, survival, and quality of life. Pyogenic, hematogenous spondylodiscitis is the most common spinal infection; however, tuberculosis-induced spondylodiscitis should also be considered. Level of evidence: level 4.

Purpose: Altered spinopelvic morphology is observed in many spine pathologies occurring during growth. The aim of the study is to better understand the sagittal compensatory mechanisms and their possible influence on the occurrence of pain in selected pediatric spine pathologies.

Methods: A bibliographic search in the PubMed database included articles published between September 1965 and July 2023. The keywords contained in the search were "spondylolysis," "spondylolisthesis," "scoliosis," "kypho," "sagittal," "pediatric," "child," "adolescent," "grow," "development," and "pain."

Results: The largest diversity in sagittal alignment patterns was reported in idiopathic scoliosis, with global flattening of the spine being the most common. Kyphotic deformations occurring during growth are characterized by structural thoracic or thoracolumbar kyphosis compensated by lumbar hyperlordosis and lower pelvic incidence. Whereas in spondylolisthesis, altered morphology of the spinopelvic junction with high values of pelvic incidence is observed. Pain does not seem to be related to sagittal alignment in idiopathic scoliosis. In Scheuermann disease, it is localized at the apex of the deformity and is associated with the curve pattern, whereas in spondylolisthesis, sagittal alignment correlates with pain scores only in high-grade slips.

Conclusion: Most of the patients with spine disorders that occurred during growth present a clinically balanced posture in the sagittal plane. It suggests that compensatory mechanisms before achieving skeletal maturity are really significant. A comprehension of sagittal alignment in spine deformities and its relationship to pain is essential for the proper assessment and treatment of these disorders.

Purpose: The purpose of this study is to compare the outcome of patients with displaced tibial tubercle fractures treated surgically who spent one or more nights in the hospital after surgery with that of patients treated in an ambulatory setting with no perioperative hospitalization. We hypothesized that tibial tubercle fractures have a low rate of complications and that most patients do well without an overnight hospital stay for observation.

Methods: We retrospectively reviewed all pediatric tibial tubercle fractures treated operatively by a single surgeon over a 13.5-year period. Fractures treated in an inpatient setting, defined as at least one night of overnight hospitalization postoperatively, were compared with fractures treated in an ambulatory setting with no perioperative hospitalization.

Results: Seventy-one fractures in 70 patients were analyzed. All fractures were treated with open reduction and internal fixation with unicortical screws. Thirty-five fractures (49.3%) were fixed in an ambulatory setting, while 36 (50.7%) were inpatient. There were no significant differences between inpatient demographics (age, gender, body mass index, fracture type). Average operative time was significantly longer in the inpatient group compared with the ambulatory group (97.8 min versus 58.8 min, p < 0.001). There was no significant difference in the incidence of complications between inpatient and ambulatory groups (25.0% versus 11.4%, p = 0.22). No cases of compartment syndrome were noted.

Conclusion: Ambulatory surgical treatment of select tibial tubercle fractures with same-day discharge is safe and efficient. Not all patients with surgically treated tibial tubercle fractures need to stay overnight in the hospital.

Purpose: Scurvy is an uncommon medical condition that affects children and is caused by an inadequate intake of vitamin C. This study presents the characteristics of patients with scurvy to raise awareness of the diagnostic process in developing countries where laboratory testing for vitamin C levels is often not available.

Methods: A retrospective study was performed from period of 2018 to 2023. Data extraction includes patient age, sex, body mass index, constitutional symptoms, musculoskeletal, mucosal, cutaneous symptoms, other accompanying disorders, anemia, erythrocyte sedimentation rate, C-reactive protein, radiographic examination, vitamin C dose, and duration of treatment. Descriptive statistical analysis was performed in this study.

Results: Eighteen cases (17 males, 1 female) of scurvy were referred to our institution. Thirteen of 18 patients were misdiagnosed before referral. The median age at presentation was 4.5 (range, 2-11) years. The average body mass index was 13.93 ± 0.63 kg/m². Half of patients had healthy weight. All patients presented with lower limb pain and 17 of 18 with refusal to walk. The median onset of diagnosis was 11 (range 4-48) weeks. White line of Frankel was described in all patients. Seven had anemia and 6 of 18 had increase in erythrocyte sedimentation rate and/or C-reactive protein levels. Only one patient had ascorbic acid levels evaluation before treatment since it was not readily available in our country. Treatment length varied from 2 weeks to 6 months.

Conclusion: The diagnosis of scurvy is frequently delayed due to its extreme rarity in modern society and its ability to mimic numerous other conditions. In children presenting with limb pain and/or reluctance to walk and pathognomonic radiological findings, physicians must prioritize scurvy as a differential diagnosis. In scurvy, vitamin C supplementation is curative.

Background: The aim of this study was to describe the epidemiology, physiopathology, and outcomes of elbow "unhappy triad" trauma in children, combining a posterior dislocation, a proximal radius fracture, and a third lesion (i.e. bony or capsuloligamentous injury).

Methods: A retrospective bicentric study was conducted between 1999 and 2020. All skeletally immature children who presented to the emergency department and underwent surgery for a proximal radius injury were selected. Among this selection, only patients with two associated ipsilateral elbow injuries (i.e. posterior elbow dislocation and a bony and/or capsuloligamentous injury) were included. Active elbow ranges of motion, Mayo Elbow Performance Score and Quick-Disabilities Of The Arm, Shoulder And Hand scores and standard radiographs were recorded at last follow-up.

Results: Twenty-one patients met the inclusion criteria (mean age at surgery = 11.4 years) among 737 selected. The "unhappy triad" diagnosis was made preoperatively in nine cases (bone lesion only), intraoperatively in nine cases, and postoperatively in one case. The third lesions were surgically treated when the lesion was a bony fracture or if the elbow remains unstable between 60° and 90° of flexion (i.e. capsuloligamentous injury). Twenty patients were reviewed (mean follow-up = 5.8 years). The complications and re-operations rates were of 10%.

Conclusion: The "unhappy" triad of the child's elbow is a rare injury, where the preoperative diagnosis is frequently missed and lead to 10% of complications and re-operations.

Level of evidence: level III.