Journal of Childrens Orthopaedics最新文献

Purpose: Paediatric forearm fractures are among the most common childhood injuries, with diaphyseal fractures often requiring surgical management due to their instability and poorer remodelling potential. Traditional methods, such as elastic stable intramedullary nailing, are effective but require secondary procedures for implant removal, increasing healthcare burdens. Bioabsorbable intramedullary nails offer an alternative, eliminating the need for implant removal. This systematic review and meta-analysis evaluates the efficacy and safety of bioabsorbable intramedullary nails compared to conventional methods.

Methods: Five studies, including 255 paediatric patients with 399 forearm fractures, were included. Of these, 159 were treated with bioabsorbable intramedullary nails. Meta-analyses assessed outcomes, including fracture healing time, complications, functional results and reoperation rates.

Results: Bioabsorbable intramedullary nails demonstrated fracture healing times comparable to elastic stable intramedullary nailing (10.67 weeks; 95% CI: 8.92-11.42) with no significant differences. Complication rates were similar, with nine re-fractures in the bioabsorbable intramedullary nail group and 10 in the elastic stable intramedullary nailing group. Secondary displacement occurred in 3.1% of bioabsorbable intramedullary nail patients versus 4.7% for elastic stable intramedullary nailing. Functional outcomes showed improved pronation (78.5° versus 72.7°, p = 0.030) and elbow flexion (153.8° versus 144.8°, p = 0.001) for bioabsorbable intramedullary nails. Pain scores were comparable, with fewer bioabsorbable intramedullary nail patients reporting postoperative pain.

Conclusions: Bioabsorbable intramedullary nails are a safe and effective alternative to elastic stable intramedullary nailing, offering equivalent clinical outcomes while eliminating the need for implant removal. Larger, long-term studies are needed to confirm these findings and evaluate the cost-effectiveness of bioabsorbable intramedullary nails in paediatric fracture management.

Purpose: To assess ultrasonographic features of hip morphology in mucopolysaccharidosis type I Hurler.

Methods: Acetabular bony rim, acetabular cartilaginous roof, alpha and beta angles, echogenicity, and hip coverage were analyzed in eight mucopolysaccharidosis type I Hurler syndrome children before and after hematopoietic stem cell gene therapy.

Results: Sixteen hips at baseline, 10 at +12 months, and 10 at + 24 months after hematopoietic stem cell gene therapy were evaluated. The median age was 22, 35, and 45 months at baseline evaluation, +12, and +24 months, respectively. Acetabular bony rim at baseline was angular in 2/16, rounded in 10/16, notched in 2/16, and flattened in 2/16; at +12 months, angular in 2/10, rounded in 5/10, notched in 3/10; at +24 months, angular in 2/10, rounded in 3/10, irregular in 1/10, and notched in 4/10. Acetabular cartilaginous roof at baseline was normal in 4/16, enlarged in 12/16; at +12 months, enlarged in 10/10 and at +24 months, enlarged in 8/10 and normal in 2/10. Echogenicity of the joint capsule at baseline was normal in 10/16, increased in 6/16; at +12 months, normal in 8/10, increased in 2/10; at +24 months, normal in 6/10, increased in 4/10. The mean femoral head coverage was 60% at baseline (16/16), 62% at +12 months (10/10), and 52% at +24 months (2/10). The mean alpha angle was 60° at baseline (16/16), 64° at +12 months (10/10), and 60° (2/10) at +24 months. The mean beta angle was 67° at baseline (16/16), 65° at +12 months (10/10), and 49° at +24 months (8/10).

Conclusions: Hip morphology of children with mucopolysaccharidosis type I Hurler syndrome before and after hematopoietic stem cell gene therapy can be evaluated by available ultrasound techniques until a median age of 45 months.

Background: Paediatric orthopaedic surgery is rarely supported by high-quality evidence, with treatment decisions generally informed by experience or case series. The European Paediatric Orthopaedic Society recognises the need to establish research priorities in the field. This study builds on previous UK research priorities to discover the most important unanswered clinical effectiveness research questions in elective and trauma care and basic science, amongst Paediatric Orthopaedic surgeons across Europe.

Methods: A modified Delphi technique, including an initial scoping survey and a two-round Delphi process conducted amongst paediatric orthopaedic surgeons in Europe.

Results: An average of 113 surgeon responses were received in each round, scoring questions from 1 (low priority) to 5 (high priority). The mean score for importance was 3.59 in elective questions, 3.13 in trauma and 3.54 in basic science. The top questions in each group were identified. The top five research priorities for elective care related to the care of - Perthes Disease, Slipped Upper Femoral Epiphysis and Developmental Dysplasia of the Hip. Those in trauma related to the treatment of fractures around the elbow, forearm and femur Basic science priorities related to pharmaceuticals in the management of paediatric orthopaedic conditions and the pathology of Perthes' Disease and Developmental Dysplasia of the Hip.

