Journal of Pediatric Orthopaedics - Most Popular Articles

Background: Foot deformities have been frequently reported in cerebral palsy (CP), and numerous diagnostic modalities and treatment options have recently been developed to achieve a better level of management for children with CP. Methods: A thorough search of the English literature, published between January 2013 and March 2016, was performed. A summary of the new findings that had not previously described was reported. The review included recent advances regarding clinical and gait evaluation, orthotic management, botulinum toxin A treatment, and surgical correction. Results: The review summarized new findings reported in 46 articles and abstracts that were published between January 2013 and March 2016. Older articles were included and cited when an original description was mentioned, or when a change or development of some findings was discussed. Conclusions: Foot deformity forms an essential part of evaluating children with CP. Dramatic advances have been achieved in gait assessment, conservative management, and surgical correction. Promising results have been reported with the goal to reach a higher level of orthopaedic care and optimize the functional potentials for children with CP. Level of Evidence: Level IV—literature review.
Posted: January 1, 2018, 12:00 am
imageBackground: Early-onset scoliosis (EOS) affects roughly 1 to 2 out of 10,000 live births per year. Because this subset of patients has a yet to achieve a majority of their skeletal growth, a number of treatment challenges need to be addressed before surgical intervention. If left untreated, EOS can cause a number of problems throughout the patient’s lifespan, particularly in regards to the growth of the thorax and pulmonary development. A wide variety of surgical systems and techniques are available to the treating surgeon. Methods: A review of the orthopaedic literature from 2010 to 2015 relating to pediatric spine growth modulation was performed. Ninety-eight papers were identified and, following exclusion criteria, a total of 31 papers were selected for further review. Results: This paper summarizes the recently published literature regarding growth-friendly spinal implants, the status of their Food and Drug Administration approval labeling as well as the indications, applications, and complications associated with their implementation. Conclusions: There are a growing number of options at the surgeon’s disposal when treating patients with EOS. As surgeons, we must continue to be vigilant in our demand for sound clinical evidence as we strive to provide optimal care for our patients. The rapidly advancing field of spinal growth modulation is exciting. More work must be done to further enhance our ability to predictably modulate growth in the pediatric spine.
Posted: January 1, 2018, 12:00 am
imageBackground: Few studies have investigated outcomes after adjunct botulinum toxin type A (BTX-A) injections into the shoulder internal rotator muscles during shoulder closed reduction and spica cast immobilization in children with brachial plexus birth palsy. The purpose of this study was to report success rates after treatment and identify pretreatment predictors of success. Methods: Children with brachial plexus birth palsy who underwent closed glenohumeral joint reduction with BTX-A and casting were included. Minimum follow-up was 1 year. Included patients did not receive concomitant shoulder surgery nor undergo microsurgery within 8 months. Records were reviewed for severity of palsy, age, physical examination scores, passive external rotation (PER), and subsequent orthopaedic procedures (repeat injections, repeat reduction, shoulder tendon transfers, and humeral osteotomy). Treatment success was defined in 3 separate ways: no subsequent surgical reduction, no subsequent closed or surgical reduction, and no subsequent procedure plus adequate external rotation. Results: Forty-nine patients were included. Average age at time of treatment was 11.5 months. Average follow-up was 21.1 months (range, 1 to 9 y). Thirty-two patients (65%) required repeat reduction (closed or surgical). Only 16% of all patients obtained adequate active external rotation without any subsequent procedure. Increased PER (average 41±14 degrees, odds ratio=1.21, P=0.01) and Active Movement Scale external rotation (average 1.3, odds ratio=2.36, P=0.02) predicted optimal treatment success. Limited pretreatment PER (average −1±17 degrees) was associated with treatment failure. Using the optimal definition for success, all patients with pretreatment PER>30 degrees qualified as successes and all patients with PER30 degrees can help identify which patients are most likely to experience successful outcomes after shoulder closed reduction with BTX-A and cast immobilization. However, a large proportion of these patients will still have mild shoulder subluxation or external rotation deficits warranting subsequent intervention. Level of Evidence: Level IV—therapeutic.
Posted: January 1, 2018, 12:00 am
imagePurpose: The purpose of this study was to investigate the indications and outcomes of dynamic splinting (DS) of the arthrofibrotic knee in the pediatric population. Methods: Seventy-four patients (41 males, 33 females) with postoperative arthrofibrosis treated with DS after an index knee surgery were reviewed. Median age was 13 years (range, 4 to 18 y), and median follow-up was 17 months (interquartile range, 10 to 28 mo). Demographics, index surgery procedure, preoperative and postoperative knee range of motion (ROM) measurements, treatment length and subsequent need for manipulation under anesthesia (MUA), and surgical lysis of adhesions (LOA) were evaluated. A ROM deficit was defined as lack of extension ≥10 degrees or lack of flexion
Posted: January 1, 2018, 12:00 am
imageNo abstract available
Posted: January 1, 2018, 12:00 am
imageBackground: The modified Dunn procedure has been shown to be safe and effective in treating unstable slipped capital femoral epiphysis (SCFE). We present a consecutive series of unstable SCFE managed by a single surgeon with a focus on timing of surgical intervention, postoperative complications, and radiographic results. Methods: Thirty-one consecutive unstable SCFEs were treated. Demographics, presentation time to time of operation, surgical times, and complications were recorded. Bilateral hip radiographs at latest follow-up were utilized to record slip angle, α angle, greater trochanteric height, and femoral neck length. Results: Thirty-one consecutive hips in 30 patients were reviewed: 15 males (50%) and 15 females (50%), average age 12.37 years (range, 8.75 to 14.8 y), 20 left hips (65%) and 11 right hips (35%). Mean follow-up was 27.9 months (range, 1 to 82 mo). Time from presentation to intervention averaged 13.9 hours (range, 2.17 to 23.4 h). Two patients (6%) developed avascular necrosis at average 19 weeks postoperative. Three patients (10%) developed mild heterotopic ossification requiring no treatment. Two patients (6%) required removal of symptomatic hardware. One patient had hardware failure and in no patients was nonunion, delayed union, or postoperative hip subluxation/dislocation seen. Three patients (10%) presented with bilateral, stable SCFE requiring contralateral in situ pinning. Five patients (16%) had sequential SCFE requiring treatment with 1 patient having an acute, unstable SCFE 10 months after the previous realignment. Mean postoperative slip angle measured 2.5 degrees (range, +19 to −9.4 degrees) (SD, 7.2), α angle 47.43 degrees (range, 34 to 64 degrees) (SD, 7.49), greater trochanteric height averaged 3.5 mm below the center of femoral head (−17.5 to +25 mm), and mean femoral neck length difference measured −7.75 mm (range, −1.8 to −18.6 mm). Conclusions: A single surgeon series of unstable SCFEs treated by a modified Dunn procedure showed a 6% incidence of avascular necrosis and low complication rates at latest follow-up. Radiographs showed restoration of the slip angle, α angle, femoral neck length, and greater trochanteric height. This series reveals the safety and effectiveness of the modified Dunn procedure for unstable SCFE. Level of Evidence: Level III—retrospective review.
Posted: January 1, 2018, 12:00 am
imageBackground: Open treatment of femoroacetabular impingement (FAI) through a surgical hip dislocation (SHD) approach has been reported to allow for improvement in pain and function. However, the approach require a trochanteric osteotomy and may be associated with high level of pain after surgery. Currently, there is no systematic approach for pain management after SHD for treatment of FAI. Methods: A retrospective chart review was used to collect data from 121 subjects (12 to 21 y and below) who received periarticular local infiltration analgesia (LIA, n=20), epidural analgesia (n=72), or intravenous patient-controlled analgesia (PCA, n=29) after SHD from January 2003 to June 2014. Verbal pain scores, opioid consumption, incidence of side effects/complications, and length of hospital stay (LOS) were recorded. All nonopioid medications with analgesic potential were included in the statistical models as potential confounding variables Results: Twelve hours after surgery, the odds of moderate/severe pain were higher in the PCA group (odds ratio, 20.5; 95% confidence interval (CI), 1.7-243.8; P=0.0166] and epidural group (odds ratio, 5.2; 95% CI, 0.7-92.0; P=0.3218) compared with the LIA group. There was no difference in pain scores across all groups 1 hour (P=0.0675) or 24 hours (P=0.3473) postoperatively. Total opioid consumption in the LIA group was 59.8% (95% CI, 15.0%-81.0%; P=0.0175) lower than the total opioid consumption in the epidural group and 60.7% (95% CI, 17.3-81.3; P=0.0144) lower than the total opioid consumption in the PCA group. LOS was increased in the epidural (mean difference, 22.1; 95% CI, 6.8-37.4 h; P=0.0051) and PCA (mean difference, 16 h; 95% CI, 1-31.5 h; P=0.0367) groups relative to the LIA group. There was 0 (0%) complication in the LIA group compared with 11 (15.3%) in the epidural group. Conclusions: LIA was more effective at controlling pain 12 hours after surgery in comparison with PCA with similar pain control to epidural. LIA was associated with significantly lower need for opioids and shorter LOS compared with the PCA and epidural protocols. Periarticular infiltration should be considered for pain management after SHD for treatment of FAI in adolescents. Level of Evidence: Level III—retrospective comparative study.
Posted: January 1, 2018, 12:00 am
No abstract available
Posted: January 1, 2018, 12:00 am
imageBackground: The Tonnis radiographic classification of developmental dysplasia of the hip (DDH) has been used as a prognostic indicator for patients with walking-age DDH. The International Hip Dysplasia Institute (IHDI) classification, a new radiographic classification system, has been proposed to be more reliable by its creators. We sought to validate its reliability using independent observers, to compare it to the Tonnis method, and to assess its prognostic significance in a large cohort of patients. Methods: A consecutive series of walking-age DDH patients were examined radiographically and classified by the Tonnis and IHDI schemes by 3 independent observers. Interobserver agreement was determined using the Kappa method. Clinical data were collected on patients with regard to success of closed reduction, need for later pelvic osteotomy, and presence of subsequent radiographic avascular necrosis (AVN). The prognostic value of the Tonnis and IHDI classifications to predict these clinical outcomes was determined. Results: A total of 287 hips were available for analysis of the classification schemes. In total, 235 hips underwent attempted closed reduction and were eligible for analysis of successful closed reduction, and 131 hips had >4-year follow-up and were utilized for analysis of late pelvic osteotomy and AVN. Both classifications showed excellent interobserver reliability and in general, there was nonstatistically significant better reliability for the IHDI versus the Tonnis classification. In multivariate analysis, both IHDI and Tonnis classifications were found to be predictive of successful closed reduction and need for late pelvic osteotomy. Both methods showed trends toward being predictive of AVN rate, without statistical significance. Conclusions: The IHDI classification is subjectively more facile to use and has excellent interrelater agreement for classifying the radiographic severity of DDH. It is also reliable in predicting success of closed reduction and need for late pelvic osteotomy. Significance: practitioners and researchers should consider the IHDI classification as a useful classification scheme and prognosticator when considering treatment options for late-presenting DDH. Significance: Practitioners and researchers should consider the IHDI classification as a useful classification scheme and prognosticator when considering treatment options for late-presenting DDH. Level of Evidence: Level III.
Posted: January 1, 2018, 12:00 am
imageHypothesis: The modified Gartland classification system for pediatric supracondylar fractures is often utilized as a communication tool to aid in determining whether or not a fracture warrants operative intervention. This study sought to determine the interobserver and intraobserver reliability of the Gartland classification system, as well as to determine whether there was agreement that a fracture warranted operative intervention regardless of the classification system. Methods: A total of 200 anteroposterior and lateral radiographs of pediatric supracondylar humerus fractures were retrospectively reviewed by 3 fellowship-trained pediatric orthopaedic surgeons and 2 orthopaedic residents and then classified as type I, IIa, IIb, or III. The surgeons then recorded whether they would treat the fracture nonoperatively or operatively. The κ coefficients were calculated to determine interobserver and intraobserver reliability. Results: Overall, the Wilkins-modified Gartland classification has low-moderate interobserver reliability (κ=0.475) and high intraobserver reliability (κ=0.777). A low interobserver reliability was found when differentiating between type IIa and IIb (κ=0.240) among attendings. There was moderate-high interobserver reliability for the decision to operate (κ=0.691) and high intraobserver reliability (κ=0.760). Decreased interobserver reliability was present for decision to operate among residents. For fractures classified as type I, the decision to operate was made 3% of the time and 27% for type IIa. The decision was made to operate 99% of the time for type IIb and 100% for type III. Summary: There is almost full agreement for the nonoperative treatment of Type I fractures and operative treatment for type III fractures. There is agreement that type IIb fractures should be treated operatively and that the majority of type IIa fractures should be treated nonoperatively. However, the interobserver reliability for differentiating between type IIa and IIb fractures is low. Our results validate the Gartland classfication system as a method to help direct treatment of pediatric supracondylar humerus fractures, although the modification of the system, IIa versus IIb, seems to have limited reliability and utility. Terminology based on decision to treat may lead to a more clinically useful classification system in the evaluation and treatment of pediatric supracondylar humerus fractures. Level of Evidence: Level III—diagnostic studies.
