Pediatric Surgeons 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

Purpose: 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. Methods: 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. 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. Conclusion: 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.

What imaging does my AIS patient need? A multi-group survey of provider preferences.

Adolescent idiopathic scoliosis (AIS) is a common diagnosis managed by pediatric orthopedic surgeons with nonoperative radiographic monitoring representing a cornerstone of treatment. Differences in practices and techniques for obtaining radiographic studies contribute to variation, cost of care, and hamper data aggregation. We surveyed several large organizations dedicated to children's orthopedics or scoliosis care to obtain a consensus for radiographic evaluation of AIS. A REDCap-based survey was developed across four institutions and beta-tested by staff and fellows from a single institution. The finalized survey was distributed to members of POSNA, PSSG, and SOSORT, and shared on social media. Participants were asked to rank the importance of various datapoints in radiographic assessment of the spinal deformity, skeletal maturity, and study indications during initial, subsequent, preoperative, and final office visits for AIS. Response rate for the overall group was 26%. Cobb angle was considered the most important (> 94%) radiographic index across all time points. For positioning, 46% of respondents favored arms bent touching clavicles as the ideal positioning for X-rays, and another 24% favored arms down with palms forward (Table2). The majority of respondents obtain lateral X-rays at the first visit (99%) and at the preoperative visit (70%). At the preoperative visit, sagittal contour (86%), apex location (85%), and Lenke classification (73%) were considered important factors to record. Flexibility studies are primarily obtained at the preoperative visit (89%) and 81% of respondents prefer bending films as the flexibility technique of choice. Regarding measures of skeletal maturity, Sanders bone age was considered to be the most important by over 70% of respondents across initial, subsequent, preoperative and brace wean visits (Fig.2). MRIs were obtained routinely by 34% of respondents and only when the patient had a concerning symptom or finding for 67% of respondents. Despite large variations in radiographic examination of AIS, large areas of agreement were found. It is important to establish standards for positioning patients, evaluating skeletal maturity, and obtaining assessments including lateral views, flexibility studies, and advanced imaging. Establishing common practices for radiographic evaluation of AIS will allow for less variation in care and for critical questions to be answered through registry formation and large multicenter data collection. This study establishes current practitioner opinion on the radiographic evaluation of the AIS patient. Minimum data sets are useful for data aggregation and answering research questions in the face of data variability. Level V.

The State of Pediatric Kidney Transplantation in India: A Survey-based Analysis of Practices, Challenges, and Educational Needs

ABSTRACT Background: Technical and immunological advancements have improved patient and graft survival rates in pediatric kidney transplantation (PKT). However, the landscape of PKT in India remains underexplored. We conducted a questionnaire-based survey among Indian pediatric surgeons to delineate contemporary trends in PKT. Methods: The online survey comprised 10 questions assessing pediatric surgeons’ involvement in PKT, existing challenges, and educational needs. Results: Of 610 surveyed pediatric surgeons, 120 responded (19.67% response rate). Majority of the respondents were affiliated with teaching programs, either in the public sector (61.18%) or in corporate setups (25.21%). While 65.83% of respondents managed pediatric patients with chronic kidney disease, only 10% had PKT programs at their institutes. Most of the respondents (67.5%) believed that pediatric surgeons should perform PKTs. Despite this, only 15.83% were part of the renal transplantation team at their institute and only 2.5% routinely performed PKTs. Most of the respondents (63.33%) advocated for mandatory KT exposure during postdoctoral training. Conclusion: Despite enthusiasm among pediatric surgeons, actual involvement remains low. Dedicated PKT programs are necessary to address these challenges along with improved training by integrating transplantation sciences into the pediatric surgical curriculum. The study underscores the need for pediatric surgeons to specialize in transplantation and advocates for policy changes to address the prevailing challenges.

GIANT OMPHALOCELE ABOUT A CASE

We report the case of a giant omphalocele 10 cm in diameter diagnosed by ultrasound in the obstetric emergency department in a patient with a full-term pregnancy in labor, in whom an emergency cesarean section was indicated with fetal extraction, performance of emergency neonatal care, coverage of the omphalocele with non-adherent wet compresses and management by the pediatric surgeon with the result of uncomplicated operative sequelae without complications.

Assessing diversity among consultant paediatric surgeons in the UK: open science, education, and academic achievement.

Assessing diversity among consultant paediatric surgeons in the UK: open science, education, and academic achievement.