Conclusions: The results will help guide clinicians, researchers and funding bodies to focus research towards important topics and improve the evidence for practice in paediatric orthopaedic surgery. We hope that this study will encourage the development of collaborative international studies to improve care in paediatric orthopaedics.

Level of evidence: Level V - decision analysis.

Purpose: The premature closure of the epiphysis of the distal radius is an infrequent condition in pediatric patients, often resulting in distal radius deformity. Currently, there is limited literature on its treatment, and controversy exists. This study aimed to evaluate the clinical efficacy of all-inside physeal bar resection with the aid of an arthroscope and patient-specific instrument.

Methods: We retrospectively reviewed the patients who sustained distal radius physeal bar resection under all-inside visualization of the arthroscope with the aid of a patient-specific instrument during 2016-2022. Follow-up was performed for a minimum of 2 years, during which pre-operative and post-operative clinical and radiological parameters were compared.

Results: There were six boys and two girls enrolled in this study. Six patients got satisfied results, while two patients didn't benefit from the surgery. The mean pre-operative RAA of the affected side was -11.4° ± 13°, while the post-operative radial articular angle was 3.4° ± 11°. There was a significant difference between them. The mean pre-operative ulnar variance was 7.6 mm ± 6 mm, while the post-operative UV was 3.3 cm ± 8 mm. There was no significant difference between them. The pre-operative modified Mayo Wrist Score was 92 ± 5, while that for post-operative was 96 ± 7.

Conclusion: All-inside physeal bar resection for partial physeal arrest of the distal radius with the aid of an arthroscopy and patient-specific instrument is minimally invasive, accurate, and safe. It should be the one option treatment for the premature closure of the distal radius epiphysis.

Purpose: In recent years, generative artificial intelligence systems have transformed the landscape of patient's access to medical information and education. As increases in general and subspeciality physician shortages lead to longer lead times for patients to get access to physicians, we aim to understand how effectively different AI platforms can respond to questions asked by parents about both operative and nonoperative scoliosis.

Methods: A survey comprised of 31 questions, among the most commonly asked, regarding scoliosis with responses from ChatGPT, Google Gemini, and Microsoft Copilot was administered to board-certified Orthopedic surgeons, fellowship trained in either pediatric or spine surgery. (four reviewers). They evaluated each output from Likert Scale of 1-5 with 5 meaning an excellent response was given and 1 meaning a poor response was given. Pairwise comparisons were used for analysis.

Results: All three generative AI technologies performed well with an overall mean rating of 3.4 which is between good and very good on the Likert Scale provided. ChatGPT performed the best out of the three, with a mean rating of 4.0, Google Gemini was second best with a mean rating of 3.1, and Copilot was third best with a mean rating of 3.1. ChatGPT compared with Gemini and Copilot revealed statistically significant differences with a p-value <0.001, with no statistical difference between Gemini and Copilot.

Conclusion: In response to common scoliosis questions asked by parents, ChatGPT, Microsoft Copilot, and Google Gemini, were scored highly by our Spine team and has important indications for use in the future.

Background: Osteogenesis imperfecta (OI) is characterized by bone fragility and deformities. Treating long bone fractures and deformities in OI patients typically involves intramedullary (IM) rods. The Simple Locking Intramedullary (SLIM) nail is a novel surgical device developed to address challenges in patients with narrow medullary canals, which are unsuitable for larger telescoping rods. This study aims to evaluate the outcomes and complications associated with SLIM nail use in pediatric patients with OI.

Methods: A retrospective chart review was conducted at our institution, analyzing 23 patients (41 limbs) who underwent surgery using the SLIM nail between April 2016 and March 2022. Data on patient demographics, surgical intervention, post-operative outcomes, and complications were collected. Radiological evaluations were performed from the immediate post-operative period up to the most recent follow-up.

Results: The SLIM nail demonstrated a 2-year survival rate of 82.8% and a 4-year survival rate of 77.1% in tibial applications. The most common complication was angular deformity in the distal tibia, occurring in 19 patients. Other complications included anterior cortical penetration, nail bending, and one case of nail breakage.

Conclusions: The SLIM nail is a viable option for patients with narrow intramedullary canals, particularly in cases where telescoping rods are not feasible. While the SLIM nail provides adequate stabilization and reduces the need for multiple surgeries, careful monitoring is essential to manage complications such as distal angular deformity. Early revision to a larger rod, when possible, is recommended to prevent further complications as the patient grows.

Level of evidence: Level IV.

Purpose: Monostotic fibrous dysplasia is a rare benign fibro-osseous disorder. Proximal femoral monostotic fibrous dysplasia is especially vulnerable to pathological fracture and deformation, requiring specific treatment strategies. Literature on pediatric proximal femoral monostotic fibrous dysplasias is sparse and without consensus. We present the largest observational cohort study on various treatment methods of pediatric proximal femoral monostotic fibrous dysplasia.

