What’s New in Pediatric Orthopaedics

This Guest Editorial presents a collection of noteworthy studies published recently, in general and subspecialty journals, mostly between October 2023 and September 2024. Preference was given to studies with a higher Level of Evidence. Trauma Shoulder and Elbow Fractures Two studies showed equivalent outcomes in comminuted clavicular fractures as well as displaced proximal humeral fractures treated nonoperatively1,2. Another study showed similar outcomes in adolescents 10 to 16 years of age with displaced proximal humeral fractures treated in situ compared with closed reduction3. One study showed that patients with nonemergency supracondylar humeral fractures who were transferred between facilities by privately owned vehicles and those who were transferred by ground ambulance had similar complication rates4. A systematic review with 1,446 patients showed that patients who underwent nonoperative treatment of type-II supracondylar humeral fractures had higher rates of residual sagittal deformity and need for a subsequent surgical procedure, although there were similar functional outcomes and patient satisfaction5. Two studies emphasized the difficulty in analyzing pediatric elbow radiographs because of anatomic variability and patient positioning, with 1 study recommending using the humeral shaft rather than the distal humerus to gauge the anterior humeral line6,7. In another study, Miller et al. recommended using the modified Jakob classification for lateral condyle humeral fractures, touting excellent interrater reliability; arthrography changed the treatment plan in only 8% of cases8. In another study on lateral condyle humeral fractures, Tippabhatla et al. identified increased age, concomitant elbow dislocation, and treatment with open reduction as risk factors for postoperative stiffness9. In a study on medial epicondyle humeral fractures, screws >4.0 mm in diameter and the use of a washer were associated with higher rates of symptoms prompting implant removal10. Forearm Fractures One investigation demonstrated an 88.7% success rate and no infections with closed reduction for type-I open both-bone forearm fractures; there are increased odds of failure for every standard deviation (0.7) increase in the cast index and post-reduction radial translation of 25% on the anteroposterior radiograph11. Another study examining refractures following operative treatment of 402 both-bone forearm fractures showed a 5.5% rate, with higher rates in patients ≤10 years of age, in single-bone fixation with an intramedullary device, and when the radius was treated nonoperatively12. Lower-Extremity Injuries Fractures and dislocations around the hip continue to be challenging. At a minimum follow-up of 6 years, in a study of Delbet II and III femoral neck fractures, Haider et al. did not find any significant difference between proximal femoral locking plates and cannulated screws with regard to union rates, osteonecrosis, or secondary surgery, although the articulotrochanteric distance was decreased in the cannulated screw group13. A systematic review with 575 patients showed that dislocations were most commonly posterior and most commonly treated with closed reduction; osteonecrosis was the most common long-term adverse event, and the most common associated injuries were labral and capsular injuries (14.0%) and acetabular fractures (9.4%)14. A randomized controlled trial of femoral fractures in children between 2 and 6 years of age showed single-limb and one-and-a-half hip spica cast treatment groups to have comparable functional and radiographic outcomes, with higher parental satisfaction and lower skin pressure ulcer rates in the single-limb hip spica cast group15. Several studies have expanded our knowledge of tibial tubercle fractures. Milner et al. found that there was a significantly higher incidence of these fractures in patients with Osgood-Schlatter disease compared with a control group at all time points, particularly at 1 month following the diagnosis16. Patients with these fractures also had 15 times greater odds of having been receiving recombinant human growth hormone therapy at the time of the injury, compared with a matched control group with midshaft tibial fractures17. Two other studies showed that the rates of acute compartment syndrome in these fractures were much lower than previously reported, suggesting that prophylactic fasciotomy and admission for monitoring may not be warranted18,19. Sheth et al. identified 3 common distal tibial physeal fracture patterns, suggesting an ability to optimize the screw trajectory in the axial plane with intraoperative fluoroscopy20. Onay et al. found that closed reduction and percutaneous fixation of distal tibial physeal fractures, compared with anatomic reduction and open techniques, could provide satisfactory intermediate-term to long-term functional outcomes without increasing complications21. Zimmerman et al. examined the practice of removing epiphyseal screws, due to potentially increased contact forces on the tibiotalar joint, and found that, at a minimum 2-year postoperative follow-up, patients with retained epiphyseal implants had similar functional outcomes to patients who had the implants removed22. Infection Magnetic resonance imaging (MRI) is the gold standard for the diagnosis of acute pediatric musculoskeletal infections, which may be easier with rapid MRI protocols without contrast and anesthesia. A study implementing such a protocol in 18-month-old to 18-year-old patients undergoing workup for acute pediatric musculoskeletal infections showed improved time to imaging, duration of imaging, and interpretation time with an approximately 10% rescan rate. These patients had a shorter hospital stay and decreased charges for their visit23. Although the Kocher-Caird criteria have been widely used to diagnose septic arthritis in children, Valisena et al. concluded that they may not be fully adequate in the current clinical environment with the increasing prevalence of Kingella kingae24. Because patients with Kingella septic arthritis often present with milder symptoms and lower