Journal of Childrens Orthopaedics最新文献

Purpose: The recurrence rate in children with idiopathic clubfoot is high. The Pirani Böhm Sinclair score is a clinical tool screening for signs of recurrence. This study examined the inter- and intra-rater reliability of video-documented Pirani Böhm Sinclair score.

Methods: In two pediatric orthopedic centers, children with idiopathic clubfoot aged 4-15 years were consecutively included and filmed using a standardized protocol to complete the Pirani Böhm Sinclair score. Four pediatric orthopedic surgeons with extensive experience treating clubfoot patients viewed the videos and scored the feet according to the Pirani Böhm Sinclair score. Intra-class correlation coefficient and Kappa statistics were used to determine reliability.

Results: Fifty-five children with 85 clubfeet were included (54% bilateral). A subset of 30 videos was reassessed at a separate occasion by two of the four raters. Fleiss unweighted Kappa showed substantial agreement between all raters for the item "early heel rise," and moderate agreement for all remaining items except "swing phase supination" which was fair. Intra-class correlation coefficient for the total Pirani Böhm Sinclair score was almost perfect for both agreement and consistency on a group level and for each rater pair, respectively. Examination of intra-rater reliability showed substantial to almost perfect agreement for five items for both raters, but not the same five items.

Conclusions: This study highlights the potential use of video-documented Pirani Böhm Sinclair score. A high level of agreement was found for the item "early heel rise" where reduced playback speed and repeated viewing may aid assessment, while a low level of agreement was observed for the clinically important item "walking supination." Further development of the scoring instructions is required.

Background: A subset of children with acute haematogenous osteomyelitis become severely ill. This study aimed to define a severe and standard course and identify potential risk factors on admission for a severe course as well as the cumulative incidence.

Methods: This retrospective cohort study included all children under 16 years with acute haematogenous osteomyelitis between January 2018 and September 2021. The outcome parameters included >2 surgical debridements, C-reactive protein level not halving in 48 h, extraosseous involvement and hospital stay >14 days. Predictor variables (delayed presentation (>5 days), C-reactive protein >250 mg/L on admission, >1 bone segment and need for intensive care unit on admission) were tested against the outcome of a severe clinical course using univariate logistic regression analysis (using p < 0.2).

Results: One hundred and twenty-one patients were included. Thirty-nine patients (32.2%) had a complicated course. Patients admitted to intensive care unit had a 2.8-times higher risk of a severe course compared to those not requiring intensive care unit (risk ratio 2.8; 95% confidence interval 1.6-4.8); having a C-reactive protein >250 mg/L on admission increased the risk of a severe course 1.7 times (risk ratio 1.71, 95% confidence interval 1.3-2.3). Having more than one bone segment involved and a delayed presentation of >5 days increased risk of a severe course by 2.4 (risk ratio 2.4, 95% confidence interval 1.6-3.6) and 1.3 times (risk ratio 1.3, 95% confidence interval 1.3-1.3), respectively, compared to the alternative. The cumulative incidence of acute haematogenous osteomyelitis ranged between 4.0% and 5.0% per year.

Conclusion: Four risk factors present on admission were identified and are suggested to modify the risk of a severe disease as well as change treatment protocols.

People living with the rare, genetic condition Duchenne muscular dystrophy have particular orthopaedic care needs that are not universally understood or implemented at sites across the UK, putting them at risk of not receiving the correct treatment. They may require orthopaedic management and intervention for contractures caused by their muscle weakness. Importantly, they are also at a high risk of fractures due to increased bone fragility as part of the nature of Duchenne muscular dystrophy but also resulting from reduced weight-bearing and from the long-term use of corticosteroids as standard of care. In addition, progressive skeletal muscle weakness increases the risk of falls that may cause fractures. DMD Care UK's orthopaedic working group has developed a guideline by consensus to inform all those involved in the orthopaedic management of people with Duchenne muscular dystrophy about the care needs and imperatives. This covers children and adults and focuses on fracture management and elective orthopaedic procedures. The guideline has been endorsed by the British Society for Children's Orthopaedic Surgery.

