Pediatric Orthopedics Research Articles

Changes in diagnostics and treatment pathways for developmental dysplasia of the hip after the introduction of national guidelines: An updated questionnaire amongst paediatric orthopaedic surgeons in The Netherlands.

Diagnostics and treatment pathways for developmental dysplasia of the hip are highly variable in clinical practice. Recently, two national guidelines were developed in the Netherlands, providing a uniform protocol for the diagnosis and treatment of developmental dysplasia of the hip in children under the age of 1 year. The aim of this survey study was to assess whether diagnostic and treatment strategies have changed amongst paediatric orthopaedic surgeons in the Netherlands compared to a similar survey study in 2011, after the introduction of the guidelines. A web-based online questionnaire was developed and shared amongst the members of the Dutch Paediatric Orthopaedic Society. The questions concerned the diagnosis and treatment of developmental dysplasia of the hip, ranging from mildly dysplastic to dislocated hips, in children under the age of 1 year. We used a questionnaire similar to the previous study and evaluated the results. Thirty-four participants completed the survey. Regarding diagnosis and follow-up, ultrasonography was generally applied for children younger than 6 months, while radiography was more frequently used for children aged 6-12 months. In 2011, radiography was more widely applied in all age groups. Initial treatment for dysplastic, stable hips was mostly active monitoring, while this was generally a rigid splint in 2011. For dislocated unstable hips, the first step in treatment was generally the Pavlik harness, as in 2011. The diagnostic and treatment pathways of developmental dysplasia of the hip in children under the age of 1 year seem to have partially changed amongst Dutch paediatric orthopaedic surgeons compared to 2011, after the publication of new guidelines.

Use of Artificial Intelligence in Cobb Angle Measurement for Scoliosis: Retrospective Reliability and Accuracy Study of a Mobile App.

Scoliosis is a spinal deformity in which one or more spinal segments bend to the side or show vertebral rotation. Some artificial intelligence (AI) apps have already been developed for measuring the Cobb angle in patients with scoliosis. These apps still require doctors to perform certain measurements, which can lead to interobserver variability. The AI app (cobbAngle pro) in this study will eliminate the need for doctor measurements, achieving complete automation. We aimed to evaluate the reliability and accuracy of our new AI app that is based on deep learning to automatically measure the Cobb angle in patients with scoliosis. A retrospective analysis was conducted on the clinical data of children with scoliosis who were treated at the Pediatric Orthopedics Department of the Children's Hospital affiliated with Fudan University from July 2019 to July 2022. Three measurers used the Picture Archiving and Communication System (PACS) to measure the coronal main curve Cobb angle in 802 full-length anteroposterior and lateral spine X-rays of 601 children with scoliosis, and recorded the results of each measurement. After an interval of 2 weeks, the mobile AI app was used to remeasure the Cobb angle once. The Cobb angle measurements from the PACS were used as the reference standard, and the accuracy of the Cobb angle measurements by the app was analyzed through the Bland-Altman test. The intraclass correlation coefficient (ICC) was used to compare the repeatability within measurers and the consistency between measurers. Among 601 children with scoliosis, 89 were male and 512 were female (age range: 10-17 years), and 802 full-length spinal X-rays were analyzed. Two functionalities of the app (photography and photo upload) were compared with the PACS for measuring the Cobb angle. The consistency was found to be excellent. The average absolute errors of the Cobb angle measured by the photography and upload methods were 2.00 and 2.08, respectively. Using a clinical allowance maximum error of 5°, the 95% limits of agreement (LoAs) for Cobb angle measurements by the photography and upload methods were -4.7° to 4.9° and -4.9° to 4.9°, respectively. For the photography and upload methods, the 95% LoAs for measuring Cobb angles were -4.3° to 4.6° and -4.4° to 4.7°, respectively, in mild scoliosis patients; -4.9° to 5.2° and -5.1° to 5.1°, respectively, in moderate scoliosis patients; and -5.2° to 5.0° and -6.0° to 4.8°, respectively, in severe scoliosis patients. The Cobb angle measured by the 3 observers twice before and after using the photography method had good repeatability (P<.001). The consistency between the observers was excellent (P<.001). The new AI platform is accurate and repeatable in the automatic measurement of the Cobb angle of the main curvature in patients with scoliosis.

