Factors Causing Dropout From Treatment During the Ponseti Method of Clubfoot Management: The Caregivers' Perspective.

A retrospective comparative study was conducted, aiming to identify factors associated with dropout from clubfoot treatment by Ponseti method in low- and middle-income countries. A prospectively gathered database of patients who received treatment at a high-volume urban clubfoot clinic over 6 years was queried for dropouts. A "dropout" was identified as any child that had not had a visit within 3 weeks of casting, 4 weeks of tenotomy or 6 months of brace follow-up. The second part of the study was a telephonic interview with caregivers of the identified dropouts to ascertain their reasons for discontinuing treatment. Of the 965 patients treated during the study period, there were 155 (16.06%) dropouts-137 (88.38%) during bracing phase and 18 (11.62%) during casting phase. Age at presentation was significantly higher among the dropouts as compared to those who did not dropout (median 9.5 and 7 months for casting and bracing dropouts respectively versus 3.5 months for regular follow-ups, p < .001). No significant correlation was found between patient dropout and sex (p = .061), or laterality (p = .071). Thirty-seven caregivers (23.8%) could be contacted telephonically; including 6 casting and 31 bracing dropouts. The most commonly cited reason for dropout from treatment was lack of family support (75.7%), followed by distance to the clinic (59.5%) and unavailability of transport (54.1%). Sixteen caregivers (43.2%) dropped out on account of migration to another town/state. Maintenance of a meticulous registry with regular update of caregivers' contact details, and interventions to mitigate the identified hurdles can help in reducing treatment dropouts.

Orthopaedic management of children with spinal dysraphism.

Aims: Children with spinal dysraphism can develop various musculoskeletal deformities, necessitating a range of orthopaedic interventions, causing significant morbidity, and making considerable demands on resources. This systematic review aimed to identify what outcome measures have been reported in the literature for children with spinal dysraphism who undergo orthopaedic interventions involving the lower limbs. Methods: A PROSPERO-registered systematic literature review was performed following PRISMA guidelines. All relevant studies published until January 2023 were identified. Individual outcomes and outcome measurement tools were extracted verbatim. The measurement tools were assessed for reliability and validity, and all outcomes were grouped according to the Outcome Measures Recommended for use in Randomized Clinical Trials (OMERACT) filters. Results: From 91 eligible studies, 27 individual outcomes were identified, including those related to clinical assessment (n = 12), mobility (n = 4), adverse events (n = 6), investigations (n = 4), and miscellaneous (n = 1). Ten outcome measurement tools were identified, of which Hoffer's Functional Ambulation Scale was the most commonly used. Several studies used unvalidated measurement tools originally developed for other conditions, and 26 studies developed new measurement tools. On the OMERACT filter, most outcomes reported pathophysiology and/or the impact on life. There were only six patient- or parent-reported outcomes, and none assessed the quality of life. Conclusion: The outcomes that were reported were heterogenous, lack validation and failed to incorporate patient or family perceptions. Until outcomes can be reported unequivocally, research in this area will remain limited. Our findings should guide the development of a core outcome set, which will allow consistency in the reporting of outcomes for this condition.

The Impact of Living with Clubfoot on Children and Their Families: Perspectives from Two Cultural Environments.

Purpose: To study the physical, emotional and social impact of clubfoot on the lives of affected children and their families. Methods: A purposive sample of children with treated idiopathic clubfoot and their parents was recruited from two geographical locations-the United Kingdom (UK) and India. Children were divided into age groups of 5-7 and 8-11 years. Questionnaires were administered separately to children and parents; the former comprised multiple-choice questions scored using an 'emoji' system, and the latter included open-ended questions divided into pre-defined themes of daily limitations, social life, general health, emotional barriers and family impact. Results: Thirty-four children and parents participated from UK; 96 children and parents participated from India. The majority of children (> 80%) reported no problems in daily activities, although 32.8% reported having pain. Difficulty finding appropriate footwear and limitation in sports were more common among UK children, whereas difficulty in squatting was more problematic for Indian children. Self and emotional perceptions regarding their appearance/condition were lower among older as compared to younger children in both countries. Parents' responses mirrored those of children; additionally they reported emotional and financial difficulties during initial treatment phase, and ongoing concerns about the future during the maintenance phase. Conclusion: Treated clubfoot continues to impact the lives of affected children and families. Perceptions of the condition and its impact vary between population groups; this needs to be appreciated when collecting and analysing outcomes.