A guideline-informed language model for paediatric cardiology demonstrates high performance in answering complex medical questions

Abstract Background Paediatric cardiology presents unique challenges with its diverse and complex cases, limited evidence base, and the necessity for multi-expert involvement in decision-making processes. In this context, the introduction of generative pre-trained transformer (GPT) based large language models (LLMs) offers a potential avenue for the provision of complex information and clinical decision support. Purpose This study evaluates the quality of three different GPT LLMs in answering complex medical questions, including a state-of-the-art preview model that incorporates the German paediatric cardiology guidelines. Methods Seven paediatric cardiologists and paediatric cardiac surgeons generated 72 questions, including complex questions and medical cases with associated questions. The questions were categorized by difficulty and required knowledge (factual and experience-based or mostly experience-based). We prompted the questions to three LLMs: GPT 3.5, GPT 4 and a GPT 4 turbo preview. The GPT 4 turbo preview was customized by incorporating all guidelines from the German Society for Paediatric Cardiology by a retrieval function. Employing one complex instruction for all questions, we prompted the LLMs to provide precise and detailed expert-level responses. The responses from each model were evaluated by experts based on relevance, factual accuracy, severity of possible harm, completeness, superfluous content, and age-related appropriateness from 0 (very bad) to 7 (very good). Differences were calculated using the Kruskal-Wallis-test in SPSS Version 28. Results Our findings indicated a good performance of all models regarding the dimensions tested. The figures show the average ratings (Figure 1, Figure 2A) and highlight significant differences after Bonferroni correction in bold (Figure 2B). The GPT 4 turbo preview, including the retrieval of guidelines, provided significantly more relevant (average rating [AR] 5.94, meaning mostly relevant), accurate (AR 5.6, meaning between somewhat and mostly accurate) and complete (AR 5, meaning fairly complete) answers compared to GPT 3.5 and GPT 4. In terms of difficulty levels or the type of questions, there was no significant difference in rating. Relevance ratings were slightly better in factual questions (AR 5.7) than in those requiring more experience-based knowledge (AR 5,3). Although GPT4 had higher average scores compared to GPT 3.5 in all dimensions except superfluous content, the differences in rating were not statistically significant. All models had relevant difficulties considering the age-related aspects of the questions (AR 4.06-4.45, p=0.455). Conclusion This study highlights the potential and limitations of AI language models in addressing complex medical questions in fields characterized by highly individualized decision-making scenarios. The findings advocate for the development of more specialized AI tools in medicine, tailored to specific medical fields and patient age groups.Fig 1:Average ratings of LLMsFig 2:Rating differences between LLMs

Benign and malignant breast lesions in children and adolescents - diagnostic and therapeutic approach.

Benign and malignant breast lesions in children and adolescents are rare compared to adults. Most tumors are benign. Malignant breast lesions are extremely rare. Fibroadenomas are the most common, accounting for 95% of all lesions. Diagnosis is based on history and physical examination of the breast and armpit. Imaging studies include ultrasound, mammography, and magnetic resonance imaging. Ultrasound is the most commonly used imaging test. Other tests are used in cases of diagnostic doubt. Core needle biopsy should be considered for appropriate diagnostic management. Excisional biopsy should be considered for complex clinical conditions and imaging studies. Except in doubtful situations in children and adolescent girls, a conservative approach and observation of the lesions along with periodic ultrasound examination initially every 6-12 months is advisable. Management of malignant breast lesions in children typically involves a multidisciplinary team consisting of pediatric oncologists, surgeons, radiation oncologists, pathologists, and other specialists and depends on the clinical condition of the patient. An important aspect is the experience of the clinician and radiologist in the treatment of breast lesions, as well as increasing patient and family awareness of possible breast lesions and self-examination. This review aims to provide a scoping overview of the available literature on benign and malignant lesions of the breast in pediatric and adolescent populations to assist physicians and surgeons in making decisions regarding the appropriate diagnosis and management of pediatric breast disease.