Enhancing biomechanical outcomes in proximal femoral osteotomy through optimised blade plate sizing: A neuromusculoskeletal-informed finite element analysis

Proximal femoral osteotomy (PFO) is a frequently performed surgical procedure to correct hip deformities in the paediatric population. The optimal size of the blade plate implant in PFO is a critical but underexplored factor influencing biomechanical outcomes. This study introduces a novel approach to refine implant selection by integrating personalized neuromusculoskeletal modelling with finite element analysis. Using computed tomography scans and walking gait data from six paediatric patients with various pathologies and deformities, we assessed the impact of four distinct implant width-to-femoral neck diameter (W-D) ratios (30 %, 40 %, 50 %, and 60 %) on surgical outcomes. The results show that the risk of implant yield generally decreases with increasing W-D ratio, except for Patient P2, where the yield risk remained below 100 % across all ratios. The implant factor of safety (FoS) increased with larger W-D ratios, except for Patients P2 and P6, where the highest FoS was 2.60 (P2) and 0.49 (P6) at a 60 % W-D ratio. Bone-implant micromotion consistently remained below 40 µm at higher W-D ratios, with a 50 % W-D ratio striking the optimal balance for mechanical stability in all patients except P6. Although interfragmentary and principal femoral strains did not display consistent trends across all patients, they highlight the need for patient-specific approaches to ensure effective fracture healing. These findings highlight the importance of patient-specific considerations in implant selection, offering surgeons a more informed pathway to enhance patient outcomes and extend implant longevity. Additionally, the insights gained from this study provide valuable guidance for manufacturers in designing next-generation blade plates tailored to improve biomechanical performance in paediatric orthopaedics.

Reevaluating Pediatric Osteomyelitis with Osteoarticular Tuberculosis: Addressing Diagnostic Delays and Improving Treatment Outcomes

Background: Pediatric osteoarticular tuberculosis (TB) remains a significant global health challenge, particularly in resource-limited settings, where delayed diagnosis and treatment frequently lead to severe long-term complications. Despite advancements in TB control, skeletal TB in children is often misdiagnosed due to its non-specific clinical presentation, contributing to poor outcomes such as joint deformities, growth disturbances, and chronic pain. The complexity of diagnosing osteoarticular TB is further exacerbated by the limited sensitivity of conventional diagnostic tools and the overlap with other musculoskeletal conditions. This study seeks to evaluate the impact of early detection and multidisciplinary management on treatment outcomes in pediatric patients with osteoarticular TB. Methods: A retrospective review was conducted at the Pediatric Orthopedics Department of the “Grigore Alexandrescu” Children’s Hospital in Romania from 2009 to 2023. Case data included clinical, imaging, and microbiological findings, and treatment outcomes in children aged 0–18 years diagnosed with tuberculous osteomyelitis. Results: The study identified varied clinical presentations, with delayed diagnosis often linked to misinterpretation of symptoms as non-TB infections. Multimodal diagnostic approaches combining imaging, microbiological testing, and histopathology improved diagnostic accuracy. Early surgical intervention alongside anti-TB therapy proved effective in reducing long-term complications. Conclusions: Timely, accurate diagnosis and multidisciplinary treatment are critical to improving outcomes in pediatric osteoarticular TB. Vaccination status and comprehensive diagnostic tools significantly influence disease progression and treatment success. The study underscores the need for enhanced screening and diagnostic methods to prevent delays in treatment.

Factors that Influence Recovery From Concussion in Young Children and Preadolescents

Objective: To examine differences in the presentation and management of concussion in younger children (aged 4–8 years) versus preadolescents (9–12 years) and identify factors that influence recovery time. Design: Retrospective analysis of prospectively collected data. Setting: Pediatric sports medicine and orthopedics clinic. Patients: Three hundred seventy-five patients aged 4 to 12 years diagnosed with concussion between 2020 and 2022. Independent Variables: Age, gender, race/ethnicity, mechanism of injury (sport vs nonsport related), neurodevelopmental or psychiatric diagnosis, concussion history, Post-Concussion Symptom Scale (PCSS) score, and Vestibular Ocular Motor Screening (VOMS) overall change scores. Main Outcome Measures: Days since injury (DSI) to initial visit, total number of visits, recovery time (days). Results: Groups significantly differed in DSI (P = 0.01) and overall VOMS change score (P = 0.03). No differences were observed between groups on total number of visits or recovery time. Patients with fewer DSI [odds ratio (OR) = 1.15], less change in overall VOMS score (OR = 1.02), lower PCSS scores (OR = 1.02), and who were injured in sport were less likely to experience a protracted recovery. Conclusions: Younger children with concussion may be appropriately treated with a similar approach to preadolescent patients despite greater DSI and differences in VOMS change scores, without sacrificing overall recovery time. Consistent with research in older cohorts, protracted recovery was seen in nonsport patients, and patients seen sooner at a specialty concussion clinic were less likely to experience a protracted recovery, endorsed lower PCSS scores, and had lower overall VOMS change scores. Further research is needed to solidify a child-specific paradigm to concussion management.

