Journal of Childrens Orthopaedics最新文献

Purpose: Posterior spinal fusion for idiopathic scoliosis is known to increase spinal height, but the impacts on weight and resulting body mass index are unknown. This study assesses body mass index, weight, and height percentile changes over time after posterior spinal fusion for idiopathic scoliosis.

Methods: Body mass index, weight, and height age- and sex-adjusted percentiles for patients with idiopathic scoliosis undergoing posterior spinal fusion between January 2016 and August 2022 were calculated based on growth charts from the Centers for Disease Control for Disease Control and compared to preoperative values at 2 weeks, 3 months, 6 months, 1 year, and 2 years. The data were analyzed for normality with a Shapiro-Wilk test, and percentiles were compared with the Wilcoxon signed-rank tests.

Results: On average, 12.1 ± 2.3 levels were fused in 269 patients 14.4 ± 1.9 years, and percentiles for body mass index, weight, and height preoperatively were 55.5 ± 29.4%, 57.5 ± 28.9%, and 54.6 ± 30.4%, respectively. Body mass index and weight percentiles decreased at 2 weeks (-10.7%, p < 0.001; -4.6%, p < 0.001, respectively) and 3 months (-6.9%, p < 0.001; -3.2%, p < 0.001, respectively) postoperatively. Postoperative weight loss at 2 weeks averaged 2.25 ± 3.09% of body weight (0.98 ± 4.5 kg), normalizing by 3 months. Body mass index percentile normalized at 1 year, but height percentile was increased at 2 weeks (2.42 ± 1.72 cm, p < 0.001) and through 2 years.

Conclusion: Despite initial height increase due to deformity correction, acute postoperative weight and body mass index percentile decreases postoperatively normalize by 1-year body mass index percentile. Physicians may benefit from utilizing this information when discussing the postoperative course of posterior spinal fusion with idiopathic scoliosis.

Level of evidence: 4, Retrospective Case Series.

Background: Ankle fracture is one of the most frequent pediatric lower-limb fractures and may result in serious complications.

Objective: This study aimed to determine the epidemiology of ankle fractures, defining fracture types, treatments, and complications in a pediatric population below 16 years old.

Methods: Medical records of all the ankle fracture patients treated in our hospital during 2004-2020 were retrospectively reviewed. Data regarding age, sex, mechanism of injury, fracture type, treatment modalities, and complications were collected.

Results: We examined records involving 328 children with 331 ankle fractures, with a ratio of 1:2 male per female. Mean annual prevalence was 24.3 per 100,000 children. Mean patient age was 11.2 ± 4.2 years, with 75.3% of them aged over 10 years. Sports activities accounted for the largest percentage of fractures (162 cases; 49.4%), followed by falls (67; 20.4%) and road traffic accidents (37; 11.3%). Physeal fractures were the most frequent type of lesion (223 cases). Most ankle fractures (60%) were managed using closed reduction and casting; for the remaining 40% of cases, fracture fixation was performed after closed or open reduction to correct the articular step-off and ensure the anatomical restoration of the physis. The main ankle fracture complication was premature growth arrest (12.1% of all physeal fractures).

Conclusion: Pediatric ankle fractures primarily affect children older than 10 years. Most of these fractures were caused by sports injuries or low-energy trauma. The majority of these fractures are physeal, and the distal tibial physis is affected 10 times more frequently than the distal fibular physis.

Level of evidence: Level III.

Background: To investigate the clinical characteristics and surgical efficacy of localized tenosynovial giant cell tumors in children.

Methods: The clinical data, surgery, and follow-up results of 17 children with localized tenosynovial giant cell tumors who visited our hospital from 2011 to 2021 were collected for statistical analysis.

Results: The median patient age was 7 years and 8 months, and the ratio of males to females was 1.43 (10/7). The predilection of disease was similar in hands and feet, and the common presenting symptom was mass. One patient experienced recurrence after surgery, and one child had postoperative functional limitations.

