Journal of Pediatric Orthopaedics - Most Popular Articles

Journal of Pediatric Orthopaedics is a leading journal that focuses specifically on traumatic injuries to give you hands-on on coverage of a fast-growing field. You'll get articles that cover everything from the nature of injury to the effects of new drug therapies; everything from recommendations for more effective surgical approaches to the latest laboratory findings. Journal of Pediatric Orthopaedics is the official journal of the: Pediatric Orthopaedic Society of North America

imageBackground: Synthetic casting materials have been used as alternatives to plaster of Paris (POP) in the treatment of clubfoot using the Ponseti method. The aim of this study was to evaluate the clinical outcome of children with idiopathic clubfoot managed by the Ponseti method using POP versus semirigid fiberglass (SRF). Methods: Medical records were retrospectively reviewed for all newborns with idiopathic clubfoot who underwent manipulation and casting by the Ponseti technique between January 2013 and December 2016 at 2 different institutions. In all, 136 consecutive clubfeet were included, of which 68 underwent casting with POP (Group A), and 68 were casted using SRF (Group B). Statistical analysis was performed using the Fisher exact test for categorical variables, and the unpaired t test for quantitative parameters. Results: Mean age at time of first cast was 10 days (range, 3 to 21 d). Mean Pirani score at start of treatment was 4.6 and 4.5 in Groups A and B, respectively. Mean number of casts for each patient in Group A was 5.2 against 4.2 in patients in Group B. Mean follow-up was 63.8 months (range, 42 to 88 mo). In each group, 4 cases of relapse were reported (2.9%). No complications related to cast phase or brace phase were recorded. Shorter duration of cast treatment was recorded in Group B. Conclusions: Despite its higher cost and slightly lower moldability, the use of SRF in experienced hands showed comparable results in idiopathic clubfeet treated by the Ponseti technique. Level of Evidence: Level III.
Posted: May 1, 2021, 12:00 am
imageBackground: One of the most common pediatric fractures is a midshaft both bone forearm fracture. The preferred nonoperative treatment is cast immobilization for 6 to 8 weeks; however, 4% to 8% refracture within 6 months. There are no comparative studies evaluating the efficacy of bracing after cast immobilization. We hypothesized that children treated with prolonged functional bracing would have a lower rate of refracture than casting alone or short-term bracing. Methods: This is a retrospective review of children younger than 15 years of age treated nonoperatively following radius and ulnar shaft fractures treated at 3 tertiary pediatric hospitals. We excluded distal radius/ulna fractures, isolated fractures of the radius/ulna, and fractures near the elbow. Logistic regression analysis on casting plus functional bracing was run to determine if age, translation, or the number of days in brace were associated with refracture. The incidence of refracture was compared between groups. Results: A total of 1549 patients were screened and 426 were included in the study [111 casting only (CO), 259 casting plus functional brace
Posted: May 1, 2021, 12:00 am
imageBackground: Many patients with spastic quadriplegic cerebral palsy (CP) and severe scoliosis develop hip displacement, whereas others do not. We investigated demographic characteristics, risk factors for CP, and imaging findings associated with nondisplaced hips in patients with CP and severe scoliosis. Methods: We retrospectively analyzed records of 229 patients with spastic quadriplegic CP and severe scoliosis who presented for treatment at our US academic tertiary care hospital between August 2005 and September 2015. Demographic characteristics, risk factors for CP, and brain magnetic resonance imaging (MRI) findings were documented. Patients were classified as Gross Motor Function Classification System (GMFCS) level 4 or higher, with 58% at GMFCS level 5.3. Displaced hips (n=181 patients) were defined as a migration percentage of ≥30% or previous surgery for hip displacement/adductor contractures. Patients who did not meet these criteria were classified as nondisplaced (n=48 patients). We used univariate analysis and multivariate logistic regression to determine associations between patient factors and hip displacement (alpha=0.05). Results: Patients born at term (≥37 wk) had 2.5 times the odds [95% confidence interval (CI): 1.3-5.0] of having nondisplaced hips compared with patients born prematurely. Females had 2.0 times the odds (95% CI: 1.0-3.9) of having nondisplaced hips compared with males. Patients with normal brain MRI findings had 9.6 times the odds (95% CI: 2.3-41) of having nondisplaced hips compared with patients with abnormal findings. Hip displacement was not associated with race (P>0.05). Conclusions: Gestational age 37 weeks or above, female sex, and normal brain MRI findings are independently associated with nondisplaced hips in patients with spastic quadriplegic CP and severe scoliosis. These findings direct attention to characteristics that may place patients at greater risk of displacement. Future work may influence preventative screening practices and improve patient counseling regarding the risk of hip displacement. Level of Evidence: Level III—retrospective comparative study.
Posted: May 1, 2021, 12:00 am
imageIntroduction: Traditionally, midshaft clavicular fractures in adolescents are treated nonoperatively. In later years, a trend toward operative treatment can be observed. Documentation of the benefit of surgery in this group is scarce. The purpose of this study is to evaluate the long-term patient reported functional outcomes and complications for patients treated operatively and nonoperatively for displaced midshaft clavicular fractures. Using the same outcomes we also compared the operative methods. Methods: One hundred nine adolescents aged 12 to 18 years sustaining displaced midshaft clavicular fractures in the period 2010 to 2016 were identified in our computerized files. Sixty-one were treated nonoperatively, 48 operatively (22 plate and 26 intramedullary nail). Their radiographs and patient journals were examined for fracture classification, wound infection, sensory affection, surgery duration, hardware removal, and nonunion (n=109). Long-term function, pain, and satisfaction were measured with Quick Disability of Arm, Shoulder, and Hand (QuickDASH), Oxford Shoulder Score and Visual Analogue Scale (n=87). Results: Operative treatment: We could find no difference in functional score outcomes. The main outcome QuickDASH was excellent in both groups (median 0 nail vs. 2.26 plate). Surgery duration was shorter with intramedullary nail. We found 2 infections and 2 sensory affections in the plate group, and 1 infection and 1 sensory affection in the intramedullary nail group. There were 2 refractures in the nail group. Operative versus nonoperative treatment: there were no differences in functional outcomes between the operative and nonoperative groups. For the main outcome QuickDASH both groups scored excellently (median 1.12 operative vs. 0 nonoperative). The nonoperative group was more satisfied with the cosmetic result. There was 1 nonunion in the nonoperative group that later was operated. Conclusions: Adolescents aged 12 to 18 years with displaced midshaft clavicular fractures show good long-term functional results after plate fixation, intramedullary nail, and nonoperative treatment. No additional benefit is demonstrated for surgery in our material. Nonoperatively treated patients are more satisfied with the cosmetic results. Little difference is seen between the operative methods in our study. We conclude that surgery should rarely be the choice of treatment for displaced midshaft clavicular fractures in adolescents. Level of Evidence: Level III study—retrospective comparative study.
Posted: May 1, 2021, 12:00 am
imageBackground: Worldwide a wide variation exists in duration of Pavlik harness treatment for infants up to 6 months with stable developmental dysplasia of the hip (DDH). The purpose of this study was to evaluate whether shortening the time to first routine follow-up ultrasound after initiation of Pavlik harness treatment would reduce treatment duration and whether this influenced radiologic outcome at 1 year of age. Furthermore, predictors of higher acetabular index (AI) at 1 year of age were investigated. Methods: A retrospective study was conducted in infants with stable DDH (Graf IIb and IIc) diagnosed and treated between 2015 and 2017. Two groups were identified: first routine follow-up ultrasound at 12 weeks after Pavlik harness initiation (group I) and first routine follow-up ultrasound at 6 weeks after Pavlik harness initiation (group II). In both groups, treatment was continued until repeat ultrasound measurements (every 6 wk) showed a normalized hip. Radiologic outcome at 1 year of age was defined as residual dysplasia measured on an anteroposterior hip radiograph according to the Tönnis table. Results: A total of 222 infants were included. The median time of Pavlik harness treatment was 12 weeks (interquartile range, 11.9 to 12.3) in group I compared with 6.1 weeks (interquartile range, 6.0 to 7.5) in group II (P
Posted: April 1, 2021, 12:00 am
imageBackground: Seymour fractures of the toe are physeal fractures with often occult concomitant nail bed injuries and thus are open fractures. They are uncommon injuries that without proper treatment can result in osteomyelitis. The literature has sparse information regarding the clinical outcomes for these injuries. Methods: A single-center retrospective review included juxta-epiphyseal fractures or Salter-Harris I/II fracture of the toe with documented concomitant nail bed injury or laceration. Clinical and radiographic data were recorded for consecutive fractures. The primary outcome was the incidence of osteomyelitis. Secondary outcomes included premature physeal arrest, development of nail dystrophy, and functionality of the toe. Results: Between 2006 and 2019, 19 patients were treated for this injury by the pediatric orthopaedic division. Complications included osteomyelitis (n=6), physeal arrest (n=4), and nail dystrophy (n=1). Days from injury to definitive treatment were significantly greater in patients who developed osteomyelitis compared with those who did not (P
