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: The treatment of acute pediatric Monteggia injuries involving a complete fracture of the ulna remains controversial. The purpose of this study is to compare the outcomes of immediate operative fixation to a trial of closed reduction and casting of acute pediatric Monteggia fractures involving complete ulna fractures. Methods: We performed a retrospective analysis of 73 patients with Monteggia injuries with complete ulna fractures presenting to 2 pediatric trauma centers from 2008 to 2018. Patients were divided in 2 groups based on the treatment received: patients in group 1 (n=37, 51%) received surgical treatment; patients in group 2 (n=36, 49%) received a trial of closed reduction and casting. The mean follow-up of 15.2 weeks (range, 4.1 to 159 wk). The incidence of radiocapitellar joint redislocation, need for further intervention, complications, and recovery of range of motion was compared between the groups. Results: There were no significant differences between groups 1 and 2 with regards to age (6 vs. 5.8 y, P=0.69), sex (54% vs. 47% female, P=0.64), or the mean maximal ulnar angulation (23 vs. 19 degrees, P=0.94). There was a higher proportion of proximal ulna fractures in group 1 versus 2 (62% vs. 33%, respectively, P=0.02). Bado type III and IV fractures were associated with operative management [odds ratio=22 (95% confidence interval: 1.68-288.7) and 14.9 (95% confidence interval: 2.09-106), respectively]. In group 2, 5 patients (13.9%) sustained a loss of radiocapitellar joint reduction following closed reduction and casting and ultimately received operative treatment. At final follow-up, there were no cases of recurrent radiocapitellar dislocation in either group, all patients achieved fracture union and regained full elbow range of motion. Conclusions: Even in the presence of a complete ulna fracture, a trial of nonoperative management of acute pediatric Monteggia fractures with closed reduction and casting can result in comparable outcomes to those obtained with immediate surgical management. The nonoperative management of Monteggia fractures requires close clinical follow-up to ensure no loss of reduction. Level of Evidence: Level IV—therapeutic studies, case series.
Posted: August 1, 2021, 12:00 am
imageBackground: We modified the original technique for percutaneous transphyseal screw which was described in 1998 by Metaizeau and colleagues for distal femoral coronal angular deformity correction; the modification is related to the screw direction, whereas the screw is administered in a retrograde pattern, starting from the epiphysis and directed toward the metaphysis. This technique opposes the original technique that was started with a metaphyseal entry point which aimed toward the epiphysis. This study evaluates the efficacy of the newly suggested surgical technique regarding the rate of correction and growth resumption after screw removal. Methods: This prospective study looked at 40 patients (65 distal femoral physes), who underwent a percutaneous retrograde transphyseal guided growth screw procedure, from October 2017 to September 2019. All the patients included had distal femoral coronal angular deformities; 52 in valgus and 13 in varus deformities. The study included 17 females with an average age of 11.75 (range: 8.4 to 14.5 y) for 29 femurs and 23 males with an average age of 13.75 (range: 11.75 to 15.6 y) for 36 femurs. The mechanical lateral distal femoral angle was measured initially, and then again was measured after reaching the desired corrected orientation. The patients were then followed up after the screw removal and followed up to maturity, if the physis had continued to grow postcorrection. The degree of correction per month was calculated, and the consequence of screw removal was detected. Follow-up average time was 12.6 months (range: 30 to 6 mo). Results: The average correction in the distal femur was 1.3 degrees per month (range: 0.5 to 1.857 degrees/mo). In all of the 65 segments (61 femurs had significant growth remaining and 4 femurs had reached skeletal maturity with suboptimal mechanical lateral distal femoral angle correction), the screws were removed at the time of angular correction. Rebound growth was observed in 15 physes with an average of 1.8 degrees (range: 2 to 3 degrees); they were stable in 42 physes and progressed in 4 physes with an average of 1.6 degrees (range: 1 to 2 degrees). Complications were minor and related to entrapment of soft tissue under the screw washer. Conclusion: Percutaneous retrograde transphyseal guided growth screw for distal femur coronal angular deformity is a minimally invasive procedure, with a statistically significant correction rate when compared with the original transphyseal screw technique. The new technique has proven to have growth resumption after screw removal with minimal complication risk. Level of Evidence: Level III—prospective observational study.