Conclusion: Extremities are common sites of localized tenosynovial giant cell tumors in children. Complete surgical resection helps reduce the recurrence rate.

Level of evidence: Level III.

Purpose: The conditions leading to growth rebound after hemiepiphysiodesis are still poorly understood. This article analyzes the radiographical outcomes after guided growth with tension band plating, using plates in idiopathic genu valgum patients and attempts to generate a predictive model of growth rebound.

Methods: Patients with idiopathic genu valgum deformity who received tension band plating were selected for evaluation. We only analyzed coronal plane deformities. Only patients with a long-standing X-ray before tension band plating surgery, a long-standing X-ray at tension band plating removal, and a long-standing X-ray at the latest follow-up after tension band plating removal were considered for this study. The change of mechanical axis deviation between the tension band plating removal and the last follow-up was evaluated for rebound, and ordinal logistic regression was performed to determine the relevant variables for predictive modeling rebound growth.

Results: Overall, 100 patients (189 legs) were analyzed. The mean mechanical axis deviation at tension band plating removal was 8.4 mm in varus direction, and the mean mechanical axis deviation at the last follow-up was -3.4 mm (p ≤ 0.001). However, 111 legs (59%) showed rebound growth, 57 (30%) stayed stable, and 21 (11%) showed a continuous correction. Six significant factors significantly influencing rebound were isolated which are clinically relevant: sex, age, baseline mechanical axis deviation, mechanical lateral distal femoral angle, and mechanical medial proximal tibial angle, and mechanical axis deviation correction rate. Mechanical axis deviation correction rate had the highest odds ratios. The machine learning classification model for predicting rebound growth built from the study data showed a misclassification rate of 39%.

Conclusion: There was a high rate of rebound growth in this cohort, especially for patients at a young age at implantation. The highest risk factors for rebound growth were male sex, and high correction rates, such as found during peak growth spurt. The proposed classification model needs more data to improve its predictive power before it can be used in clinics.

Level of evidence: Level III.

Background: The study aim was to present four new well-documented cases of spontaneous improvement of olisthetic scoliosis and to analyze well-documented cases from the literature.

Methods: Surgical log search and systematic review were conducted. Inclusion criteria were (1) age less than 18 years, (2) symptomatic high-grade (≥50%) spondylolisthesis, (3) scoliosis ≥20^o, (4) primary surgical treatment via lumbosacral fusion, (5) complete x-rays, and (6) minimum 1-year radiographic follow-up or until curve resolution.

Results: A total of 13 patients with average age of 13.9 years were included in the study, 4 from the authors' surgical logs and 9 from the literature. Slip percentage of L5-S1 ranged from 51% to 95%. Olisthetic curve magnitude averaged 34.6° (range: 20°-45°) with majority (8/13) demonstrating long thoracic curves with lateral trunk shift. All but one of these were apex right with rightward trunk shift. The remainder of the curves were isolated lumbar curves, with an apex left morphology without trunk shift. Eleven of the 13 patients showed curve improvement following isolated lumbosacral fusion. Three patients experienced a decrease in curve magnitude of 12°-28° and eight patients enjoyed complete resolution (≤10°) of their scoliosis.

Conclusion: The current study summarizes 13 well-documented cases of olisthetic scoliosis (4 new cases and 9 from the literature) that associated with symptomatic high-grade spondylolisthesis. All were treated via a primary posterior lumbosacral fusion strategy. Eleven of the 13 curves showed spontaneous improvement (8 complete resolution of scoliosis) following their lumbosacral surgery.

Level of evidence: Therapeutic level IV.

Purpose: Previous literature has shown decreases in pediatric trauma during the COVID-19 outbreak, but few have analyzed beyond the peak of the pandemic. This study assesses the epidemiology of pediatric trauma cases in a high-volume teaching hospital in New York City before, during, and after the height of the COVID-19 pandemic.