Necrotizing enterocolitis in term infants with congenital heart disease and preterm infants after surgery

Background: The purpose of this study was to report and compare the surgical outcomes of preterm-related necrotizing enterocolitis (PNEC) and congenital heart disease (CHD)-related necrotizing enterocolitis (CDNEC). Materials and Methods: Preterm infants without CHD and term infants with CHD who developed NEC and needed surgery were included in this cohort study between 2018 and 2021 at our university-affiliated hospital. A board-certified pediatric cardiologist examined all the patients with echocardiographic and cardiac examinations to diagnose CHD, and a pediatric surgeon evaluated the neonates for surgical indications. Patient characteristics, pregnancy history, and surgical and mortality outcomes were collected from the infants’ medical records. Results: Forty infants with NEC were included. The CDNEC and PNEC groups consisted of 18 and 22 infants, respectively. Although the disease-specific mortality rate was higher in the CDNEC group than in the PNEC group, the difference was insignificant (55.5% and 40.9%, respectively, P=0.36). There was no statistically significant difference in the time of NEC occurrence, location, type of surgery, or indications for surgery between the two groups. Conclusion: Despite the pathophysiologies of CDNEC and PNEC being different, the characteristics, pregnancy history, surgical, and mortality outcomes of these two types are similar in infants who undergo surgical treatment.

An analysis regarding the ultimate outcome of abstracts presented at the European Paediatric Surgeons' Association (EUPSA) Congresses.

The objective of this study is to analyze the conversion rate of abstracts presented at the European Paediatric Surgeons' Association (EUPSA) congress into full-text publications and to conduct a thorough analysis of the attributes and quality of the papers published. Abstract books including the years 2017 to 2022 were reviewed. Searches on PubMed and Google Scholar, utilizing keywords from the titles and the author names, were conducted to trace subsequent full-text publications. A categorical analysis detected variations and trends, with a significance threshold of P < 0.05. Quantitative data were presented as means ± standard deviations (SD), while categorical data were represented as counts (n) and percentages (%). A total of 2,139 abstracts were presented at the EUPSA annual meetings during five consecutive congresses. The average number of presented abstracts was 427.6 ± 20.4 per year from across 63 different countries. European countries contributed the majority (71%). The presentations included both oral (n=817, 38.2%) and poster presentations (n=1322, 61.8%). They predominantly focused on clinical topics (90.6%). Single-center retrospective studies were the most common study design (43.7%). Out of all abstracts presented, 1033 (48.3%) were published within an average time interval of 1.39 ± 1.19 years after presentation. Most journals had an impact factor (IF) between 1 and 5 (74.5%). There was no significant year-to-year variation in publication rates (p=1). Basic science studies were published in journals with significantly higher IF compared to clinical studies (p<0.001). The publication rate of abstracts presented at the EUPSA annual congress stands at 48.3%, aligning with the rates observed in other similar studies. This suggests that abstracts submitted to the EUPSA congresses were evaluated and scored rigorously, adhering to international selection criteria. Furthermore, the majority of these abstracts were published in journals with moderate to high impact factors, providing quantitative evidence of the scientific quality of research within the field of pediatric surgery.

Assessing use of the WHO surgical safety checklist for pediatric surgery in Senegal: A nationwide survey

Introduction The World Health Organization (WHO) introduced the surgical safety checklist (SSC) to reduce postoperative morbidity and mortality; however, its use in low- and middle-income countries is still low. Methods We conducted a survey from January 2 to 22, 2024, in public hospitals’ pediatric surgery departments and units in Senegal to assess the use of the WHO SSC or an adapted version. Results The participation rate was 100% (23 hospitals), with 11 second-level hospitals (47.8%) and 10 (43.5%) having at least two pediatric surgeons. All hospitals had an anesthetist nurse, and 18 hospitals (78.3%) had at least two scrub nurses. For the surgical workload, 14 hospitals (60.9%) had five to 10 surgical interventions weekly. Eleven hospitals (47.8%) had training on use of the SSC, and 8 of the 23 hospitals (34.8%) used the SSC. The WHO SSC nonutilization was mainly due to a lack of training in nine hospitals (60%) and SSC unavailability in five hospitals (33.3%). Members of 22 hospitals (95.6%) were available for training on use of the SSC. Conclusion The WHO SSC is poorly used in pediatric operating rooms of public hospitals in Senegal. The main reasons for nonutilization are remediable.

Practice Patterns Vary Widely in the Care of Pediatric and Adolescent Pelvic and Acetabular Fractures: A CORTICES Survey.