Fractures of the Proximal Femur in Childhood: A Review.

BACKGROUND: Femoral neck fractures in children are rare injuries, occurring due to high-energy trauma. Due to the unique anatomy and blood supply of the proximal femur in growing children, these fractures are notorious for high rates of complications despite appropriate management. Classification of these fractures is according to the Delbet system, which not only guides management but also gives prognostic clues. Multiple fixation methods have been described and there is no consensus on what constitutes the best treatment. Osteonecrosis, non-union, coxa vara and premature physeal arrest are the most frequent complications. PURPOSE: To review the current knowledge, discuss controversial aspects, and provide suggestions for future research. METHODS: We have reviewed the literature on paediatric proximal femur fractures and have provided an evidence-based guide to the diagnosis and management of these injuries. Common complications have been elaborated and options for their prevention and/or management discussed. CONCLUSION: There is universal agreement that anatomic reduction and stable internal fixation, supplemented by spica immobilization in younger children, are essential to obtain good outcomes. The role of capsular decompression, choice and configuration of implant, and appropriate timing of surgery are aspects that continue to be debated. Multicenter prospective studies are necessary to standardize treatment of these challenging injuries.

Modified Dunn Osteotomy for Moderate and Severe Slipped Capital Femoral Epiphysis - A retrospective study of thirty hips.

BACKGROUND: Modified Dunn procedure has become popular for the treatment of severe cases of slipped capital femoral epiphysis (SCFE). We assessed the outcomes in a consecutive series of thirty Indian adolescents treated by the modified Dunn procedure. MATERIALS AND METHODS: All patients treated by the modified Dunn procedure by a single senior Paediatric Orthopaedic surgeon over six years were retrospectively reviewed. Only moderate and severe slips undergoing modified Dunn procedure were included. Clinical records and radiographs were reviewed to obtain demographic information; to classify the slips by duration of symptoms, severity and physeal stability; and to assess the outcomes by Harris Hip Score, radiological changes and rate of complications. RESULTS: Thirty consecutive hips with 19 stable and 11 unstable slips were included. Mean age was 13.05 years, 25 boys and 5 girls; six were acute slips, six chronic and eighteen acute-on-chronic. There were 20 moderate and 10 severe slips. Slip angle correction was on average 43.63° ± 8.42° (p < 0.001). At a mean follow-up of 25.36 months, the slip angle averaged 9.9° ± 3.78°, and alpha angle was 33.63° ± 4.14. The average Harris Hip Score was 81.833 ± 7.12 points, with six excellent, 17 good, six fair and one poor result. Osteonecrosis occurred in two hips (6.6%). One hip had post-operative subluxation which was corrected. CONCLUSION: This study adds to the evidence that the modified Dunn procedure is safe, reliable and reproducible. It should be the first choice for the treatment of moderate and severe SCFE.

Swaddling Practices in an Indian Institution: Are they Hip-Safe? A Survey of Paediatricians, Nurses and Caregivers.

PURPOSE: Traditional infant swaddling or binding with hips and knees extended is a known risk factor for Developmental Dysplasia of the Hip (DDH), while 'hip-safe swaddling' with hips and knees flexed is believed to eliminate this risk. We conducted a survey to determine the prevalent practices for infant swaddling in India; why mothers practice swaddling and who teaches them; and whether Paediatricians, nurses and caregivers are aware of hip-safe swaddling. METHODS: Anonymous one-time surveys were conducted in three groups-Paediatricians, Nurses and caregivers - at a tertiary-care, urban based, paediatric and maternity hospital. RESULTS: Forty-five paediatricians, 219 nurses and 100 caregivers were surveyed. Ninety percent caregivers practiced traditional swaddling, for on average 10.2 hours a day, starting soon after birth, up to 4.2 months of life. Traditional swaddling was advocated by 99% nurses and 53% Paediatricians. Reasons for swaddling included sleep, warmth and the misbelief that the child's legs would remain bowed if not bound straight; contrarily few mothers (8%) avoided swaddling out of superstition. Mothers learnt swaddling mainly from relatives (94%) and nurses (64%). Most nurses (70%) had learnt the practice during nursing training. Only 6.6% Paediatricians, 4% caregivers and 0% nurses were aware of 'hip-safe swaddling'. CONCLUSION: Traditional swaddling of infants is a practice deeply rooted in India, born out of misbeliefs, and propagated by lack of awareness. Training in hip-safe swaddling targeted at nurses and Paediatricians would be an effective initial step in creating awareness among mothers and changing their practices.

