Journal of Childrens Orthopaedics最新文献

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.

Background: Proximal femoral and/or pelvic osteotomies (PFPOs) can be indicated for a multitude of hip pathologies in (often asymptomatic) children, to prevent future hip problems. These procedures can result in significant blood loss. Tranexamic acid (TXA) is an antifibrinolytic agent routinely administered in adult trauma and joint reconstruction surgery to reduce blood loss. TXA is also registered for use in children and reported safe and beneficial for pediatric trauma, cardiac, and spinal surgery. However, for pediatric orthopedics, particularly for PFPOs, the available evidence is limited. Therefore, the current trial will investigate the potential reducing effect of preoperative TXA on intraoperative blood loss in pediatric PFPOs.

Methods: In this single-center, double-blind, randomized placebo-controlled trial, we aim to include 180 participants aged from 1 to 18 years undergoing PFPOs for any indication at our institution. Participants will be randomized to receive either TXA or placebo (saline) during anesthetic induction. The primary outcome is intraoperative estimated blood loss (mL/kg), which is determined gravimetrically. Secondary outcomes include the percentage of patients with excessive blood loss (>20 mL/kg), procedure time and hospital stay, and postoperative hemoglobin level changes.

Discussion: This will be the first prospective study investigating the effect of preoperative TXA on intraoperative blood loss in pediatric PFPOs. Its results will help to determine whether it would be advisable to adopt preoperative TXA as a standard medication to minimize blood loss and prevent complications in this vulnerable population.

Trial registration: EudraCT: 2022-002384-30. Prospectively registered on September 26, 2022.

Background: Legg-Calvé-Perthes disease is a self-limiting disorder that develops in children following interruption of the blood supply to the capital femoral epiphysis. This review outlines the current knowledge on the epidemiology, natural evolution, clinical spectrum, and management of the disease.

Methods: The literature pertaining to these aspects of the disease were studied and summarized in this review.

Results: Epidemiological studies suggest that environmental factors contribute to the causation of the disease. Incidence rates monitored over time indicate that the incidence of Legg-Calvé-Perthes disease is declining. The natural evolution followed on sequential plain radiographs enables division of the disease into Stages Ia, Ib, IIa, IIb, IIIa, IIIb, and IV. Reversible deformation of the capital occurs in Stages Ia-IIa simply on standing while irreversible deformation may occur in Stages IIb and IIIa. Treatment of Legg-Calvé-Perthes disease in Stages Ia-IIa aims to prevent the femoral head from getting deformed by containment and avoidance of weight-bearing. In Stages IIb and IIIa, treatment aims to remedy the effects of early irreversible deformation of the femoral head. In Stage IIIb and IV, treatment is directed to correcting the altered shape of the femoral head. The impression that these treatment methods are helpful is based on poor quality evidence.

Conclusion: There is an urgent need to undertake Level I studies to establish the efficacy of currently treatment.

Level of evidence: level V.

Purpose: Patients of elective orthopedic surgeries often reduce activity levels during postoperative recovery. It is unclear whether these extended periods of modified activities lead to weight changes. The purpose of this study was to evaluate changes in body mass index percentile in pediatric patients over 2.5 years following primary musculoskeletal surgeries.

Methods: Institutional records for utilized current procedural terminology codes were used to identify patients aged 21 years or younger who underwent elective surgery at a single pediatric orthopedic institution between October 2016 and December 2018. Non-primary surgeries and patients without preoperative body mass index measurements were excluded. Demographic characteristics, height, weight, and body mass index within 30 months of surgery were collected. Body mass index relative to age was calculated. Analysis of body mass index changes at follow-up intervals of 3-7, 9-18, and 24-30 months after surgery was performed for the overall sample, within surgical categories, and within preoperative weight classifications.

Results: A total of 1566 patients (53.1% female, average age 12.4 years) were included. Over one-third of patients were overweight or obese at presentation. The average change in body mass index percentile relative to baseline was increased at all follow-up intervals. Values reached significance at 9-18 months (p = .002) and 24-30 months (p = .001). While underweight and normal-weight patients had increased body mass index at all three timepoints, overweight or obese patients decreased.

Conclusions: Patients undergoing elective orthopedic procedures may experience significant changes in body mass index percentile postoperatively. At extremes of weight, patients experience improvement toward the mean, but most patients may undergo body mass index increases beyond what would be expected during normal growth.

Level of evidence: Retrospective level III.