Postoperative Immobilization Period for Pediatric Supracondylar Fractures: The Shorter the Better?

BACKGROUND: There are now recognized standards of care published by the British and American Orthopaedic Associations which detail key areas of evidence-based recommendations for the treatment of children with displaced supracondylar humerus fractures. Although many aspects of treatment are covered in these recommendations, both the American and British Orthopaedic Associations do not recommend the exact duration of immobilization postoperatively. METHODS: This study retrospectively compared outcomes of operatively managed supracondylar fractures immobilized postoperatively for short immobilization (SI) defined as 28 days or less, with long immobilization (LI) defined as more than 28 days. The outcomes measured were clinical (deformity, range of motion, and pin site infection) and radiologic (loss of position after the removal of K-wires, Baumann's angle, anterior humeral line, refracture, and signs of osteomyelitis). Demographic data were recorded to evaluate and ensure satisfactory matching of the 2 groups for analysis. RESULTS: The study included 193 pediatric supracondylar fractures over a 4-year period which were treated with manipulation under anesthetic and K-wire fixation. The difference in average time in plaster between the 2 groups was statistically significant (SI: n=27.5 d, SD 1.23; LI: n=43.9 d, SD 15.29, P =0.0001). Data for operative techniques-closed or open reduction (SI: n=66, LI: n=78, P =0.59), and crossed wires (SI: n=37, LI: n=50, P =0.57) between the two groups showed no statistical significance. There was no statistical difference between the groups for the average number of days postoperatively at which wires were taken out (SI: n=28.9 d, SD 5.95, LI: n=30.1 d, SD 5.57, P =0.15), number of pin site infections requiring antibiotic treatment (SI: n=3, LI: n=5, P =0.70), or children from each group who were recorded to have regained full range of motion symmetrical to their contralateral arm (SI: n=79, LI: n=99, P =0.74). CONCLUSIONS: Our study therefore suggests that shorter immobilization of these patients (SI group) does not yield a higher rate of complications including refracture and malunion.

Hip sonography according to Graf: practical notes for the student, the examiner and the reviewer.

Since the publication of Professor Reinhard Graf's work in 1980, Graf's technique has become the gold standard for screening Developmental Dysplasia of the Hip (DDH) in many European and non-European countries. Despite the fact that it is supported by robust literature evidence, there is criticism about its reliability and reproducibility, questioning severalaspects of the diagnostic procedure. There is, however, concern, based on recent literature, about the quality and reliability of the published data, which may, in many cases, be based on inadequate scans, and therefore any conclusions drawn have to be questioned. The aim of this review is to demonstrate the most important aspects of Graf's technique, to clarify the potential sources of confusion and to flag up the most common errors and mistakes made, either during the ultrasound examination, or during the reporting procedure. Furthermore, this review can be used as a guide for reviewers and editors and should help to enhance the quality control of publications on this subject.

Hip reconstruction in cerebral palsy: Lessons from a single center and 137 hips.

Background: This large, retrospective, single-center study aimed to compare the outcomes of unilateral hip reconstruction and bilateral hip reconstruction in children with non-ambulatory cerebral palsy and ascertain risk factors for recurrent instability and reoperation. Method: We performed a retrospective review of 137 hip reconstructions performed for patients with cerebral palsy. Preoperative and postoperative clinical and radiological parameters were documented, including hip migration percentage, acetabular index, the Gross Motor Function Classification System, the Melbourne Cerebral Palsy Hip Classification System, hip abduction, and pelvic obliquity. Results: Overall, 49 patients underwent bilateral hip reconstruction, and 37 patients underwent unilateral hip reconstruction. In the unilateral hip reconstruction group, the reconstructed hip remained stable (with a migration percentage < 33%) in 59% of patients compared to 74.4% of the more affected hips in the bilateral hip reconstruction group (p = 0.02). Of the unreconstructed hip in the unilateral hip reconstruction group, 74.4% remained stable (with a migration percentage < 33%), compared to 78.8% of the less affected hips in the bilateral hip reconstruction group. A level pelvis was maintained at final follow-up in significantly more patients in the bilateral hip reconstruction group than the unilateral hip reconstruction group (p = 0.002). Further surgical intervention was performed in 41% of the unilateral hip reconstruction group, compared with 11.5% in the bilateral hip reconstruction group (p = 0.001). Surgery performed under the age of 8 years and not performing an acetabular osteotomy were found to be risk factors for recurrent instability in all groups. Conclusion: Our series suggests that in terms of recurrent instability after hip reconstruction in cerebral palsy, protective factors against this complication include bilateral hip reconstruction, hip reconstruction after 8 years of age, and the use of an acetabular osteotomy.

Functional and Clinical Outcomes of Combined Simultaneous Bilateral Anterior Distal Femoral Plate Hemiepiphysiodesis and Hamstrings Release in Management of Knee Flexion Contractures in Children With Neuromuscular Disorders.