Policy and practice review consensus statements and clinical guidelines on managing pediatric trauma and orthopedics during the COVID-19 pandemic: a systematic review on the global response for future pandemics and public health crises.

The COVID-19 pandemic has been recognized as an unprecedented global health crisis. Over 7 million mortalities have been documented with many paediatric fatalities. Trauma and orthopaedic care, much like other specialities, were marginalized due to resource allocation during the pandemic which affected paediatric care. This is the first systematic review to centralise and compile the recommended published guidelines from professional bodies in principally English speaking countries on managing paediatric trauma and orthopaedic care. These guidelines will be required to be implemented sooner and more effectively in case of future pandemics with similar impact. A search was conducted on PubMed/MedLine, Cochrane Library and Embase using terms including p(a)ediatric or child* and/or COVID* or coronavirus or SARS-CoV-2 and/or trauma and/or orthop(a)edic* with a simplified MeSH heading [mh] in order to make the search as comprehensive as possible. General terminology was utilized to make the search as exhaustive as possible for this systematic review. Another search was conducted on resources available in the public domain from professional bodies publishing on consensus statements and clinical practice guidelines in countries where English is the principal language managing pediatric trauma and orthopedics. The review adhered to PRISMA guidance. The search revealed a total of 62 results from both databases and professional bodies. Duplicates were removed. This was then reviewed to identify a total of 21 results which fit the inclusion criteria and included within the main analysis. The guidelines from professional bodies were outlined and categorized into aspects of clinical care. The impact of COVID-19 pandemic has compelled for changes in clinical practice and pediatric management. The systematic review highlights the relevant guidelines on service provision for pediatric patients including indications for urgent referrals, surgical prioritization, reasons for follow-up and trauma guidelines. The rationale for care during the unpredictable evolution of the COVID-19 pandemic may have the potential to be translated and replicated in future pandemics of similar significance.

3D printing application for orthopedic pediatric surgery – a systematic review

PurposeThis paper aims to present a systematic review of the latest scientific literature, in the context of pediatric orthopedics, on the development by additive manufacturing of anatomical models, orthoses, surgical guides and prostheses and their clinical applications.Design/methodology/approachFollowing the current guidelines for systematic reviews, three databases (Elsevier Scopus®, Clarivate Web of ScienceTM and USA National Library of Medicine PubMed®) were screened using a representative query to find pertinent documents within the timeframe 2016–2023. Among the information, collected across the reviewed documents, the work focused on the 3D printing workflow involving acquisition, elaboration and fabrication stages.FindingsFollowing the inclusion and exclusion criteria, the authors found 20 studies that fitted the defined criteria. The reviewed studies mostly highlighted the positive impact of additive manufacturing in pediatric orthopedic surgery, particularly in orthotic applications where lightweight, ventilated and cost-effective 3D-printed devices demonstrate efficacy comparable to traditional methods, but also underlined the limitations such as printing errors and high printing times. Among the reviewed studies, material extrusion was the most chosen 3D printing technology to manufacture the typical device, particularly with acrylonitrile butadiene styrene.Originality/valueTo the best of the authors’ knowledge, this is the first systematic review which annotates, from a more engineering point of view, the latest literature on the admittance of the clinical application of additive manufacturing (and its effects) within typical pediatric orthopedic treatments workflows.

Reducing Postoperative Opioids in Pediatric Orthopaedics: An Updated Tiered Prescription Guideline with a “Tier 0”