Posted: January 1, 2021, 12:00 am
imageBackground: The aim of this study was to assess the accuracy of clinical screening examination in newborns with dislocated hips compared with ultrasound scan (USS). Methods: Newborns, up to 3 months of age, with confirmed hip dislocations on USS were prospectively enrolled in a multinational observational study. Data from 2010 to 2016 were reviewed to determine pretreatment clinical examination findings of the treating orthopaedic surgeon as well as baseline ultrasound indices of developmental dysplasia of the hip (DDH). All infants had been referred to specialist centres with expertise in DDH, due to abnormal birth examination or risk factor. Results: The median age of the study population was 2.3 weeks and 84% of patients were female. Of the total 515 USS-confirmed dislocated hips included in the study, 71 (13.8%) were incorrectly felt to be reduced on clinical examination by the treating orthopaedist (P
Posted: September 1, 2020, 12:00 am
imageIntroduction: The ability for teams to work together in a coordinated manner may be where the greatest improvements in health care occur in the next generation. To perform at the highest level there are several key principles that all teams must have no matter what playing field they are on, including health care. Methods: Several resources were used to identify the challenges we face in health care with respect to the delivery of quality care, improving outcomes and decreasing complications. A search of the lay press and scientific literature was evaluated to identify those key elements that lead to improvements in team performance. In addition, personal observations were accumulated with time and examples of strategies used at home institutions were identified. Results: The teams in our pediatric orthopaedic practices are many and include those in the clinic, the operating room, research, and our administrative office. The Institute of Medicine, in their influential article in 1999, defined the alarming rates of complications/harm occurring in the US health care system. In response, the Agency for Healthcare Research and Quality (AHRQ) and the Department of Defense (DOD) collaborated to create the Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) in 2006. This was implemented in military facilities and later civilian hospital settings with varied success in civilian hospital settings. Discussion: They defined key principles based around team structure, communication, leadership, situation monitoring, and mutual support. Other important foundational attributes of a successful team include identifying the vision of the team, hiring top-talent in the form of hard and soft skills, having open communication, being goal-focused, practicing accountability, and having an organized team. We can look to excellent examples in medicine, business, and sports to see where and how high-functioning teams have existed and to learn from them to implement similar successful teams. Conclusions: Team performance is a function of talented members who share a common vision, who have the opportunity to voice their thoughts/opinions, and have the ability to be accountable to each other. Surgeons need to lead by example, and provide each member of the team an opportunity to contribute in a meaningful way which ultimately will improve the lives of the patients we are honored to care for.
Posted: July 1, 2020, 12:00 am
imageBackground: Nerve injuries occur in approximately 11% of pediatric extension supracondylar humerus fractures (SCHF), yet there is scarce literature to guide clinicians on management. The primary goal of this study was to report the presentation, treatment, and outcome of motor nerve injuries associated with extension SCHF. Our secondary goal was to determine which injury and treatment factors were associated with prolonged motor nerve recovery. Methods: Two hundred forty-four traumatic nerve injuries associated with extension SCHF treated at a single institution between 1996 and 2012 were reviewed. Patients with iatrogenic nerve injuries or subjective paresthesias without motor deficit were excluded. Univariable and multivariable general linear modeling were used to compare recovery times across nerve injury types and to determine the effect of injury and treatment characteristics on recovery time. Results: Patients were a mean age of 6.7 years, with 89% presenting with a single nerve injury and 29% of the cohort experiencing a concurrent vascular injury. The majority of injuries (62%) were to the median nerve. Forty-three (18%) cases had acute nerve decompression at the time of fracture fixation. Five cases required subsequent surgery for poor nerve recovery; none of which underwent initial nerve decompression. Thirty-one patients were lost to follow-up after injury. Median time to nerve recovery was 2.3 months (IQR 1.4 to 3.7 mo); 60% of injuries had nerve recovery by 3 months and 196 (92%) patients had complete nerve recovery at final follow-up. A greater percentage of isolated median nerve (70%) injuries recovered within 3 months compared with radial nerve (42%) injuries (P=0.01). Multivariable analysis demonstrated that multiple nerve injuries took 54% longer to recover than single median nerve injuries (P=0.01), and single radial nerve injuries took 30% longer to recover than single median nerve injuries (P=0.04). Conclusions: The majority of nerve injuries associated with pediatric extension SCHF recover within 6 months without acute nerve decompression. The presence of either an isolated radial nerve injury or multiple nerve injuries is associated with prolonged motor recovery. Level of Evidence: Level IV.
Posted: October 1, 2019, 12:00 am
imageBackground: Fibular hemimelia is the most common deficiency involving the long bones. Paley classification is based on the ankle joint morphology, identifies the basic pathology, and helps in planning the surgical management. Reconstruction surgery encompasses foot deformity correction and limb length equalization. The SUPERankle procedure is a combination of bone and soft tissue procedures that stabilizes the foot and addresses all deformities. Methods: We retrospectively reviewed 29 consecutive patients (29 limb segments), surgically treated between December 2000 and December 2014. Among the 29 patients, 27 were treated with reconstructive procedures. Type 1 (8 patients) cases were treated with only limb lengthening, and correction of tibial deformities. Type 2 (7 patients) cases were treated by distal tibial medial hemiepiphysiodesis or supramalleolar varus osteotomy. In type 3 (10 patients) cases, the foot deformity was corrected using the SUPERankle procedure. Type 4 (2 patients) cases were treated with supramalleolar osteotomy along with posteromedial release and lateral column shortening. In a second stage, limb lengthening was performed, using the Ilizarov technique. In the remaining 2 patients (type 3A and type 3C), amputation was performed using Syme technique as a first choice of treatment. Results: The results were evaluated using Association for the Study and Application of Methods of Ilizarov scoring. Excellent results were obtained in 15 of 27 (55%) patients. Six (22%) patients had good results, 4 (14.8%) had fair results, and 2 (7%) had poor results. Mean limb length discrepancy at initial presentation was 3.55 cm (range: 2 to 5.5 cm) which significantly improved to 1.01 cm (range: 0 to 3 cm) after treatment (P=0.015). Conclusions: Our results and a review of the literature clearly suggest that limb reconstruction according to Paley classification, is an excellent option in the management of fibular hemimelia. Our 2-staged procedure (SUPERankle procedure followed by limb lengthening) helps in reducing the complications of limb lengthening and incidence of ankle stiffness. Performing the first surgery at an earlier age (below 5 y) plays a significant role in preventing recurrent foot deformities. Level of Evidence: Level IV.
Posted: October 1, 2019, 12:00 am
imageBackground: The purpose of this meta-analysis is to review clinical outcomes and complications following pediatric anterior cruciate ligament (ACL) reconstruction. Methods: The PubMed and EMBASE databases were searched for studies on ACL ruptures in the skeletally immature from 1985 to 2016. Full-text studies in English and performed on humans were included (n=5718). Titles included discussed operative intervention on skeletally immature patients with ACL tears (n=160). Studies that reported rerupture and/or complications with ACL reconstruction specific to the pediatric population, specifically growth disturbance, were then included in a secondary analysis (n=45). Complications not specific to the pediatric population were excluded. Demographics, graft type, surgical technique, follow-up, growth disturbance, rerupture, and patient-reported outcome scores were collected. Data were analyzed in aggregate. Results: In total, 45 studies were included with 1321 patients and 1392 knees. The average age was 13.0 years, 67% were male, and mean follow-up was 49.6 months. There were 115 (8.7%) reruptures in the initial 160 studies reviewed. In total, 94.6% of patients with rerupture required revision ACL surgery. There were 58 total growth disturbances (16 required corrective surgery, or 27.6%). Eighteen knees (3.7%) developed angular deformity, most commonly valgus. There were 37 patients (7.5%) had at least a 1 cm limb-length discrepancy. A total of 23 studies reported International Knee Documentation Committee scores (range, 81 to 100, 88% grade A or B). In total, 20 studies reported excellent Lysholm scores with mean scores of 94.6. Conclusions: Growth disturbance can occur with any of the reconstruction techniques. Proper surgical technique is likely more important than the specific reconstruction technique utilized. Patients with rerupture require surgery at much higher rates than those with growth disturbance. Although much attention has been focused on growth disturbance, we suggest that equal attention be given to the prevention of rerupture in this age group. Level of Evidence: Level III.