Posted: August 1, 2021, 12:00 am
imageBackground: Fractures involving the distal tibia growth plate are common in children. Injury or treatment that damages the growth plate may result in progressive angular deformity or leg length discrepancy. There is no consensus on treatment and follow-up of these injuries. This study aims to describe which factors increase the risk of premature physeal closure (PPC). Material and Methods: A systematic review and meta-analysis were performed. Altogether 395 articles were reviewed, and ultimately 12 of them were found eligible, comprising 1997 patients. The most usual type of fracture was Salter-Harris (SH) II (n=855, 49%) followed by SH III (n=296, 17%) and SH I (n=261, 15%). The risk of PPC according to number of reduction attempts, method of treatment, and residual displacement was the primary outcome. Results: The total rate of PPC was 13% (n=245). The PPC rate varied from 0.2% to 42% across the studies. Patients with SH IV fractures were most likely to develop PPC (20%), followed by those with SH II (12%) (P2) reduction maneuvers were associated with a higher risk of PPC (pooled odds ratio, 8.5; 95% confidence interval, 6.3-12.17; P
Posted: August 1, 2021, 12:00 am
imageBackground: Despite being a common procedure, there are no standard protocols for postoperative immobilization and rehabilitation following reconstructive hip surgery in children with cerebral palsy (CP). The purpose of this study was to investigate variability in postoperative management and physical therapy (PT) recommendations among orthopaedic surgeons treating hip displacement in children with CP. Methods: An invitation to participate in an anonymous, online survey was sent to 44 pediatric orthopaedic surgeons. The case of a child undergoing bilateral femoral varus derotation osteotomies and adductor tenotomies was presented. Surgeons were asked to consider their typical practice and the case scenario when answering questions related to immobilization, weight-bearing, and rehabilitation. Recommendations with increasingly complex surgical interventions and different age or level of motor function were also assessed. Results: Twenty-eight orthopaedic surgeons from 9 countries with a mean 21.3 years (range: 5 to 40 y) of experience completed the survey. Postoperative immobilization was recommended by 86% (24/28) of respondents with 7 different methods of immobilization identified. All but 1 (23/24) reported immobilizing full time. Most (20/23) reported using immobilization for 4 to 6 weeks. Return to weight-bearing varied from 0 to 6 weeks for partial weight-bearing and 0 to 12 weeks for full weight-bearing. PT in the first 1 to 2 weeks postoperatively was reported as unnecessary by 29% (8/28) of surgeons. PT for range of motion, strengthening, and return to function was recommended by 96% (27/28) of surgeons, starting at a mean of 2.6 weeks postoperatively (range: 0 to 16 wk). Only 48% (13/27) reported all of their patients would receive PT for these goals in their practice setting. Inpatient rehabilitation was available for 75% (21/28) but most surgeons (17/21) reported this was accessed by 20% or fewer of their patients. Conclusions: Postoperative immobilization and PT recommendations were highly variable among surgeons. This variability may influence surgical outcomes and complication rates and should be considered when evaluating procedures. Further study into the impact of postoperative immobilization and rehabilitation is warranted.
Posted: August 1, 2021, 12:00 am
imageBackground: While management recommendations for distal radius fractures in both young and skeletally mature patients have been generally well-established, controversy still exists regarding optimal management in adolescent patients approaching skeletal maturity. Thus, the goal of this review is to analyze relevant literature and provide expert recommendations regarding the management of distal radius fractures in this patient population. Methods: A PubMed search was performed to identify literature pertaining to distal radius fractures in adolescent patients, defined as 11 to 14 years in girls and 13 to 15 years in boys. Relevant articles were selected and summarized. Results: Distal radius fractures demonstrate significant potential for remodeling of angular deformity and bayonet apposition, even in patients older than 12 years of age. Rotational forearm range of motion and functional outcomes are acceptable with up to 15 degrees of residual angulation. Closed reduction and percutaneous pinning reduces fracture redisplacement but has a high associated complication rate. There is no literature comparing plate versus pin fixation of distal radius fractures in the pediatric population, but in adults plate fixation is associated with higher cost with no improvement in long-term functional outcomes. Conclusions: Remodeling can still be expected to occur in adolescent patients, and even with residual deformity functional outcomes after distal radius fractures are excellent. Up to 15 degrees of residual angulation can be accepted before considering operative management. Smooth pins should be considered over plates as first-line operative management for unstable fractures that fail nonoperative treatment.
Posted: July 1, 2021, 12:00 am
imageIntroduction: Tibial shaft fractures are common injuries in the adolescent age group. Potential complications from the injury or treatment include infection, implant migration, neurovascular injury, compartment syndrome, malunion, or nonunion. Methods: Published literature was reviewed to identify studies which describe the management options, complications, and outcome of tibial shaft fractures in adolescents. Results: Acceptable alignment parameters for tibial shaft fractures have been defined. Operative indications include open fractures and other severe soft tissue injuries, vascular injury, compartment syndrome, ipsilateral femoral fractures, and polytrauma. Relative indications for operative treatment are patient/family preference or morbid obesity. Closed reduction and cast immobilization necessitates radiographic observation for loss of reduction over the first 3 weeks. Cast change/wedging or conversion to operative management may be required in 25% to 40%. Flexible nailing provides relative fracture stability while avoiding the proximal tibial physis, but the fracture will still benefit from postoperative immobilization. Rigid nailing provides greater fracture stability and allows early weight bearing but violates the proximal tibial physis. Plate and screw osteosynthesis provide stable anatomic reduction, but there are concerns with delayed union and wound complications related to the dissection. External fixation is an excellent strategy for tibia fractures associated with complex wounds but also requires observation for loss of reduction. Discussion and Conclusions: The majority of adolescent tibia shaft fractures can be successfully managed with closed reduction and cast immobilization. Unstable fractures that have failed cast treatment should be treated operatively. Flexible intramedullary nailing, rigid intramedullary nailing, plate and screw osteosynthesis, and external fixation are acceptable treatment options that may be considered for an individual patient depending upon the clinical scenario.