BackgroundThere is growing data on strategies to reduce opioid prescriptions in pediatric orthopaedics. Our institution implemented tiered guidelines for opioid discharge prescriptions in 2018 to standardize prescribing patterns across our entire pediatric orthopaedics practice. In 2022, we updated the tiered system with a goal to further minimize the quantity of opioids prescribed and eliminate opioids altogether for certain procedures. The aim of this project was to evaluate the effects of the updated tiered guidelines for discharge opioid prescribing following common pediatric orthopaedic procedures. MethodsA quality improvement project was conducted at a single academic institution. Guidelines for discharge opioid prescriptions were updated in January 2022 and established 5 tiers of increasing invasiveness for 28 procedures. The updated guidelines included a “Tier 0” which provided no opioids, reorganized surgical tiers based on prior data, and decreased the doses recommended for tiers. Opioid prescriptions were reported as oral morphine equivalents (OMEs). Univariate tests were performed to assess statistically significant differences before and after implementation of updated guideline eras, comparing 2020–2021 and 2022. ResultsOverall, 747 patients (2020–2021, n ​= ​500; 2022, n ​= ​247) were included. The proportion of patients receiving discharge opioid prescriptions decreased from 89.8% to 80.6% (P ​< ​0.05), between 2020 and 2021 and 2022. This resulted in decreased overall OME prescribed (median 75 vs 45, P ​< ​0.05) and OME prescribed in those >10 years (135 vs 113, P ​< ​0.05) while 30-day refill rates (9.4% vs 6.1%), and OME per kilogram in those <11 years of age (median 0.9 vs 0.8) remained unchanged (both P ​> ​0.05). Discharge prescriptions falling within overall guidelines increased after guideline implementation (83.3% vs 85.4%), though this was not statistically significant and guideline adherence was low among Tier 0 ​at 31%. ConclusionsIncluding “Tier 0” of procedures receiving no opioid prescriptions, reorganizing procedures within tiers, and decreasing the recommended doses to an already strict tiered guideline for discharge opioid prescriptions significantly decreased the quantity of opioids prescribed. We noted continued excellent overall adherence and, importantly, no overall increase in refills, with areas for improvement in Tier 0. Quality improvement projects can continue to reduce the amount of opioids prescribed following pediatric orthopaedic procedures. Key Concepts(1)Updated tiered guidelines, including a “Tier 0” for discharge opioid prescriptions following pediatric orthopaedic procedures were effective in reducing the quantity of opioids provided at discharge.(2)A continued high adherence rate was observed with the updated guidelines, though areas for improvement include adherence to no opioids in Tier 0.(3)Refill rates remained similar after implementation of the updated guidelines.(4)The study results suggest opportunities for continued improvement projects to reduce the number of unnecessary opioids prescribed to pediatric orthopaedic patients. Level of EvidenceIII.

Management of Syndesmotic Ankle Injuries: Results of a Survey of Pediatric Orthopaedic Society of North America Members

BackgroundAlthough utilization of dynamic suture-button fixation for adult syndesmotic injuries has shown improved outcomes over static screw fixation, data in pediatric populations is limited. This study evaluated trends in management and identified factors influencing surgeon choice of implant for pediatric syndesmotic injuries. MethodsThe Pediatric Orthopaedic Society of North America (POSNA) members were surveyed regarding syndesmotic injury implant preferences between October 2021 and May 2022. Respondents that opted out, treated <1 syndesmotic ankle injury in the past year, or had conflicting financial obligations were excluded. Results were summarized and analyzed using logistic regression to assess for significance between years posttraining and technique preference. Odds ratios (OR) and 95% confidence intervals (CI) were calculated for significance (P-values<.05). ResultsAmong 103 respondents to the survey (with 102 complete responses), 25% were <5 years posttraining, 24% between 5 and 10 years, 21% between 11 and 15 years, and 28% ​> ​15 years posttraining. Twenty-four percent (24/102) preferred screw versus 76% (78/102) preferring suture-button implants for syndesmotic injuries. Members >15 years posttraining were 4.7 times more likely to prefer screw implants compared to members <5 years posttraining (OR ​= ​4.7; 95% CI, 1.14–19.34; P ​= ​.03). Since starting their clinical practice, 62 respondents (60%) reported an implant preference change, with avoidance of secondary surgery (46/62; 74%) and extrapolation from adult outcomes (39/62; 63%) cited as primary motivating factors. Of the 40 members with no preference change, comfort with the procedure was the primary cited reason (33/40; 83%). Among those choosing operative intervention, radiograph-based cases showed preference for the suture-button in 70%–79% of respondents for skeletally mature patients versus 71%–81% for skeletally immature patients. ConclusionsOur data shows that the shift over time from screw to suture-button implant fixation for pediatric and adolescent syndesmotic ankle injuries is largely due to interest in avoiding implant removal and extrapolation from superior outcomes seen with suture-button use in adults. Larger comparative studies of pediatric and adolescent patients treated with suture-button versus screw fixation are needed to establish standards of care for these challenging injuries. Key Concepts(1)Literature for operative syndesmotic injury management in adults has shown improved outcomes of dynamic suture-button fixation over static screw fixation, but data in pediatric and adolescent populations is limited.(2)A survey of 102 POSNA members shows that 76% prefer suture-button, 24% prefer screw fixation with members >15 years posttraining 4.7 times more likely to prefer screw fixation to members <5 years posttraining.(3)Among 62 respondents who switched implant preference during their clinical practice, avoidance of secondary surgery and extrapolation from outcomes in adults were the two most cited reasons.(4)Among 40 respondents who did not switch implant preference, comfort with the procedure was the most cited reason.(5)Comparative studies of suture-button versus screw implants for treatment of pediatric and adolescent syndesmotic ankle injuries are needed to establish an evidence-based standard of care management. Level of EvidenceLevel V: Expert Opinion