inflammatory marker laboratory values, children infected with K. kingae may not meet all of the Kocher-Caird criteria, which may lead to an underdiagnosis or misdiagnosis. Furthermore, Kingella cultures are better diagnosed with nucleic acid amplification assays. In a retrospective review of 135 children with septic arthritis, Moore-Lotridge et al. looked at the preoperative to postoperative change in C-reactive protein (CRP) at postoperative day 2 as an indicator of next steps in care25. There was a 22% increased risk of escalated care for each 10-unit increase in preoperative or postoperative CRP. Patients with a preoperative CRP of >90 mg/L and a postoperative day 2 elevation had markedly greater length of hospital stay and adverse outcomes. Lower Extremity Clubfoot How do patients with idiopathic clubfoot treated with Ponseti casting compare with their peers with regard to gross motor skills at 3 years of age? Rice et al. found that approximately 50% of their patients scored below the 25th percentile, with approximately one-quarter of patients scoring below the 10th percentile26. Factors associated with low gross motor scores were the need for repeat percutaneous heel cord tenotomy and poor compliance with bracing; bracing compliance reduced the odds of being below the 25th percentile by 80%. Limb Deformity and Reconstruction When comparing Kirschner wire with plate fixation for calcaneal lengthening osteotomies in flexible flatfoot, Tippabhatla et al. found that both methods were equivalent in terms of correction achieved, duration of casting, time to healing, and clinical outcome scores at the final follow-up, but the plate group experienced higher rates of complications and of reoperation due to pain caused by implants27. A study of distraction osteogenesis in a goat model found that reverse dynamization, using modular struts during the distraction phase followed by rigid fixation during the consolidation phase, resulted in earlier formation of regenerate bone compared with static fixation and demonstrated a more mature regenerate28. Two studies of the sleeper plate technique identified continued concerns. A retrospective study compared 25 patients treated with a sleeper plate with 47 patients treated with complete removal and found that 48.5% of patients in the sleeper group maintained the correction compared with 72.2% of patients in the removal group, and 17.3% of the patients with sleeper plates experienced tethering29. Another retrospective study evaluated the sleeper plate technique in 13 patients (19 knees) with multiple hereditary exostosis who underwent tibial or femoral hemiepiphysiodesis30. All patients with tibial sleeper plates developed osseous ingrowth into the empty screw hole leading to tethering and overcorrection, indicating that sleeper plates should not be used in multiple hereditary exostosis. Neuromuscular Disorders A long-term follow-up study investigating hip displacement in children with cerebral palsy following selective dorsal rhizotomy found that the rate of displacement, when evaluated by the Gross Motor Function Classification System (GMFCS), was consistent with that reported in published population studies31. Selective dorsal rhizotomy did not positively or negatively affect hip displacement when reviewed 5 years after the procedure, and the GMFCS level was still the most predictive factor of hip pathology. Kiapekos et al. had a 5-year follow-up study of children who underwent either a proximal femoral osteotomy alone or proximal femoral osteotomy combined with a pelvic osteotomy32. Despite having a higher preoperative migration percentage, the combined procedure group had a lower rate of failure (migration percentage of >50%). For hips that have already dislocated, the McHale procedure has been described for salvage. In a study of 65 hips (52 patients), a significant reduction in pain was noted along with improvements in personal hygiene and quality of life33. Despite a complication rate of 33.9%, >80% of caregivers would choose this procedure again or recommend the procedure to others. In a randomized study comparing functional electrical stimulation with traditional ankle-foot orthosis use, over one-half of the patients with hemiplegic cerebral palsy (13 of 25) chose to continue with functional electrical stimulation treatment, despite no significant improvement in ankle dorsiflexion or the participation domain of the Cerebral Palsy Quality of Life Questionnaire34. The authors emphasized the opportunity for a functional electrical stimulation trial when considering treatment strategies for patients with foot drop. Upper-extremity function in children with cerebral palsy was studied in a longitudinal fashion from the patient age of 18 months to 18 years to identify how hand function changes over time. Children had significant development at an early age, mainly before 2 years and 6 months of age, in the group classified as Manual Ability Classification System (MACS) level I35. The period of rapid development was somewhat longer for children in MACS level II (during the preschool period), and until the age of 7 years in MACS level III. The amount of hand function persisted until the age of 18 years, indicating the need for intensive motor training during the early preschool period. The landscape of treatment for children with spinal muscular atrophy has become a moving target since the introduction of disease-modifying agents, leaving us with gaps in the knowledge with regard to the new natural history of hips and spines. When nusinersen was administered in later childhood after the onset of symptoms, Kuong et al. found that 95% of hips subluxated or dislocated within 3 years36. Moreover, the Reimer migration index continued to deteriorate for most hips over time, indicating that muscle imbalance with weaker hip abductors persists despite some improvement in muscle power with nusinersen treatment. Hip Developmental Dysplasia of the Hip (DDH) Residual acetabular dysplasia (RAD) after treatment for DDH continues to be an important topic. Bavan et al. evaluated 305 patients treated with a Pavlik harness and found that 