Journal of Childrens Orthopaedics最新文献

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).

Aim of the study: Aim is to define whether the type of anesthesia during the reduction and fixation of a pediatric forearm fracture, can influence the fracture reduction technique.

Materials and methods: All surgically treated forearm fractures were enrolled: patients underwent a different anesthesiology protocol depending on the on-call anesthesiologist: deep sedation in which the patient is still able to breathe with limited external support and nerve block (group A) and general anesthesia with curare (group B). Demographic data, type of fracture, surgical timing and technique, anesthesia type and timing, and clinical outcomes were recorded.

Outcomes: Of the total 326 patients considered, 228 children were treated by closed reduction (70%), and 98 children were treated by open reduction (30%). Of the latter, 75% of the fractures reduced open were of group A and 25% were of group B. In more detail, in group A, of the 162 patients, 73 (45%) required an open reduction, while 89 (55%) did not. In group B, of the 164 patients, 25 (15%) required an open reduction, while 139 (85%) did not. This resulted in being statistically significant (p = 0.001). No statistically significant results emerged from the data related to complication and range of motion apart from the pronation movement (p = 0.153).

Conclusion: According to our data, the use of curare, in a pediatric forearm fracture reduction and stabilization surgery, leads to a reduction in the number of open treatments. If deep sedation and nerve block are preferred to improve postoperative pain control, the technique and timing should be improved to facilitate reduction.

Objective: To evaluate the performance of three large language models in answering questions regarding pediatric developmental dysplasia of the hip.

Methods: We formulated 18 open-ended clinical questions in both Chinese and English and established a gold standard set of answers to benchmark the responses of the large language models. These questions were presented to ChatGPT-4o, Gemini, and Claude 3.5 Sonnet. The responses were evaluated by two independent reviewers using a 5-point scale. The average score, rounded to the nearest whole number, was taken as the final score. A final score of 4 or 5 indicated an accurate response, whereas a final score of 1, 2, or 3 indicated an inaccurate response.

Results: The raters demonstrated a high level of agreement in scoring the answers, with weighted Kappa coefficients of 0.865 for Chinese responses (p < 0.001) and 0.875 for English responses (p < 0.001). No significant differences were observed among the three large language models in terms of accuracy when answering questions, with rates of 83.3%, 77.8%, and 77.8% for Claude 3.5 Sonnet, ChatGPT-4o, and Gemini in the Chinese responses (p = 1), and 83.3%, 83.3%, and 72.2% for ChatGPT-4o, Claude 3.5 Sonnet, and Gemini in the English responses (p = 0.761). In addition, there was no significant difference in the performance of the same large language model between the Chinese and English settings.

Conclusions: Large language models demonstrate high accuracy in delivering information on dysplasia of the hip, maintaining consistent performance across both Chinese and English, which suggests their potential utility as medical support tools.

Level of evidence: Level II.

Purpose: A majority of ambulant children with cerebral palsy (CP) develop progressive musculoskeletal pathology (MSP) during growth. Fixed flexion deformity at the knee joint (FFDKn) contributes to flexed knee gait and is prone to relapse after index multi-level surgery. This perspective introduces the concept of "knee surveillance" (KS), defined as a repeated systematic assessment of gait and knee range of motion until skeletal maturity. KS aims to detect early FFDKn, allowing for early intervention with minimally invasive techniques such as anterior distal femur hemiepiphysiodesis (ADFH), and reduce the need for higher-risk surgery such as distal femoral extension osteotomy (DFEO) and patellar tendon shortening (PTS).

Methods: Recent literature on the assessment of ambulant children with CP, consensus statements on indications for dose-based knee surgery, and the indications for ADFH have been reviewed and synthesized. These provide a preliminary evidence base for the concept of KS in ambulant children with CP.

Conclusion: We propose the concept of KS for ambulant children with CP. The goals of KS are early detection of knee flexion deformity, early intervention, less invasive surgery, and better long-term outcomes. There is preliminary evidence to suggest that soft-tissue surgery, in combination with ADFH, can reduce, or perhaps replace, the need for more invasive surgery such as DFEO and PTS.

Level of evidence: IV.

