The Predictive Value of Radiographs and the Pirani Score for Later Additional Surgery in Ponseti-Treated Idiopathic Clubfeet, an Observational Cohort Study.

There are few validated predictors of the need for additional surgery in idiopathic clubfeet treated according to the Ponseti method. Our aim was to examine if physical examination (Pirani score) and radiographs at the age of three months (after initial correction of the clubfeet) can predict the future need for additional surgery. In this retrospective cohort study, radiographs of idiopathic clubfeet were made at the age of three months. The Pirani score was determined at the first cast, before tenotomy, and at the age of three months. Follow-up was at least five years. The correlation between the radiograph, Pirani score, and the need for additional surgery was explored with logistic regression analysis. Parent satisfaction was measured with a disease-specific instrument. The study included 72 clubfeet (50 children) treated according to the Ponseti method. Additional surgery was needed on 27 feet (38%). A larger lateral tibiocalcaneal angle (i.e., equinus) and a smaller lateral talocalcaneal angle (i.e., hindfoot varus) at the age of three months were correlated with the need for additional surgery. Higher Pirani scores before tenotomy and at the age of three months also correlated with additional surgery. Parent satisfaction was lower in patients who needed additional surgery. Both the Pirani scores and the lateral radiographs are predictive for future additional surgery.

Treatment of closed femoral shaft fractures in children aged 2-10 years: a systematic review and meta-analysis.

OBJECTIVE: To review current literature on treatment of closed femoral shaft fractures in children of 2-10 years old, with subgroup analysis of children aged 2-6 years, comparing intramedullary nailing (IMN) to conservative treatment modalities. METHODS: We included clinical trials and observational studies that compared traction and subsequent casting (TSC), spica casting and IMN for treatment of femur shaft fractures in children of 2-10 years of age. Subgroup analysis of children aged 2-6 years was performed. RESULTS: Compared to treatment with immediate spica casting, IMN led to significantly less coronal angulation (mean difference (MD): 2.03 degrees, confidence interval (CI) 1.15-2.90), less sagittal angulation (MD: 1.59 degrees, CI 0.82-2.35) and lower rates of LLD (Risk difference (RD): 0.07, CI 0.03-0.11). In terms of rehabilitation, IMN leaded to shorter time until walking with aids (MD: 31.53 days, CI 16.02-47.03), shorter time until independent ambulation (MD: 26.59 days, CI 22.07, 31.11) and shorter time until full weight bearing (MD: 27.05 days, CI 6.11, 47,99). Compared to TSC, IMN led to a lower rate of malunion (RD: 0.31, CI 0.05-0.56), shorter hospital stays (MD: 12.48 days, CI 11.57, 13.39), time until walking with aids (MD: 54.55, CI 40.05-69.04) and full weight bearing (MD: 27.05 days [6.11, 47,99]). CONCLUSION: Although a lack of quality evidence, this systematic review showed a clear tendency to treatment with elastic intramedullary nails of femoral shaft fractures in children of 2-10 years of age.

Tranexamic acid reduces blood loss in paediatric proximal femoral and/or pelvic osteotomies.

PURPOSE: Proximal femoral and/or pelvic osteotomies (PFPO) are associated with significant blood loss, which can be harmful, especially in paediatric patients. Therefore, considering methods to reduce blood loss is important. The purpose of this study was to examine the efficacy of tranexamic acid (TXA) in reducing intraoperative estimated blood loss (EBL) in paediatric patients undergoing a PFPO. METHODS: Paediatric patients who had a PFPO between 2014 and 2019 were retrospectively reviewed. Outcome measures included patient demographics, TXA use (none, preoperative and/or intraoperative bolus, pump), EBL, transfusion rate and thromboembolic complications. Univariate and multivariate analyses were performed to assess associations between investigated outcome measures and EBL. RESULTS: A total of 340 PFPO (263 patients) were included. Mean age at surgery was 8.0 years (sd 4.3). In all, 269 patients received no TXA, 20 had a preoperative bolus, 43 had an intraoperative bolus and eight patients had other TXA regimes (preoperative and intraoperative bolus or pump). Overall, mean blood loss was 211 ml (sd 163). Multivariate analysis showed significant associations between higher EBL and higher age at surgery, male sex, higher body mass index and longer procedure time. There was a significant association between lower EBL and a preoperative TXA bolus: 66 ml (33%) less EBL compared with patients without TXA (95% confidence interval -129 to -4; p = 0.04). No thromboembolic complications were reported in any of the studied patients. CONCLUSION: Preoperative TXA administration is associated with a decreased EBL in PFPO. No thromboembolic events were reported. Administering TXA preoperatively appears to be effective in paediatric patients undergoing a PFPO. LEVEL OF EVIDENCE: Level III - retrospective comparative study.

Congenital Forearm Pseudarthrosis, a Systematic Review for a Treatment Algorithm on a Rare Condition.