Posted: July 1, 2021, 12:00 am
imageIntroduction: Adolescents undergoing pediatric orthopaedic surgery typically experience an uncomplicated postoperative course. However, adolescence represents a unique transition period from pediatric to adult physiology. As a result, the astute pediatric orthopaedic surgeon will be aware of unique medical and social scenarios which are relevant to adolescents during the perioperative course including the risk of venous thromboembolism (VTE), prevalence of mental health conditions, and rising use of electronic cigarettes or “vaping” to consume nicotine and cannibas. Discussion: Adolescents are at a greater risk of VTE after pediatric orthopaedic surgery. In particular, adolescent females with a family history of blood clotting disorders and those with a change in mobility after surgery should be considered for prophylaxis. The prevalence of adolescent mental health conditions including anxiety, depression, and behavioral issues is increasing in the United States. Higher levels of preoperative anxiety and the presence of mental health pathology are associated with slower recovery, higher levels of postoperative pain, and the increased likelihood for chronic pain. Several quick screening instruments are available to assess adolescents for preoperative anxiety risk, including the Visual Analogue Scale for Anxiety or the Amsterdam Perioperative Anxiety Information Scale. Unfortunately, electronic cigarettes have become increasingly popular for the consumption of nicotine and cannabis among adolescents. Preoperative use of combustive cigarettes (nicotine/cannabis) represents perioperative risks for induction/anesthesia, postoperative pain, and analgesia requirements and issues with delayed wound and fracture healing. Conclusions: VTE, underlying mental health conditions, and usage of nicotine and cannabis are clear detriments to the recovery and healing of adolescent patients following orthopaedic surgery. Therefore, standardized screening for adolescents before orthopaedic surgery is indicated to identify perioperative risk factors which have negative impacts on functional outcomes.
Posted: July 1, 2021, 12:00 am
imageBackground: Distal radius physeal bar with associated growth arrest can occur because of fractures, ischemia, infection, radiation, tumor, blood dyscrasias, and repetitive stress injuries. The age of the patient as well as the size, shape, and location of the bony bridge determines the deformity and associated pathology that will develop. Methods: A search of the English literature was performed using PubMed and multiple search terms to identify manuscripts dealing with the evaluation and treatment of distal radius physeal bars and ulnar overgrowth. Single case reports and level V studies were excluded. Results: Manuscripts evaluating distal radial physeal bars and their management were identified. A growth discrepancy between the radius and ulna can lead to distal radioulnar joint instability, ulnar impaction, and degenerative changes in the carpus and triangular fibrocartilage complex. Advanced imaging aids in the evaluation and mapping of a physeal bar. Treatment options for distal radius physeal bars include observation, bar resection±interposition, epiphysiodeses of the ulna±completion epiphysiodesis of the radius, ulnar shortening osteotomy±diagnostic arthroscopy to manage associated triangular fibrocartilage complex pathology, radius osteotomy, and distraction osteogenesis. Conclusions: Decision-making when presented with a distal radius physeal bar is multifactorial and should incorporate the age and remaining growth potential of the patient, the size and location of the bar, and patient and family expectations.
Posted: July 1, 2021, 12:00 am
imageBackground: Frankly dislocated hips occur in ∼1% to 3% of infants with developmental dysplasia of the hip and are often difficult to treat. In the most severely dislocated hips, the femoral head is positioned outside the posterior/lateral rim of the acetabulum and is irreducible, that is, the femoral head will not reduce by positioning the leg. The purpose of this study was to determine risk factors, using univariate and multivariate analyses, for Pavlik harness failure in infants who initially presented with irreducible/dislocated hips (confirmed by dynamic sonography). Methods: Following institutional review board approval, 124 infants (170 hips) with frankly dislocated hips treated using a Pavlik harness between 2000 and 2018 were evaluated. Patients’ demographic characteristics, clinical findings, dynamic sonographic findings (dislocated-fixed vs. dislocated-mobile), age at onset of Pavlik harness treatment, duration of harness usage, and follow-up treatments were recorded. Univariate analyses were used to determine risk factors for treatment failure. Results: In frankly dislocated hips (confirmed by dynamic sonography to be positioned outside the posterior/lateral rim of the acetabulum), Pavlik harness treatment was successful in 104 of 170 hips (61%) while it failed in 66 hips. Mean follow-up was 4.86±4.20 years. Univariate analysis determined the risk factors to be onset of treatment after the seventh week of age (P=0.049) and initial mobility (dislocated-fixed group) (P
Posted: July 1, 2021, 12:00 am
imageBackground: Diagnosis and treatment for developmental dysplasia of the hip (DDH) varies greatly depending on condition severity, age at diagnosis, and professional opinion. Little is known about patient experiences across the globe. We aimed to characterize global patient and caregiver experiences during DDH care and to highlight patient-identified priorities. Methods: We developed a cross-sectional survey in collaboration with 7 DDH outreach organizations. DDH patients and/or their caregivers (above 18 y old) were invited to complete an international online survey about their experiences. Participants were recruited through web media of all collaborating organizations. Data collection took place over 3 months. Descriptive statistics were used to analyze quantitative results. Qualitative content analysis was used to categorize open-ended responses. Results: A total of 739 participants completed the survey, representing 638 (86.3%) parents/guardians of DDH patients, and 101 (13.7%) patients. Three hundred eighty-six (52.2%) participants received diagnosis by 3 months of age; mean age of diagnosis was 15.96 months (90% confidence interval=12.04, 19.91). Of 211 participants with family history of DDH, 68 (32.3%) did not receive DDH screening. Of 187 patients born breech, 82 (43.9%) did not receive DDH screening. In total, 36/94 (38.3%) participants with both family history and breech birth did not receive DDH screening. Most participants reported treatment (696/730, 95.3%), including bracing (n=461) surgery (n=364), and/or closed reduction (n=141). A total of 144 patients reported >1 surgery; 82 reported >3 surgeries. Participants reported a range of 1 to 400 visits to health care professionals for DDH care across 1 to 66 years. Lack of information and resources on treatment practicalities and timelines, along with emotional burden of diagnosis, were greatest challenges reported. Conclusion: Results demonstrate that DDH diagnosis and treatment can pose significant burden on patients and caregivers. Reliable public information is needed to support those affected. Global educational efforts are needed to raise awareness of DDH risk factors, signs, and symptoms among care providers, to increase awareness and improve identification, screening, and monitoring of at-risk children.
