Journal of Childrens Orthopaedics最新文献

Introduction: The neck-shaft angle and head-shaft angle in children with varying levels of neurological disability were evaluated to define change over different ages.

Methods: Children aged 1-12 years with spastic cerebral palsy, spinal muscular atrophy types 1 and 2, or typical development were reviewed to evaluate the neck-shaft angle and head-shaft angle. Patients were divided into five groups: Gross Motor Function Classification System levels I and II, Gross Motor Function Classification System level III, Gross Motor Function Classification System levels IV and V, spinal muscular atrophy types 1 and 2, and typical development. A linear mixed model was utilized to evaluate neck-shaft angle and head-shaft angle.

Results: Data from 196 children (mean age 4.8 ± 4.5 years) were included. Gross Motor Function Classification System levels I and II: 22 children, 130 hip radiographs measured, neck-shaft angle 143.7 ± 7.4, and head-shaft angle 160.0 ± 7.1. Gross Motor Function Classification System level III: 8 children, 33 hips evaluated, neck-shaft angle 153.1 ± 4.3, and head-shaft angle 163.4 ± 4.2. Gross Motor Function Classification System levels IV and V: 30 children, 137 hip radiographs measured, neck-shaft angle 156.4 ± 5.6, and head-shaft angle 167.9 ± 6.8. Spinal muscular atrophy types 1 and 2: 32 children, 83 hip radiographs measured, neck-shaft angle 161.9 ± 9.7, and head-shaft angle 173.4 ± 7.4. Typical development: 104 children, 222 hip radiographs measured, neck-shaft angle 138.6 ± 7.0, and head-shaft angle 156.4 ± 5.9. There were significant statistical differences when comparing neck-shaft angle and head-shaft angle.

Conclusion: As children grow, neck-shaft angle and head-shaft angle tend to decrease in typical development and Gross Motor Function Classification System levels I and II groups. However, in low-tone (spinal muscular atrophy types 1 and 2) and high-tone groups (Gross Motor Function Classification System levels IV and V), neck-shaft angle and head-shaft angle tend to increase with age. In both low-tone and high-tone groups, coxa valga is observed. When evaluating the effect of proximal femur-guided growth, these defined normal growth patterns should be considered.

Level of evidence: Level III Retrospective comparative study.

Objective: Osteochondromas are common bone tumors with hyaline cartilage-covered heads, arising from cortical and medullary bone. Solitary medial proximal tibial osteochondromas (MPTOs) can cause pes anserinus syndrome via compression. However, the literature lacks comprehensive studies on MPTO-related pes anserinus syndrome and its surgical outcomes.

Material and method: The study reviewed 227 patients diagnosed with osteochondroma between January 2018 and January 2022, with 21 patients meeting inclusion criteria: under 19 years, MPTO, surgical excision, histological diagnosis, ≥1-year follow-up. Cases with irregular follow-ups and multiple hereditary exostoses were excluded. Different surgical techniques were employed based on lesion characteristics. Postoperative weight bearing was allowed, and follow-ups involved postoperative complications assessment, clinical data collection, imaging, and functional evaluations using the International Knee Documentation Committee (IKDC) and Hospital for Special Surgery Pediatric Functional Activity Brief Scale scoring systems.

Results: The study involved 21 adolescents (15 ± 2 years). Lesion types were predominantly pedunculated (86%) and surgical interventions involved pes anserinus split (76%) or tenoplasty (24%). No significant correlations were observed between lesion dimensions and IKDC scores. Split intervention led to a significant improvement in IKDC scores (p < 0.01), while tenoplasty showed similar results (p < 0.05). Athlete status did not affect IKDC scores significantly, but both athletes and non-athletes demonstrated improvements (p < 0.05).

Conclusion: The negative impact of MPTOs causing pes anserinus tendinitis on the patient's quality of life and activity can be completely corrected with surgical treatment. Complete pes anserinus tendon cutting and subsequent repair are recommended if they facilitate surgery. The study underscores the importance of surgical management for MPTO-related pes anserinus syndrome and provides insights into the effectiveness of different surgical techniques.

Achondroplasia, the most common form of inherited disproportionate short stature, is caused by mutations in the fibroblast growth factor receptor 3 gene. The typical clinical features of achondroplasia include short stature, rhizomelic disproportion, joint hyperlaxity, spinal deformity and deformity of the upper and lower limbs. The latter are among the challenges of state-of-the-art orthopaedic treatment plans and significantly contribute to the burden of the disease in individuals with achondroplasia. Multidisciplinary preoperative individual decision-making concerning surgical interventions should be considered. New medical treatments for achondroplasia have been developed and (some) have been approved for clinical use in several countries. While the number of research articles on achondroplasia is increasing rapidly, many unknown or controversial orthopaedic topics remain. Furthermore, in view of new medical developments with improvements in growth and potentially other effects, the timing and algorithms of orthopaedic treatments (e.g. guided growth, limb lengthening and deformity correction) need to be re-evaluated. While standing height is the primary research focus in medical therapy, it is crucial to comprehensively assess orthopaedic parameters in this multifactorial disease. The current treatment of patients with achondroplasia requires specialised multidisciplinary centres with transitional care and individual orthopaedic counselling.

Purpose: The British Orthopaedic Association Standards for Trauma-4 includes pediatric Gustilo-Anderson type I upper limb open fractures and recommends surgical debridement as the preferred method of treatment. The reported incidence of fracture-related infection is low in patients with this injury pattern and the evidence supporting debridement is therefore weak. The aim of this systematic review is to compare infection rates between non-operative management and operative debridement in children with Gustilo I upper limb fractures who did not require surgical fixation.