Lengthening After Nonvascularized Fibula Grafting for Large Postinfective Bone Defect: A Case Report with Long Follow-up.

CASE: We describe a case of lengthening of the tibial regenerate after nonvascularized fibula grafting, for postinfective tibial gap nonunion in a child. A large tibial defect secondary to osteomyelitis in a 10-month-old boy was reconstructed using a 5-cm fibula autograft. Concomitant distal tibial physeal arrest led to progressive shortening. Distraction osteogenesis was performed, through the grafted segment, on 2 occasions-at the ages of 3.5 and 8 years-to achieve total lengthening of 9 cm and good functional recovery at 11.5 years of age. CONCLUSION: The tibial regenerate after nonvascularized fibula grafting in children has good potential for distraction osteogenesis.

Preparation of cement spacer in treatment of segmental bone defects in children by the induced membrane technique: A technical note.

The Masquelet Induced Membrane Technique (IMT) is one of the tools in the surgeon's armamentarium for the management of segmental bone defects. The first stage of the IMT includes the insertion of a cement spacer, which is typically fashioned by the free-hand technique. We propose a novel technique for preparation of the cement spacer using a split syringe barrel as a mould. This technique produces a uniformly cylindrical spacer with minimum cement spillage, while also minimizing thermal damage to the surrounding soft tissues. It is a simple and cost-effective method that can be adapted for use in any long bone in children.

Lower-Limb Ischemia at Birth Because of Spontaneous Arterial Thrombosis: A Case Report.

CASE: A full-term neonate presented with right lower extremity ischemia at birth because of spontaneous thrombosis of the right common iliac artery. He was initially managed with supportive treatment, anticoagulation, and dressings; however, advanced gangrenous changes precluded salvage of the ischemic limb. A guillotine amputation was performed at day 15 of life, and the stump went on to heal well by secondary intention. CONCLUSION: Thromboembolic events occurring in infancy are well-recognized phenomena; however, it is far rarer to encounter a neonate born with "congenital gangrene". We discuss the etiology, approach to diagnosis, and treatment of this rare but devastating condition.

Tuberculosis of the spine in children - does drug resistance affect surgical outcomes?

BACKGROUND CONTEXT: The emergence of drug resistance has complicated the management of spinal tuberculosis (TB). While it is well known that the medical management of drug-resistant spinal TB is more difficult, the surgical outcomes of the same have not been studied sufficiently, particularly in children. PURPOSE: To analyze the surgical outcomes in a cohort of children treated for spinal TB, and to thus assess whether drug resistant (DR) disease is associated with poorer surgical outcomes. STUDY DESIGN/SETTING: Retrospective observational study. PATIENT SAMPLE: All children diagnosed and treated for tuberculous spondylodiscitis at a single center between January 2014 and June 2017. OUTCOME MEASURES: Surgical outcomes in terms of neurological status and kyphosis angle at final follow-up, and complication rates. METHODS: Radiographic and clinical data of children treated for spinal TB with minimum two-year follow-up were retrospectively analyzed. Data gathered included age, gender, level of spine affected, number of vertebrae involved, neurology (Frankel grade), microbiological reports, duration and type of anti-tuberculous therapy (ATT), details of Orthopaedic management and complications during treatment. In DR cases, the time from presentation to starting of second-line ATT was also assessed. Radiographs were reviewed to note the pre- and post-operative degree of kyphosis as well as the angle at final follow-up. Patients that developed major complications were compared statistically with those that did not. RESULTS: Forty-one consecutive children (mean age 8.5 ± 4.2 years, 20 boys, 21 girls) were treated for spinal TB with a mean follow-up of 31.2 ± 6.4 months. Fifteen were managed conservatively, of which only one had DR-TB. Of the 26 managed surgically, 13 were managed with first-line ATT and 13 required second-line ATT. Of this latter group, eight had microbiologically proven drug resistance, whereas five were switched to second-line therapy presumptively because of failure to show an adequate response to first-line regimen. At last follow-up, all children had completed the prescribed course of ATT and had been declared cured. Neurological improvement was seen in all but one patient; and at last follow-up, 18 children were Frankel E, seven were Frankel D, and one was Frankel B. 1The immediate post-operative Kyphosis angle averaged 24.38° ± 15.21°. However, six children showed a subsequent worsening of kyphosis, and the Kyphosis angle at last follow-up averaged 30.96° ± 23.92°. Five children had major complications requiring revision surgery; complications included wound dehiscence, vertebral collapse, screw pull-out and implant breakage. Significantly higher number of patients in the group with complications had required second-line ATT (p < .05). CONCLUSIONS: In a cohort of children treated surgically for spinal tuberculosis, a higher complication rate, and thus poor surgical outcomes, were found to be associated with drug resistant disease.