Purpose: Congenital radioulnar synostosis is a congenital disorder affecting the elbow. We aimed to investigate the baseline characteristics and the clinical and functional outcome of a cohort of children with congenital radioulnar synostosis undergoing operative and non-operative treatment.

Methods: This multicenter retrospective study evaluated children with congenital radioulnar synostosis admitted to three European pediatric orthopedic centers from January 1998 to April 2021. Baseline characteristics were extracted from medical records. Operative cases treated with rotational osteotomy were further analyzed. Outcomes were assessed using the Mayo Elbow Performance Score and the Quick-DASH questionnaire.

Results: Ninety-seven patients (122 forearms) were included. Forearm positions were predominantly neutral or excessively pronated. Type 3 Congenital radioulnar synostosis was the most common radiographic finding. A total of 52 patients (66 forearms) underwent proximal derotational osteotomy, achieving a neutral forearm position in 61.9% of cases. Six complications were reported. The mean follow-up was 4.5 ± 3.4 years. MEPS averaged 90.6 points and Quick-DASH 18.5 points. No significant differences were found between operated and non-operated cases. MEPS results were good or excellent in 77.9% of patients, while only 31% reported a Quick-DASH ≤ 7points.

Conclusion: We present the largest case series of pediatric congenital radioulnar synostosis to date. Mild deformities caused minimal disability and required no surgery. For severe malrotation, proximal derotational osteotomy was safe, with low complication rates, restoring a neutral forearm position and yielding outcomes comparable to non-surgical management of mild cases.

Knee periarticular and intra-articular fractures in children and adolescents have specific features and should be carefully detected. Typical non-contact and contact mechanisms that may lead to an anterior cruciate ligament injury in a skeletally immature patient can cause a tibial eminence fracture. During patellar dislocation or other traumatic events, pure chondral fractures can occur and should be excluded. During sports, traumatic events leading to a forceful quadriceps contraction can cause specific paediatric fracture patterns such as patella sleeve and tibial apophyseal fractures. This review will highlight controversies and innovative aspects of non-operative and operative treatment, basic science, new evidence and unanswered questions for these fractures. Level of evidence: level V.

Purpose: Pedobarography is frequently employed for the identification and characterisation of foot pathologies in paediatrics. However, the lack of standardised normalisation methods presents a challenge for cross-age comparisons. This cross-sectional study provides normative plantar pressure data for typically developing children aged 4-17 years and compares normalisations and explanatory powers of parameters measuring peak and total load.

Methods: Dynamic foot pressure of 101 typically developing children aged 4-17 years was measured at self-selected speed using the mid-gait protocol. They were divided into five age groups: 4-6, 7-8, 9-11, 12-14 and 15-17 years old. Force and pressure variables measuring peak and total load were normalised by body weight or scaled by maximum value and the foot region where the peak pressure occurred was identified.

Results: The absolute values demonstrated an increase in load with advancing age. In contrast, when normalised to body weight, peak pressure and pressure time integrals decreased. The scaled peak pressure showed a load shift to the forefoot. The results indicate that the normalised parameters exhibit superior qualitative significance, suggesting a more dynamic gait pattern and improved morphology of the foot in relation to body weight with increasing age.

Conclusions: This study shows that standardisation of the measurement protocol is imperative because results in typically developing children can vary depending up parameter selection and normalisation technique.

Level of evidence: 3.

Purpose: It was aimed to determine whether there is a statistically significant difference between various types of displaced supracondylar fractures of the humerus in children with movement impairment according to Flynn's classification.

Methods: Clinical results of 263 patients who were operated on with closed reduction and percutaneous pinning for displaced supracondylar fracture of the humerus were evaluated. Flynn's classification was used to compare movement impairment.

Results: One year after the procedure, only one patient in the category of extension fractures of type II displacement, and only in elbow flexion, had an unsatisfactory treatment outcome according to Flynn. All other patients achieved a satisfactory treatment outcome, with the vast majority, 252 patients (96%), in the excellent category. Four patients were in the good category, one patient in the fair category, and the aforementioned one patient in the poor category.

Conclusion: In 1 year after the surgery, the limitation of elbow mobility is usually insignificant regardless of the grade of displacement or type of supracondylar fracture of the humerus.