The Lack of Reporting Social Determinants of Health in Pediatric Orthopaedic Randomized Controlled Trials.

Social determinants of health (SDOHs) affect health outcomes outside the hospital, and understanding them can enhance postoperative outcomes in orthopaedic surgery patients. This study aimed to describe the prevalence of randomized controlled trials (RCTs) in pediatric orthopaedic journals reporting on the SDOHs of their patient cohorts. We hypothesize that many SDOHs will be underreported in RCTs investigating pediatric orthopaedic surgery. Utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, the authors queried the PubMed database to examine SDOHs from 2 pediatric orthopaedic journals: Journal of Pediatric Orthopaedics and Journal of Pediatric Orthopaedics: Part B. The inclusion criteria incorporated RCTs published between 2005 and April 2024. The exclusion criteria included any articles that were not RCTs published in this period. One hundred thirteen articles met the search criteria, with 31 excluded because they did not fall from 2005 to 2024. Eighty-two were published from 2005 to 2024, but 6 RCTs were excluded, as 3 were non-RCTs, and 3 examined cadavers. Seventy-six RCTs were included for analysis, with 65 articles from the Journal of Pediatric Orthopaedics and 11 articles from the Journal of Pediatric Orthopaedics: Part B. Articles originated from 17 countries, with the United States producing 61.8% (47) of the included studies. Of all 76 included studies, 96.1% (73) reported age, 88.2% (67) reported sex/gender, 30.3% (23) reported BMI, 21.1% (16) reported race/ethnicity, 5.3% (4) reported educational level, 2.6% (2) reported stress, and 2.6% (2) reported insurance. Smoking status, socioeconomic status, income levels, and employment status were each reported by only 1 study. The RCTs examining pediatric orthopaedic surgery tend to scarcely report SDOHs. Future RCTs should expand beyond demographic characteristics such as age, race/ethnicity, sex/gender, and BMI and incorporate other relevant SDOHs. This will allow us to develop a more comprehensive understanding of health outcomes in the pediatric orthopaedic population. I; Therapeutic Studies.

Do ChatGPT and Gemini Provide Appropriate Recommendations for Pediatric Orthopaedic Conditions?

Artificial intelligence (AI), and in particular large language models (LLMs) such as Chat Generative Pre-Trained Transformer (ChatGPT) and Gemini have provided additional resources for patients to research the management of healthcare conditions, for their own edification and the advocacy in the care of their children. The accuracy of these models, however, and the sources from which they draw conclusions, have been largely unstudied in pediatric orthopaedics. This research aimed to assess the reliability of machine learning tools in providing appropriate recommendations for the care of common pediatric orthopaedic conditions. ChatGPT and Gemini were queried using plain language generated from the American Academy of Orthopaedic Surgeons (AAOS) Clinical Practice Guidelines (CPGs) listed on the Pediatric Orthopedic Society of North America (POSNA) web page. Two independent reviewers assessed the accuracy of the responses, and chi-square analyses were used to compare the 2 LLMs. Inter-rater reliability was calculated via Cohen's Kappa coefficient. If research studies were cited, attempts were made to assess their legitimacy by searching the PubMed and Google Scholar databases. ChatGPT and Gemini performed similarly, agreeing with the AAOS CPGs at a rate of 67% and 69%. No significant differences were observed in the performance between the 2 LLMs. ChatGPT did not reference specific studies in any response, whereas Gemini referenced a total of 16 research papers in 6 of 24 responses. 12 of the 16 studies referenced contained errors and either were unable to be identified (7) or contained discrepancies (5) regarding publication year, journal, or proper accreditation of authorship. The LLMs investigated were frequently aligned with the AAOS CPGs; however, the rate of neutral statements or disagreement with consensus recommendations was substantial and frequently contained errors with citations of sources. These findings suggest there remains room for growth and transparency in the development of the models which power AI, and they may not yet represent the best source of up-to-date healthcare information for patients or providers.