Posted: January 1, 2018, 12:00 am
imageBackground: Adolescent idiopathic scoliosis (AIS) patients undergoing posterior spinal fusion (PSF) experience variations in their hospital care, which may lead to differences in objective and patient-reported outcomes. The purpose of this study was to demonstrate that using plan of care—educating families preoperatively and standardizing some aspects of care—would decrease time to mobility and time to discharge while maintaining pain control and patient satisfaction. Methods: Chart review was conducted in 3 groups—preprotocol (December 2008 to December 2009, n=51), first protocol (December 2, 2009 to July 24, 2013, n=100), and second protocol (July 25, 2013 to June 1, 2014, n=39)—to track pain scores (0 to 10), time to regular diet, Foley catheter removal, epidural catheter removal, mobility, and discharge. Patient satisfaction surveys (0 to 10) were administered before discharge. Statistical analysis was performed using a 1-way analysis of variance test with Tukey post hoc analysis. Results: Average pain scores were similar in all groups. Time to sitting was significantly reduced in both first protocol (27.2±9.8 h, P=1×10−8) and second protocol (28.4±13.6 h, P=3×10−5) compared with preprotocol (40.2±15.4 h). Time to discharge was significantly lower in second protocol (84.3±27.2 h, P=0.036) compared with first protocol (98.4±27.8 h). Patient satisfaction with care was significantly higher in first protocol (9.1/10, P=2×10−6) and second protocol (8.6/10, P=5×10−4) compared with preprotocol (6.5/10). Conclusions: By educating families preoperatively and standardizing portions of postoperative care in PSF for AIS, pain scores were significantly reduced while overall satisfaction remained high. Specifically, by removing the epidural and Foley catheters on postoperative day 2, time to discharge was dramatically decreased by 15 hours. The application of a multidisciplinary, evidence-driven plan of care for AIS patients undergoing PSF improves throughput and has beneficial effects on objective and patient-reported outcomes. Level of Evidence: Level III—retrospective case series.
Posted: December 1, 2017, 12:00 am
imageBackground: The objective of the research was to study the relevance of intraoperative neuromonitoring throughout all stages of surgical management in patients with progressive early-onset scoliosis (EOS). The routine monitoring of spinal cord potentials has gradually become standard of practice among spinal surgeons. However, there is not a consensus that the added expense of this technique necessitates monitoring in all stages of surgical management. Methods: A retrospective review of 180 surgical cases of 30 patients with EOS from July 2003 to July 2012 was performed. All monitoring alerts as judged by the neuromonitoring team were identified. Both somatosensory-evoked potentials and transcranial electric motor-evoked potentials were studied and no limiting thresholds for reporting electrophysiological changes were deemed appropriate. Results: Of 150 monitored cases there were 18 (12%) monitoring alerts. This represented 40% of the patient cohort over the 9-year study period. Conclusions: Index versus routine lengthening rate of alerts showed no significant difference in incidence of monitoring alerts. Conversely, several patients whose primary implantation surgeries were uneventful had monitoring alerts later in their treatment course. Intraoperative neuromonitoring is warranted throughout all stages of surgical management of EOS. Level of Evidence: Level IV. This study is a retrospective review of surgical cases of 30 patients with EOS.
Posted: December 1, 2017, 12:00 am
imageStudy Design: A retrospective review of prospective data Objective: The purpose of this study was to compare operative and nonoperative patients with similar curve magnitudes to determine motivating factors associated with surgical correction in “smaller” curves. Summary of Background Data: Despite traditional treatment recommendations on major curve angle measurements, many patients with thoracolumbar/lumbar (TH/L) curves of smaller magnitudes are unhappy and desire correction. Methods: A prospectively enrolled multicenter adolescent idiopathic scoliosis database was queried. Patients with major TH/L curves
Posted: December 1, 2017, 12:00 am
imageBackground: Intraoperative neuromonitoring (IONM) is widely used to reduce postoperative neurological complications during scoliosis correction. IONM allows intraoperative detection of neurological insults to the spinal cord and enables surgeons to react in real time. IONM failure rates can reach 61% in patients with cerebral palsy (CP). Factors decreasing the quality of IONM signals or making IONM impossible in CP patients undergoing scoliosis correction have not been well described. Methods: We categorized IONM data from 206 children with CP who underwent surgical scoliosis correction at a single institution from 2002 through 2013 into 3 groups: (1) “no signals,” if neither somatosensory-evoked potentials (SSEP) nor transcranial motor-evoked potentials (TcMEP) could be obtained; (2) “no sensory,” if no interpretable SSEP were obtained regardless of interpretable TcMEP; and (3) “no motor,” if no interpretable TcMEP were obtained regardless of interpretable SSEP. We analyzed preexisting neuroimaging, available for 93 patients, and neurological status of the full cohort against these categories. Statistical analysis of univariate and multivariate associations was performed using logistic regression. Odds ratios (ORs) were calculated with significance set at P
Posted: December 1, 2017, 12:00 am
imageBackground: Our objective was to quantify blood loss and transfusion requirements for high-dose and low-dose tranexamic acid (TXA) dosing regimens in pediatric patients undergoing spinal fusion for correction of idiopathic scoliosis. Previous investigators have established the efficacy of TXA in pediatric scoliosis surgery; however, the dosing regimens vary widely and the optimal dose has not been established. Methods: We retrospectively analyzed electronic medical records for 116 patients who underwent spinal fusion surgery for idiopathic scoliosis by a single surgeon and were treated with TXA. In total, 72 patients received a 10 mg/kg loading dose with a 1 mg/kg/h maintenance dose (low-dose) and 44 patients received 50 mg/kg loading dose with a 5 mg/kg/h maintenance dose (high-dose). Estimated blood loss and transfusion requirements were compared between dosing groups. Results: Patient characteristics were nearly identical between the 2 groups. Compared with the low-dose TXA group, the high-dose TXA group had decreased estimated blood loss (695 vs. 968 mL, P=0.01), and a decrease in both intraoperative (0.3 vs. 0.9 units, P=0.01) and whole hospitalization (0.4 vs. 1.0 units, P=0.04) red blood cell transfusion requirements. The higher-dose TXA was associated with decreased intraoperative (P=0.01), and whole hospital transfusion (P=0.01) requirements, even after risk-adjustment for potential confounding variables. Conclusions: High-dose TXA is more effective than low-dose TXA in reducing blood loss and transfusion requirements in pediatric idiopathic scoliosis patients undergoing surgery. Level of Evidence: Level—III, retrospective cohort study.
Posted: December 1, 2017, 12:00 am
imageBackground: Stüve-Wiedemann syndrome is a rare inherited condition, which is frequently fatal in infancy. Those patients who survive into childhood demonstrate a complex progressive deformity of the long bones, with high rates of recurrence after initial successful correction. Because of the rarity of the condition there is, at present, limited evidence on the most appropriate treatment. Methods: We describe our experience in the management of 4 patients, who underwent correction of deformity and fixation with Fassier-Duval telescopic rods. Results: In this series we have seen good correction of deformity and maintenance of alignment, with improvement in the walking ability of children treated with this technique. Conclusion: Fassier-Duval rodding has a role in the prevention of recurrence of deformity and should be considered as a means to reduce the number of operative procedures required. Level of Evidence: Level IV—therapeutic.
Posted: December 1, 2017, 12:00 am
imageBackground: Clinical evidence regarding the ability of braces to decrease the risk of curve progression to surgical threshold in patients with adolescent idiopathic scoliosis (AIS) continues to strengthen. Unfortunately, there is still a great deal of uncertainty regarding the impact of brace wear on psychosocial well-being or the impact of psychological well-being on brace wear adherence. The purpose of this study is to evaluate psychosocial well-being, in particular body image and quality of life (QOL), and brace wear adherence in female AIS patients undergoing brace treatment. Methods: The Bracing in Adolescent Idiopathic Scoliosis Trial (BrAIST) was a multicenter, controlled trial using randomized and preference assignments into an observation or brace treatment group. BrAIST patients were skeletally immature adolescents diagnosed with AIS having moderate curve sizes (20 to 40 degrees). Patients in the bracing group were instructed to wear a thoracolumbosacral orthosis, at least 18 h/d. Scores on the Spinal Appearance Questionnaire and the PedsQL4.0 Generic Scales from 167 female BrAIST patients who were randomized to brace treatment (n=58) and patients who chose brace treatment (n=109) were analyzed. Results: At baseline and at 12 months, no differences were found between the least-adherent brace wear group (
Posted: December 1, 2017, 12:00 am
imageBackground: The aim of surgical treatment of scoliosis is to obtain fusion of the spinal column, balanced in the coronal and sagittal planes. Great success has been attained with coronal correction; however, the sagittal profile has received less attention, resulting in little correction of sagittal plane alignment. The purpose of this study was to compare uniplanar and fixed pedicle screws in the correction of the thoracic sagittal alignment in the treatment of adolescent idiopathic scoliosis (AIS). Methods: The sagittal profile of 2 groups of patients undergoing posterior spinal fusion (PSF) for AIS was compared. One group had uniplanar screws (n=16) as bone anchors, and the second group had fixed screws (n=20). Consecutive patients with AIS treated by PSF during 2004 to 2006 with fixed screws; and those treated in 2008 with uniplanar screws were included in the study. Data included: patient demographics, medical conditions, curve type, Risser stage, coronal and sagittal curve magnitude, curve flexibility, osteotomies, fusion levels, type and location of instrumentation, curve magnitude at the initial postoperative visit and at final follow-up. ANOVA and χ2 testing was completed. A P
Posted: December 1, 2017, 12:00 am
imageBackground: Spinal muscular atrophy (SMA) is a progressive neuromuscular disease commonly including progressive scoliosis resulting in severe deformity and negatively affecting pulmonary function. Surgical correction and stabilization of this progressive deformity is generally recommended; however, the timing and method of surgical fixation remains controversial. Methods: Retrospective review of clinical, radiographic, and pulmonary function data from 16 children with SMA and surgically treated scoliosis between 1985 and 2013. Radiographic data included direct measures of major curve, coronal balance, pelvic obliquity, T1-T12 height, T1-S1 height, and T1-rod length. Estimations of rib collapse, thoracic cavity shape, and space-available-for-lung (T6:T12, width ratio; T6:T10, rib-vertebral-angle difference ratios; and lung height) were determined. Eleven patients were able to complete pulmonary function testing. Results were compared with published outcomes for growing rod constructs. Results: Posterior spinal fusion was performed at an average age of 9.8±3.6 years. The mean age at most recent follow-up was 19.4 years (range, 10 to 37 y), with a mean follow-up of 10.1 years (range, 3.1 to 26 y). Radiographic measurements improved from preoperative to latest follow-up as follows: major curve, 78±20 degrees to 27±24 degrees; coronal balance, 4.1±4.0 cm to 1.9±2.2 cm; pelvic obliquity (median), 23 to 5 degrees; T1-T12 height, 19±3 cm to 22±3 cm; T1-S1 height, 31±7 cm to 36±6 cm; T1-rod length, 0.8±1.1 cm (postop) to 2.8±1.6 cm (final); and space-available-for-lung ratio, 0.88±0.26 to 0.95±0.25. Rib collapse continued throughout the follow-up period in all but 1 patient. Pulmonary function testing demonstrated a decrease in rate of decline in forced vital capacity and forced expiratory volume when comparing preoperative with postoperative rates. Mean length of stay was 7.8±4.4 days. Complications included reintubation for low tidal volumes (n=1), pneumonia (n=1), superficial wound breakdown (n=1), and superficial infection (n=1). Conclusions: Definitive posterior spinal fusion for treatment of scoliosis associated with SMA is effective at controlling curve progression and pelvic obliquity without negatively impacting the space-available-for-lung ratio, trunk height, or pulmonary function at 10 years follow-up. Level of Evidence: Therapeutic Level IV.
Posted: December 1, 2017, 12:00 am