Posted: July 1, 2021, 12:00 am
imageIntroduction: The transition from pediatric to adolescent fractures can lead to uncertainty on what level of surgical correction is warranted as remodeling is limited in these older patients. Discussion: Adolescent diaphyseal radial shaft fractures present several unique challenges; the radial bow must be restored to preserve forearm rotation and there are several clinical scenarios where plating, even in the skeletally immature child, is strongly recommended and will have more reliable results over flexible intramedullary nails. In addition, judging how much angulation, rotation, and displacement will remodel in the older child can be a challenging decision, even for experienced pediatric orthopaedists. Conclusion: This overview discusses parameters for acceptable alignment in these fractures, when surgical fixation should be considered, and circumstances where plating should be considered over flexible nails.
Posted: July 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
imageCongenital tibial pseudarthrosis is a rare condition seen in neurofibromatosis type 1 (NF1), and treatment is complex. A randomized, placebo-controlled trial of bone morphogenetic protein (rhBMP-2; INFUSE bone graft) at time of tibial surgery was developed by the Neurofibromatosis Clinical Trials Consortium. Patients were randomized to receive rhBMP-2 that would, or would not, be added to the standard surgical procedure consisting of resection of pseudarthrosis tissue, insertion of a rigid intramedullary rod, and placement of autogenous iliac crest bone graft. Despite involvement of 16 centers with wide experience with NF1 orthopaedic management, only 5 patients (of 54 required) were able to be enrolled in the study during a 3-year time period. Because of the inability to recruit sufficient patients, this study was closed in June 2019, with plans to terminate. The obstacles that were encountered during the study are summarized. The authors question whether a randomized, placebo-controlled trial of a rare pediatric orthopaedic condition is possible to accomplish. Recommendations are provided to guide future studies of orthopaedic manifestations of NF1.
Posted: January 1, 2021, 12:00 am
imageBackground: This study aimed to investigate if nonsteroidal anti-inflammatory drugs (NSAIDs) used in the acute phase of bone healing in children with fractures result in delayed union or nonunion as compared with patients who do not take NSAIDs for pain control during this same time period. Methods: In this prospective, randomized, parallel, single-blinded study, skeletally immature patients with long bone fractures were randomized to 1 of 2 groups for their postfracture pain management. The NSAID group was prescribed weight-based ibuprofen, whereas the control group was not allowed any NSAID medication and instead prescribed weight-based acetaminophen. Both groups were allowed to use oxycodone for breakthrough pain. The primary outcome was fracture healing assessed at 2, 6, and 10 weeks. Results: One-hundred-two patients were enrolled between February 6, 2014 and September 23, 2016. Ninety-five patients (with 97 fractures) completed a 6-month follow-up (46 patients with 47 fractures in the control group and 49 patients 50 fractures in the NSAID group). None achieved healing at 1 to 2 weeks. By 6 weeks, 37 of 45 patients (82%) of control group and 46 out of 50 patients (92%) of ibuprofen group had healed fractures (P=0.22). At 10 to 12 week follow-up, 46 (98%) of the control group fractures were healed and 50 (100%) of the ibuprofen group fractures were healed. All were healed by 6 months. Healing was documented at a mean of 40 days in the control group and 31 days in the ibuprofen group (P=0.76). The mean number of days breakthrough oxycodone was used was 2.4 days in the control group and 1.9 days in the NSAID group (P=0.48). Conclusion: Ibuprofen is an effective medication for fracture pain in children and its use does not impair clinical or radiographic long bone fracture healing in skeletally immature patients. Level of Evidence: Level I—therapeutic.