Demographic and Practice Variability Amongst Indian Centres in a Multicentre Prospective Observational Study on Developmental Dysplasia of the Hip.

BACKGROUND: Since 2017, five Indian centres have enrolled into the International Hip Dysplasia Registry for prospective collection of data on Developmental Dysplasia of Hip (DDH). AIMS: To assess how baseline patient characteristics and initial treatment modalities differ across these five centres. METHODS: Registry data collected over 3 years were analyzed. Children with DDH that had radiograph-based diagnoses were included. RESULTS: Collectively, there were 234 hips (181 patients), of which 218 had undergone surgery. Overall, median age at presentation was 25.3 months (IQR 16.8-46.0); female/male ratio was 2.6:1 (range 1.46-4.75:1); with 42%, 29%, and 29% unilateral left, bilateral and unilateral right hip dislocations respectively. Most were IHDI grade III and IV dislocations (94%). Closed reduction was performed at all but one centre, at median 15.3 months (IQR 9.6-21.1). Open reduction (OR) as a stand-alone procedure was performed at all centres, at median 20.8 months (IQR 15.4-24.9). Combination of OR with a single osteotomy, femoral (FO) or acetabular (AO), was performed at all centres at median 29.7 months (IQR 22.1-43.5). However, for the same age group, three centres exclusively performed FO, whereas the other two exclusively performed AO. The combination of OR with both FO and AO was used at all centres, at median 53.4 months (IQR 42.1-70.8). CONCLUSIONS: The preliminary findings of this multi-centre study indicate similar patient demographics and diagnoses, but important differences in treatment regimens across the five Indian centres. Comparison of treatment regimens, using the 'centre' as a predictive variable, should allow us to identify protocols that give superior outcomes.

Chondral Shear Fracture of the Capitellum in Adolescents-A Report of Two Late Diagnosed Cases and a Review of Literature.

The chondral shear fracture is a rare sub-type of pediatric capitellum fractures, in which the fractured fragment is almost entirely cartilaginous. Since the fractured fragment is not visible on plain radiographs, these injuries are often missed on initial presentation resulting in delayed diagnosis and poor outcomes. To our knowledge, only eight such cases have been reported in the past. We report the cases of two adolescents with chondral shear fractures of the capitellum, that were initially missed. They both presented to us several months following trauma, with pain and restricted elbow range of motion. They were treated by excision of the intra-articular loose fragment, and one child also required radial head excision due to advanced radio-capitellar arthritis. Both had good outcomes at 1 year follow-up. We provide a review of literature on this injury and emphasize the need for having a high index of suspicion when dealing with elbow trauma in adolescents, so as to avoid missing this rare, but distinct fracture pattern.

Measurement of spinopelvic parameters in healthy adults of Indian origin - A cross sectional study.