27% of hips had RAD at 2 years and 19% of hips had RAD at 4 years. Patients with RAD were in the harness longer and had a lower alpha angle at the conclusion of treatment37. For a minimum 4-year follow-up, Paranjape et al. examined 41 patients (46 hips) with a dislocated hip treated with a Pavlik harness38. At the final follow-up, 30% of hips had RAD. Of the hips with RAD, 93% had normal morphology at the conclusion of treatment. No differences were detected between groups with regard to age at presentation or time in the harness. Two retrospective studies evaluated the role of abduction bracing and the development of RAD after closed and open reduction39,40. In both studies, abduction bracing was not associated with decreased rates of RAD at 2 years and 4 years following reduction, but was associated with a lower rate of early secondary surgery. Legg-Calvé-Perthes Disease The treatment of residual deformity in Legg-Calvé-Perthes disease is challenging, with little known about intermediate and long-term outcomes. Of 51 patients who underwent surgical hip dislocation with relative femoral neck lengthening and femoral head-neck osteochondroplasty (minimum follow-up of 4 years), survival was 80% at 5 years and 66% at 10 years41. Factors associated with failure were preoperative pain and severity of the proximal deformity. Slipped Capital Femoral Epiphysis (SCFE) The timely diagnosis of SCFE, which helps to minimize the risk of associated complications, can be affected by socioeconomic determinants of health. In a retrospective study, Smith et al. evaluated 351 patients who underwent surgical treatment for SCFE42. In their cohort, 37% of patients had a delay in diagnosis of ≥12 weeks, with increased risk for patients with public insurance and those from single-family households. Although there are known risk factors for the development of SCFE, some of these associations are being revisited. A retrospective study of 65 patients with SCFE found that 32% had abnormal thyroid-stimulating hormone values at presentation, a rate much higher than previously reported43. Another study used a multi-institutional database to analyze risk factors for SCFE44. The incidence of SCFE in patients undergoing human growth hormone treatment was high and increased in a dose-dependent manner. Sports In a prospective study to assess for growth disturbance, Bolzinger et al. followed patients with a mean age of 13.2 years (range, 9 to 16 years) at the time of primary anterior cruciate ligament (ACL) reconstruction using semitendinosus autograft for 2 years45. Transphyseal fixation yielded a high rate of growth disturbances (leg-length discrepancy and axial deviation), although none was clinically relevant. The incidence of ACL injuries continues to rise in the adolescent population. In a study of patients ≤18 years of age (mean age, 16.1 ± 1.3 years [range, 13 to 18 years], regardless of the sport played) who underwent a primary ACL reconstruction between 2015 and 2020, Maheshwer et al.46 found that high school freshmen and seniors had an increased risk of ACL retear and that football (31.8%) and soccer (27.3%) were the most common sports played by patients with an ipsilateral retear. Patients who underwent hamstring autograft reconstruction had a higher incidence of retear compared with other graft types. Although allografts used for ACL reconstruction historically have demonstrated higher failure rates, 1 group showed that its use in patients who do not participate in competitive pivoting sports may bring the failure rate down to an acceptable level47. 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complication rates with increasing age at the index surgical procedure to a to delay treatment until months of to proximal failure in controlled at and with and the use of all screws or with all were associated with lower rates of an to the For proximal was identified in of patients and changes in sagittal in either were the for its development In another study, et al. found the rate of an to the after to be after a mean of 2 years after and only of the patients in the study had not had an to the at 5 years after the When comparing the final a that the quality of with the a that quality of in children and the group had significantly scores in the pain and and and suggesting a between caregivers and In patients with a minimum 2-year follow-up after from surgery, the risk of was with 66% of those patients of having acute to 2 years from most commonly for of In a patients treated with implants and had that persisted over time, with no of A retrospective database review of patients with from the showed patients who reported a of with only of those patients being evaluated with an MRI was found on MRI in of those A of patients from 10 who underwent anterior tethering a incidence of 50% by months such patients later to posterior spinal significantly more often and had mean at the final follow-up, compared with those without identified A study on patients with a posterior distraction showed spinal over the in both the and sagittal without of at a mean of years patients had most commonly due to implant of all and continues to be a much as more for which success is affected by a of Two studies described the modified and the The study that the modified and the to provide and rapid of and the study high interrater for use of the modified with a Another study to a bone age that could be with radiographs of the or The distal tibial and the age for early and the calcaneal the age in the The of the distal tibial and the most into in The of reviewed a of published studies to the 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be an to to hip dislocation in some children with cerebral significant treatment delay in pediatric fractures. is the clinically important treatment delay that could casting failure in pediatric patients with a This study found that children after the had a 25% failure rate with casting alone compared with for those who before Although of adolescents with presentation with casting this study to better on the of in fractures. 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