BACKGROUND: We examined the clinical and functional outcomes of the simultaneous anterior distal femoral 8-plate hemiepiphysiodesis (ADF8PH) and hamstring release, for fixed knee flexion deformity in children with neuromuscular disease. To our knowledge, no published evidence is available that reports the outcomes of this combined techniques. METHODS: Electronic medical records were retrospectively reviewed for 19 consecutive children who underwent bilateral ADF8PH and concomitant hamstrings release in our institution from 2012 to 2019. Relevant demographics, Gross Motor Functional Classification Score and preoperative and postoperative knee flexion contractures and popliteal angles were documented. RESULTS: The average age at the time of operation was 12±2.1 years. There were 15 males and 4 females. Diagnoses included cerebral palsy (n=16), Cornelia de Lange syndrome (n=1), hereditary spastic paraplegia type 56 (n=1) and fructose-1,6 bisphosphonate aldose B deficiency (n=1). Mean length of follow-up was 3.8 years (range: 1.5 to 7 y). Mean fixed knee flexion deformity improved from 28.9 to 13.4 degrees (P<0.001) at an average correction rate of 0.94 degrees per month. Mean popliteal angle improved from 81.8 to 44.4 degrees (P<0.001) in the early postoperative phase and to 51.8 degrees (P<0.001) in latest clinic review. Mean time to correction was 18.9 months. The agreed treatment goals of maintaining or promoting the use of standing frame and spinal/postural symmetry was attained in 18 patients (94.7%). Postoperative knee pain was reported in 2 cases (10.5%). We report 2 complications; 1 case of neurapraxia and 1 case of sepsis because of respiratory infection. CONCLUSION: Simultaneous bilateral ADF8PH with hamstrings release is a promising effective technique for correction of knee flexion contractures in skeletally immature individuals with neuromuscular disabilities. Our findings demonstrate improvement in clinical outcomes and maintaining functional outcomes, indicating the validity of this approach as a satisfactory, less invasive alternative in the management of this deformity. LEVEL OF EVIDENCE: Level IV-therapeutic study.

International Interdisciplinary Consensus Meeting on the Evaluation of Developmental Dysplasia of the Hip.

In September 2018, an international meeting of doctors of various disciplines, with expertise in the detection and treatment of DDH, was held in Csolyospalos, Hungary. The aim was to achieve consensus on the detection and early treatment of the condition and to develop a standardized system of teaching and training for hip ultrasound. There was strong agreement that US screening is essential. Specifically the Graf technique was selected as the technique of choice. Universal US screening was strongly favored. Screening should be carried out as soon as possible, but not later than the sixth week of age. US screening is cost-effective, does not result in overtreatment, and contributes to a reduction of long-term consequences. The essential principle of treatment is timely application of a device to achieve reduction, retention and maturation, by holding the hips in flexion, and a safe degree of abduction. It was agreed that the effectiveness of any screening policy depends on the correct scanning technique. Therefore, standardization of teaching and training of the Graf technique is mandatory. A unified teaching policy and materials should be developed for this purpose. Certification, re-certification and audit were discussed. The group, which has been formalized as the International Interdisciplinary Consensus Committee On DDH Evaluation (ICODE), will continue to meet and work towards establishing international consensus on DDH, standardizing and developing teaching and training of the Graf technique for hip US, and maintaining standards for detection and management.

Comparison of Ponseti versus surgical treatment for idiopathic clubfoot: a short-term preliminary report.

UNLABELLED: The Ponseti method of treatment for congenital clubfeet has gained widespread clinical acceptance. We have used manipulation, serial casting, and surgery to treat congenital clubfeet for almost 3 decades. Considering the Ponseti method of treatment to replace our traditional treatment method, we conducted a randomized, controlled trial evaluating the short-term outcome of the two treatment protocols. We evaluated foot function and applied a standardized measure of health status for children with orthopaedic problems. Nineteen patients (28 feet) were included in the trial. Nine infants (12 feet) were assigned to the Ponseti treatment group, and 10 (16 feet) were assigned to a group with initial casting and posteromedial release at the age of 6 to 8 months. The minimum followup was 3.3 years (mean, 3.5 years; range 3.3-3.8 years). Outcome measures included the Functional Rating System of Laaveg and Ponseti, the Pediatric Outcomes Data Collection Instrument (PODCI), and standardized radiographic measurements. At last followup the mean Functional Rating score was higher in the Ponseti group. Passive dorsiflexion and passive inversion-eversion were better in the Ponseti group. PODCI scales were comparable and radiographic outcome measures were similar in both groups. This trial has documented a favorable short-term outcome for the Ponseti method when compared with a traditional treatment protocol. LEVEL OF EVIDENCE: Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Treatment of unicameral calcaneal bone cysts in children: review of literature and results using a cannulated screw for continuous decompression of the cyst.

Nine unicameral bone cysts of the calcaneus in children were managed surgically using the technique of continuous decompression with titanium cannulated cancellous screws. The average age of the patients at surgery was 12.8 years. At follow-up a minimum of 2 years after surgery, eight cysts showed complete healing; one patient showed healing with residuals. Irritation at the screw insertion site necessitated early removal of the screw in one patient; implant-related problems were not observed in the other patients. Patients were allowed to bear weight after surgery. Implant extraction was performed after full consolidation of the cyst and was uneventful in all patients. A review of the literature and the different treatment modalities used for managing calcaneal cysts is also presented.