Methods: Pediatric patients with proximal femoral monostotic fibrous dysplasia were included, from 10 academic hospitals for oncological orthopedics (2000-2021). Baseline characteristics, treatment strategies, and complications were assessed. Primary outcomes were failure rates, failure-free survival, and risk factors for failure. Failure was defined as fracture, progressive deformity, or surgical (re-)intervention after the start of treatment.

Results: Forty-one pediatric patients with proximal femoral monostotic fibrous dysplasia were included (median age = 11 years (range = 6-16), n = 21 (51%) male). Median follow-up was 5.1 years (range = 0.8-18.6). Index procedure was watchful waiting (n = 9), percutaneous procedure (n = 4), open procedure (n = 15), or internal fixation (n = 13). Failure rates were 11%, 50%, 40%, and 31%, respectively (p = 0.41). Overall, 2- and 5-year failure-free survival was stable at 87.5% (95% confidence interval = 64.6-110.4). Risk factors associated with failure were fracture at diagnosis (hazard ratio = 3.7, 95% confidence interval = 1.2-11.5), calcar involvement (hazard ratio = 2.6, 95% confidence interval = 0.7-9.4), and male sex (hazard ratio = 2.1, 95% confidence interval = 0.6-7.8).

Conclusion: In cases with low fracture and deformity risk, watchful waiting can be a viable management option for proximal femoral monostotic fibrous dysplasia. When intervention is necessary, internal fixation is advised to prevent fractures and deformity. Curettage with grafting or bone substitute injections should be used with hesitance. Currently, there is no clearly superior treatment for pediatric proximal femoral monostotic fibrous dysplasia, leaving treatment choices to be based on individual characteristics.

Introduction: Elastic stable intramedullary nailing is widely recognized for treating pediatric forearm fractures due to its stable fixation and minimal impact on soft tissue. Traditionally, casting has followed elastic stable intramedullary nailing; however, recent studies question its necessity. This study evaluates the outcomes of omitting casts post-elastic stable intramedullary nailing, examining healing speed and quality of life compared to cases where casting was applied.

Materials and methods: A prospective study was conducted from 2022 to 2024 in an urban hospital, where children with both-bone midshaft forearm fracture were randomized to receive or not receive casting after elastic stable intramedullary nailing. Age- and sex-matched patients were selected to allow for accurate comparison. The study included patients aged 5 to 14 years. Outcomes were measured using radiographic scores and quality-of-life assessments.

Results: From a total of 355 patients, 136 cases were included in the assessment. Analysis indicated faster healing in patients without postoperative casting, as evidenced by higher REBORNE scores at 3 weeks and 2 months. Quality of life, measured by the Pediatric Quality of Life Inventory, was also significantly improved in the no-cast group at 6 weeks.

Discussion: Our findings suggest that elastic stable intramedullary nailing provides sufficient stability for both-bone midshaft forearm fracture, making additional casting unnecessary. Early mobilization led to better functional outcomes without increasing complications. Although some minor early discomfort was reported, the cast-free approach proved effective and safe.

Conclusion: Elastic stable intramedullary nailing remains the gold standard for treating pediatric forearm fractures. Our preliminary results indicate that for both-bone midshaft forearm fracture, elastic stable intramedullary nailing can be safely performed without postoperative casting, promoting faster healing and better patient satisfaction.

Purpose: We investigated the medium-term clinical results and revision rate of arthroscopic rim-preserving saucerization for symptomatic lateral discoid meniscus in children.

Methods: A single-centre, retrospective study was conducted on patients treated with arthroscopy for symptomatic discoid lateral meniscus between December 2005 and May 2019. Eligibility criteria were patients <16 years at the time of surgery and a minimum follow-up of 5 years. Preoperative data (age, sex, symptoms and physical examination), arthroscopic findings (Watanabe and Ahn classifications, meniscal instability and the presence of meniscal tear), treatment (saucerization ± stabilization ± meniscal repair), patient-reported outcome measurements (Lysholm, Tegner and Ikeuchi scores) and arthroscopic revision rate were recorded.

Results: In all, 47 (72%) of the 65 eligible patients replied to the questionnaires and were therefore included (9 bilateral cases). The mean age at the time of surgery was 8.6 ± 3.3 years. Patient-reported scores were all improved after a mean follow-up of 10.5 years (5-15.9): Ikeuchi (64.2% excellent-good versus 3.6%), Lysholm (90.5 versus 72.9) and Tegner (5 versus 4.3). Two patients developed osteochondritis dissecans of the lateral femoral condyle which healed following non-operative measures. There was no other complication. An arthroscopic revision was performed in 10 patients (17.9%) after a mean follow-up of 2.7 years.

Conclusion: The medium-term results of rim-preserving arthroscopic saucerization are favourable, yet with a substantial arthroscopic revision rate. Risk factors for failure and revision should be further investigated.