Posted: September 1, 2020, 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: 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: 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
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
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: 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: 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
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
imageObjectives: The purpose of this study was to evaluate the type and severity of orthopaedic and associated injuries for snowmobile, All-terrain vehicles (ATV) and motorized dirtbike accidents in a pediatric patient population. Methods: A total of 758 patients who presented following either snowmobile (n=87), ATV-related (n=308) or dirtbike (n=363)-related trauma at our institution between 1996 and 2015 were retrospectively reviewed. Results: A total of 441 axial and appendicular fractures occurred requiring 533 procedures. Snowmobile and dirtbike accidents were associated with a higher rate of fractures (63%, 64%) than the ATV group (50%) (P=0.0008). Snowmobile injuries had the highest rate of spinal (23%) and lower extremity fractures (53%) (P=0.0004). Snowmobile and dirtbike cohorts had higher rate of femur fractures (22%, 17%, P=0.001) whereas the ATV cohort had higher rates of upper extremity (18%), hand (11%), scapula (4.6%), and open fractures (28.6%) (P
Posted: September 1, 2018, 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 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
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
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
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
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
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
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
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
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
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
imageChildren’s ankle fractures are the second most common growth plate fractures in humans and one of the top 10 reasons for pediatric orthopaedic hospital admissions. Because triplane and Tillaux fractures occur during the period of distal tibial physeal closure, they are considered transitional injuries. The distal tibial physis closes in a unique, asymmetric pattern (middle, then medial, and finally lateral), and it is the portion of the physis that is open at the time of injury that is vulnerable to fracture in this age group. Triplane and Tillaux fractures occur after supination external rotation and compression stress with unpredictable multiplanar fracture patterns. The fracture may appear different on different x-ray projections, making computed tomography mandatory to determine the number of fragments. Because most of these fractures are intra-articular, anatomic or near-anatomic reduction of the joint surface is recommended to minimize future posttraumatic ankle arthritis. Because these fractures occur at the end of growth, they rarely result in growth arrest.
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
imageLegg-Calvé-Perthes (LCP) disease has an extensive history that has provided an ongoing intellectual challenge for the orthopaedic community. Debate around etiology and treatment of LCP disease continues even after its initial description in the early 1900s. In order for modern day clinicians to have a full understanding of the condition, one must be a scholar of its development. The purpose of our review will be to discuss the scientific communities' understanding of presentation, etiology, and treatment of LCP disease over time. Level of Evidence Level V.
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
imageBackground Treatment methods in Legg-Calve-Perthes disease (LCPD) have varied during the 100-year history of this disorder. This is a review of the present practice of bracing in LCPD. Methods Published articles from the last 35 years were reviewed including primary analyses of bracing, meta-analysis, and summaries of present opinion. The recent literature was also evaluated to determine the present bracing practices. Results Studies performed regarding specific braces failed to show that they offer any advantage over other methods of management, including no treatment. Similarly, meta-analyses showed that hips treated with nonoperative containment had little difference in outcome based on present methods of analysis. Opinion papers suggested that the use of braces in LCPD should be significantly decreased or discontinued altogether. There is a major controversy regarding weaning and discontinuation of bracing. The use of Petrie casts can be considered in “salvage” techniques of hips with subluxation or hinged abduction. Conclusions The present literature does not provide evidence sufficient to support the use of bracing in LCPD. On the basis of this review, our recommendation is that the abduction orthosis should rarely be used in the treatment of LCPD. Petrie casts still have a role in short-term treatment in patients with deformed femoral heads before complete reossification.
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
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
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
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

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).

imageDistraction osteogenesis is a widely used surgical technique to treat bone deformity and shortening. Several biological treatments have been studied to enhance bone formation during distraction osteogenesis in animals. However, role of osteoactivin in the osseous tissues during distraction osteogenesis remains poorly understood. In this animal experimental study, we investigated the spatiotemporal expression of osteoactivin by immunohistochemistry and real-time PCR using a mouse model for tibial lengthening. Furthermore, to address the role of osteoactivin in bone lengthening, we subjected the osteoactivin-transgenic mice to distraction osteogenesis model. During the lag phase, the fibroblast-like cells (possible progenitors of the osteoblasts or chondrocytes), which mainly express osteoactivin, were infiltrated into the osteotomy site. Osteoactivin was ubiquitously expressed in the lengthened segment during the distraction and consolidation phases. Consistent with the immunohistochemical analysis, the levels of the osteoactivin transcripts in the tibias were significantly increased throughout the distraction osteogenesis process. The bone mineral content in the osteoactivin-transgenic mice calculated using peripheral quantitative computed tomography was also significantly increased at the remodeling zone. The histomorphometric analysis revealed that newly formed callus resorption in the remodeling zone was significantly reduced but bone formation was not altered in the osteoactivin-transgenic mice. We conclude that osteoactivin functions as an inhibitor of callus resorption during the consolidation phase of distraction osteogenesis.