Pediatric pelvic and acetabular fractures are rare but potentially devastating injuries and significant management variation exists across the United States. This study sought to elucidate treatment decision-making trends, involvement of adult trauma fellowship-trained surgeons in pediatric care, and pre- and postoperative transfer patterns. Pediatric orthopaedic surgeons who serve as trauma liaisons at 20 PTCs were surveyed regarding training, practice volume, and factors contributing to institutional management of pelvic and acetabular injuries. Five clinical scenarios of pelvic ring and acetabular fractures that varied by injury pattern, age, and sex were presented. Descriptive statistics were used to summarize the results. Eighteen institutions responded to the survey (90% response rate, 16 Level, 1 PTC). All surgeons were pediatric fellowship-trained (77.7% in practice >5y). The four most common factors affecting whether surgeons independently managed both pelvic ring and acetabular fractures were patient age, fracture characteristics, displacement and need for surgery. The majority reported managing <10 acetabular (72.2%) but >10 pelvic ring (77.8%) injuries per year. In the clinical scenarios, patients <10 were more likely to have treatment decisions made by a pediatric orthopaedic surgeon. Older patients were more likely to be transferred to another institution for surgery but were often transferred back to the PTC postoperatively. In all clinical scenarios other than posterior hip dislocation, a trauma fellowship-trained surgeon was more likely to be the operative surgeon, even when the patient was not transferred. There is substantial variation in the management of pediatric and adolescent pelvic and acetabular fractures. Even at tertiary care PTCs, volumes are low, and trauma fellowship-trained surgeons are often involved in decision-making and operative management. Age and injury pattern seem to play a large role in variation, and patient transfers between facilities are common. V.

Early detection and management of congenital pulmonary airway malformation in a newborn with stable clinical course

Introduction: Congenital pulmonary airway malformation (CPAM) is a rare developmental lung anomaly characterized by cystic lung lesions, constituting about 25% of congenital pulmonary anomalies. It typically occurs sporadically and is not significantly associated with race, age, or other maternal factors. The prenatal course of CPAM can vary based on factors such as lesion size, mediastinal shift, and associated anomalies. While the overall prognosis is generally favorable in the absence of severe complications like hydrops fetalis, which can adversely affect outcomes, management strategies include corticosteroids, thoracoamniotic shunt (TAS), and, in severe cases, open fetal surgery or the EXIT procedure. Postnatal surgical excision usually offers a curative outcome with an excellent prognosis. Without surgical intervention, there are risks of recurrent infections and, rarely, malignant transformation. Effective prenatal detection significantly impacts clinical decision-making and neonatal outcomes, and the necessity and timing of surgery for asymptomatic infants remain subjects of ongoing debate, underscoring the need for personalized, multidisciplinary care. Case Report: A female infant, delivered at 38 weeks via Cesarean section, was diagnosed with CPAM following routine prenatal ultrasound. Presence of extensive cystic regions in the right lung confirmed the diagnosis and a CPAM volume ratio (CVR) of 0.37 indicated a low risk of severe complications. The pregnancy was largely uneventful, with maternal chronic hypertension managed by Nifedipine and mild intermittent asthma. Postnatal chest radiography corroborated the CPAM diagnosis, while an abdominal ultrasound investigated intrahepatic calcifications. Maternal screening for cytomegalovirus and toxoplasmosis yielded negative results, and postnatally, the infant also tested negative for both infections. The neonate, though asymptomatic and stable, required close monitoring in the neonatal intensive care unit to prevent potential respiratory compromise. Conclusion: Advances in prenatal imaging have greatly improved the early detection and management of CPAM, allowing for targeted neonatal care and strategic planning. This case highlights the importance of a multidisciplinary approach involving obstetricians, maternal-fetal medicine specialists, neonatologists, and pediatric thoracic surgeons in the effective management of CPAM. Early identification and diligent postnatal monitoring are essential for ensuring optimal outcomes and minimizing the risk of complications. The coordinated care and strategic decision-making exemplified in this case underscore the potential for enhanced neonatal health and long-term well-being through comprehensive management of congenital anomalies.

Perioperative Management of Tibial Spine Fractures in Pediatric Patients: A Delphi Study to Identify Principles of Treatment.