BACKGROUND: Restoration of spinopelvic balance during spinal surgery is very important to ensure a good outcome. Many studies have been conducted to define the normal ranges, examining the correlation between these individual parameters and their relation with spinal parameters of thoracic kyphosis and lumbar lordosis. The ranges, specific to individual ethnicities, is very essential to restore the sagittal balance in patients suffering from spinal degenerative conditions. Hence this study aims to define the average ranges of relevant spinopelvic parameters in the adult population of Indian origin. METHODS: A observational cross sectional study was conducted in 130 healthy volunteers in Mumbai without having any spine, hip or pelvis pathology. Spinopelvic parameters like Pelvic Incidence(PI), Sacral Slope(SS) and Pelvic Tilt(PT) were studied and compared between various other similar studies with patients of different ethnicities. The correlation of those parameters with each other was also evaluated. RESULTS: The mean value of PI was 51.50(±6.85°), that of SS was 39.17° (±6.26°) and for PT it was 12.32°(±5.41°). These values were statistically significant between both sexes for PI and PT. The strongest positive correlation among the parameters was between pelvic incidence and sacral slope, with a r-value of 0.668. Comparison of our study with similar studies within the country (Chennai, Delhi and Surat) showed statistically significant differences in PT and SS of all three studies while PI was not significant when compared with the Surat study. CONCLUSION: There appears to be considerable variation of the values of the spinopelvic parameters as determined by various studies due to ethnic variations. Further studies should be done with larger samples and directed towards early detection of individuals at risk of developing degenerative spinal disorders with sagittal imbalance, so that interventions can be made at an earlier stage.

Computed Tomography Scan-Based Morphometric Analysis of Lateral Masses of Atlas Vertebrae in Normal Indian Population.

STUDY DESIGN: A cross-sectional observational study involved the analysis of computed tomography (CT) scan data from 125 Indian subjects of 18 years or older with normal imaging findings. Scans were obtained from patients with head injuries as a part of the screening process along with brain CT scans. PURPOSE: To establish the dimensions of lateral masses of the atlas vertebrae in normal disease-free Indian individuals. OVERVIEW OF LITERATURE: Lateral mass fixation has become the standard of care in fixation of the supra-axial cervical spine. Many studies have investigated the dimensions of lateral masses in cadaveric specimens; however, studies involving the radiological morphometric analysis of the lateral masses of the atlas vertebra in living patients are lacking. METHODS: Subjects underwent craniovertebral junction CT scans during evaluations of head injury. All had normal radiology reports. The CT scans were obtained using a CT Philips Brilliance 64 machine (Philips, Amsterdam, Netherlands) with a slice thickness of 1 mm and then analyzed using Horos software ver. 2.0.2 (Horos Project, Annapolis, MD, USA) on a MacBook. RESULTS: Lateral masses of the atlas vertebrae were found to be larger in males than females and larger on the right than the left side. The angle of permissible medialization was found to be larger on the right side. The analysis of the average dimensions indicated the conventionally described screw positions to be safe. CONCLUSIONS: The present study provides information that may help to establish standard dimensions of lateral masses of the atlas vertebrae among the normal Indian population. We demonstrate that there is no significant difference when compared with the Western population. The results presented here will be of use to clinicians as they may inform preoperative planning for lateral mass fixation surgeries.

Anterior Release and Anterior Reconstruction for a Neglected Osteoporotic Odontoid Fracture.

A 70 years old lady presented to us with history of a fall 3 months prior. She had suffered a type 2 odontoid fracture with atlantoaxial dislocation, that was not reducible by traction. She had symptoms of neck pain with inability to hold the neck upright. The patient was subsequently planned for anterior release and reduction of odontoid fracture dislocation with posterior stabilization in the same sitting. The patient was treated with cervical skeletal traction and immobilized. However, she developed occipital sore during the period and was mobilized with brace after which she developed myelopathic symptoms and gait disturbance due to the collapse of fracture segment. The patient was planned for anterior release and fixation with contoured reconstruction plate fixing C1 lateral mass to the lateral mass on the right side and C1 lateral mass to C2 body on the left side primarily with distraction of the C1-C2 joint by autologous tricortical iliac bone graft. The posterior stabilization was planned after healing of the sore, and the patient was counseled for the same. However, the patient was lost on follow-up and returned at 3-month postoperative period with collapse of the graft, resubluxation of C1-C2 segment, and failure of anterior fixation. The standard modality of treatment for such cases includes an anterior release of contracted soft tissues and ligaments and posterior stabilization with fusion in a single setting. However, it is the posterior fixation that stabilizes the fracture and prevents it from redislocation. Anterior fixation as a stand-alone treatment in osteoporotic bone has high risks of failure due to severe posterior tensile stresses. This article describes the importance of posterior fixation in osteoporotic bone based on our experience.