imageBackground: The purpose of this study was to compare the outcomes of the SHILLA GROWTH GUIDANCE SYSTEM and “intermittent distraction growing rod” (IDGR) in the treatment of children (less than 10 y of age) with progressive spinal deformity. This was a multicenter retrospective study of the SHILLA used as an alternative treatment to IDGR to support an HDE submission for Food and Drug Administration approval. Methods: Inclusion criteria were progressive scoliosis in a patient less than 10 years of age at index procedure. The study population consisted of 19 SHILLA and 6 IDGR patients whose mean age was 6.1 and 5.8 years, respectively. Group demographics were similar between the 2 groups. Results: The initial major curve magnitude was 70.3 degrees for SHILLA and 68.3 degrees for IDGR, which decreased postoperatively to 22.4 degrees (68.1% improvement) and 32.2 degrees (52.9% improvement). During the first 4 years the correction for SHILLA varied from 40.5% to 53.4% and for IDGR from 40.9% to 56.9%. At last follow-up, T1-S1 length was 32.9 cm for SHILLA (4.2 increase from preoperation) and 34.0 cm (5.0 cm increase from preoperation) for IDGR. Average growth per month from T1-S1: SHILLA 0.14 cm, IDGR 0.11 cm. Sagittal T2-T12 preoperatively was 36.3 degrees for SHILLA and 30.0 degrees for IDGR. There were 29 reoperations in 12 of the 19 SHILLA patients (63.2%) and 40 reoperations in all 6 of the IDGR patients (100%) related to the index procedure. Conclusions: The SHILLA GROWTH GUIDANCE SYSTEM compares favorably with traditional IDGR constructs in terms of correction of the major curve, spinal length and growth, and maintenance of sagittal alignment. The >4-fold decrease in additional surgeries makes the SHILLA an attractive alternative to minimize comorbidities associated with additional surgeries. Levels of Evidence: Level III.
Posted: December 1, 2017, 12:00 am
imageBackground: Scoliosis has been shown to have detrimental effects on pulmonary function, traditionally measured by pulmonary function tests, which is theorized to be correlated to the distortion of the spine and thorax. The changes in thoracic volume with surgical correction have not been well quantified. This study seeks to define the effect of surgical correction on thoracic volume in patients with adolescent idiopathic scoliosis. Methods: Images were obtained from adolescents with idiopathic scoliosis enrolled in a multicenter database (Prospective Pediatric Scoliosis Study). A convenience sample of patients with Lenke type 1 curves with a complete data set meeting specific parameters was used. Blender v2.63a software was used to construct a 3-dimensional (3D) computational model of the spine from 2-dimensional calibrated radiographs. To accomplish this, the 3D thorax model was deformed to match the calibrated radiographs. The thorax volume was then calculated in cubic centimeters using Mimics v15 software. Results: The results using this computational modeling technique demonstrated that surgical correction resulted in decreased curve measurement as determined by Cobb method, and increased postoperative thoracic volume as expected. Thoracic volume significantly increased by a mean of 567 mm3 (P
Posted: December 1, 2017, 12:00 am
imageBackground: Respiratory weakness and spinal deformity are common in patients with spinal muscular atrophy (SMA). Posterior (distraction type) growing rods have recently gained favor as a treatment option in this population, due to their ability to prevent spinal deformity progression and their potential to allow lung volumes to increase over time. The objective of this study was to determine the impact of posterior growing rods on the spinal alignment and respiratory function in children with SMA with intermediate term follow-up. Methods: A single center, retrospective review was performed on SMA patients treated with growing rods, inserted between 2004 and 2010, with a minimum of 2-year follow-up. SMA type, changes in the route of bi-level positive airway pressure respiratory support and the amount of time receiving respiratory support are reported. Pulmonary function tests (PFTs) and radiographs were reviewed and data evaluated preinsertion, postinsertion, and at latest follow-up. Results: Sixteen children with SMA (5 type I, 11 type II) met inclusion criteria. The average age of insertion was 5.8 (±1.5) years, the median number of lengthenings was 4 (range, 3 to 5), and the median time between insertion and last clinical review was 4.7 (range, 2.7 to 9.5) years. Radiographic review demonstrated significant (P
Posted: December 1, 2017, 12:00 am
imageBackground: There is a need to better assess patient satisfaction and surgical outcomes. The purpose of the current study is to identify how preoperative expectations can impact postsurgical satisfaction among youth with adolescent idiopathic scoliosis undergoing spinal fusion surgery. Methods: The present study includes patients with adolescent idiopathic scoliosis undergoing spinal fusion surgery enrolled in a prospective, multicentered registry examining postsurgical outcomes. The Scoliosis Research Society Questionnaire—Version 30, which assesses pain, self-image, mental health, and satisfaction with management, along with the Spinal Appearance Questionnaire, which measures surgical expectations was administered to 190 patients before surgery and 1 and 2 years postoperatively. Regression analyses with bootstrapping (with n=5000 bootstrap samples) were conducted with 99% bias-corrected confidence intervals to examine the extent to which preoperative expectations for spinal appearance mediated the relationship between presurgical mental health and pain and 2-year postsurgical satisfaction. Results: Results indicate that preoperative mental health, pain, and expectations are predictive of postsurgical satisfaction. Conclusions: With the shifting health care system, physicians may want to consider patient mental health, pain, and expectations before surgery to optimize satisfaction and ultimately improve clinical care and patient outcomes. Level of Evidence: Level I—prognostic study.
Posted: December 1, 2017, 12:00 am
imageBackground: Despite recent popularity of sacral alar iliac (SAI) screws for fusion to the pelvis for neuromuscular scoliosis, there are little data regarding the failure rate of this technique compared with traditional modes of iliac fixation. Theoretical advantages of the SAI screws are obviating the need for a rod to iliac screw connector and a lower implant profile. The purpose of this study is to determine whether SAI screws have fewer failures than iliac screws in neuromuscular scoliosis. Methods: Review of neuromuscular patients treated with posterior spinal fusion with pelvic fixation from 2004 to 2012 with minimum 2-year follow-up was conducted. Medical records and imaging studies were reviewed. Patients were divided into 2 groups based on the type of pelvic fixation (SAI or iliac screws), and implant failures were compared between the groups. Results: A total of 101 patients were reviewed, including 55 patients with iliac screws and 46 patients with SAI screws. Implant failures included: disengagement of the rod to iliac screw connector (10%, 10/101), separation of screw head from screw shaft (4%, 4/101), and set screw disengagement (2%, 2/101). The SAI group had a lower implant failure rate (7%, 3/46) compared with the iliac screw group (24%, 13/55) (P=0.031). Rod to iliac screw connectors failed in 18% (10/55) of patients. There were significantly less surgical revisions in the SAI group (2%, 1/46) for pelvic screw prominence compared with the iliac screw group (11%, 6/55) (P=0.027). Conclusions: SAI screws had a lower rate of implant failure and revision surgery compared with iliac screws. If rod to screw connector failures are excluded, the failure rate of SAI screws of 6.5% (3/46) is similar to that of iliac screws 5.5% (3/55); therefore, the most important advantage of the SAI technique may be obviating the need for a screw to rod connector. Level of Evidence: Level III.
Posted: December 1, 2017, 12:00 am
imageBackground: Osteogenesis imperfecta (OI) is a heritable skeletal disorder characterized by bone fragility and short stature that is usually due to mutations in 1 of the 2 genes that code for collagen type I α-chains. The association between hip dysplasia and OI has not been systematically investigated. In this single-center study, we retrospectively reviewed all cases of OI associated with hip dysplasia to describe clinical characteristics and the effect of therapy. Methods: We reviewed the charts of 687 patients with OI who were seen at the Shriners Hospital for Children in Montreal between 1999 and 2013 to identify patients with a diagnosis of hip dysplasia. Clinical characteristics and the course after therapeutic interventions were extracted from the charts. Results: Hip dysplasia was diagnosed in 8 hips of 5 patients (4 boys, 1 girl; age at diagnosis ranged between 3 wk and 27 mo old). The prevalence of hip dysplasia and OI was therefore 0.87% (per patient). In 4 of the 5 patients (80%), OI was caused by mutations affecting the C-propeptide of collagen type I, which is otherwise rare in OI. Among the 26 patients with C-propeptide mutations followed at our institution, 4 (15%) had hip dysplasia. Pavlik harness treatment was attempted in 2 patients (3 hips) but was not effective in either case and resulted in avascular necrosis of 1 hip. Femoral varus derotational shortening osteotomies using a telescopic rod were performed in all 8 hips along with a closed reduction in 4 hips and an open reduction in 4 hips. Concomitant pelvic osteotomies were performed in 2 hips (1 patient). Surgery resulted in redislocation of 1 hip; all other surgically treated hips remained reduced. Conclusions: Clinical screening for hip dysplasia is difficult in OI owing to the bowing of the proximal femur and the risk of causing fractures. OI patients with positive C-propeptide mutation should therefore be screened for hip dysplasia by use of ultrasound. Presence of a C-propeptide mutation appears to be a risk factor for hip dysplasia (80%). It appears that Pavlik harness treatment is not useful in children with OI. The usual treatment of children with OI who pull to stand or started walking with femoral deformity is femoral osteotomy and rodding. In case of associated hip dysplasia with a dislocation, open reduction of the hip and a possible concomitant pelvic osteotomy appears to be a valid management option. Level of Evidence: Level IV.
Posted: October 1, 2017, 12:00 am
imageThe author describes step-by-step the technique for Fassier-Duval rodding of both femurs and tibiae in osteogenesis imperfecta. Preoperative evaluations and planning, postoperative care and place of bisphosphonates as explained. Emphasis is given on the different tricks to avoid intraoperative problems.
Posted: September 1, 2017, 12:00 am
imageAmputation is not a defeat or failure of treatment, but an effective management strategy for certain conditions in the pediatric population. The principles of management, especially in the pediatric population, have not changed. Current surgical strategies focus on providing an optimal residual limb for prosthetic fitting. New technology provides improvement in the design and fabrication of prosthetic devices.
Posted: September 1, 2017, 12:00 am
No abstract available
Posted: September 1, 2017, 12:00 am
imageIn the last 35 years, orthopaedic surgeons have witnessed 3 major advances in the technique of limb lengthening: “distraction osteogenesis” facilitated by Gavriil Ilizarov method and infinitely-adaptable circular fixator with fine-wire bone fragment fixation; the introduction of the “6-strut” computer program-assisted circular fixators to effect complex deformity correction simultaneously; and the development of motorized intramedullary lengthening nails. However, the principles and associated complications of these techniques are on the basis of observations by Codivilla, Putti, and Abbott from as much as 110 years ago. This review notes the contribution of these pioneers in limb lengthening, and the contribution of Thor Heyerdahl principles of tolerance and diversity to the dissemination of Ilizarov principles to the Western world.
Posted: September 1, 2017, 12:00 am
imageSuccessful limb reconstruction surgery not only relies on surgical skill but probably more on assessment and planning before intervention. A clear appreciation of the child as a whole, an understanding of natural history and the ability to carefully evaluate the patient clinically are key to successful treatment. The appropriate use of investigations and the ability to analyze, plan and execute a treatment plan is challenging and requires experience and training. This paper outlines some of the steps required to assess the patient with a complex limb deformity.
Posted: September 1, 2017, 12:00 am
imageThis article presents an approach to the musculoskeletal problems of children with amyoplasia. Although a very high percentage of children with have ambulatory potential, activity and function decline over time. Strong consideration of external resources and support available to the child and family are important considerations in recommending surgery as is the timing of interventions to align with childhood development.
Posted: September 1, 2017, 12:00 am
imageHemiepiphyseodesis for angular deformities in the growing child is effective and avoids the complications of osteotomies and gradual correction with external fixation. This article reviews applications of screw hemiepiphyseodesis for coronal and sagittal plane deformities in the lower extremity. Indications, technical pearls, and pitfalls are discussed.
Posted: September 1, 2017, 12:00 am
imageAlthough the core principles of managing infantile Blount disease generally remain unchanged, treatment modalities have evolved over the years. Consensus has yet to be reached regarding the efficacy of bracing. Children with Blount disease commonly have advanced bone age, which may impact the timing and magnitude of (over) correction of angular deformity. Techniques of growth modulation, based on the tension band principle, continue to gain popularity. Although there are limited reports in the last decade on proximal tibial osteotomy for this developmental disorder, both acute and gradual correction remain viable treatment options in the appropriate setting. In certain older children (>7 y old) with advanced stages of the disease, a medial hemiplateau elevation combined with lateral proximal tibial hemiepiphysiodesis may be needed to address the epiphyseal deformity. Given the possibility of unpredictable proximal tibial physeal activity, all children with Blount disease should be followed at regular intervals till skeletal maturity. To provide sufficient granularity for pooled analyses and help establish evidence-based clinical guidelines, standardization of reporting clinical outcomes among children with Blount disease is encouraged.