Posted: September 1, 2021, 12:00 am
imageWe sought to better understand the relationship between Patient-Reported Outcomes Measurement Information System (PROMIS) mobility, pain interference (PI) and depressive symptoms scores, as well as determine what patient factors and PROMIS domains were associated with worse pain coping (PROMIS PI), in a pediatric orthopaedic population. Between 27 August 2015 and 30 April 2019, new pediatric orthopaedic patients 18 years or younger (or their guardians as a proxy) were asked to complete PROMIS mobility, PI and depressive symptoms domains at an academic medical center pediatric orthopaedic clinic. Pearson correlation coefficients (r) were calculated between each PROMIS domain. Linear multivariate regression analysis was used to determine patient characteristics and PROMIS domains associated with presenting PROMIS PI scores. There was a strong-moderate correlation between PROMIS mobility and PI (r = −0.66, P
Posted: September 1, 2021, 12:00 am
imageFear of falling (FOF) indicates loss of confidence in the ability to perform daily living activities without falling. Although specific questionnaires do exist to assess FOF in different patient populations, any of them targets the pediatric patients with neuromuscular diseases which falling is a frequent symptom. This study aims to present the development of a self-report FOF questionnaire for children with neuromuscular diseases, pilot application of the questionnaire, and its preliminary psychometric properties. An International Classification of Functioning, Disability and Health (ICF)-based ‘Pediatric Fear of Falling Questionnaire’ for neuromuscular diseases (Ped-FOF) was created by the study team following the steps of developing an instrument. The questionnaire included 34 items which were organized based on the ‘Activities and Participation’ component of ICF-children and youth. Thirty children with Duchenne muscular dystrophy (DMD) were recruited to obtain preliminary reliability and validity results of the questionnaire. The mean Ped-FOF score of study population was 15.30 ± 7.03. According to the preliminary results, intraclass correlation coefficient was 0.715 [confidence interval (CI) 95%], and moderate correlations between Ped-FOF and functional performance and quality of life were determined (P 
Posted: September 1, 2021, 12:00 am
imageA prospective study to find a correlation between the severity of clubfoot and the number of casts required for the correction was conducted. The relationship of early relapse with the severity of the deformity was also studied. A total of 42 infants (61 feet) with primary and idiopathic clubfeet were included in the study. Previously treated and clubfeet due to secondary causes were excluded. All clubfeet were treated by the Ponseti method, and the Pirani score, Dimeglio score and Foot Bimalleolar (FBM) angle were taken at presentation and before every casting and at 6 months of follow-up. The average age of the child at presentation was 24 days, the average initial Pirani score was 4.172, the average initial Dimeglio score was 14.36 and the average FBM angle was 63.87 degrees. The average number of corrective casts given was 5.08 (range 2–8). The regression analysis showed a low correlation between Pirani and Dimeglio scores with the number of casts. There was no correlation between FBM angle and casting. Eleven of the 61 feet had a relapse (18%). Ten of 11 relapsed feet had a midfoot Pirani score of equal to or more than 2. The regression analysis shows a low correlation between Pirani and Dimeglio scores with the number of casts. There was no correlation between FBM angle and casting. Midfoot score equal to or more than 2 is a significant risk factor for relapse.
Posted: September 1, 2021, 12:00 am
imageThe role of intrinsic muscles of the foot in the medial longitudinal arch mechanism was investigated in several recent studies. It is determined that the abductor hallucis muscle (AHM) has an important role in dynamic support of the arch. Objective of our preliminary study was to establish a relationship between the navicular drop index (NDI) and the AHM abduction force. A single group exploratory design was used. The participants were 127 athletes aged 8–16 years (m/f 74/53; 11.99 ± 2.11 years; 156.21 cm ± 15.51 cm; 47.61 kg ± 13.96 kg; 2–5 training h/week), examined at a regular sport medical checkup. Abductor hallucis force was measured by a digital Algometer FPX 25/220, which is a newly developed approach that should be properly assessed in further studies to establish standardization and qualification of the algometer for this specific use. Navicular drop test has been performed as originally developed by Brody. Data were analyzed using Student’s t-test, Mann–Whitney U test, contingency coefficients and logistic regression. Average NDI was found to be significantly different comparing the group with positive abduction force and the group that cannot perform the active abduction. Logistic regression indicated that the variable representing impossible active abduction was significantly associated with NDI. Preliminary results showed that there was a strong relationship between the hallux active abduction force and NDI in young athletes: the higher abduction force correlates to lower NDI. To determine clinical relevance of our investigation, further study is planned in which hallux active abduction force and NDI would be compared and correlated pre- and postspecific strengthening program.
Posted: September 1, 2021, 12:00 am
imageWe aimed to determine the quantitative value of derotation of calcaneo pedal block (DCPB) of Dimeglio system equivalent to talar head reduction of Pirani system. We also compared the ankle dorsiflexion obtained post tenotomy for different measures of DCPB. The study involved 53 idiopathic clubfoot children (86 feet) treated with Ponseti technique. Percutaneous Achilles tenotomy to correct ankle equinus was performed when forefoot adduction, heel varus were corrected and ankle dorsiflexion was
Posted: September 1, 2021, 12:00 am
imageThis study was done to identify how well clinical scores and their sub-scores correlate with the radiographic parameters in idiopathic clubfoot. We studied 76 patients of idiopathic clubfoot who are from 5 months to 12 months of age. Deformity was assessed clinically with Pirani and Dimeglio scores and radiologically using eight parameters. Correlation between clinical and radiological scores was studied. All the eight radiological parameters were showing statistically significant correlation with clinical scores – both Pirani and Dimeglio scores. The mean total Pirani score at the time of X-ray was 2.31 with a SD of 1.58 (N = 118 minimum score = 0 and maximum score = 5.5), whereas the mean radiographic score was 3.67 with a SD of 2.1 (N = 118, minimum score = 0, maximum score = 8). The mean total Dimeglio score at the time of X-ray was 9.03 with a SD of 3.54 (N = 118, minimum score = 4 and maximum score = 15), whereas the mean total radiographic score was 3.67 with a SD of 2.1 (N = 118, minimum score = 0, maximum score = 8). Clinical scores correlate well with radiological parameters in infants with idiopathic clubfoot and hence the routine use of radiographs can be avoided in evaluation and follow-up thereby avoiding exposure to radiation.