Posted: September 1, 2019, 12:00 am
imageBackground: With observed success and increased popularity of growth modulation techniques, there has been a trend toward use in progressively younger patients. Younger age at growth modulation increases the likelihood of complete deformity correction and need for implant removal before skeletal maturity introducing the risk of rebound deformity. The purpose of this study was to quantify magnitude and identify risk factors for rebound deformity after growth modulation. Methods: We performed a retrospective review of all patients undergoing growth modulation with a tension band plate for coronal plane deformity about the knee with subsequent implant removal. Exclusion criteria included completion epiphysiodesis or osteotomy at implant removal, ongoing growth modulation, and 5 degrees rebound and 30% had >10 degrees rebound in HKA after implant removal. Females below 10 years and males below 12 years at time of growth modulation had greater mean change in HKA after implant removal compared with older patients (8.4 vs. 4.7 degrees, P=0.012). Patients with initial deformity >20 degrees had an increased frequency of rebound >10 degrees compared with patients with less severe initial deformity (78% vs. 22%, P=0.002). Conclusions: Rebound deformity after growth modulation is common. Growth modulation at a young age and large initial deformity increases risk of rebound. However, rebound does not occur in all at risk patients, therefore, we recommend against routine overcorrection. Level of Evidence: Level IV—retrospective study.
Posted: August 1, 2019, 12:00 am
imageIntroduction: Adolescent idiopathic Scoliosis (AIS) affects 2% to 3% of the population of which only 0.3% to 0.5% of affected patients will have a curvature of >20 degrees, the curve magnitude at which treatment is generally recommended. For AIS the current natural history data is limited and most of the information comes from a small body of literature from the University of Iowa. Methods: The Iowa natural history studies began as retrospective reviews but beginning in 1976, the cohort was followed prospectively. Outcomes assessed in this group of patients included; mortality, pulmonary function, pregnancy-(effect of pregnancy on scoliosis and the effect of scoliosis on pregnancy), radiographic, curve progression, and osteoarthritis. In addition, validated questionnaires were used to evaluate back pain, pulmonary symptoms, general function, depression, and body image. Results: Patients with untreated AIS can function well as adults, become employed, get married, have children, and grow to become active older adults. Unfortunately, untreated scoliosis may lead to increased back pain and pulmonary symptoms for patients with large thoracic curves. Patients with untreated AIS can also develop substantial deformity, and the cosmetic aspect of this condition cannot be disregarded. Conclusions: The summary findings of this unique lifetime natural history of AIS patients provides patients and parents a solid evidence base upon which to make informed decisions.
Posted: July 1, 2019, 12:00 am
imageBackground: Early-onset scoliosis (EOS) is defined as the diagnosis of a spinal deformity before the age of 5 years. It can be divided into idiopathic, neuromuscular/syndromic, and congenital etiologies. Methods: The literature on the natural history of EOS was summarized. Results: The natural history varies with the etiology of EOS. Idiopathic curves may benefit from early serial casting. The natural history of neuromuscular and syndromic scoliosis is highly dependent on the natural history of the underlying disorder. Congenital scoliosis has a variable prognosis depending on the location and extent of the congenital malformations. Conclusions: Treatment of children with EOS is customized to the particular disorder. While lack of treatment has been shown to lead to increased mortality, extensive early definitive fusion may lead to thoracic insufficiency. Delaying definitive surgery and the use of growing instrumentation may provide benefit in maintaining pulmonary health. Clinical Relevance: Potential disturbance of growth must be considered in the treatment of young children with scoliosis.
Posted: July 1, 2019, 12:00 am
Background: In order to determine whether treatments are effective in the treatment of meniscus tears, it is first necessary to understand the natural history of meniscus tears. The purpose of this paper is to review the literature to ascertain the natural history of meniscus tears in children and adolescents. Methods: A search of the Pubmed and Embase databases was performed using the search terms “meniscus tears,” “natural history of meniscus tears,” “knee meniscus,” “discoid meniscus,” and “natural history of discoid meniscus tears.” Results: A total of 2567 articles on meniscus tears, 28 articles on natural history of meniscus tears, 8065 articles on “menisci,” 396 articles on “discoid meniscus,” and only 2 on the “natural history of discoid meniscus” were found. After reviewing the titles of these articles and reviewing the abstracts of 237 articles, it was clear that there was little true long-term natural history data of untreated meniscus tears nor whether treating meniscus tears altered the natural history. Twenty-five articles were chosen as there was some mention of natural history in their studies. Conclusions: There are few long-term data on untreated meniscal tears or discoid meniscus, or tears in children and adolescents. The literature suggests that there is a higher incidence of chondral injury and subsequent osteoarthritis, but there are many confounding variables which are not controlled for in these relatively short-term papers.
Posted: July 1, 2019, 12:00 am
imageBackground: Lower extremity malalignment is a common problem presented to pediatric orthopaedists. Risk for early arthritis is often a concern among parents seeking advice and treatment. We seek to review previous research with regard to the natural history of malalignment. Methods: A search of available literature on PubMed was constructed to capture articles covering the natural history of malalignment, secondary to childhood fracture as well as congenital and acquired pediatric deformity. In order to remain strictly relevant to pediatrics, articles reviewing deformities acquired in adulthood were not referenced. Biomechanical data and animal studies were included when deemed appropriate. Results: High-quality data with regard to long-term risk of arthritis due to malalignment is lacking. Through a combination of biomechanical data, animal models, and a small body of longitudinal clinical data, it is clear that some patients with malalignment progress to early arthritic change. Unfortunately, detailed risk factors of who is at high risk versus low risk remains difficult to determine. Conclusions: Treatment of minor lower extremity malalignment is not supported by the current orthopaedic literature. Treatment plans should focus on the presence of symptoms, and in asymptomatic but severe cases. Even in more severe cases, strong evidence to support prophylactic realignment is not available. Evidence to suggest that preventative realignment is superior to intervention at the time of symptom onset does not exist.
Posted: July 1, 2019, 12:00 am
imageBackground: Structural hip abnormalities have long been suspected of causing hip osteoarthritis. The concept of deformity of the proximal femur as a cause of osteoarthritis (OA) started with description of the tilt deformity and progressed to the pistol grip, then eventually cam-type femoroacetabular impingement (FAI). Acetabular over-coverage or retroversion as a cause of impingement is commonly referred to as pincer-type FAI. The primary research question we asked was: what is the natural history of hips with FAI? Methods: We reviewed the literature to identify studies with cross-sectional and longitudinal evidence of the effect of FAI on the development of or association with hip OA. Results: In cross-sectional and longitudinal natural history studies of hip OA, cam-type FAI has consistently shown an association with developing OA. In regard to pincer-type FAI, the data are less convincing with some studies suggesting an increased risk and others showing a protective effect of the acetabular over-coverage. It is clear that not all patients with cam FAI get OA but the altered anatomy does increase the relative risk of developing OA. Conclusions: Cam-type FAI is associated with the development of hip OA; however, there is no role for prophylactic surgery in the asymptomatic hip with the anatomy predisposing to FAI. Further interventional studies are needed to determine whether surgical correction of cam-type FAI in the symptomatic hip alters the natural history of the condition.
Posted: July 1, 2019, 12:00 am
imageBackground: The long-term effects of small limb length discrepancies have been poorly documented in the literature. References to low back pain, hip pathology, knee pathology, and foot problems abound in the popular literature. Health care providers frequently recommend the use of lifts for structural and functional limb length discrepancies, yet the natural history of limb length inequality as well as the effectiveness of treatments that may be recommended are obscure. The purpose of this paper is to document and evaluate the literature associated with small limb length discrepancies. Methods: A search of the English literature was carried out using PubMed to identify papers dealing with the effects of limb length discrepancies. Papers reporting only expert opinion or case reports were excluded. Results: Papers dealing with the natural history of limb length discrepancy as well as studies in which gait analysis was performed in patients with limb length discrepancy were identified. Only 10% of the population has exactly equal lower limb lengths. Approximately 90% of the population has a limb length discrepancy 2.0 cm are frequently a problem. There is some evidence that limb length discrepancies as little as 5 mm can lead to long-term pathology.