Posted: September 1, 2017, 12:00 am
imageMultiple versions of ring fixators are currently available to orthopaedic surgeons. Although the traditional Ilizarov-type ring fixator is still available, many surgeons are now using computer-assisted hexapod frames. There has been a recent surge in the number of different hexapod ring fixators on the market. This article will review some of the new trends in ring fixator hardware and software as well as discuss possible future directions of ring fixator development.
Posted: September 1, 2017, 12:00 am
imageTechniques change, but principles are forever. The techniques used to correct lower extremity deformities in children should be based on the principles of assessment and management of those deformities. This writing is a summation of the introductory lecture on deformity correction that highlights some of those principles.
Posted: September 1, 2017, 12:00 am
imageAlthough cubitus varus has been regarded as a purely cosmetic problem in the pediatric population, symptomatic elbow instability, and ulnar neuropathy from the mechanical axis malalignment have been reported in adults. This overview discusses the biomechanical axis disruption that leads to soft tissue and morphologic bony alterations in the elbow and offers a compelling argument for corrective osteotomy to treat pediatric cubitus varus.
Posted: September 1, 2017, 12:00 am
No abstract available
Posted: July 1, 2017, 12:00 am
imageLower extremity deformities of patients with arthrogryposis multiplex congenita present a wide spectrum of severity and deformity combinations. Treatment goals range from merely ensuring comfortable seating and shoe wear, to fully independent and active ambulation, but the overarching intention is to help realize the patient’s greatest potential for independence and function. Treatment of hip and knee contractures and dislocations has become more interventional, whereas treatment of foot deformities has paradoxically become much less surgical. This article synopsizes the treatment strategies presented in September 2014 in Saint Petersburg, Russia at the second international symposium on arthrogryposis.
Posted: July 1, 2017, 12:00 am
imageBackground: The multiplier method (MM) is frequently used to predict limb-length discrepancy and timing of epiphysiodesis. The traditional MM uses complex formulae and requires a calculator. A mobile application was developed in an attempt to simplify and streamline these calculations. We compared the accuracy and speed of using the traditional pencil and paper technique with that using the Multiplier App (MA). Methods: After attending a training lecture and a hands-on workshop on the MM and MA, 30 resident surgeons were asked to apply the traditional MM and the MA at different weeks of their rotations. They were randomized as to the method they applied first. Subjects performed calculations for 5 clinical exercises that involved congenital and developmental limb-length discrepancies and timing of epiphysiodesis. The amount of time required to complete the exercises and the accuracy of the answers were evaluated for each subject. Results: The test subjects answered 60% of the questions correctly using the traditional MM and 80% of the questions correctly using the MA (P=0.001). The average amount of time to complete the 5 exercises with the MM and MA was 22 and 8 minutes, respectively (P
Posted: April 1, 2017, 12:00 am
imageBackground: Children with flatfeet are frequently referred to pediatric orthopaedic clinics. Most of these patients are asymptomatic and require no treatment. Care must be taken to differentiate patients with flexible flatfeet from those with rigid deformity that may have underlying pathology and have need of treatment. Rigid flatfeet in infants may be attributable to a congenital vertical talus (CVT); whereas those in older children and adolescents may be due to an underlying tarsal coalition. We performed a review of the recent literature regarding evaluation and management of pediatric flatfeet to discuss new findings and suggest areas where further research is needed. Methods: We searched the PubMed database for all papers related to the treatment of pediatric flatfoot, tarsal coalition, and CVT published from January 1, 2011 to December 31, 2014, yielding 85 English language papers. Results: A total of 18 papers contributed new or interesting findings. Conclusions: The pediatric flexible flatfoot (FFF) remains poorly defined, making the understanding, study, and treatment of the condition extremely difficult. Pediatric FFF is often unnecessarily treated. There is very little evidence for the efficacy of nonsurgical intervention to affect the shape of the foot or to influence potential long-term disability for children with FFF. The treatment of tarsal coalition remains challenging, but short-term and intermediate-term outcome studies are satisfactory, whereas long-term outcome studies are lacking. Management of the associated flatfoot deformity may be as important as management of the coalition itself. The management of CVT is still evolving; however, early results of less invasive treatment methods seem promising. Level of Evidence: Level 4—literature review.
Posted: December 1, 2016, 12:00 am
imageNo level 1 evidence is available to guide the surgical treatment of adolescent clavicle fractures. Adult literature is not applicable as adolescent mid-diaphyseal clavicle fractures do not develop nonunions, and only a small percentage (10% to 20%) are symptomatic from malunions. Current indications for operative fixation are: (1) completely displaced midshaft fracture with shortening of >2 cm; (2) superior displacement with skin tenting and/or an impending open fracture; (3) associated neurovascular injury; (4) open clavicular fracture; and (5) floating shoulder with a completely displaced clavicular fracture. Future large prospective randomized studies will need to be performed to accurately define which adolescent patients will “truly” benefit from surgical intervention.
Posted: June 1, 2016, 12:00 am
imageDespite the increasing popularity of operative treatment in adolescent tibia fractures, casting remains a viable first-line treatment. Because the selection bias in published reports does not allow direct comparison between casting and flexible nail treatment of closed pediatric tibia fractures, it is unclear whether flexible nailing offers any advantages over casting. This overview discusses parameters of acceptable alignment, indications, techniques for successful reduction and casting, subsequent inpatient and outpatient management including wedging of casted tibia fractures, expected outcomes, and comparison of casting with flexible nailing. As with any orthopaedic procedure, careful attention to patient selection, indications, and detail facilitates successful cast treatment in this older pediatric population.
Posted: June 1, 2016, 12:00 am
imagePediatric open fractures are rare, occurring in approximately 2% to 9% of all pediatric fractures. Type I open fractures represent the most common type of open fractures seen in pediatrics and are commonly caused by low-energy mechanisms. The management of these injuries has been primarily dictated by the adult literature. Immediate antibiotic administration, specifically a first generation cephalosporin, has been shown to reduce infection rates. The duration of antibiotic treatment is less clear, but longer courses of antibiotics have not been significantly better than a shorter course. Retrospective case series have shown no difference in infection rates with nonoperative management of type I open fractures. However, concern regarding serious and even life-threatening infection continues to limit the universal adoption of nonoperative treatment protocols. A prospective randomized control trial is underway and will hopefully elucidate which open fractures can be safely managed with prompt antibiotic administration and nonoperative care.
Posted: June 1, 2016, 12:00 am
imagePediatric ankle injuries are common, especially in athletes; however, the incidence of syndesmosis injuries in children has been scarcely reported. Injuries to the ankle syndesmosis, termed “high ankle sprains,” can affect high-level and recreational athletes and have been related to delayed return to play, persistent pain, and adult injuries have been associated with long-term disability. Syndesmotic injuries do occur in children, especially those who participate in sports that involve cutting and pivoting (football, soccer) or sports with rigid immobilization of the ankle (skiing, hockey). Unstable pediatric syndesmosis injuries requiring surgical fixation are often associated with concomitant fibular fracture in skeletally mature children. Physician vigilance and careful clinical examination coupled with appropriate radiographs can determine the extent of the injury in the majority of circumstances.
Posted: June 1, 2016, 12:00 am
imageThe treatment of pediatric diaphyseal femur fractures, particularly length-unstable fractures, continues to be an area of controversy in patients from age 6 to skeletal maturity. Submuscular bridge plating is an alternative that allows for stable internal fixation while minimizing soft tissue disruption. We describe a surgical technique that has simplified both implantation and removal. This technique provides a stable construct in comminuted and unstable fracture patterns allowing for early mobilization with minimal complications.
Posted: June 1, 2016, 12:00 am
imageMost proximal and diaphyseal pediatric humeral fractures can be treated successfully by closed means; however, certain patient factors or fracture characteristics may make surgical stabilization with flexible intramedullary nails (FIN) a better choice. Common indications for FIN of pediatric humeral fractures include unstable proximal-third fractures in children nearing skeletal maturity, unstable distal metaphyseal-diaphyseal junction fractures, shaft fractures in polytraumatized patients or patients with ipsilateral both-bone forearm fractures (floating elbow), and prophylactic stabilization of benign diaphyseal bone cysts or surgical stabilization of pathologic fractures. FIN can be safely inserted in an antegrade or retrograde manner depending on the fracture location and configuration. Careful dissection at the location of rod insertion can prevent iatrogenic nerve injuries. Rapid fracture union and return to full function can be expected in most cases. Implant prominence is the most common complication.
Posted: June 1, 2016, 12:00 am
imageDespite advances in patient safety since the landmark Institute of Medicine Report To Err is Human was published, adverse events and medical errors remain a persistent problem throughout health care. Safety experts have examined the practices in high-risk industries that maintain outstanding safety records for strategies to address the problem. Those efforts led to the development of Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS), a patient safety program that incorporates the principles of crew resource management and teamwork successfully used by industry into the health care setting. Evidence supports that the knowledge, skills, and attitudes, that comprise the core of TeamSTEPPS program, can improve safety and outcomes when used by members of the health care team. Successful implementation should assist the transition of health care workers from functioning as individual experts to performing as members of expert teams.
Posted: July 1, 2015, 12:00 am
imageBackground: Spinal bracing is widely utilized in patients with moderate severity adolescent idiopathic scoliosis with the goal of preventing curve progression and therefore preventing the need for surgical correction. Bracing is typically initiated in patients with a primary curve angle between 25 and 40 degrees, who are Risser sign 0 to 2 and 25 degrees primary curve Cobb angle. Curve progression was monitored with minimum 2-year follow-up. Results: Sixteen patients in the observation group and 21 patients in the bracing group completed 2-year follow-up. All patients in the observation group progressed to fulltime bracing threshold. In the nighttime bracing group, 29% of the patients did not progress to 25 degrees primary curve magnitude. Rate of progression to surgical magnitude was similar in the 2 groups. Conclusions: Risser 0 patients presenting with mild idiopathic scoliosis are at high risk for progression to >25 degrees primary curve magnitude. Treatment with the Charleston nighttime bending brace may reduce progression to full-time bracing threshold. No difference in progression to surgical intervention was shown between nighttime bracing and observation for small curves. Level of Evidence: Level II—therapeutic study (prospective comparative study).
Posted: September 1, 2014, 12:00 am
imageBackground: Much attention has been given to the relationship between various training factors and athletic injuries, but no study has examined the impact of sleep deprivation on injury rates in young athletes. Information about sleep practices was gathered as part of a study designed to correlate various training practices with the risk of injury in adolescent athletes. Methods: Informed consent for participation in an online survey of training practices and a review of injury records was obtained from 160 student athletes at a combined middle/high school (grades 7 to 12) and from their parents. Online surveys were completed by 112 adolescent athletes (70% completion rate), including 54 male and 58 female athletes with a mean age of 15 years (SD=1.5; range, 12 to 18 y). The students’ responses were then correlated with data obtained from a retrospective review of injury records maintained by the school’s athletic department. Results: Multivariate analysis showed that hours of sleep per night and the grade in school were the best independent predictors of injury. Athletes who slept on average
Posted: March 1, 2014, 12:00 am