Posted: September 1, 2021, 12:00 am
imageThe aim of the study was to evaluate flexible flatfoot (FFF) diagnostic and current therapeutic modalities, as well as treatment expectations, among members of the European Paediatric Orthopaedic Society (EPOS). A 59-questions survey on FFF diagnosis and treatment preferences was distributed to EPOS members. The survey consisted of six sections (1) general clinical parameters; (2) foot aspects; (3) X-ray angles (or lines); (4) expectations; (5) standard clinical assessment; and (6) management options. Descriptive statistics were performed. A total of 93 responses were analysed. In general, clinical parameters, age (91.4% of cases), laxity (81.7%), diffuse pain (84.9%), and pain at the ankle joint (81.7%) were rated as ‘average’ and ‘crucial importance’ by the vast majority of respondents. Meary’s angle (47.3% of cases), talonavicular coverage (35.5%), and lateral talocalcaneal angle (35.5%) were assessed as main radiological tools in the FFF evaluation. Among respondents, 61.3% rated ‘improved ability to walk longer without symptoms’ as of ‘crucial importance’. Eighty-two percent of the respondents felt less than 10% of patients with FFF are candidates for corrective surgery. Arthroereisis (29.3%) was the most common surgical procedure (16.4% for subtalar and 12.9% for extra-articular arthroereisis, respectively), followed by lateral column lengthening (17.9%) and medializing calcaneal osteotomy (12.3%). There is great variation among respondents in diagnostic and treatment preferences in the management of children with FFF. The results of the EPOS 2019 FFF survey clearly show that large-scale, multicentric, international studies are necessary to elucidate which diagnostic and treatment practices lead to the best outcomes.
Posted: September 1, 2021, 12:00 am
imageThe aim of the study was to compare the clinical, radiological and functional outcomes between idiopathic and non-idiopathic congenital vertical talus (CVT) treated with soft tissue release. All the consecutive cases with CVT treated with soft tissue release were prospectively followed up. Indication for soft tissue release was either late presented or failed serial manipulation and cast application. Nineteen children (33 feet) with a minimum follow-up of 2 years following the soft tissue release (the mean 5.5 years follow-up) were included. The children without any other joint involvement with the normal spine without syndromic association were categorized as idiopathic (15 feet) and the rest were categorized as non-idiopathic (18 feet). Clinical and radiological scoring was done using Adelaar and Kodros scores. The morphological, functional and radiological outcomes were assessed using the International Clubfoot Study Group evaluation scale. The clinical, radiological and functional outcomes of the idiopathic and non-idiopathic groups were compared. The range of motion was significantly higher in the idiopathic group. The functional outcome was satisfactory in both groups. All the radiological parameters improved significantly in both groups. The functional outcome was considerably better in the idiopathic group. There was no significant difference in clinical and radiological outcomes among the two groups. Soft tissue release is an effective surgery for deformity correction in children with CVT. A good clinical outcome is observed in both groups. The range of motion was significantly higher in the idiopathic group. The overall outcome was similar in both groups.