The Delphi technique is a structured, iterative group survey method utilized to reach a consensus among experts in a field regarding topics with evidence-based equipoise. Currently, there are few studies at the highest levels of evidence published on the perioperative tibial spine management, making it an ideal subject to utilize expert opinion to reach consensus decision. The purpose of this study was to utilize a Delphi-method survey to achieve consensus statements regarding the perioperative management of tibial spine fractures. Before study initiation, 3 rounds of surveys were agreed upon, maintaining the traditional Delphi principles. Consensus was defined as 75% agreement or disagreement on a Likert scale. An anonymous survey consisting of 50 statements describing the management of tibial spine fractures preoperative and postoperative in varying scenarios was distributed to a group of 44 pediatric sports medicine orthopaedic surgeons utilizing an electronic survey software system. Of 44 surgeons invited to participate, 24 responded to round 1, 28 responded to round 2, and 25 responded to round 3. Consensus was achieved for the following: use of x-ray to determine initial treatment; casting for a minimum of 3 weeks for nonoperative management, but <3 weeks if treated with surgical fixation; advanced imaging to avoid missing concomitant injury; the necessity of physical therapy, but not continuous passive motion (CPM); and for arthroscopic surgical intervention. It was also agreed that functional testing is important in return-to-play (RTP) decision-making, though the specific timelines and clearance criteria could not be agreed upon. There were statements that displayed continued disagreement, including the role of aspiration, preoperative range of motion management, and the timing of surgical scheduling. Utilizing a Delphi methodology with experienced surgeons on tibial spine treatment, consensus in the management of tibial spine fracture was achieved for definitive management strategies. Further study will be important to optimize our management of this youthful population with tibial spine fractures.

Hiding in Plain Sight: Radiologic and Pathologic Findings Can Identify Beckwith-Wiedemann Syndrome in Patients With Wilms Tumor.

Most pediatric specialists, including hematologists/oncologists, surgeons, radiologists, and pathologists, are familiar with the diagnosis and management of Wilms tumor (WT). However, it may be challenging to identify the underlying conditions causing cancer predisposition, which can change the management for the patient and potentially their entire family. In this paper, we present 3 cases of clinically suspected WT associated with Beckwith-Wiedemann syndrome (BWS). We review the radiologic and histologic findings to diagnose BWS. We also discuss the implications of a BWS diagnosis on the clinical management of WT and follow-up guidelines for BWS patients.

Markers of consciousness in infants: Towards a 'cluster-based' approach.

As recently as the 1980s, it was not uncommon for paediatric surgeons to operate on infants without anaesthesia. Today, the same omission would be considered criminal malpractice, and there is an increased concern with the possibility of consciousness in the earliest stage of human infancy. This concern reflects a more general trend that has characterised science since the early 1990s of taking consciousness seriously. While this attitude shift has opened minds towards the possibility that our earliest experiences predate our first memories, convincing demonstrations of infant consciousness remain challenging given that infants cannot report on their experiences. Furthermore, while many behavioural and neural markers of consciousness that do not rely on language have been validated in adults, no one specific marker can be confidently translated to infancy. For this reason, we have proposed the 'cluster-based' approach, in which a consensus of evidence across many markers, all pointing towards the same developmental period, could be used to argue convincingly for the presence of consciousness. CONCLUSION: We review the most promising markers for early consciousness, arguing that consciousness is likely to be in place by 5 months of age if not earlier.

The Diagnosis and Management of Pediatric Blunt Abdominal Trauma-A Comprehensive Review.

Blunt abdominal trauma in childhood has always been full of diagnostic and therapeutic challenges that have tested the clinical and radiological skills of pediatric surgeons and radiologists. Despite the guidelines and the studies carried out so far, to this day, there is no absolute consensus on certain points of view. Around the world, a paradigm shift towards non-operative treatment of hemodynamically stable children, with low complication rates, is noticeable. Children with blunt abdominal trauma require a standardized methodology to provide the best possible care with the best possible outcomes. This comprehensive review systematizes knowledge about all aspects of caring for children with blunt abdominal trauma, from pre-hospital to post-hospital care.

Do Not Forget the Spine MRI in Children With Arthrogryposis Multiplex Congenita: High Prevalence of Tethered Spinal Cord and Preliminary Clinical Findings Following Detethering.