Latest Results for Journal of Children's Orthopaedics

The latest content available from Springer

Abstract

Purpose

Amputations and fitting surgery have a long history in children with limb deficiencies. With the current developments in limb reconstruction and new techniques in prosthetics, the indications for amputation and fitting surgery might have shifted, but still have a very important role in creating high functional performance, optimal participation and quality of life. The purpose of this current concepts article is to give an overview of the indications, dilemmas and technical considerations in the decision-making for amputation and fitting surgery. A special part of this overview is dedicated to the indications, variations and outcomes in rotationplasties.

Methods

The article is based on the experience of a multidisciplinary reconstruction team for children with complex limb deficiencies, as well as research of the literature on the various aspects that cover this multidisciplinary topic.

Results

For those children with a more severe limb deficiency, reconstruction is not always feasible for every patient. In those cases, amputation with prosthetic fitting can lead to a good result. Outcomes in quality of life and function do not significantly differ from the children that had reconstruction. For children with a postaxial deficiency with a femur that is too short for lengthening, and with a stable ankle and foot with good function, rotationplasty offers the best functional outcome. However, the decision-making between the different options will depend on different individual factors.

Conclusions

Amputations and rotationplasties combined with optimal prosthesis fitting in children with more severe limb deficiencies may lead to excellent short- and long-term results. An experienced multidisciplinary team for children with complex limb deficiencies should guide the patient and parents in the decision-making between the different options without or with prosthesis.

Posted: December 1, 2016, 12:00 am

Abstract

Background

An accessory navicular is generally asymptomatic and discovered incidentally on radiographs. The natural history of an accessory navicular in the pediatric population is largely undescribed.

Methods

The medical charts of 261 pediatric subjects undergoing 2620 annual unilateral radiographs of the foot and ankle (age range 0.25–7 years at enrollment) were reviewed. Radiographs were examined to determine the incidence of accessory navicular, with focus on the age at appearance and, if present, the age at fusion. Skeletal maturity was graded based on ossification pattern of the calcaneal apophysis.

Results

Accessory navicular was identified in 19 subjects (n = 12 males, n = 7 females, p = 0.43), appearing significantly earlier in the female subjects than in the male ones (p = 0.03). Fusion was documented in 42% (n = 8) of subjects, occurring at a mean (±standard deviation) age of 12.5 ± 1.0 years in females and 14.1 ± 2.7 years in males. Skeletal maturity grading demonstrated comparable stages of maturity at the time of fusion between male and female subjects (p = 0.5). Based on an analysis of 160 subjects with serial images extending at least one standard deviation past the mean age of appearance, the overall incidence was 12%.

Conclusion

Our review of pediatric subjects showed that accessory navicular appeared earlier in females than in males. Fusion occurred in 42% of patients at comparable levels of skeletal maturity between the male and female subjects. No significant differences in overall incidence, skeletal maturity, fusion rate, or age of fusion were noted between the male and female subjects.

Posted: December 1, 2016, 12:00 am

Abstract

Background

Avascular necrosis (AVN) is a significant and potentially devastating complication following the treatment of developmental dysplasia of the hip (DDH). The reported rate of AVN following closed reduction for DDH ranges from 4 to 60%, and the resultant influence on hip development remains unclear.

Purpose

A systematic review of the literature was undertaken to evaluate the frequency of AVN after more than 5 years of follow-up in children that underwent closed reduction at younger than 2-years of age for DDH.

Methods

The search strategy was formulated with key-concepts and keywords identified using the patient problem, intervention, comparison and outcome process. Searches were undertaken using Pubmed, Scopus and Web of Science up to and including May, 2016 to identify potential studies.

Results

A total of seven papers met the a priori inclusion and exclusion criteria of this review. The overall rate of significant AVN in 441 patients (538 hips) was 10% at a mean length of follow-up of 7.6 years (5–18.8) following closed reduction. This finding can be used to inform the feasibility of future intervention studies, and act as a baseline for which surgeons to compare their results to a ‘standard’.