Posted: July 1, 2019, 12:00 am
imageBackground: Slipped capital femoral epiphysis (SCFE) occurs at a rate of 1 in 10,000 to 20,000 children. Methods: A PubMed search was undertaken to evaluate recent SCFE literature. A convenience sample of articles were selected and summarized. Results: Most slips appear well tolerated long-term with ∼5% resulting in total hip arthroplasty (THA) at 20-year follow-up. Classic data reveals poor outcomes following closed reduction for treatment of SCFE. Improvements in intraoperative fluoroscopy and avoidance of pin penetration have reduced the rates of chondrolysis. Unfortunately, avascular necrosis remains a known risk in patients, occurring in 15% to 50% of patients following acute, unstable slips. This is the most common cause of THA in patients with SCFE. Rate of THA due to degenerative arthritis secondary to SCFE is more difficult to determine and occurs at a later age. Although realignment procedures to address anatomic abnormalities from SCFE have increased in popularity, it is unclear if this prevents degenerative arthritis and subsequently reduces the rate of THA. SCFE patients face an increased risk of disability and death due to their underlying medical comorbidities. Interventions for weight loss, blood pressure management, and lifestyle adjustments should be considered at the time of SCFE diagnosis. Conclusions: SCFE remains a challenging and common condition for pediatric orthopedists. Although innovative techniques have been proposed, long-term outcome data still supports in situ pinning for stable slips, and in situ pinning with capsular decompression for unstable slips to minimize the risk of avascular necrosis.
Posted: July 1, 2019, 12:00 am
Background: Increased participation in youth sports is associated with increased rates of anterior cruciate ligament (ACL) tears in the skeletally immature. Historically, ACL reconstruction was avoided in the skeletally immature, or delayed until skeletal maturity, to avoid physeal injury and growth disturbance. Current practices and meta-analyses support early ACL reconstruction in some groups, to allow for return to activities and to avoid delayed cartilage/meniscus injury. Purpose: The purpose of this article was to report on the natural history of ACL injuries in the skeletally immature. Methods: A review of published literature on pediatric, skeletally immature ACL tears and conservative, nonoperative treatment was conducted via Pubmed articles published from 1970 to 2018. The search criteria included the key terms “anterior cruciate ligament,” “pediatric” and/or “adolescent,” and “conservative” and/or “nonoperative treatment.” A PRISMA workflow was used to narrow down the articles to those relevant to our analysis and available in full text format. Results: Multiple articles on the nonoperative treatment of the ACL showed secondary meniscal and cartilage damage at the time of follow-up. Some articles showed no difference between the rates of secondary injuries between the surgical and nonsurgical treatment groups; however, the nonsurgical treatment groups were often on significant activity modification. Some articles concluded that nonoperative treatment of the ACL tear may be appropriate in low risk, lower level activity patients, and those that will comply with activity restrictions. Even with bracing and PT programs, active athletes treated without surgery appear to have a concerning rate of secondary meniscus injury after the primary ACL injury event. Conclusions: The natural history of the ACL tear shows nonoperative treatment for the skeletally immature may be a viable treatment pathway for those who are able to comply with the physical activity restrictions. For the general population of young, active adolescents, an ACL injury treated nonoperatively often leads to secondary meniscal and/or cartilage damage, which may lead to knee degeneration and functional instability.
Posted: July 1, 2019, 12:00 am
imageBackground: Delayed diagnosis of flexor tendon injury in children is common, and consequent flexor sheath scarring may necessitate a 2-stage reconstruction. Previous studies show variable outcomes after 2-stage flexor reconstruction in children, especially those below 6 years old. We evaluated functional and subjective outcomes of primary repair and staged reconstruction of zone I and II tendon injuries in children under 6 years of age. Methods: A retrospective chart review identified 12 digits in 10 patients who had undergone surgical treatment of a zone I or II flexor tendon injury. Seven digits had a primary repair and 5 had a 2-stage reconstruction. Time delay from injury to surgery for primary repairs averaged 18 weeks and for 2-stage reconstruction averaged 24 weeks. Outcomes included total active motion, tip pinch and grip strength, sensation, and the Pediatric Outcomes Data Collection Instrument (PODCI). Results: Average follow-up was 8 years. At final follow-up, mean total active and passive motion of the involved digit was similar between the primary reconstruction and staged groups, and 58% had a “good” or “excellent” American Society for Surgery of the Hand; total active motion (ASSH TAM) result (71% in the primary repair group, 40% in the 2-stage reconstruction group). All regained grip and pinch strength equal to the contralateral hand. The average PODCI Upper Extremity score was 99 (99 in the primary repair group, 98 in the 2-stage reconstruction group) and PODCI Global Function score was 94 (97 in the primary repair group, 91 in the 2-stage reconstruction group). No complications occurred. Conclusions: Our small study demonstrates that both primary repair and 2-stage flexor tendon reconstruction have acceptable long-term functional and subjective outcomes in children below 6 years old, although staged reconstruction had a lower overall ASSH TAM score and subcategorical PODCI scores. Although staged reconstruction has acceptable outcomes in this population, prompt primary repair of flexor tendon injuries in children should always be attempted. Level of Evidence: Level 4—therapeutic.
Posted: May 1, 2019, 12:00 am
imageBackground: Closed reduction (CR) is a common treatment for infantile developmental dysplasia of the hip. The purpose of this observational, prospective, multicenter study was to determine the early outcomes following CR. Methods: Prospectively collected data from an international multicenter study group was analyzed for patients treated from 2010 to 2014. Baseline demographics, clinical exam, radiographic/ultrasonographic data, and history of previous orthotic treatment were assessed. At minimum 1-year follow-up, failure was defined as an IHDI grade 3 or 4 hip and/or need for open reduction. The incidence of avascular necrosis (AVN), residual dysplasia, and need for further surgery was assessed. Results: A total of 78 patients undergoing CR for 87 hips were evaluated with a median age at initial reduction of 8 months (range, 1 to 20 mo). Of these, 8 hips (9%) were unable to be closed reduced initially. At most recent follow-up (median 22 mo; range, 12 to 36 mo), 72/79 initially successful CRs (91%) remained stable. The likelihood of failure was unaffected by initial clinical reducibility of the hip (P=0.434), age at initial CR (P=0.897), or previous treatment in brace (P=0.222). Excluding those hips that failed initial CR, 18/72 hips (25%) developed AVN, and the risk of osteonecrosis was unaffected by prereduction reducibility of the hip (P=0.586), age at CR (P=0.745), presence of an ossific nucleus (P=0.496), or previous treatment in brace (P=0.662). Mean acetabular index on most recent radiographs was 25 degrees (±6 degrees), and was also unaffected by any of the above variables. During the follow-up period, 8/72 successfully closed reduced hips (11%) underwent acetabular and/or femoral osteotomy for residual dysplasia. Conclusions: Following an initially successful CR, 9% of hips failed reduction and 25% developed radiographic AVN at early-term follow-up. History of femoral head reducibility, previous orthotic bracing, and age at CR did not correlate with success or chances of developing AVN. Further follow-up of this prospective, multicenter cohort will be necessary to establish definitive success and complication rates following CR for infantile developmental dysplasia of the hip. Level of Evidence: Level II—prospective observational cohort.
Posted: March 1, 2019, 12:00 am
imageOptimal clinical decision making and surgical management of hip dysplasia in children with cerebral palsy (CP) requires an understanding of the underlying pathophysiology (pathomechanics and pathoanatomy), incidence, and natural history. The incidence of hip dysplasia in children with CP is directly related to the degree of motor impairment. A subluxated or dislocated hip in a child with CP can compromise the quality of life for both the child and their caregivers. The goal of this article is to highlight the events over the last 25 years that have had the greatest impact on the management of hip dysplasia in children with CP. It is my opinion that the 2 most significant advances during this time have been the development of a classification system based upon motor impairment (the Gross Motor Function Classification System), and the development of surveillance programs for hip dysplasia in children with CP. This article will contrast neuromuscular hip dysplasia with developmental dysplasia of the hip. It will be shown how the development and utilization of the Gross Motor Function Classification System has contributed to our understanding of the epidemiology and natural history of hip dysplasia in children with CP, and to the assessment of outcomes following surgical management. The impact of hip surveillance programs on early soft tissue surgeries, skeletal hip reconstructions, and the incidence of hip dislocations and salvage surgeries will be reviewed. Challenges in the implementation of hip surveillance programs in resource poor and decentralized health care delivery systems will be considered, and innovative approaches identified.