Methods: Institutional data on pediatric trauma orthopedic cases from January 1, 2018 to November 30, 2021 were extracted. The following time frames were studied: (1) April 1-June 22 in 2018 and 2019 (pre-pandemic), (2) April 1-June 22, 2020 (peak pandemic), and (3) April 1-June 22, 2021 (post-peak pandemic). Inferential statistics were used to compare patient and trauma characteristics.

Results: Compared to the pre-pandemic cohort (n = 6770), the peak pandemic cohort (n = 828) had a greater proportion of fractures (p < 0.01) and had a significantly decreased overall traumas per week rate (p < 0.01) and fractures per week rate (p < 0.01). These decreased trauma (p < 0.01) and fracture rates (p < 0.01) persisted for the post-peak pandemic cohort (n = 2509). Spatial analysis identified zip code clusters throughout New York City with higher rates of emergency department presentation during the peak pandemic compared to pre-pandemic, and these areas aligned with lower-income neighborhoods.

Conclusion: During the peak of the pandemic, overall trauma and fracture volumes decreased, the types of prevalent injuries changed, and neighborhoods of different economic resources were variably impacted. These trends have mostly persisted for 12 months post-peak pandemic. This longitudinal analysis helps inform and improve long-term critical care and public health resource allocation for the future.

Level of evidence: Level III.

Purpose: To examine whether differences in bone resorption patterns in the anterior portion of the femoral head correlate with the prognosis of Legg-Calvé-Perthes disease.

Methods: Seventy-eight patients with unilateral Legg-Calvé-Perthes disease, who were diagnosed after 6.0 years of age, underwent the Salter innominate osteotomy from 1987 to 2013, and were followed up to skeletal maturity. The anterior bone resorption pattern of the femoral head was evaluated from a frog-leg lateral hip radiograph made in the middle of the fragmentation period, and classified into two types, an epiphysis-preserved type (P) and a physis-disrupted type (D). The correlation between the type of bone resorption and the Stulberg outcome was analyzed.

Results: The Stulberg outcomes were grade I for 9 patients, grade II for 31, grade III for 35, and grade IV for 3, with a mean follow-up period of 8.3 ± 2.7 years. Fifty-one patients demonstrated the type P hips and 27 did the type D hip. In a subset analysis of patients with the modified lateral pillar group-B hips in the younger group (6.0-8.9 years of age at diagnosis), the percentages of the favorable and unfavorable outcomes significantly differed between the two types (p = 0.013). Anteroposterior enlargement of the affected femoral head was significantly greater in the type D hips than the type P hips (p = 0.014).

Conclusion: Unfavorable hip morphology at skeletal maturity can be predicted in patients with the lateral pillar group-B hips by focusing on bone resorption patterns of the anterior portion of the femoral head.

Level of evidence: Level III, prognostic study.

Objectives: The aim of this study was to report the incidence of femoral nerve palsy in developmental dysplasia of the hip children treated with Pavlik harness, to identify any possible associated risk factors, and to evaluate its outcome without any specific strap release.

Methods: A retrospective chart review was conducted on all cases of femoral nerve palsy in a consecutive series of children who underwent Pavlik harness treatment for developmental dysplasia of the hip. In unilateral cases, the developmental dysplasia of the hip was compared to the contralateral side. All hips with femoral nerve palsy were compared to the remaining hips of the series and any possible risk factor for paralysis was recorded.

Results: In total, 53 cases of femoral nerve palsy of various severity were identified from a group of 473 children with 527 hips treated for developmental dysplasia of the hip at an average age of 3.9 months. However, 93% occurred during the first 2 weeks of treatment. Femoral nerve palsy was more common in older and larger children with the most severe Tonnis type, and a hip flexion angle in the harness above 90° (p < 0.03 for all). All of them resolved spontaneously before completion of treatment without any specific measures. We found no correlation between the presence of femoral nerve palsy or the time taken for spontaneous resolution and treatment failure using the harness.