Posted: December 1, 2016, 12:00 am

Abstract

For decades, the classic indication for limb lengthening has been reserved for anisomelia that was expected to reach or exceed 5 cm at maturity. Epiphysiodesis was reserved for discrepancies in the 2–5 cm range. With the increasing sophistication of fixators, including rail, hexapod, and hybrid, complex deformities may be corrected simultaneously while moderate to extreme lengthening is achieved. More recently, iterations of telescoping intramedullary rods have further strengthened our armamentarium. Meanwhile, permanent epiphysiodesis techniques, both open and percutaneous, have yielded to more versatile and reversible tethering of one (angle) or both (length) sides of a physis. While the techniques of guided growth and callotasis seem to be diametrically opposed, they may be used in a tandem or complementary fashion, for the benefit of the patient. If treatment is undertaken during skeletal growth, one must be aware that issues remain regarding the accurate assessment of skeletal maturity and prediction of the ultimate outcome. Therefore, there is potential for over- or undercorrection. Reversible and serial guided growth now enable the surgeon to commence intervention at a comparatively young age, for the purpose of optimizing limb alignment and reducing the ultimate discrepancy. Frame application may be delayed or, in some cases, avoided altogether. With the limb properly aligned at the outset of lengthening, elective use of a telescoping intramedullary nail may now be favored over a frame accordingly.

Posted: December 1, 2016, 12:00 am

Abstract

Objectives

In the last decades, limb lengthening has not been limited to the treatment of patients with dwarfism and deformities resulting from congenital anomalies, trauma, tumor and infections, but, has also been used for aesthetic reasons. Cosmetic lengthening by the Ilizarov method with circular external fixation has been applied to individuals with constitutional short stature who wish to be taller.

Materials and methods

From January 1985 to December 2010, the medical records of 63 patients with constitutional short stature (36 M, 27F; 126 legs) who underwent cosmetic bilateral leg lengthening using a hybrid advanced fixator according to the Ilizarov method, were reviewed, retrospectively. The mean age was 24.8 years, while the mean preoperative height was 152.6 cm. Paley’s criteria were used to evaluate problems, obstacles, and complications from the time of surgery until 1 year after frame’s removal.

Result

The mean lengthening achieved in all patients was 7.2 cm (range: 5–11 cm), with a mean duration of treatment of 9 months and 15 days (range: 7–18 months). The mean follow-up time was 6.14 years (range 1–10).

Conclusion

The cosmetic leg lengthening was helpful to all patients, improving their social capabilities and self-confidence. All patients considered their stature as normal and they reported satisfaction and gratification with important changes in their professional and personal life. Cosmetic leg lengthening may raise some ethical objections and for that reason patients should be well informed about all the risks and complications related to this type of surgery.

Posted: December 1, 2016, 12:00 am

Abstract

When we lengthen a bone in a child, the parents and the family circle are often obsessed by the amount a lengthening obtained. However, for the surgeon, lengthen a bone is quite pretty easy, but dealing with the joints above and below the lengthening area can be very challenging. Indeed, during the lengthening process, muscles and tendons will be progressively stretched, leading to potential joint contracture or even dislocation. The objective of the surgeon will be to avoid this situation. The first mean at disposal is the physiotherapy in order to help the joints to be more supple and to maintain their range of motion. The second mean is the soft tissue release before the surgery, during the lengthening process, or after the hardware removal when the capacities of physiotherapy are overdone. As a last resort, it can be helpful to bridge the joint to protect it during the lengthening.

Posted: December 1, 2016, 12:00 am

Abstract

Successful deformity correction depends on establishing the aetiology of the deformity. Clinical examination, additional laboratory tests and consultation with other experts may be needed to complete the workup. Imaging studies should include full-length standing X-rays in all relevant planes, and additional imaging modalities like computed tomography (CT) and magnetic resonance imaging (MRI) may add information on bone morphology and growth plates’ anatomy. Based on the data, analysis of the deformity and length differences is performed, followed by prediction of deformities at skeletal maturity. The patients need to be followed up on a regular basis and repeat analysis should be done to improve the accuracy of prediction for final limb length difference. Limb deformity and lengthening correction plans are drawn and updated during follow-up, to achieve straight and equal lower limbs at maturity. Timely surgical procedures are performed using appropriate techniques and the most modern technologies available. These principles are discussed and demonstrated with case examples.

Posted: December 1, 2016, 12:00 am

Abstract

Background

Reimer’s migration percentage (MP) is the most established radiographic risk factor for hip migration in cerebral palsy (CP), and it assists surgical decision-making. The head–shaft angle (HSA) measures the valgus of the head and neck in relation to the shaft and may also be a useful predictor of hip migration at a young age. This study first defined normal values and investigated whether the head–shaft angle (HSA) is a continuous risk factor for hip migration in CP.

Methods

Three hundred and fifty AP pelvic radiographs of 100 consecutive children comprising the hip surveillance programme in our region were analysed for MP and HSA. Inclusion criteria were children with spastic CP and Gross Motor Function Classification System (GMFCS) levels of III–V, along with a minimum follow-up of 5 years. The mean age was 8.8 (range 3–18) years and the mean follow-up time was 7.5 (range 5–10) years. Radiographs of 103 typically developing children (TDC) were selected for the control group. The reliability of the measurements was determined. A random effects analysis was used to assess the relationship between MP and HSA for all data and for MP > 40 %.

Results

The TDC cohort had a mean HSA of 157.7° whilst that for the CP cohort was 161.7°. The value declined with age in both groups but remained consistently higher in the CP group. A random effects analysis considering the longitudinal data showed that there was no significant effect of HSA on MP. Similarly, when excluding CP patients with MP < 40 %, there was no significant effect of HSA on MP.

Conclusions

This study found no correlation between HSA and hip migration in children with CP in this age group. Using the HSA as a routine radiographic measure in the management pathway across childhood does not offer any added value. Early enrolment onto the hip surveillance programme could offer a better prediction of hip migration using the HSA at a very young age.

Level of evidence

II retrospective prognostic study.

Posted: December 1, 2016, 12:00 am
Posted: December 1, 2016, 12:00 am

Abstract

Purpose

Tibialis anterior tendon transfers (TATT) are commonly performed in young children following Ponseti casting for clubfeet. The classic TATT involves advancing the tendon through a hole drilled in the ossified cuneiform. The aim of this study was to determine if tendons transferred through unossified bones have untoward effects on subsequent bone development.

Method

Twenty-five piglets underwent one of five surgical procedures. An 18-gauge needle was then used to place a tunnel through the bony or cartilaginous portion of the calcaneus (through direct visualization) and isolated slips of the flexor digitorum superficialis (FDS) were placed through the tunnels, as determined by surgical procedure. Radiographic and/or histologic evaluations of the calcaneal apophyses were then performed. A discrete (1–4) and dichotomous “Normal” or “Abnormal” scoring system was developed and its reliability assessed to grade the appearance of the calcanei. Calcaneal appearances following the surgical procedures were then compared with controls. The average load to failure of a subset of transferred tendons was then compared using an MTS machine.

Results

The proposed apophyseal grading system (1–4) demonstrated an intraclass correlational coefficient (ICC) for consistency of 0.92 [95% confidence interval (CI) 0.88 < ICC < 0.95] and ICC for agreement of 0.91 (95% CI 0.86 < ICC < 0.95), indicating strong agreement and consistency. Similarly, Fleiss’ kappa for the 1–4 scoring system was found to be 0.67, indicating substantial agreement between reviewers. When the 1–4 system was translated into the dichotomous scheme “Normal” and “Abnormal”, the kappa value increased to 0.94, indicating strong agreement. Forty-six apophyses (13 control and 33 operative) were assessed using this scoring scheme. Apophyseal transfers were significantly more abnormal than controls (p < 0.0001), while no difference in abnormalities was found following tunnel placement alone (p = 1). Mechanical testing of the tendons transferred to bone or through the cartilaginous apophysis demonstrated no significant differences (p = 0.2).

Conclusion

Tendon transfers through unossified bones altered subsequent bone development.

Significance

While the long-term consequence of these structural changes is unknown, these findings suggest that tendon transfers through unossified bones should be avoided and alternative methods of tendon fixation explored.

Posted: December 1, 2016, 12:00 am

Abstract

Purpose

Instability of the knee is a common finding in patients with congenital limb deficiency. The instability can be attributed to soft tissue abnormalities, frontal, sagittal or rotational deformity of the lower limb and bony dysplasia of the patella or of the femoral condyles. In most of the cases, these pathomorphologic changes stay asymptomatic in daily activity. However, instability can appear during deformity correction and bone-lengthening procedures, leading to flexion contracture or subluxation of the knee.

Methods

A review of pediatric orthopaedic literature on different factors of knee instability, state-of-the-art treatment options in congenital limb deficiency and in cases of lengthening-related knee subluxation is presented and the authors’ preferred treatment methods are described.

Results

Leg lengthening and deformity correction in patients with congenital limb deficiencies can be achieved with various techniques, such as guided growth, monolateral or circular external fixation and intramedullary lengthening nails. Radiographic assessment and clinical examination of the knee stability are obligatory to estimate the grade of instability prior to surgical procedures. Preparatory surgery, as well as preventive measures such as bracing, bridging of the knee and intensive physical therapy, can help to avoid subluxation during lengthening in unstable knees.

Conclusions

Adequate surgical techniques, preventive measures and early detection of signs of subluxation can lead to good functional results in patients with congenital limb deficiency.

Posted: December 1, 2016, 12:00 am

Abstract

Limb-length discrepancies and extremity deformities are among the most common non-traumatic orthopaedic conditions for which children are hospitalised. There is a need to develop new treatment options for lower-limb length discrepancy in order to ameliorate treatment outcomes, avoid or reduce rates of complication and provide early rehabilitation. The authors report on the basic principles, experimental and clinical data, advantages, problems and complications of a combined technique associating the Ilizarov method and flexible intramedullary nailing (FIN) in limb lengthening and deformity correction in children. They describe features of the use of hydroxyapatite-coated intramedullary nails in patients with certain metabolic bone disorders and in cases where bone consolidation has been compromised. The advantages of bone lengthening using a combined technique (circular fixator plus FIN) are a lower healing index, quicker distraction-consolidation, a reduced rate of septic and bone complications, the ability to correct deformities gradually and the increased stability of bone fragments during the external fixation period and after frame removal.

Posted: December 1, 2016, 12:00 am

Abstract

Unlike external fixators, the use of solid intramedullary lengthening nails is restricted to defined anatomical preconditions, such as an adequate bone length. Furthermore, all deformity corrections except the lengthening procedure have to be implemented intraoperatively and cannot be adjusted postoperatively. Conversely, even complex deformity corrections can be performed using intramedullary devices after a thorough preoperative planning. For preparation of the intramedullary cavity as well as positioning of the lengthening nail according to the preoperative planning, reaming the medullary canal with rigid reamers which don’t follow the line of least resistance is inevitable. However, the application of solid lengthening nails might be limited, especially in children with ongoing epiphyseal growth, although a central perforation of the growth plate was shown to have no adverse effects on the growth potential. In cases with complex or multilevel deformities, an additional osteotomy and locking plate fixation could sometimes be a valuable solution in order to avoid external fixation. The low complication rate as well as the reduced compromising of soft tissues and periosteum render intramedullary lengthening nails the state-of-the-art procedure for limb lengthening in combination with deformity correction in patients who meet the anatomical preconditions.