Posted: July 1, 2018, 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
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
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
Patients with arthrogryposis often require anesthesia for surgical procedures. Intubation can be challenging due to lack of visualization. Anesthetic maintenance is fairly routine. Pheripheral blocks are an important adjunct to postoperative pain management.
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
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
imageMost proximal humerus fractures in skeletally immature individuals are treated nonoperatively with excellent functional results. Extensive remodeling of the proximal humerus and the wide arc of motion of the glenohumeral joint accommodate a large degree of fracture displacement and angulation. The treatment of severely displaced fractures and/or severely angulated fractures continues to be debated. Older patients and those with significantly displaced fractures may benefit from surgery because of their inability to remodel displacement and angulation during their limited remaining growth. The decision to treat a proximal humerus fracture in a skeletally immature patient operatively versus nonoperatively is dependent on the following 3 factors: displacement, bone age, and capacity to remodel. There is an increasing trend toward treating severely displaced and severely angulated fractures surgically, especially in older patients and adolescents. Smooth wires, percutaneous threaded wires, cannulated screws, and retrograde elastic stable intramedullary nailing are acceptable options for fixation.
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
imageBackground: Radial neck fractures in children are rare, representing 5% of all elbow pediatric fractures. Most are minimally displaced or nondisplaced. Severely displaced or angulated radial neck fractures often have poor outcomes, even after open reduction, and case series reported in literature are limited. The aim of the study is to analyze the outcomes of patients with a completely displaced and angulated fracture who underwent open reduction when closed reduction failed. Methods: Between 2000 and 2009, 195 patients with radial neck fractures were treated in our institute. Twenty-four cases satisfied all the inclusion criteria and were evaluated clinically and radiologically at a mean follow-up of 7 years. At follow-up, the carrying angle in full elbow extension and the range of motion of the elbow and forearm were measured bilaterally. We recorded clinical results as good, fair, or poor according to the range of movement and the presence of pain. Radiographic evaluation documented the size of the radial head, the presence of avascular necrosis, premature physeal closure, and cubitus valgus. Results: Statistical analysis showed that fair and poor results are directly correlated with loss of pronation-supination (P=0.001), reduction of elbow flexion-extension (P=0.001), increase of elbow valgus angle (P=0.002), necrosis of the radial head (P=0.001), premature physeal closure (P=0.01), and associated lesions (olecranon fracture with or without dislocation of the elbow) (P=0.002). Discussion: In our cases, residual radial head deformity due to premature closure of the growth plate and avascular necrosis were correlated with a functional deficit. Associated elbow injury was coupled with a negative prognosis. In our series, about 25% of patients had fair and 20% had poor results. Outcomes were good in 55% and felt to represent a better outcome than if the fracture remained nonanatomically reduced with residual angulation and/or displacement of the radial head. This study reports the largest series of these fractures with a combination of significant angulation and displacement of the fracture requiring open reduction. We feel that open reduction is indicated when the head of the radius is completely displaced and without contact with the rim of the metaphysis.
Posted: December 1, 2014, 12:00 am
imageSurgical hip dislocation (SHD) is a versatile approach used to address both intra-articular and extra-articular pathology around the hip joint in both pediatric and adult patients. It allows anterior dislocation of the femoral head for direct visualization of the hip joint while preserving femoral head vascularity and minimizing trauma to the abductor musculature. Previously described indications for SHD include femoroacetabular impingement, deformity resulting from Legg-Calve-Perthes disease, slipped capital femoral epiphysis, periarticular trauma, benign lesions of the hip joint, and osteochondral lesions. In this review, we will describe current surgical techniques, indications, and clinical outcomes for SHD.
Posted: October 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
imageBackground: Legg-Calvé-Perthes disease (LCPD) is an idiopathic avascular necrosis of the femoral head primarily affecting children of ages 4 to 12 years. There is no clear consensus on nonoperative or operative treatment protocols for pediatric patients presenting with LCPD. This study uses meta-analysis and a binary logistic regression model to analyze the radiographic outcomes of these treatment modalities in pediatric patients. Methods: Clinical studies describing patients undergoing either nonoperative or operative treatment of LCPD published from 1960 through 2010 were searched electronically and manually. Eligible studies consisted of (1) a minimum of 10 patients; (2) listed age at the time of diagnosis or treatment; (3) performed an initial severity assessment using the Herring or Catterall classification; (4) detailed the type of intervention; and (5) reassessment of radiographic outcome after a minimum of 1 year after treatment using the Mose or Stulberg classification. Results: Twenty-three studies, 1232 patients, and 1266 hips met the inclusion criteria. Among patients younger than 6 years, operative and nonoperative treatments are equally as likely to results in a successful radiographic outcome [odds ratio (OR)=1.071; P=0.828; 95% confidence interval (CI), 7.377-32.937]. In patients older than 6 years, operative treatment is nearly twice as likely to result in a successful radiographic outcome (OR=1.754; P
Posted: October 1, 2012, 12:00 am
imageThis article reviews the current best evidence for musculoskeletal interventions in children with ambulatory cerebral palsy (CP). The effectiveness of interventions in CP must first consider what CP and its associated pathophysiology are and take into account the heterogeneity and natural history of CP to put definitions of “effectiveness” into perspective. This article reviews the current standards of the definition and classification of CP, discusses the natural history and specific goals for the management of ambulatory CP, as well as the outcome measures available to measure these goals. The current best evidence of effectiveness is reviewed for specific interventions in children with ambulatory CP including spasticity management with botulinum toxin A injections and selective dorsal rhizotomy; multilevel orthopaedic surgery to address contractures and bony deformity; and the role of gait analysis for surgical decision-making before orthopaedic surgery.
Posted: September 1, 2012, 12:00 am
imageBackground: Supracondylar humerus fractures are widely considered the most common fracture of the elbow in children. Fractures can range from a less severe, nondisplaced type I fracture to a more severe, displaced type III fracture with no cortical contact. Type III fractures can lead to adverse physical, social, and emotional consequences if they are not treated effectively. The American Academy of Orthopaedic Surgeons recently carried out a systematic review of the literature to develop a clinical practice guideline. The guidelines provided answers for the following questions regarding the treatment for type III supracondylar fractures (1) which is the preferred treatment for displaced supracondylar fractures of the humerus: reduction and casting versus closed reduction and percutaneous pinning; (2) which is the preferred method for fixing displaced supracondylar fractures of the humerus: medial (crossed) versus lateral pinning; and lastly, (3) does open reduction cause increased stiffness or have a high rate of complication? The purpose of this paper is to summarize and highlight the major findings from this systematic review. Methods: PubMed, EMBASE, CINAHL, and The Cochrane Central Register of Controlled Trials were searched to locate 1726 relevant articles published from January 1966 to July 29, 2010. Of these, 44 met our criteria for inclusion and were reviewed systematically. Results: On the basis of the results from the systematic review: (1) we suggest closed reduction with pin fixation for patients with displaced (eg, Wilkins type II and III and displaced flexion) pediatric supracondylar fractures of the humerus. (2) The practitioner might use 2 or 3 laterally introduced pins to stabilize the reduction of displaced pediatric supracondylar fractures of the humerus. Considerations of potential harm indicate that the physician might avoid the use of a medial pin. (3) The practitioner might perform open reduction for displaced pediatric supracondylar fractures of the humerus after closed reduction if varus or other malposition of the bone occurs. Conclusions: Clearly, controversy exists regarding the best treatments for pediatric supracondylar humerus fractures. Properly designed randomized controlled trials comparing treatment options are necessary to determine optimal treatments. Level of Evidence: Level II.
Posted: September 1, 2012, 12:00 am