Conclusion: Femoral nerve palsy is most observed with higher Tonnis types and high hip flexion angles in the harness, but its presence by itself is not predictive of treatment failure. It resolves spontaneously before completion of treatment and does not require any strap release or harness discontinuation.

Level of evidence: Level III.

Purpose: This study aimed to determine the functional and radiographic outcomes following corrective distal humeral osteotomies for the treatment of supracondylar fracture malunions in children. We hypothesized that such secondary reconstructive procedures could restore a reasonable and near-normal amount of functionality in a large patient cohort at a tertiary referral center.

Methods: We retrospectively reviewed the clinical and radiological records of 38 children who underwent corrective osteotomy for posttraumatic supracondylar humeral malunion using K-wire fixation. All clinical data were extracted after chart review, including age, sex, dominant side whenever available, follow-up duration, and elbow range of motion preoperatively and at the final visit. Radiographic parameters, including Baumann's angle, humeroulnar angle, humerocondylar angle, and elbow range of motion were evaluated preoperatively, postoperatively, and at the final visit to identify the surgical correction outcomes.

Results: The mean age of the patients at fracture was 5.6 (±2.7) years, and the mean age at surgical intervention was 8.6 (±2.6) years. The mean follow-up period of the current series was 28.2 (±31.1) months. Baumann's angle, humeroulnar angle, and humerocondylar angle were successfully restored to physiological ranges (72.6°, 5.4°, and 36.1°, respectively). Postoperatively, elbow extension improved from -22° (±5.7) to -2.7° (±7.2) versus flexion from 115° (±13.2) to 128.2° (±11.1). Three revision surgeries (8%) were encountered.

Conclusions: Corrective osteotomy of the distal humerus with K-wire fixation is a reliable method to efficiently correct malunion of the distal humerus in different planes, thereby improving elbow range of motion and appearance.

Level of evidence: level IV: Retrospective therapeutic study.

Objectives: Distal forearm fractures are the most common pediatric fractures. This study aimed to investigate the effectiveness of below-elbow cast treatment for displaced distal forearm fractures in children compared to above-elbow cast through meta-analysis of randomized controlled trials.

Methods: Several databases from January 1, 2000 until October 1, 2021 were searched for randomized controlled trials that assessed below versus above-elbow cast treatment of displaced distal forearm fractures in pediatric patients. The main meta-analysis comparison was based on the relative risk of loss of fracture reduction between children undergoing below versus above-elbow cast treatment. Other outcome measures including re-manipulation and cast-related complications were also investigated.

Results: Nine studies were eligible of the 156 articles identified, with a total of 1049 children. Analysis was undertaken for all included studies with a sensitivity analysis conducted for studies with high quality. In the sensitivity analysis, the relative risks of loss of fracture reduction (relative risk = 0.6, 95% confidence interval = 0.38, 0.96) and re-manipulation (relative risk = 0.3, 95% confidence interval = 0.19, 0.48) between the below and above-elbow cast groups were in favor of below-elbow cast and statistically significant. Cast-related complications were in favor of below-elbow cast but did not attain statistical significance (relative risk = 0.45, 95% confidence interval = 0.05, 3.99). Loss of fracture reduction was noted in 28.9% of patients treated with above-elbow cast and 21.5% in below-elbow cast. Re-manipulation was attempted in 48.1% versus 53.8% of children who lost fracture reduction in the below-elbow cast and above-elbow cast groups, respectively.

Conclusion: Below-elbow cast treatment was favored, with statistical significance, in terms of loss of fracture reduction and re-manipulation, and was not associated with a higher risk of cast-related complications. The accumulative evidence currently does not support above-elbow cast treatment and below-elbow cast treatment should be the mainstay for displaced distal forearm fractures in children.

Level of evidence: Level I, meta-analysis of therapeutic level I studies.