Posted: December 1, 2016, 12:00 am

Abstract

Pin-tract infection (PTI) is the most commonly expected problem, or even an almost inevitable complication, when using external fixation. Left unteated, PTI will progress unavoidably, lead to mechanical pin loosening, and ultimately cause instability of the external fixator pin–bone construct. Thus, PTI remains a clinical challenge, specifically in cases of limb lengthening or deformity correction. Standardised pin site protocols which encompass an understanding of external fixator biomechanics and meticulous surgical technique during pin and wire insertion, postoperative pin site care and pin removal could limit the incidence of major infections and treatment failures. Here we discuss concepts regarding the epidemiology, physiopathology and microbiology of PTI in paediatric populations, as well as the clinical presentations, diagnosis, classification and treatment of these infections.

Posted: December 1, 2016, 12:00 am

Abstract

Purpose

Children with cerebral palsy often have musculoskeletal disorders involving the hip. There are several procedures that are commonly used to treat these disorders. Proximal femur prosthetic interposition arthroplasty (PFIA) is an option for non-ambulatory children with cerebral palsy who have a painful, spastic dislocated hip. The purpose of our study was to evaluate the results of PFIA by examining treatment outcomes, complications, and overall effects on the child and their caregiver.

Methods

Charts were reviewed over a 5-year period at our institution. The focus of the data collection was pain, range of motion (ROM), and overall clinical outcome. Clinical outcome was graded as excellent, good, fair, and poor. Length of follow-up, presence of heterotopic ossification, femoral prosthesis migration, and information provided by competed caregiver questionnaires were analyzed.

Results

A total of 16 hips in 12 patients met the inclusion criteria. Average age at time of surgery was 12 years 1.2 months. Average follow-up was 40.4 months. Three hips required revision surgery. Average time before revision surgery was 16 months. Overall outcomes were excellent/good for seven hips and fair/poor for nine. Pain outcomes were excellent/good for nine hips and fair/good for seven. ROM outcomes were excellent/good for nine hips and fair/poor for seven. The majority of caregivers surveyed would recommend this procedure.

Conclusion

Clinical evaluation of the effectiveness of PFIA yielded variable results with this cohort of children with regards to pain and range of motion. Despite these varied results, the majority of caregivers were satisfied with the outcome and would recommend PFIA. PFIA is a salvage option for the painful, spastic dislocated hip, but significant evidence to prove its effectiveness over other salvage procedures is lacking. Based on our results, we conclude that PFIA has the ability to benefit children with cerebral palsy with an acceptable risk profile similar to that reported in recent publications.

Level of evidence IV; retrospective case-series.

Posted: December 1, 2016, 12:00 am

Abstract

Purpose

When treating slipped capital femoral epiphysis (SCFE), a smooth pin with a hook or a short threaded screw can be used to allow further growth, which could be important to prevent the development of impingement and early arthritis. The purpose of this investigation was to measure growth in three dimensions after fixation of SCFE.

Methods

Sixteen participants with unilateral SCFE, nine girls and seven boys with a median age of 12.0 years (range 8.4–15.7 years), were included. The slipped hip was fixed with a smooth pin with a hook, and the non-slipped hip was prophylactically pinned. At the time of surgery, tantalum markers were installed bilaterally on each side of the growth plate through the drilled hole for the pin. Examination with radiostereometric analysis (RSA) was performed postoperatively and at 3, 6 and 12 months. The position of the epiphysis in relation to the metaphysis was calculated.

Results

At 12 months, the epiphysis moved caudally, median 0.16 mm and posteriorly 2.28 mm on the slipped side, in comparison to 2.28 cranially and 0.91 mm posteriorly on the non-slipped side, p = 0.003 and p = 0.030, respectively. Both slipped and non-slipped epiphysis moved medially, 1.52 and 1.74 mm, respectively. A marked variation in the movement was noted, especially on the slipped side.

Conclusions

The epiphysis moved in relation to the metaphysis after smooth pin fixation, both on the slipped side and on the prophylactically fixed non-slipped side, implying further growth. The RSA method can be used to understand remodelling after ‘growth-sparing’ fixation of SCFE.

Posted: December 1, 2016, 12:00 am

Abstract

Introduction

The purpose of this study was to evaluate shoulder function following minimally invasive subtotal subscapularis muscle and periarticular capsuloligamentous arthroscopic release in children with Erb’s palsy.

Methods

A prospective study was conducted on 15 consecutive children who underwent subtotal subscapularis muscle and periarticular capsuloligamentous arthroscopic release to treat internal rotation contracture of the shoulder joint after Erb’s palsy. Age at surgery ranged from 24 to 38 months (average 28.3) (2.4 years). All of the patients were assessed clinically and radiologically preoperatively and postoperatively at regular intervals. The Mallet scoring system was used to analyze the results.

Results

The mean external rotation improved from −24° to +46° (p = 0.001) at the last follow-up. Active internal rotation was preserved in all cases. At the final follow-up, there had been no loss of the external rotation gained and no recurrence of internal rotation contracture of the shoulder, and the mean Mallet score (total) had improved from 11 to 17 points (p = 0.001).

Conclusions

In children aged from 1 to 3 years, an arthroscopic release procedure alone may successfully restore function and yield a centered glenohumeral joint, which has a beneficial effect on glenoid remodeling.

Level of evidence

Level IV.

Posted: December 1, 2016, 12:00 am

Abstract

In paediatric orthopaedics, deformities and discrepancies in length of bones are key problems that commonly need to be addressed in daily practice. An understanding of the physiology behind developing bones is crucial for planning treatment. Modulation of the growing bone can be performed in a number of ways. Here, we discuss the principles and mechanisms behind the techniques. Historically, the first procedures were destructive in their mechanism but reversible techniques were later developed with stapling of the growth plate being the gold standard treatment for decades. It has historically been used for both angular deformities and control of overall bone length. Today, tension band plating has partially overtaken stapling but this technique also carries a risk of complications. The diverging screws in these implants are probably mainly useful for hemiepiphysiodesis. We also discuss new minimally invasive techniques that may become important in future clinical practice.

Posted: December 1, 2016, 12:00 am

Abstract

Purpose

The epidemiology and risk factors for developmental dysplasia of the hip (DDH) are still being refined. We investigated the local epidemiology of DDH in order to define incidence, identify risk factors, and refine our policy on selective ultrasound screening.

Methods

With a cohort study design, data were prospectively recorded on all live births in our region from January 1998 to December 2008. We compared data on babies treated for DDH with data for all other children. Crude odds ratios (ORs) were calculated to identify potential risk factors. Logistic regression was then used to control for interactions between variables.

Results

There were 182 children born with DDH (with a total of 245 dysplastic hips) and 37,051 without. The incidence was 4.9 per 1000 live births. Female sex (adjusted OR 7.2, 95% confidence interval [CI] 4.6–11.2), breech presentation (adjusted OR 24.3, 95% CI 13.1–44.9), positive family history (adjusted OR 15.9, 95% CI 11.0–22.9) and first or second pregnancy (adjusted OR 1.8, 95% CI 1.5–2.3) were confirmed as risk factors (p < 0.001). In addition, there was an increased risk with vaginal delivery (adjusted OR 2.7, 1.6–4.5, p < 0.001) and post-maturity (OR 1.7, 1.2–2.4, p < 0.002).

Conclusions

One in 200 children born within our region requires treatment for DDH. Using both established and novel risk factors, we can potentially calculate an individual child’s risk. Our findings may contribute to the debate regarding selective versus universal ultrasound screening.

Level of Evidence

Prognostic Study: Level 1.

Posted: December 1, 2016, 12:00 am
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Journal of Pediatric Orthopaedics B - Current Issue