imageGrowth plate fractures of the distal femur are challenging to treat, with complications that require a secondary surgery 40% to 60% of the time. These fractures often necessitate operative intervention, even in the youngest patients and even with minimal apparent displacement. Treatment varies with the Salter-Harris (SH) classification and with the extent of initial displacement, ranging from simple casting for nondisplaced SH I fractures to open reduction and internal fixation for almost all SH III and IV fractures. Poor outcomes have been associated with pediatric fracture care of SH III and IV in 29% to 32% of cases. There are many pitfalls that have to be avoided in the treatment of these fractures to prevent malunion, growth arrest, and posttraumatic arthritis.
Posted: June 1, 2012, 12:00 am
imagePhyseal fractures of the distal tibia and fibula are common and can be seen at any age, although most are seen in the adolescent. An understanding of the unique anatomy of the skeletally immature ankle in relation to the mechanism of injury will help one understand the injury patterns seen in this population. A thorough clinical exam is critical to the diagnosis and treatment of these injuries and the avoidance of potentially catastrophic complications. Nondisplaced physeal fractures of the distal tibia and fibula can be safely treated nonoperatively. Displaced fractures should undergo a gentle reduction with appropriate anesthesia while multiple reduction attempts should be avoided. Gapping of the physis >3 mm after reduction should raise the suspicion of entrapped periosteum that will increase the risk of premature physeal closure. Open reduction of displaced Salter-Harris type III and IV fractures is critical to maintain joint congruity and minimize the risk of physeal arrest.
Posted: June 1, 2012, 12:00 am
imageThe fundamental principles of fracture care apply to medial epicondyle fractures in that the goals of treatment are to obtain fracture healing and to promote a return of appropriate motion, strength, and stability. Recent studies have revealed limitations of some classically described evaluation methods and have revealed more precise methods of measuring displacement. The authors of this manuscript describe established principles of care and incorporate recent evidence-based articles to help the clinician study the issues relative to the clinical evaluation and the operative and nonoperative treatment of medial epicondyle fractures.
Posted: June 1, 2012, 12:00 am
imageThe majority of pediatric finger fractures can be treated by closed means with expected excellent outcomes. However, a subset of fractures can turn “ugly,” with complications such as growth arrest, malunion, and joint dysfunction if not recognized and treated appropriately. The present paper discusses several fractures in a child’s fingers that can cause substantial problems if not recognized promptly, highlighting important themes in the evaluation and treatment of a child’s injured finger.
Posted: June 1, 2012, 12:00 am
imageIn a preliminary report in 1965, Axer proposed femoral varus derotation osteotomy as an alternative method for treating Legg-Calve-Perthes disease. Thereafter, this became one of the most popular operative methods in the treatment of the disease. A literature analysis of this method experienced during the years is discussed and the investigator's personal approach is described.
Posted: September 1, 2011, 12:00 am
imageResidual hip deformities secondary to Legg-Calvé-Perthes disease (LCPD) include growth disturbance of the proximal femoral physis with nonspherical femoral head, overriding greater trochanter with short femoral neck and secondary remodeling of the acetabulum. These deformities can change the mechanical function of the hip joint and contribute to femoroacetabular impingement. All these deformities need to be recognized and its contribution to the patient's symptoms understood before a treatment strategy can be planned. Safe surgical dislocation of the hip allows for complete inspection of the hip joint and dynamic assessment of femoroacetabular contact during hip motion. The goals of this paper are to review the pathophysiology, clinical presentation, imaging findings, and the management of femoroacetabular impingement in patients with LCPD. We sought to present our treatment philosophy for patients who were diagnosed and treated for LCPD as a child and present with femoroacetabular impingement as adolescents and young adults. Level V Expert opinion.
Posted: September 1, 2011, 12:00 am
imageBackground Hip distraction in Legg-Calvé-Perthes disease unloads the joint, which negates the harmful effect of the stresses on the articular surface, which may promote the sound healing of the areas of necrosis. Methods Nonarticulated arthrodiastasis without soft tissue release using an Ilizarov external fixator was applied to 29 patients with Legg-Calvé-Perthes disease (older than 8 y at onset and lateral pillar type C or B). Results Follow-up period ranged from 2.5 to 11 years with an average of 7.5 years. Twenty-seven cases (93%) had improvement of the range of motion postoperatively. Preoperatively, all patients had constant pain, whereas at last follow-up 26 (86%) patients had no pain and 3 had an improvement. Stulberg classification was applied to 21 cases who reached skeletal maturity at last follow-up: 9 cases were type II, 7 cases were type III, 4 cases were type IV, and 1 case was type V. Conclusions Nonarticulated hip distraction without soft tissue release seems to be a valid treatment option in cases with Legg-Calvé-Perthes disease where poor results are expected from conventional treatment.
Posted: September 1, 2011, 12:00 am
imageLegg-Calve-Perthes disease is a complex pediatric hip disorder with many uncertainties. Various theories on its etiology have been proposed but none have been validated conclusively. Through experimental studies, however, some insight into the pathogenesis of a femoral head deformity after ischemic necrosis has been gained. These studies reveal that mechanical and biological factors contribute to the development of the femoral head deformity. Better understanding of the pathobiology of Legg-Calve-Perthes disease will lead to the development of more effective treatments, which are able to specifically target the pathogenic processes.
Posted: September 1, 2011, 12:00 am
imageGrowth in childhood and in puberty has a major influence on the evolution of spinal curvature. The yearly rate of increase in standing height and sitting height, bone age, and Tanner signs are essential parameters. Additionally, biometric measurements must be repeated every six months. Puberty is a turning point. The pubertal diagram is characterized by two phases: the first two years are a phase of acceleration, and the last three years is a phase of decelaration. Thoracic growth is the fourth dimension of the spine. Bone age is an essential parameter. Risser 0 covers two third of the pubertal growth. On the acceleration phase, olecranon evaluation is more precise than the hand. On the deceleration phase, the Risser sign must be completed by the hand maturation. A 30 degree curve at the very beginning of puberty has 100% risk of surgery. Any spinal, if progression is greater than 10 degree per year on the first two years of puberty the surgical risk is 100%.
Posted: January 1, 2011, 12:00 am
imageFractures of the distal radius account for 80 percent of pediatric forearm fractures. The rapid growth of the distal radial physis and the on-going transformation of the metaphysic explain the propensity for fractures in this location and the potential for fracture remodeling. Fractures of the distal ulna are less common and usually occur in conjunction with fractures of the distal radius. In general both injuries can be managed by closed treatment and casting. Indications for skeletal fixation and/or open reduction are discussed. Complications are infrequent but not insignificant and usually treatable with early recognition and appropriate intervention.
Posted: March 1, 2010, 12:00 am
imageA small subset of serious injuries to the pediatric elbow, deemed “TRASH” lesions, are easily missed on radiograph because of their benign appearance. These lesions however, represent a group of osteochondral injuries, which if treated insufficiently result in chronic long-term consequences. Epiphyseal separations, a displaced intra-articular medial condyles before ossification of the secondary center, capitellar shear fractures, radial head fractures with radiocapitellar subluxation and osteochondral fractures of the olecranon, radial head or distal humerus with joint incongruity comprise the group of “TRASH lesions”. These injuries are usually seen in children less than 10 years of age who sustain high-energy trauma. The challenge is a prompt diagnosis requiring a high level of suspicion and early additional imaging. Many of these injuries are displaced and unstable requiring anatomic reduction, internal fixation with or without soft tissue repair for further stability. These injuries when diagnosed late, missed completely or treated improperly without aggressive surgical care can result in long-term complications. Surgical reconstruction of the late presenting malunion is difficult.
Posted: March 1, 2010, 12:00 am
imageAcceptable alignment of forearm fractures in children is controversial. An initial attempt at closed reduction in the emergency department is appropriate for the majority of these injuries. Complex or unstable fractures and those that cannot be maintained in acceptable alignment are candidates for surgical intervention. As a general guideline, fractures with complete displacement will remodel satisfactorily. However, angulation may be more critical for preservation of forearm rotation. Up to 15 degrees angulation is recommended as maximum angulation for mid-shaft and distal-shaft fractures in children younger than 8 years old. But 10 degrees is recommended as the maximum acceptable angulation for older children and proximal shaft fractures. When malunion is greater than this, remodeling is unreliable but may occur for fractures with less than 20-30 degrees of angulation.
Posted: March 1, 2010, 12:00 am