Modern technologies for medical rehabilitation of children with knee joint injuries

Pathology of the knee joint in children is a pressing problem in pediatric traumatology, orthopedics and pediatrics. The frequency of injuries to the knee joint is determined by the complexity of its structure, biomechanical features with a high probability of overload. At the same time, intra-articular injuries in children and adolescents, accounting for up to 7 % in the structure of inpatient pathology, are the cause of pronounced functional disorders of the lower limb and the risk of developing post-traumatic osteoarthritis Currently, physical factors are widely used at various stages of medical rehabilitation of children with damage to the capsular-ligamentous apparatus of the knee joint. The conducted studies have established the effectiveness of using local air cryotherapy in the early postoperative period, characterized by a pronounced anti-edematous, analgesic effect. Early regression of pain and elimination of microcirculatory disorders in the area of injury as a result of a course of pulsed low-frequency magnetic therapy at various stages of medical rehabilitation of children with damage to the capsular-ligamentous apparatus of the knee joint have been recorded. The beneficial effect of a pulsed low-frequency electrostatic field on indicators of orthopedic status, and thermography indicators in the area of injury in children with knee joint injuries has been established. Data were obtained on more pronounced regression of pain, earlier restoration of range of motion in the damaged joint and relief of signs of post-traumatic synovitis with the complex use of a pulsed low-frequency electrostatic field and robotic mechanotherapy in children with damage to the capsular ligamentous apparatus of the knee joint. The obtained clinical and functional results are of great importance for injuries of the knee joint with the risk of contractures in the postoperative period.

Complications of Hardware Removal in Pediatric Orthopaedic Surgery.

Hardware removal (HR) is one of the most common surgical procedures in pediatric orthopaedics. Surgeons advocate for HR for a variety of reasons, including to limit peri-implant fracture risk, restore native anatomy for adult reconstruction surgery, permit bone growth and development, and mitigate implant-related pain/irritation. To our knowledge, no recent study has investigated the characteristics and complications of HR in pediatric orthopaedics. The goal of this study is to report the prevalence and complications of hardware removals across all of pediatric orthopaedic surgery. A retrospective case series was conducted of all hardware removals from 2012 to 2023 performed at a single urban tertiary-care children's hospital. Cases were identified using CPT codes/billing records. Spinal hardware and cases for which hardware was either implanted or explanted at an outside hospital were excluded. Patient demographic and clinical data were recorded. For patients with multiple hardware removals, each case was recorded independently. A total of 2585 HR cases for 2176 children met study criteria (57.7% male; mean age 12.3±4.4y). The median postoperative follow-up time was 1.7 months (interquartile range: 0.6 to 6.9). The most common sites of hardware removal were the femur/knee (32.7%), tibia/fibula/ankle (19.3%), and pelvis/hip (18.5%). The most common complications included sustained, new-onset postoperative pain (2.6%), incomplete hardware removal (1.6%), and perioperative fracture (1.4%). The overall complication rate of hardware removal was 9.5%. Eighty-eight percent of patients who underwent hardware removal for pain experienced pain relief postoperatively. HR >18 months after insertion had a 1.2x higher odds of overall complication (P=0.002) and 3x higher odds of incomplete removal/breakage (P<0.001) than hardware removed 9 to 18 months after insertion. The overall complication rate of hardware removal across a large series in the pediatric population was 9.5%. Despite hardware removal being one of the most common and often routine procedures in pediatric orthopaedics, the complication rate is not benign. Surgeons should inform patients and families about the likelihood of success and the risks of incomplete removal during the informed consent process. IV.

Femoral Lengthening in Children with Congenital Femoral Deficiency: A Systematic Review.

Congenital femoral deficiency (CFD) presents a significant challenge in pediatric orthopaedics, characterized by a spectrum of congenital anomalies ranging from mild femoral shortening to complete absence of the proximal femur and hip joint. This review aims at reviewing the latest concepts of femoral limb lengthening modalities in treating CFD, to explore the efficacy, complications, and long-term outcomes of various surgical techniques. A comprehensive search of the literature was performed for clinical studies involving lengthening in patients with proximal focal femoral deficiency (PFFD) in several databases. We analyze the evolution of limb lengthening procedures, from the Wagner and Ilizarov methods to the latest advancements in distraction osteogenesis, and assess their role in addressing the functional needs of patients. We also analyze the possible risk factors for the occurrence of complications with each method and alternatives to avoid them. The review highlights the importance of individualized treatment plans, considering factors such as the degree of femoral deficiency and the potential for achieving a functional limb length; however, it requires a multidisciplinary approach and careful preoperative planning to optimize patient outcomes. The review underlines the need for ongoing research to refine surgical techniques and to compare them and improve the quality of life for individuals with PFFD. Level III. See Instructions for Authors for a complete description of levels of evidence.