Arthrogryposis multiplex congenita (AMC) encompasses congenital conditions with joint contractures in 2 or more joints. Patients with AMC may have scoliosis and neural axis malformations. The study aimed to determine the prevalence of tethered spinal cord (TSC), characterized by a low-lying conus medullaris, and secondarily, present preliminary findings following surgical untethering in children with AMC. Patients 18 years of age and younger with a diagnosis of AMC and a spine MRI were identified. The presence of a TSC was defined as a low-lying conus with termination at or below the lower third of the L2 vertebral body. A pediatric neurosurgeon and a pediatric orthopaedic surgeon independently reviewed MRIs. The medical records of patients with AMC who underwent untethering were examined to evaluate preoperative and postoperative clinical findings. The prevalence of TSC in our AMC patients was compared with published normative data using χ2 analysis. Forty-two of 105 AMC patients (40%) had TSCs. There was a greater percentage of patients with AMC and a TSC compared with the unaffected population (P<0.0001). Sixteen patients underwent detethering through filum terminale sectioning. Nine patients had preoperative neurological deficits in addition to their AMC. There were no postoperative complications. All patients had improvement in their bowel and bladder symptoms within 3 months after their detethering procedure. TSC is more prevalent in the pediatric population with AMC compared with those without AMC. MRI is recommended for all patients with AMC due to its high prevalence. Although not a benign procedure, surgical detethering may have potential benefits for children with AMC. Level IV-therapeutic study.

Surgical management protocol for disk battery ingestion.

Disk battery (DB) ingestion in children can lead to severe complications and mortality. This study details our experience in managing DB ingestion and its complications. We analyzed data from all patients treated for DB ingestion at our hospital from June 2010 to January 2024. A protocol established in 2010 requires angio-CT scans for esophageal DB cases and a multidisciplinary approach involving gastroenterologists, otolaryngologists, pediatric and airway surgeons, and cardiac surgeons. We treated 22 patients. In June 2010, following the tragic death of a patient from an undiagnosed DB ingestion that led to an aortoesophageal fistula, our protocol was established. All DBs were removed endoscopically. Four patients needed additional surgery: two had tracheal resection/anastomosis and esophageal repair for large tracheoesophageal fistulas; one required aortic wall reinforcement with a patch; one underwent endoscopic removal with a sternal split to explore the aortic arch. All 22 patients survived and recovered clinically. One developed bilateral vocal cord palsy as a complication. Effective management of DB ingestion complications necessitates a collaborative, multidisciplinary approach. Our protocol has improved management strategies and patient outcomes.

The inferior sacral iliac line as a horizontal reference plane in paediatric pelvic radiographs.

While often used, Hilgenreiner's line may not always be a reliable reference plane following triple innominate pelvic osteotomy or trauma to the triradiate cartilage. The inferior sacral-iliac line is a horizontal line connecting the sclerotic corners of the inferior sacral-iliac joints. This is a consistent landmark in the ossifying infant pelvis as well as the fully developed adult pelvis. The goal of this study was to determine if there is a difference in measurements between the inferior sacral-iliac line and Hilgenreiner's line in order to identify an alternative horizontal reference plane. 3 reviewers (fellowship-trained paediatric orthopaedic surgeon, junior orthopaedic resident, senior orthopaedic resident) reviewed 100 paediatric non-osteotomized pelvises. The difference between Hilgenreiner's line and the inferior sacral-iliac line were measured and reported. Measurements were repeated a minimum of 48 hours apart, resulting in 600 comparisons between Hilgenreiner's line and the inferior sacral-iliac line. The standard error of measurement was calculated to assess the variation in measurements between each individual observer and the group as a whole. The mean standard error of measurement between Hilgenreiner's line and the inferior sacral-iliac line was 0.44° (95% CI, ± 0.86). Reviewers 1-3 demonstrated a mean standard error of measurement of 0.38, 0.28, and 0.35 (95% CI, ± 0.74, 0.55, and 0.86) respectively. There was no statistically significant difference between reviewers (p > 0.05). Intra-observer reliability for reviewers 1, 2, and 3 was 0.64 (0.47-0.76), 0.75 (0.63-0.83), and 0.54 (0.32-0.69) respectively, with an inter-observer reliability of 0.42 (0.20-0.60) degrees. In this proof-of-concept study, the inferior sacral-iliac line was found to be an appropriate alternative to Hilgenreiner's line that is easily identifiable for all levels of orthopaedic training. Future inferior sacral-iliac line studies should demonstrate the reliability of multiple acetabular measurements, both pre- and post-osteotomy.

Roles of pediatric surgeons in palliative pediatric oncology.

Pediatric surgeons engaged in oncology will inevitably treat patients receiving palliative care, but their role in this context is poorly described. This article identifies some of the challenges and opportunities of surgical involvement in pediatric oncology palliative care, underscoring how the surgeon's expertise can be exploited to significantly benefit children with cancer. Specific examples of skills (procedural, communication, and coordination) that surgeons can provide to the multidisciplinary palliative care teams are described and the importance of collaboration is highlighted.