Latest Results for Journal of Children's Orthopaedics

The latest content available from Springer

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

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

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

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

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

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
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

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

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

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

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

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

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

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

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

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

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
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Journal of Pediatric Orthopaedics B - Current Issue

The journal highlights important recent developments from the world's leading clinical and research institutions. The journal publishes peer-reviewed papers on the diagnosis and treatment of pediatric orthopedic disorders. It is the official journal of IFPOS (International Federation of Paediatric Orthopaedic Societies).

imageThe aim of the study was to determine if the use of an Instructional Video will decrease anxiety during cast removal. We enrolled 60 healthy children undergoing their first cast removal following conservative fracture treatment. Patients were divided into one of three groups (1) No Video (control group), (2) watching a video of a well-tolerated pediatric cast removal (Instructional Video), or (3) watching a nonmedical Children’s Video during cast removal. We assessed anxiety to the cast saw by recording heart rate in the waiting room, during the procedure, and 1–2 min after the procedure. There were no significant differences in waiting room, procedure, and post-procedure heart rates between the two interventions and the control group. The mean change in heart rate from baseline to the procedure room for the Instructional Video cohort exhibited a similar increase (25.8 beats/min) in heart rate during cast removal as the No Video group (26.3 beats/min), while the Children’s Video had the smallest change in heart rate (17.7 beats/min) with a trend towards significance (P = 0.12). The results were not statistically significant for the full linear mixed-effect model on the three measurements. When we use age to control for variability in the data, we have a moderate effect size between Children’s Video and control (η2P = 0.0592), revealing that certain ages likely benefited from the Children’s Video intervention. Distraction using a Children’s Video may help reduce anxiety during cast removal whereas the Instructional Video did not reduce anxiety as hypothesized.
Posted: July 1, 2021, 12:00 am
imagePatient-reported outcome (PRO) instruments are critical to evaluate the natural history of conditions and treatment effects, but have not been well studied in pediatric limb deformity. The goal of this study was to identify and assess the most commonly used PROs in pediatric limb deformity surgery across a representative sample of the recent orthopedic literature. A review was performed from 1 January 2016 to 31 December 2018 in five orthopedic journals previously identified as having the greatest impact: Journal of Pediatric Orthopaedics, Journal of Pediatric Orthopaedics B, Journal of Children’s Orthopaedics, The Journal of Bone and Joint Surgery, and The Bone and Joint Journal. Clinical research studies involving pediatric population, operative management of limb deformity, and PRO measures were reviewed. The initial search of 3489 publications found 130 clinical articles involving operative management of pediatric limb deformity. Thirty-one studies (24%) met inclusion criteria, in which a total of 23 different PRO instruments were used. An average of 1.5 PRO instruments was reported per study (range 1–4). No outcome instrument was used by more than five different studies in this review, and no instrument validated in the pediatric population was used by more than three different studies. PROs currently used in pediatric limb deformity surgery are highly heterogeneous, as well as underutilized. Future research is necessary to either validate a current PRO in pediatric limb deformity or to develop a new instrument using pediatric Patient-Reported Outcomes Measurement Information System or Pediatric Outcomes Data Collection Instrument as a benchmark.
Posted: July 1, 2021, 12:00 am
imageA quality improvement protocol was implemented in a large tertiary care pediatric hospital to reduce the rate of transitions from emergency department (ED)-applied casts to another form of immobilization (waterproof cast, removable brace, or sling). The local standard of care prior to implementing this quality improvement project involved applying long-arm casts in the ED for children presenting with stable upper extremity injuries (those not requiring a reduction). We created a multidisciplinary quality improvement team with orthopedic and ED providers, as well as cast technicians, with the aim of reducing the transition rate of ED-applied casts in clinic by 50%. Multiple Plan-Do-Study-Act cycles were performed and data were evaluated monthly. Charge fees were determined to assess differences in costs between splints and casts. An independent samples t-test for equality of means was used to determine the ED length of stay of each group. Baseline data determined a cast transition rate of 59.9%. After implementing the quality improvement protocol, the cast transition rate was reduced to 25.0%, a 58% reduction. The length of stay in the ED for a patient receiving a splint as opposed to a cast was 26.2 ± 8.0 min shorter. The charge to a patient receiving a splint rather than an ED-applied cast was $291.25 less. In conclusion, implementation of a multidisciplinary quality improvement protocol resulted in a more than 50% reduction in the transition rate of ED-applied casts in the clinic. Furthermore, healthcare charges to families were reduced by nearly $130 000 annually after implementation of this protocol.
Posted: July 1, 2021, 12:00 am
imageUltrasound shear wave elastography (SWE) is a noninvasive, reliable and reproducible method, used for the qualitative and quantitative evaluation of tissues. The aim of this study was to compare muscle elasticity between the healthy and the involved sides in children with neonatal brachial plexus palsy (NBPP) using the elastography tool and to assess whether the difference was correlated with the Mallet grading system. We repeatedly measured the shear modulus coefficient of several muscles around the shoulder in stretched or passively relaxed positions on 14 patients. We evaluated the abductor muscles (supraspinatus and deltoid), the infraspinatus, the pectoralis major and the latissimus dorsi. We found a mean shear modulus significantly higher in most studied muscles in the pathologic side (P 
Posted: July 1, 2021, 12:00 am
imageThis study investigates determinants of pediatric orthopedic surgery patients’ parent or guardian (caregiver) satisfaction with the physician in an outpatient office setting. This was a cross-sectional survey study of 200 English-speaking caregivers of pediatric patients that checked into the pediatric orthopedic clinic at the authors’ institution from 1 March 2017 to 1 November 2018. Questionnaires given in clinic include the Newest Vital Sign and The Literacy in Musculoskeletal Problems survey to measure general and musculoskeletal health literacy, respectively, demographic information, expected/estimated wait time, Consultation and Relational Empathy Measure, and Consumer Assessment of Healthcare Providers and Systems Clinician and Group. After multivariate regression, only perceived physician empathy as measured by the Consultation and Relational Empathy Measure score was significantly correlated with caregiver satisfaction (P
Posted: July 1, 2021, 12:00 am
imageThis cross-sectional study aims to investigate the relationship between the simplified olecranon, simplified digital, and distal radius and ulna (DRU) classifications, and whether they can aid in more comprehensive maturity assessment together. Left hand and wrist and lateral elbow radiographs from pediatric patients were assessed using the three skeletal maturity indices. The association between maturity indices was investigated using Goodman and Kruskal’s gamma, and by mapping of individual grades based on chronological age. Specific maturity grades, at which peak height velocity (PHV) occurs as previously identified, were based upon to explore how the three systems interact. A total of 114 patients (63.2% girls) were studied. Correlations and associations between the three maturity parameters were significant (all at P 
Posted: July 1, 2021, 12:00 am
imageThe lateral capitello-humeral angle (LCHA), which is an index of sagittal alignment of the elbow, has gradually been adopted for the postoperative assessment of radiographic results. However, the normal values and ranges of the LCHA remain unclear. A retrospective cohort study was performed to evaluate the normal values and ranges of the LCHA in a sample of healthy children with even distributions of age, sex and laterality. A total of 168 radiographs of the elbows of healthy children (age range, 0–11 years) with even distributions of age, sex and laterality were reviewed. The primary aim was to analyze the normal values and ranges of the LCHA categorized by age, sex and laterality. The secondary aim was to assess the association of the LCHA with increasing age. The LCHA between sex or laterality in each age category was also compared. The mean LCHA of the 168 patients was 47.1° (range, 27°–63°). There was a weak association between the LCHA and increasing age (r = 0.41). The mean LCHA in females (49.1°) was significantly larger than that in males (45.1°). Significant sex-related differences were observed in age categories between 2 and 7 years. Results of this study will be useful in the postoperative radiographic assessment of sagittal alignment of the elbow in children.
Posted: July 1, 2021, 12:00 am
imageTo retrospectively evaluate the clinical and radiographic outcomes of fractures of the base of the proximal phalanx (FBPP) in children by closed reduction and cast immobilization (CRCI) and closed reduction and percutaneous pinning (CRPP). Thirty-four consecutive children with FBPP were treated by CRCI (group A) and CRPP (group B). The diaphyseal axis-metacarpal head angle (DHA) was measured in anteroposterior radiographs before and after treatment. At the last follow-up visit, the range of motion of the injured finger was evaluated by the Total Active Flexion Scale. One year and more after the index procedure, patients were asked to answer the Michigan Hand Outcomes Questionnaire (MHQ). Fifteen patients (44.1%) were in group A and 19 (55.9%) in group B. groups A and B did not differ significantly in their demographics and preoperative DHA (P > 0.05). However, the postoperative DHA improved significantly after treatment, whether group A (P 