Three-dimensional-printing-guided preoperative planning of upper and lower extremity pediatric orthopedic surgeries: A systematic review of surgical outcomes.

Three-dimensional printing has evolved into a cost-effective and accessible tool. In orthopedic surgery, creating patient-specific anatomical models and instrumentation improves visualization and surgical accuracy. In pediatric orthopedics, three-dimensional printing reduces operating time, radiation exposure, and blood loss by enhancing surgical efficacy. This review compares outcomes of three-dimensional printing-assisted surgeries with conventional surgeries for upper and lower extremity pediatric surgeries. A complete search of medical literature up to August 2023, using Ovid Medline, EMBASE, Scopus, Web of Science, and Cochrane Library was conducted in compliance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Broad search terms included "pediatrics," "orthopedic," and "3D-printing." Eligible studies were assessed for intraoperative time, blood loss, and fluoroscopy exposure. Out of 3299 initially identified articles, 14 articles met inclusion criteria. These studies included 409 pediatric patients, with ages averaging 9.51 years. The majority were retrospective studies (nine), with four prospective and one experimental study. Studies primarily utilized three-dimensional printing for navigation templates and implants. Results showed significant reductions in operative time, blood loss, and radiation exposure with three-dimensional printing. Complication occurrences were generally lower in three-dimensional printing surgeries, but there was no statistical significance. Three-dimensional printing is an emerging technology in the field of orthopedics, and it is primarily used for preoperative planning. For pediatric upper and lower extremity surgeries, three-dimensional printing leads to decreased operating room time, decreased intraoperative blood loss, and reduced radiation exposure. Other uses for three-dimensional printing include education, patient communication, the creation of patient-specific instrumentation and implants. Level III.

Management of Pediatric Elbow Fractures and Dislocations.

Pediatric elbow fractures and dislocations have always been a challenge from a diagnostic and therapeutic point of view, primarily due to the complex nature of the pediatric elbow, especially its developmental anatomy. They must be diagnosed and treated on time to prevent numerous complications with long-term consequences. With the development of radiology and pediatric surgery and orthopedics, as well as the development of modern osteosynthesis materials, concerning current scientific and professional knowledge, the outcomes are getting better, with fewer acute and chronic complications. This comprehensive review aims to provide clinicians current knowledge about pediatric elbow fractures and dislocations so that in daily practice they have as few doubts as possible with the best possible treatment outcomes.

Sex Diversity and Equity Among Fellows of the American Orthopaedic Association.

We hypothesized that women are underrepresented among fellows of the American Orthopaedic Association (AOA) relative to their prevalence among faculty at departments of orthopaedic surgery. Clinical faculty at departments of orthopaedic surgery that are affiliated with residency training programs were analyzed for AOA membership. Participation-to-prevalence ratios (PPRs) were calculated for men and women with AOA membership relative to their prevalence among orthopaedic surgeon faculty. A PPR of <0.8 or >1.2 indicated under- or overrepresentation, respectively. PPR values between 0.8 and 1.2 indicated equivalent representation. Sex disparities in AOA membership were explored by academic rank and orthopaedic subspecialty. There were 4,310 orthopaedic surgery faculty, and 998 (23.2%) had AOA membership. Overall, women formed the minority of members in the AOA study cohort (11.4%), but they had equivalent representation relative to their prevalence among faculty (10.0%, PPR = 1.14, p = 0.210). In the AOA study cohort, women were the minority at each academic rank, including assistant professor (20.2% versus 79.8%, p < 0.001), associate professor (16.8% versus 83.2%, p < 0.001), and full professor (7.0% versus 93.0%, p < 0.001). However, women had greater representation in the AOA study cohort at each academic rank than would be expected based on their prevalence among faculty, including the assistant (PPR = 1.45), associate (PPR = 1.56), and full (PPR = 1.27) professor levels. Similarly, in the AOA study cohort, women were the minority in each orthopaedic subspecialty, but were only underrepresented in pediatric orthopaedics (PPR = 0.74). Women had greater representation in the AOA study cohort than would be expected by their prevalence among faculty in hand surgery (PPR = 1.51) and orthopaedic sports medicine (PPR = 1.33). In contrast, men had equivalent representation in each orthopaedic subspecialty. Women form a minority group in the AOA, but they exhibit greater representation in the AOA than would be expected based on their prevalence among faculty at each academic rank, and they have greater representation than men, who exhibit equivalent representation across all academic ranks. Collectively, these results disproved our hypothesis, and suggest that women are participating in the AOA at rates that are greater than their prevalence among faculty. Equitable participation of women in orthopaedic surgery is necessary to promote diversity and inclusion in the specialty. The AOA may be an important catalyst for future positive diversity and inclusion efforts within orthopaedic surgery.