Background: Supracondylar humerus fractures are common in childhood, and postoperative follow-up planning for surgically treated fractures is still controversial. This study aims to investigate the interobserver and intraobserver reliability of the Radiographic Union Score for Tibial Fracture in the postoperative radiological follow-up of pediatric supracondylar humerus fractures and to evaluate the clinical results with the scores obtained during follow-up.

Methods: In this prospective study, patients who were operated on for supracondylar humerus fractures were called for follow-up three times: postoperative splint removal, pin removal, and final control. A total of 58 patients, 34 boys and 24 girls, who provided regular follow-ups, were included in the study. During follow-ups, the Radiographic Union Score for Tibial Fracture was calculated by evaluating the patients' elbow anteroposterior and lateral radiographs, and the elbow joint range of motion was recorded with a goniometer. In two experiments, orthopedic surgeons evaluated intraobserver and interobserver reliability using the intraclass correlation coefficient at different times. The patients were evaluated at the last follow-up according to the Flynn criteria.

Results: The first follow-up Radiographic Union Score for Tibial Fracture (median (range) was 8 (7-10), the second follow-up was 11 (9-12), and the third follow-up was 12 (11-12). Range of motion was 40° at the first follow-up, 90° at the second follow-up, and 120° at the third follow-up. Radiographic Union Score for Tibial Fracture and range of motion increased significantly as the weeks progressed (p < 0.001). Interobserver intraclass correlation coefficient at first follow-up was 0.80 (95% confidence interval 0.69-0.87), second follow-up was 0.85 (0.77-0.91), and third follow-up was 0.79 (0.67-0.87). Intraobserver intraclass correlation coefficient was 0.92 (0.88-0.95) at the first follow-up, 0.93 (0.98-0.96) at the second follow-up, and 1.00 (1.00-1.00) at the third follow-up. Flynn score results are functional; the cosmetic results were excellent in 46 patients, good in 4 patients, fair in 5 patients, poor in 3 patients, and cosmetic results were excellent in 54 patients and good in 4 patients.

Conclusion: Our study determined that the radiographic union of fractures in pediatric supracondylar humerus fractures is reliably evaluated with the Radiographic Union Score for Tibial Fracture score. Radiographic Union Score for Tibial Fracture can be used to provide data-driven estimates of splint and pin removal.

Level of evidence: Level II, prospective study.

The use of external fixators is part of the cultural background of orthopedic surgeons in treating numerous clinical conditions. Over the years, fixator design and biomechanical knowledge have led to different solutions and techniques, and bone lengthening and its better understanding come together with the development of external fixators and the application of the biological principle of distraction osteogenesis. The authors conducted a literature review about using external fixators and lengthening systems in pediatric upper limbs. Despite the applications of external fixators in upper limbs remaining much more limited than those of the lower limbs, there are indications of traumatic, congenital, tumor, and infectious etiologies. However, despite the spread of new systems of plate and screws and intramedullary lengthening nails, the problems about when to use external fixation remain unsolved. Another debated point is about using monolateral or circular frames for humeral lengthening and the correction of forearm deformities in multiple hereditary exostoses disease (MHE) or radial longitudinal deficiency sequelae. Monoaxial fixators retain a prominent role for skeletal lengthening in all the districts examined, although their role could be outclassed by the motorized intramedullary nails, especially for humeral lengthening. Hexapod systems are likely to represent the future for the correction of multiplanar forearm deformities; however, multicenter studies on larger series will be necessary to better validate their applications and advantages.

Preoperative planning is crucial for successful surgical outcomes. 3D printing technology has revolutionized surgical planning by enabling the creation and manufacturing of patient-specific models and instruments. This review explores the applications of 3D printing in pediatric orthopedics, focusing on image acquisition, segmentation, 3D model creation, and printing techniques within specific applications, including pediatric limb deformities, pediatric orthopedic oncology, and pediatric spinal deformities. 3D printing simultaneously enhances surgical precision while reducing operative time, reduces complications, and improves patient outcomes in various pediatric orthopedic conditions. 3D printing is a transformative technology in pediatric orthopedics, offering significant advantages in preoperative planning, surgical execution, and postoperative care.