Posted: July 1, 2021, 12:00 am
imageThe primary aim of this study was to assess the epidemiological evaluation of acute pediatric hand injuries frequently encountered in emergency department units. Its secondary aim was to identify the risk factors associated with such injuries. Out of the 1547 acute hand and forearm injury cases admitted to emergency trauma department between March 2017 and March 2018, the 129 injuries pertaining to children were included in the study. Mechanism, time, etiology, injured structures, anatomical regions, cut structures, and occupational accident status were determined in addition to demographic information. The injuries were evaluated according to circadian rhythm in order to ascertain the hours of intensification. The Modified Hand Injury Severity Score (MHISS) was used to assess injury severity. The mean age of 129 patients was 10.1 years. The most injuries were observed in the groups of patients over 12 years of age (57, 44%), and 0–6 years of age (42, 32%), respectively. Nineteen students participating in vocational internships were injured (14%). Twenty-six cases (20%) in the 12-year-old group involved punching glass, and 34 (26%) cases in the 0–6 age groups involved fingertip crush injuries. Temporal injury intensity was seen to have increased between 12.00 and 19.00 hours. The mean MHISS was 41 (8–120). Injury prevention measures need to be increased, particularly for fingertip injuries. A specific injury severity assessment system is also required for pediatric hand injuries, which are often simpler and easier to treat than adult hand injuries. Additionally, training and increasing awareness are believed to be important steps in preventing pediatric hand injuries.
Posted: July 1, 2021, 12:00 am
imagePatients with pediatric trigger thumb present with fixed contracture of the interphalangeal joint (IPJ) or snapping of the thumb. We applied a hand-based dynamic splint using coils at the IPJ. The aim of this study was to report the clinical outcomes of splint therapy versus observation. One hundred twenty-nine thumbs (112 patients and 57 boys) were examined retrospectively. At initial presentation, parents selected the treatment after explanation of pathology and consents were obtained. Treatment was concluded when full extension or resolution of the involved IPJ was achieved; alternatively, surgical treatment was offered for patients who failed to improve. Improvement in extension loss to 0° and hyperextension was defined as resolution of the IPJ. Surgery was not selected as a first-line treatment strategy in any of the cases in this study. The rate of resolution was 59% at 31 months of follow-up in the splint group (99 thumbs) and 43% at 30 months in observation group (30 thumbs); there was no significant difference between the groups (P = 0.15). Twenty-one thumbs showed locking of the IPJ in the extended position during splint therapy, but all recovered with a 71% rate of resolution. The splint group showed a higher rate of resolution than the observation group; however, there was no significant difference between therapies. Our study showed that 55% of patients with pediatric trigger thumb showed resolution following conservative treatment for an average of 30 months until surgery could be performed under local anesthesia. Splint therapy and observation are viable treatment options prior to surgery.
Posted: July 1, 2021, 12:00 am
imageTo estimate and rank cure and recurrence rates between conservative and operative treatments for trigger thumb in children. A systematic review was conducted by searching PubMed and Scopus. Eligible criteria were comparative studies included non-syndromic trigger thumbs, aged up to 10 years, reported at least 20 thumbs and followed up at least 12 months. Two assessors independently extracted data and appraised for cure, recurrence rates among observation, stretching, splinting, open surgery, and percutaneous surgery. We assessed the risk of bias in non-randomized studies of interventions. A network meta-analysis, and probability of being the best outcomes were estimated with surface under the cumulative ranking curves (SUCRA). From 6853 searched articles, eight studies (799 children and 981 thumbs) were included. Mean age was 1.87–2.83 years and average followed up time was 1–5.7 years. Open surgery, percutaneous release, splinting, and stretching had higher cure rate than observation; pooled risk ratio (95% confidence interval) of 2.06 (1.53–2.78), 1.79 (1.26–2.53), 1.76 (1.30–2.36), and 1.37 (0.93–2.03), respectively. Percutaneous release increased risk of recurrence 3.29 times (1.42–7.60) when compared with open surgery. The best cure rates were open surgery (SUCRA = 95) followed by splint (SUCRA = 63.4), and percutaneous technique (SUCRA= 62.8). The highest recurrence rates were percutaneous (SUCRA = 97.3), and open surgery (SUCRA = 62.4). Splint is the most appropriate intervention for pediatric trigger thumb. After failed conservative methods, open surgery is considered for operative treatment. Level of evidence: Therapeutic study level II–III.
Posted: July 1, 2021, 12:00 am
imageThe aim of the study was to assess the correlation between femoral neck-shaft angles (NSAs) and skeletal maturity in EOS reconstructions from a large population of children. Full-body three-dimensional (3D) reconstructions were generated from 1005 children and young adults (4–24 years old; 449 male, 556 female) using the EOS three-dimensional/3D scanner, with images taken during routine clinical practice. The true NSAs were measured and assessed for correlation with individuals’ chronological age and bone age, based on cervical vertebral morphology. Statistical analysis was performed using Spearman correlation, independent t-test and multiple linear regression. NSAs of older and younger individuals within each bone age group and chronological age were further assessed by t-test. NSA values fell from mean 131.89° ± 6.07° at 4 years old to 128.85° ± 4.46° at the age of 16, with only minor decreases thereafter. Significantly higher NSAs (3.16° and 4.45°, respectively) were found in those with a bone age advanced or delayed by more two or more stages compared to their peers of the same chronological age (P 
Posted: July 1, 2021, 12:00 am
imageThe purpose of this study was to compare 2D femoral torsional values to measurements made from 3D reconstructions, in pediatric patients with torsional pathology. Seventeen patients were included in this study. Femoral torsion was measured in 2D and 3D and compared using interclass correlation and Bland–Altman plots. The 2D and 3D measurements had excellent correlation (r > 0.79, P
Posted: July 1, 2021, 12:00 am
imageThe aim of the study was to evaluate the correlation between femoral anteversion, supratrochanteric torsion (STT), and infratrochanteric torsion (ITT) in healthy developing pediatric femurs using MRI. This study included 282 (164 males and 118 females) patients aged 1–18 years. The axial MRI of patients with benign tumoral lesions of the femur was retrospectively reviewed. The measurements were performed through axial images of contralateral healthy femurs. Femoral anteversion, STT, and ITT were measured twice by two orthopedic surgeons. The Pearson correlation coefficient was used to test for the correlation of age between STT, ITT, and femoral anteversion in children. All femoral anteversion, STT, and ITT measurements showed excellent intraobserver and interobserver reliability (P 
Posted: July 1, 2021, 12:00 am
imageThe purpose of this study was to evaluate differences in clinical presentation and extent of surgery required based on skeletal maturity between two cohorts of adolescent hip arthroscopy patients. We hypothesized that skeletal immaturity would be associated with a lower frequency of pincer impingement and a decreased need for surgical acetabuloplasty. A database of 1481 hip arthroscopies performed by a single orthopaedic surgeon between 2008 and 2016 was queried. Patients ≤18 years of age with femoroacetabular impingement were divided into two groups based on Risser score: Risser 1–4 (skeletally immature) or Risser 5 (skeletally mature). Groups were compared with respect to presentation, diagnosis, and arthroscopic procedures performed. Eighty-eight skeletally immature and 49 skeletally mature patients were included. Mixed impingement was more common in skeletally mature patients than immature (67.3% vs. 48.9%, P = 0.037). Skeletal maturity was associated with a significantly increased probability of undergoing acetabuloplasty (odds ratio = 4.6, 95% confidence interval 1.4–15.5; P = 0.014). Extent of chondral degeneration was similar between groups. Our findings support the hypothesis that skeletally immature hips undergo acetabuloplasty less frequently and demonstrate similar chondromalacia compared with a skeletally mature cohort. These results suggest that arthroscopic treatment for impingement-associated hip pain may be a reasonable option to consider for symptomatic skeletally immature patients who have completed a structured course of nonoperative treatment. Additional longitudinal outcomes data are needed to clarify the natural history of impingement-associated hip pain in younger populations and whether hip arthroscopy delays progression of osteoarthritis in these patients.
Posted: July 1, 2021, 12:00 am
imageLegg–Calvé–Perthes disease (LCPD) often produces a residual deformity, typically consistent with coxa magna, coxa plana, and ellipsoidal shape. Depending on the degree of asphericity and flatness, this morphology was classified by Stulberg in stages III and IV. Thus far, few studies have investigated physeal injury as an etiological cause or evaluated its progressive profile throughout Waldenström’s reossification stage and the remodelling stage. In this study, we analysed the ellipsoidal process of the femoral head. This was a retrospective control case study involving 83 unoperated hips with LCPD and Stulberg stages III and IV outcome. The data were compared with those obtained for 49 healthy contralateral hips (control). The Ellipsoidal Index, the presence of a double epiphyseal reossification nucleus, physeal narrowing, intraphyseal angle, epiphyseal height, diameter of the head, and Reimer’s Index were determined. Measurements were performed at four-time points: the year the reossification stage was initiated, the final growth stage, and two equally spaced time points in between. The Ellipsoidal Index gradually increased throughout the course of the disease from 1.6 in the initial reossification stage to 2.0 at the end of growth. In the control cases, this value was consistently 1.4. More ellipsoidal deformity was observed in Stulberg stage IV versus Stulberg stage III patients (P 
Posted: July 1, 2021, 12:00 am
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