Posted: September 1, 2021, 12:00 am
imageOur study aimed to compare the clinical and radiographic outcomes of transitional distal tibia fractures treated with K-wire fixation versus screw fixation after open reduction. A retrospective study was performed on all displaced transitional distal tibia fractures that underwent operative fixation. Following open reduction, surgical fixation was performed using either percutaneously inserted 2.0 mm K-wires, or 4.0 mm partially-threaded cannulated cancellous screws. Clinical and radiographic outcomes between the two groups were assessed using the modified Weber score. Other outcome measures assessed were surgical time, casting duration, follow-up duration and duration before return-to-sports. We recruited 49 patients with transitional distal tibia fractures requiring open reduction and surgical fixation. There were 18 patients in the K-wiring group (KWG), and 31 patients in the screw fixation group (SFG). All patients in both groups had excellent clinical and radiographic outcome based on the modified Weber’s scoring, full radiological healing, and no residual displacement upon final follow up. The KWG had significantly shorter surgical time (41.0 min versus 75.1 min, P
Posted: September 1, 2021, 12:00 am
imageThe objective of this study was to report the midterm outcomes and complications of ankle Dias-Tachdjian pronation-eversion external rotation (PEER) physeal fracture in children treated by ORIF with combined medial and lateral incision. A total of 21 children with ankle Dias-Tachdjian PEER physeal fracture underwent open reduction internal fixation treatment with combined medial and lateral incision between January 2015 and October 2017. The lateral distal tibia angle (LDTA) was measured to evaluate angular deformity and the X-rays were taken to evaluate the premature physeal arrest. All patients were followed up for an average time of 20.1 months (ranging from 17 to 25 months). Bone healing was achieved in all cases. American Orthopedic Foot and Ankle Society-Ankle and Hindfoot (AOFAS-AH) score of the patients improved from median 31 (11, 38) preoperation to median 68 (63, 73) postoperation to median score 91 (87, 96) at last follow-up. LDTA of the patients improved from 70.5 ± 4.9 preoperation to 90.0 ± 1.2 postoperation, to measure 90.6 ± 3.7 at last follow-up. The differences were statistically significant (P 
Posted: September 1, 2021, 12:00 am
imageThe use of an orthopedic traction table (OTT) during elastic stable intramedullary nailing (ESIN) in the management of displaced diaphyseal tibia fractures (DTFs) is controversial. The aim of this study was to evaluate the clinical and radiological outcome of children with displaced DTF managed by ESIN with and without the use of an OTT. Medical records were retrospectively reviewed for all pediatric patients sustaining DTF managed by ESIN from 2011 to 2019 at two different institutions. In all, 160 consecutive children with displaced DTF were recorded, of whom 80 underwent operative treatment by ESIN without OTT (group A), and 80 by ESIN with the use of an OTT and skeletal traction (group B). ESIN outcome measure scale, Beaty radiologic criteria and Radiographic Union Scale for Tibia fractures (RUST) score were used to evaluate the results. Average patient age at time of injury was 10.8 years (range 7–15). The mean follow-up was 55.8 months (range 12–96). All complications (2.5%) and poorer results according to ESIN outcome measure scale and Beaty radiological criteria were recorded among children managed with OTT. No complications related to pin insertion for skeletal traction were observed. Mean RUST score, length of surgery and cumulative time of radiation exposure were comparable between the two groups. Children with a displaced DTF treated by ESIN without the use of OTT showed superior results as there are no additional procedures (traction wire insertion and removal) decreased theater time and no complications with similar radiation dose.
Posted: September 1, 2021, 12:00 am
imageThe primary aim of this study is to test the association of open tibial fractures (OTF), in a paediatric age group, with socioeconomic deprivation. The secondary objectives are to more clearly define the epidemiological characteristics of these high-energy injuries. A consecutive series of patients with OTF presenting to a major trauma centre at a children’s hospital in Liverpool had age, gender, fracture pattern, mechanism, timing of the injury and their postcode of residence recorded. Those cases outside Liverpool, Sefton and Knowsley local authorities were excluded from incidence calculations. Postcodes were used to generate deprivation scores (Index of Multiple Deprivation, 2010) based on census data (2011). Cases were ranked and allocated to deprivation quintiles. A comparison to the normal population within Merseyside was undertaken using regression analysis. There were 71 cases over a 9-year period. Fifty cases resided within the geographical limits of Merseyside and were included in the incidence calculations. The annual incidence of paediatric OTF is 3.09 per 100 000 children (0–16 years). The median age at injury was 11 years (range 2–16) and this occurred most usually during term-time between 3 and 5 p.m. from road traffic collisions. Paediatric OTFs are strongly associated with socioeconomic deprivation. The association with deprivation reflects an exposure to unsafe roads in busy urban areas with limited access to safe playing spaces. Socioeconomically deprived men are most at risk from this injury. The links between deprivation and outcomes of treatment or long-term prospects are unclear.
Posted: September 1, 2021, 12:00 am
imageFractures of the distal femur metaphysis (DFM) are rare. The main objective of this study was to retrospectively evaluate the clinical and radiographic outcomes of displaced DFM fractures in children treated by elastic stable intramedullary nailing (ESIN). We retrospectively reviewed 24 DFM fractures, including five pathological fractures secondary to non-ossifying fibroma (mean age, 10.9 years; range, 6-16) who underwent surgical treatment by ESIN. The patients were followed radiographically and clinically on a regular basis. Sixteen boys and eight girls were included in the study. Radiographically, all fractures healed, but five healed with complications. Most of the DFM fractures were transverse (n = 18, 75%), and all patients but two (91.7%) underwent closed reduction and stabilization of the fracture. All the patients were pain-free at their last follow-up. All regained full normal activities, although five patients developed a postoperative complication (20.8%). At the last follow-up visit, all fractures achieved union including the two cases of nonunion; moreover, none of the patients showed any signs of growth arrest or disturbances in radiological and clinical assessment. On the ESIN outcome measure scale, 12/24 patients (50%) had excellent results, 11/24 (45.8%) had good-satisfactory results and 1/24 (4.2%) had poor results. Fracture of the DFM can be challenging due to the relatively short length of the distal fragment, the proximity of the growth plate and the tendency of the distal fragment to displace. Following the surgical principles and understanding the anatomical constraints of the distal femur help to obtain satisfactory clinical and radiological results.
Posted: September 1, 2021, 12:00 am
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