Methods: A systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Eligibility criteria included patients <18 years with Gustilo-Anderson type I upper limb fractures managed with either antibiotics alone or with operative debridement. Patients in whom the fracture was stabilized were excluded, and the Risk Of Bias In Non-randomized Studies-of Interventions tool was used to evaluate bias.

Results: Eleven, predominantly retrospective studies were identified, involving 537 patients with fractures including 466 forearm, 70 wrist, and one humerus. A non-operative management strategy was used in 293 patients with one superficial infection (0.3%). Operative debridement was used in 244 patients with one superficial infection (0.4%).

Conclusion: The optimal management of Gustilo-Anderson type I pediatric upper limb fractures is unclear. Based on the current evidence base, surgical debridement does not appear to reduce the rate of infection. The decision to manage these injuries aggressively should therefore be individualized to consider patient age, mechanism, and clinical extent of injury.

Level of evidence: level II.

Purpose: This study aimed to analyse the effect of the femoral derotational osteotomy (FDRO) on joint kinematics, kinetics, joint and muscle forces, and muscle moments in patients with idiopathic increased femoral anteversion compared with typically developing children (TDC).

Methods: In this retrospective study, 17 patients (25 limbs, 13.2 ± 2.2 years, femoral anteversion = 49.0° ± 7.1°) were compared to nine TDC (9 limbs, 12.0 ± 3.0 years, femoral anteversion = 18.7° ± 4.1°). Gait analysis was performed 8.5 ± 7.2 months pre-surgery and 17.3 ± 5.5 months post-surgery. Joint angles, moments and forces as well as muscle forces and muscle contributions to joint moments were analysed using statistical parametric mapping.

Results: Significant improvements in kinematics (hip rotation, foot progression, knee and hip flexion) were observed pre- to post-FDRO. Joint forces remained unaltered after surgery and did not differ from TDC. Gluteus minimus and deep external rotators muscle forces decreased in mid-stance, while adductor muscle forces increased during stance post-op compared to pre-op. Due to an improved knee extension postoperatively, the rectus femoris muscle force decreased to normal values during mid- and terminal stance. Postoperatively, only the deep external rotator muscle forces differed from TDC.

Conclusions: This study showed that FDRO can restore muscle forces and muscle contributions to joint moments in addition to normal gait kinematics, while joint contact forces remain within normative ranges. This knowledge might also apply to other conditions in which pathological femoral anteversion is present.

Purpose: Septic arthritis of the hip in children and adolescents is a common condition requiring timely diagnosis and intervention. Surgical irrigation and debridement is typically performed through the anterior approach because of concerns about injury to the medial femoral circumflex artery leading to avascular necrosis. While there are multiple studies investigating the sequelae of anterior and medial approaches for reduction of developmental dislocation of the hip, none have compared these approaches for the pediatric septic hip. We hypothesize that there will be no significant difference in the rate of avascular necrosis when comparing the medial and anterior approaches to the septic hip in pediatric patients.

Methods: A retrospective review was performed of pediatric septic hips treated with irrigation and debridement through either a medial or anterior approach at a single institution over an 18-year period of time. The primary outcome measure was the development of avascular necrosis.

Results: Thirteen of 164 patients (7.9%) developed avascular necrosis. Avascular necrosis was noted in 9 of 101 patients who had anterior approach and 4 of 63 patients who underwent medial approach (p = 0.76). The average age for patients developing avascular necrosis was 10.0 years old versus 6.8 years old in patients who did not develop avascular necrosis (p = 0.01). The average follow-up was 3.3 years in patients with avascular necrosis versus 1.5 years for patients who did not develop avascular necrosis (p = 0.01).

Conclusion: Medial approach to the pediatric septic hip does not increase the rate of avascular necrosis compared to the anterior approach.

Level of evidence: Retrospective comparison study, Level III.

Background: Distraction therapy use such as virtual reality is novel in the pediatric orthopedic field. In this study, we use subjective and objective metrics to evaluate virtual reality efficacy to reduce anxiety and pain in a pediatric orthopedic cohort.

Methods: A prospective randomized controlled trial included patients between age 5 and 17 years, presenting to a tertiary care pediatric orthopedic clinic. Parallel groups underwent orthopedic procedures in clinic, utilizing immersive and interactive virtual reality distraction therapies versus standard of care. Procedures included cast application, cast removal, bone pin removal, and fracture reduction. All preprocedure parameters were similar between the groups. Primary outcome was the difference between maximum procedural heart rate and baseline. Secondary outcomes included Wong Baker FACES Rating Scale (Wong & Baker, 1988, Oklahoma, USA) for pain and Visual Analog Scale scores for anxiety.

Results: Ninety-five patients (66 M, 29 F) underwent 59 cast removals, 26 cast applications, 7 percutaneous pin removals, and 3 fracture reductions. Average patient age in the virtual reality and control cohorts was 10.1 (5-17) and 10.6 (5-17), respectively. Average change in maximum heart rate in the virtual reality and control groups was 10.6 ± 10.1 versus 18.4 ± 11.0 (p = 0.00048). The virtual reality group demonstrated trends toward lower perceived anxiety (1.7 ± 2.8 versus 2.9 ± 3.6, p = 0.0666) when compared to controls.

Conclusions: This level 1 study is the first to utilize objective biometric measurements to evaluate use of interactive virtual reality during multiple types of pediatric orthopedic procedures in the clinical setting. The findings suggest that an interactive and immersive virtual reality experience can be effective in reducing pain and anxiety.

Level of evidence: Level 1, Randomized Controlled Trial.