Single institution clinical results in patients with Legg-Calvé-Perthes disease that undergo femoral varus osteotomy

Background: Legg-Calvé-Perthes disease is a significant topic in pediatric orthopedics due to its high incidence and often unclear prognosis. Both conservative and surgical treatments are widely practiced today, aiming primarily to contain the femoral head, reduce stress on the affected avascular zone, and minimize loss of sphericity of the femoral head. The aim of this study is to evaluate the clinical results in early age patients with Perthes disease which undergo femur osteotomy in a single institution. Materials and Methods: A retrospective study involving 81 hips in 79 patients was conducted at a single institution. Inclusion and exclusion criteria were set. Patients with a primary diagnosis of Legg-Calvé-Perthes disease were operated on – varus femoral osteotomy was done in all patients. The patients were classified using the Stulberg and Herring classifications, and were divided into three main groups depending on the disease severity preoperatively. Clinical and radiographic results were collected and analyzed. Results: Poor clinical outcomes (Stulberg III, IV, V) were observed in 47% of the patients. There was a direct correlation between the degree of poor outcomes and the age at onset of the disease. The average limb length discrepancy was 0.9 cm (range: 0.0–2 cm), with 23 patients having a discrepancy greater than 1 cm. Twelve patients required contralateral epiphysiodesis in the knee area to equalize limb length. Conclusions: Patients with Hering B and B/C, as well as Stulberg I and II stages over the age of six, have excellent outcomes following varus femoral osteotomy. Unsatisfactory and poor results are observed in patients with Hering and Stulberg IV and V grade hip joints. The early onset of the disease, as well as the lack of a unified treatment protocol, necessitate further and more in-depth studies in this area.

Outcomes of Hip Shelf Procedure in Treating Legg-Calvé-Perthes Disease

Introduction: Legg-Calvé-Perthes disease (LCPD) is a pediatric ischemic condition of the femoral head leading to necrosis. This study evaluates the hip shelf procedure's effectiveness in treating LCPD and the resulting clinical outcomes. Methods: A retrospective analysis of 17 patients treated with the hip shelf procedure at the Pediatric Orthopedics and Traumatology Department of CHU Hassan II, Fes, over ten years. Data on patient demographics, clinical presentations, radiological assessments, and surgical outcomes were analyzed. Results: The average age at consultation was 9 years, with a male predominance (88.2%). Radiological staging showed most patients in the fragmentation or reconstruction stages. Post-operative results indicated significant improvement in hip joint stability and remodeling. Conclusion: The hip shelf procedure is effective in managing LCPD, promoting favorable hip joint remodeling and function in pediatric patients. Early intervention is crucial for optimal outcomes.

A literature review of current surgical treatment for congenital pseudoarthrosis of the tibia

Congenital pseudarthrosis of the tibia (CPT) is an infrequently observed condition. However, it is considered to be one of the most complex ailments in the field of pediatric orthopedics. In cases where a tibial fracture is absent, the conventional treatment approach involves using bracing as a preventive measure against fractures. Various surgical modalities have been proposed for the management of CPT, including intramedullary (IM) rod fixation, external fixators, on-lay grafts, cancellous grafts, periosteal grafts, Paley cross-union, amputation, vascularized fibula grafts, and induced membrane techniques. These modalities can be used in different combinations and permutations. The need for repetitive surgical interventions due to unsuccessful therapeutic outcomes or modifications in secondary treatments can significantly disrupt the childhood experience, resulting in prolonged and recurrent functional limitations. In certain instances, amputation may be required as a primary or secondary treatment modality. This literature review will clarify the current surgical interventions for CPT disease based on a summary of research data. The surgery the patient receives significantly impacts their general health and capacity to heal.