Level of evidence: Level III-retrospective comparative study.

Purpose: The purpose of this study was to assess the ability of radiographic measures to predict displacement on computed tomography (CT) for transitional ankle fractures.

Methods: This study is a retrospective review of pediatric patients who presented with Tillaux (Salter-Harris III) and triplane (Salter-Harris IV) fractures at a single institution. Radiographs and CT measurements were performed by three independent evaluators. Intraclass correlation coefficients (ICCs) were calculated to determine interrater reliability. Spearman correlations were performed to assess the correlations between each radiographic parameter and CT measurements.

Results: A total of 61 patients were included in this study. The average age of patients was 12.3, and 65.6% of patients were male. There was an almost even split of triplane (55.7%) and Tillaux (44.3%) fractures. Overall, measurements showed at least good interobserver agreement (ICC >0.6). Radiographic anteroposterior view showed the least reliable measurements compared to the mortise and lateral views. There was significant correlation between CT displacement and the following measures on radiographs: tibiofibular clear space on the mortise view (ρ = 0.27, p < 0.05), articular displacement on the mortise view (ρ = 0.35, p < 0.01), articular displacement on the lateral view (ρ = 0.28, p < 0.05), and epiphyseal displacement on the lateral view (ρ = 0.55, p < 0.001).

Conclusions: There are several radiographic parameters that significantly correlate with increased displacement of transitional ankle fractures on CT. Increased articular displacement on the mortise and lateral view, as well as increased tibiofibular clear space on the mortise view, correlates with increased displacement. These radiographic parameters may be good indicators for the selective use of CT scans for transitional ankle fractures.

Level of evidence: Level III, retrospective comparative study.

Purpose: Manual anthropometric evaluations of pediatric lower extremities are essential in orthopedic pediatric practice due to their noninvasive and time-feasible nature. Therefore, this study aims to assess the test-retest reliability of clinical measurements obtained on children to examine measurement stability over time.

Methods: In a test-retest design, data were collected from 50 Danish school children with 5-to 6 weeks between sessions. Measurements encompassed the joint range of motion (ROM), rotational profile, and angular alignment of lower extremities for a representative sample of school children. Reliability was assessed using intraclass correlations (ICC), and agreement was assessed using limits of agreement (LoA) and precision.

Results: Reliability analysis revealed excellent results for foot length (ICC > 0.9), good results for foot width (ICC < 0.9), and poor to moderate results for all other measurements (ICC < 0.5, ICC < 0.75). Agreement results for hallux valgus were acceptable (within established reference) and the remaining variables were not acceptable (outside established reference).

Conclusions: The majority of the manual assessment procedures were found to have poor reliability. This study highlights the need for reliable and time-efficient tools to assist clinicians in assessing manual clinical measurements and future research should explore this.

Level of evidence: Level III.

Purpose: Osteogenesis imperfecta is a rare disorder characterized by bone fragility. The current gold standard treatment for long bone fractures and deformities is telescopic intramedullary rods. Although the use of plates as a standalone implant has been discouraged, recent research has investigated their use as an adjunct to intramedullary fixation. This scoping review aims to assess the current literature on plates for the treatment of long bone metaphyseal and diaphyseal fractures and deformities in osteogenesis imperfecta.

Methods: The MEDLINE, Embase, CENTRAL, and CDSR databases were searched via PubMed, Ovid, and Cochrane. Titles and abstracts of studies were screened, followed by full assessment of selected articles. Studies included were peer-reviewed, published in English in the last 20 years, and investigated plating alone or combined with other implants for the treatment of metaphyseal or diaphyseal long bone fractures and deformities in osteogenesis imperfecta.

Results: Eleven articles were included: four investigated plating alone, two compared different implants, and five assessed plating as an adjunct to intramedullary fixation.

Conclusions: Using plates alone is not recommended due to the high rate of complications, implant-related complications, and revision surgeries. However, they can be used when deemed appropriate by the surgeon or in narrow canals. Overall, the use of plates as an adjunct to intramedullary nails shows promising results, although further research is required to determine the indications for additional plating and the best timing of plate removal.

Level of evidence: Level III (scoping review).