BACKGROUND: A congenital forearm pseudarthrosis is a rare condition and is strongly associated with neurofibromatosis type 1. Several surgical techniques are described in the literature, but the most optimal treatment strategy remains unclear. This systematic review aims to develop a treatment algorithm that may aid in clinical decision making. METHODS: The PROSPERO registration number for this study was CRD42018099602 and adheres to the PRISMA guidelines for systematic reviews. Embase, MEDLINE, Cochrane Central, Web of Science, and Google Scholar databases were searched for published studies reporting on congenital forearm pseudarthrosis not related to other underlying pathologies like bacterial infection or fibrous dysplasia. Results were not restricted by date or study type, only English literature was allowed. Studies were assessed for quality using the critical appraisal checklist for case reports from the Joanna Briggs Institute. Patient characteristics, underlying disease, type of surgery, union rate, and functional outcome were extracted from included studies. RESULTS: Of 829 studies identified, 47 were included in this review (17 case series and 30 case reports, a total of 84 cases). A one-bone forearm procedure showed highest union rates (92%), however, it results in loss of forearm rotation. Free vascularized fibula grafting showed high union rates (87%) and was related to good functional outcome of elbow flexion and forearm rotations. Other procedures showed disappointing outcomes. CONCLUSIONS: Congenital forearm pseudarthrosis is best treated with a free vascularized fibula grafting, a one-bone forearm procedure should be used as a salvage procedure. Evidence extracted from the case reports was sufficient to generate a treatment algorithm to be used in clinical pediatric practice. LEVEL OF EVIDENCE: Level IV-therapeutic.

Screening program for neonates at risk for developmental dysplasia of the hip: comparing first radiographic evaluation at five months with the standard twelve week ultrasound. A prospective cross-sectional cohort study.

PURPOSE: To assess whether delayed radiological hip screening at five months (versus ultrasound at 3 months) results in a higher incidence of persistent developmental dysplasia of the hip (DDH) at 18 months. METHODS: We analyzed 3536 screened neonates (2009-2013) at age two to three weeks. In the case of risk factors for DDH, 460 infants were assigned to a pelvic radiograph at five months between 2009 and 2010 and 651 infants were assigned to an ultrasound at three months (2011-2013). In the case of DDH, appropriate treatment was started and radiological follow-up occurred at eight, ten, 12, and 18 months. We compared incidence and severity of persistent DDH at 18 months. Analysis was performed using linear regression. RESULTS: Both groups were comparable for risk factors (breech, gender, twins, family history). Eighty-nine patients (2.5%) showed DDH (n = 43 (group 1), n = 46 (group 2)). At 18 months, ten patients showed persistent DDH (n = 8 (group 1), n = 2 (group 2) (7.7% vs. 0.3% respectively)). The mean acetabular index (AI) at 18 months in group 1 (left hip) is 22.4° (95% CI 20.6-24.3°) vs. group 2 at 22.3° (95% CI 21.2-23.4°) (p = 0.098). The mean AI in group 1 (right hip) is 21.9° (95% CI 18.9-24.9°) vs. 21.2° (95% CI 20.5-22.0°) in group 2 (p = 0.293). Adjusted for risk factors, there is no difference in incidence of persistent DDH between both groups after 18 months (OR 0.519; 0.07, 3.845). DISCUSSION: This study revealed no significant difference in incidence or severity of persistent DDH at 18 months between the two screening groups. These results suggest justification for delayed screening to prevent overtreatment of immature hips. CONCLUSION: In clinically stable hips, delayed ultrasound between three and five months is regarded as safe and could prevent for overtreatment of mild dysplastic hips.

[Müller-Weiss disease: idiopathic avascular necrosis of the navicular bone]. / Ziekte van Müller-Weiss: idiopathische avasculaire necrose van os naviculare.

BACKGROUND: Müller-Weiss disease is a rare and complex foot disorder. The underlying aetiology of this condition involves abnormal loading of the navicular bone combined with delayed ossification. Müller-Weiss disease is progressive and ultimately results in deformation and fragmentation of the navicular bone with plantar-flexed hindfoot varus. In patients with a severe form of this foot deformity, treatment involves arthrodesis of the midfoot with bridging of the navicular bone. CASE DESCRIPTION: A 43-year-old female patient was seen in our outpatient clinic with pain in her right foot. Her symptoms had been present for seven months and had developed spontaneously without prior trauma. Imaging investigations resulted in the diagnosis of Müller-Weiss disease in both her right and her left foot. CONCLUSION: It is important to recognize this condition at an early stage so that patients can receive conservative treatment initially.

[A boy with a painful upper leg]. / Een jongen met een pijnlijk bovenbeen.

A 13-year-old boy came to the Emergency Department with a Salter Harris type 1 epiphysiolysis of the distal femur. These fractures can be treated with a closed reduction and possible fixation. They cause a growth disturbance in 65 % of dislocated cases and therefore should be clinically evaluated until skeletal maturity.

[A man with a dell over the symphysis pubica]. / Man met pijnlijke delle over symphysis pubica.

A 46-year-old man was referred to our emergency room after minimal trauma. He was diagnosed with symphysiolysis, which was based on a congenital variant instead of a traumatic injury.