imageThe aim of this study was to establish whether children treated with subtalar arthroereisis for flexible flatfoot were able to return to sport activities. We reviewed 49 patients with a mean age at the time of surgery of 10.7 years. The type of sport activities, the number of sessions per week, the time dedicated to each session, and the level achieved were assessed preoperatively and at the last follow-up. Overall, 45 patients returned to sports after surgery. Surgery did not alter the duration, frequency, and type of sporting activities, but the participation in physical activities as well as the emotional status and footwear issues improved.
Posted: January 1, 2018, 12:00 am
imageThe aim of this paper is to report the outcomes and any complications with arthroscopic bioabsorbable nail fixation of tibial eminence fractures in skeletally immature patients. We retrospectively reviewed all surgically treated tibial eminence fractures treated by a single surgeon and seven patients were identified with a minimum 2-year follow-up. Mean deficits of flexion and extension were minimal. Satisfactory Tegner levels, Lysholm knee scores, and International Knee Documentation Committee subjective scores were reported. Arthroscopic fixation of tibial eminence fractures with bioabsorbable nails yields satisfactory outcomes for this uncommon injury and obviates the need for future hardware removal.
Posted: January 1, 2018, 12:00 am
imageAchieving adequate dorsiflexion in neglected clubfoot cases remains challenging. On a close observation of the Ponseti method, we have now made certain modifications from the standard Ponseti protocol. This has helped us improve functional results, as well as reduce the number of casts in this walking-age group. From March 2011 onward, we managed 62 neglected clubfeet in 41 patients with the modified protocol. All these patients were treated with serial weekly above-knee casts. The feet were assessed by Dimeglio and Pirani scorings, which were done every week. These children were closely monitored and followed up at regular intervals for any signs of relapses. The mean age group was 3.1 years (1.1–12 years). The mean follow-up period for these feet was 3 years (1.2–4 years). Mean Dimeglio score before treatment was 15.9, and after treatment it was 0.52. Mean Pirani score before treatment was 4.21 and after treatment it was 0.03. The average number of casts before tenotomy with our modified method was 6.9. Percutaneous tenotomy was done in all the cases. The mean dorsiflexion achieved at the end of treatment was 21.3° (15°–40°). Our modified Ponseti technique is a very effective and reproducible method for correction of neglected clubfeet. We feel that an extensive soft tissue surgery may not be required for neglected clubfeet even up to the age of 10 years.
Posted: January 1, 2018, 12:00 am
imageWe evaluated the novel application of supracutaneous locked plates in pediatric open tibia fractures. Pediatric open tibia fractures stabilized with a locked supracutaneous plate from January 2011 to December 2014 were reviewed. Twenty-eight children, mean age 8.9 years, with 29 open tibia fractures were included. Nine of these children who had metaphyseal or metadiaphyseal fractures did not require joint spanning. The mean follow-up duration was 13.5 months. The mean time to uneventful union was 11.46 weeks, with no unacceptable malunion. Supracutaneous locked plates showed early union and no refractures. They could favorably replace tubular external fixators in stabilizing pediatric open tibia fractures.
Posted: January 1, 2018, 12:00 am
imageLong-term outcomes of Ponseti casting have consistently shown improvement over soft-tissue release. The incidence of foot pain and overcorrection in clubfeet treated by Ponseti method has not been reported. We studied the rate of overcorrection and its association with pain in clubfeet treated with Ponseti casting. A retrospective review of clubfoot patients treated with Ponseti method with at least 8 years of follow-up was carried out. Patient charts were reviewed for demographic data, recurrence, type and number of procedures, and patient-reported complaints of foot pain. Pedobarographs were used to document overcorrection. Eighty-one patients comprising 115 clubfeet were included in the study. There were 14 (12.2%) feet with valgus overcorrection and 101 feet that had achieved a normal, plantigrade position. Overall, 50% of patients with overcorrected clubfeet and 32% with corrected, plantigrade clubfeet experienced pain. Overcorrection was found to be predictive of pain complaints (P
Posted: January 1, 2018, 12:00 am
imageCurrently, the timing of surgery for congenital pseudarthrosis of the tibia (CPT) remains controversial. The aim of this study was to investigate the results of treatment of pseudarthrosis of the tibia in children younger than 3 years of age. A retrospective study was carried out to explore the relationship between postoperative complications and the age of surgery in children with CPT. The analysis was carried out on 42 patients with Crawford type IV CPT treated with a combined surgical technique between 2008 and 2012. Patients were divided into two groups according to their age: group A (3 years). The incidence rates of refracture, ankle valgus, tibial valgus, and limb-length discrepancy of the two groups were evaluated. Primary bone union was achieved in 28 out of 29 (97%) patients in group A and 12 out of 13 (92%) patients in group B (P>0.05). In group A, six (21%) patients developed a refracture; 14 (48%) patients had ankle valgus with a mean degree of 11° (range: 5°–25°); 11 (38%) patients had tibial valgus with a mean tibial valgus deformity of 8.6° (range: 5°–20°); and 12 (41%) patients had limb-length discrepancy with a mean limb length of 2.9 cm (range: 0.5–4 cm). In group B, five (38%) patients developed refracture; seven (54%) patients had ankle valgus with a mean degree of 14° (range: 5°–30°); seven (54%) patients had tibial valgus with a mean tibial valgus deformity of 10.7° (range: 5°–20°); and 10 (77%) patients had limb-length discrepancy with a mean limb length of 2.8 cm (range: 1.5–3 cm). Groups A and B were significantly different in limb-length discrepancy (P=0.033). This study suggests that there is no need to defer surgery for pseudarthrosis of the tibia until the child is older than 3 years of age.
Posted: January 1, 2018, 12:00 am
The purpose of this study was to identify the rates of chondral injury, soft tissue impingement, and bony impingement in pediatric patients undergoing the modified Brostrom procedure with ankle arthroscopy for lateral ankle instability. A retrospective review of all patients undergoing a modified Brostrom procedure with ankle arthroscopy performed by two surgeons at a tertiary care children’s hospital between October 2002 and April 2014 was performed. Data were collected regarding demographics, history and initial presentation, nonoperative management, surgical procedure and arthroscopic findings, and clinical follow-up. All patients had symptoms of ankle instability and had failed nonoperative management before surgery. A total of 69 patients were reviewed (75 ankles), of whom 54 (78%) were female and six underwent bilateral surgery. The mean±SD age was 15.2±2.6 years, and the mean BMI was 23.6±5.0 kg/m2. All patients had preoperative radiography and MRI. Preoperative imaging within 1 year before surgery was available for review of 57 (76%) ankles, with 16 (28%) having open physes, 28 (49%) having closing physes, and 13 (23%) having closed physes. All patients reviewed underwent the Brostrom procedure with Gould modification and routine concurrent arthroscopy. During arthroscopy, anterior soft tissue impingement was noted in 49 (65%) ankles, synovitis in 40 (53%), chondral defect in eight (11%), loose body in three (4%), and none were found to have bony impingement. Soft tissue impingement (65%) is common in pediatric patients undergoing surgery for lateral ankle instability. Bony impingement (0%) and chondral injury (11%) are uncommon. This is in contrast to the adult population where bony impingement and chondral injury are more common. Level of Evidence: Level IV Case Series.
Posted: January 1, 2018, 12:00 am
imageFocal periphyseal edema (FOPE) zones were first described in 2011. The aim of this report was to investigate the clinical course of patients with FOPE zones. Three adolescent patients with a FOPE zone in the knee were treated and observed for a maximum of 2 years. No symptoms or leg-length discrepancy developed at the final follow-up after conservative therapies. This is the first report on the follow-up of FOPE zones with a maximum of 2 years. The results suggest that observation of FOPE zones may be sufficient without invasive examinations and treatment.
Posted: January 1, 2018, 12:00 am
imageThis retrospective cohort study examined 20 patients (48 physes), 11 boys and nine girls, who were treated with hinge-plate or eight-plate. The mean age of the patients at surgery was 11.9±2.6 years. The mean follow-up duration was 13±2.7 months. The radiographic measurement of both distal femoral and proximal tibial deformity showed significant correction, with no difference between the hinge-plate and the eight-plate. Both screw divergence angle and the hinge angle showed significant changes at the last follow-up. The deformity correction of the distal femoral physis was quicker than the proximal tibial physis. The rate of mechanical femoral–tibial angle correction was 0.97°/month if both femoral and tibial physes were treated. Level of evidence: III.
Posted: January 1, 2018, 12:00 am
imageAn adolescent obese boy showed late-onset unilateral tibia vara associated with physeal separation (slipped epiphysis) of the lateral proximal tibia and physeal widening of the lateral distal femur. These affected physes showed normal signal intensities by MRI. He was treated with lateral hemiepiphysiodesis of the left proximal tibia and the distal femur using two parallel eight-Plates, and varus deformity rapidly improved postoperatively without recurrence. This is the first case of late-onset tibia vara caused by lateral physeal separation of the proximal tibia. Normal growth of the medial physes around the knee would contribute toward significant correction after surgery.
Posted: January 1, 2018, 12:00 am
imageto evaluate the effectiveness of the Ponseti method in treating syndrome-associated (nonidiopathic) congenital talipes equinovarus. This was a retrospective consecutive review over a 12-year period in a tertiary centre of all patients with syndrome-associated talipes equinovarus treated with the Ponseti method. The primary outcome measure at the final follow-up was the functional correction of the deformity. There were 16 (28 feet) children, with an average follow-up of 7 years (range: 4–12). The average age at presentation was 6.1 (range: 2–17) weeks. Deformities were severe, with an average Pirani score of 5.0 (range: 3.0–6.0). Initial correction was achieved in all children, with an average of 6 (range: 4–9) Ponseti casts and a tendo-Achilles tenotomy performed in 21/28 (75%) feet. Satisfactory outcome at the final follow-up was achieved in 23/28 (82%) feet. The Ponseti method is an effective first-line treatment for syndrome-associated talipes equinovarus to achieve functional painless feet; children will often require more casts and have a higher risk of relapse.
Posted: January 1, 2018, 12:00 am
imagePopliteal artery injury is most commonly associated with high-energy trauma, which is easily diagnosed upon initial physical examination. However, in some situations, the diagnosis of arterial injury is delayed because of slow progression of arterial insufficiency, which may lead to limb amputation. We report a rare case of popliteal arterial occlusion with the presence of arterial pulses during initial assessment, resulting from a neglected proximal ibial physis fracture. This case shows that even in the presence of foot pulses, the surgeon must consider the possibility of a popliteal artery damage whenever trauma is seen near the knee joint.
Posted: January 1, 2018, 12:00 am
imageVascular deficiencies and reduced perfusion of the anterior tibial artery and the dorsalis pedis artery were suggested as causes of congenital talipes equino varus (CTEV). In this study, we assessed the prevalence of arterial abnormalities in patients with CTEV (50 patients; 74 feet) compared with a normal control group (16 patients; 32 feet) by Doppler ultrasound and Ankle Brachial Index. The flow was normal in the control group and was deficient in 39.19% of clubfoot patients. In severe clubfoot cases, the deficiency was found to an extent of 76.67%. In conclusion, the anterior tibial artery and dorsalis pedis artery are deficient in CTEV patients; to avoid postoperative skin sloughing, arterial supply must be protected using a judicious incision.
Posted: January 1, 2018, 12:00 am
imageTibial tuberosity avulsion fractures are injuries accounting for less than 3% of all epiphyseal and 1% of all physeal injuries in adolescents. Bilateral injuries are very rare, with only 19 cases described in the literature. These types of fractures occur commonly in male teenagers during sport activities and are often associated with other orthopaedic disorders. We report the case of a male teenager with simultaneous bilateral tibial tubercle fractures, describe the evolution and treatment of this injury and review the literature on this subject. Level of evidence: Case report.
Posted: January 1, 2018, 12:00 am
imageThe aim of this study was to determine whether persistent idiopathic toe walking leads to compensatory skeletal changes in the pediatric foot and ankle. Foot radiographs of children diagnosed with idiopathic toe walking and sex-matched and age-matched controls were retrospectively reviewed. Five blinded providers assessed the foot radiographs for skeletal changes to the ankle. The relationship between each measure and toe-walking status was examined. Providers observed radiographic evidence of skeletal changes of the talus in idiopathic toe walkers compared with controls, suggesting that persistent toe walking impacts the skeletal development of the talus. Level of Evidence: prognostic level III
Posted: January 1, 2018, 12:00 am
imageWe report a unique case of post-traumatic avascular necrosis of tibia in a 12-year-old boy following a Salter–Harris type II physeal injury of the proximal tibia. The diagnosis was made on the basis of classical radiological findings. The only clinical symptom was diffuse shin pain. The patient was managed conservatively. At our 2-year follow-up, there was clinical and radiological evidence of spontaneous resolution of avascular necrosis, but with sequelae. The child developed a limb-length discrepancy and genu valgum. The parents of the child refused further treatment.
Posted: January 1, 2018, 12:00 am
imageTumors are a rare cause of ankle-region pain. Osteochondroma is one of the most common benign bone tumors, but is rarely localized to the foot bones. Here, we describe a case of a solitary osteochondroma of the sinus tarsi presenting in an 8-year-old boy with a history of recurrent ankle sprains and limited range-of-motion of the subtalar joint. Treatment was surgical excision of the tumor, and the patient is now symptom free. Clinical presentation, treatment, pathoanatomy, localization, and complication of this benign form of tumor are discussed and all previously reported cases are reviewed to provide a more comprehensive picture of osteochondroma of talus.
Posted: January 1, 2018, 12:00 am
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