Implants removal in children: results of a survey among Italian orthopaedic surgeons.

In the treatment of paediatric limb disorders, the use of metal implants has been increasing over the last decades. Recent studies have addressed the decision of orthopaedic surgeons regarding the removal of implants after the treatment of fracture, and there is a growing consensus within the scientific community supporting the choice of not removing implants in children. This survey aimed to investigate the rationale behind the Italian orthopaedic community's decision regarding metal implant removal in paediatric patients. An electronic questionnaire was sent to all members of the Italian Paediatric Orthopaedic and Traumatology Society, Italian Orthopaedic and Traumatology Society, Italian Club of Osteosynthesis, and South Italy Society of Orthopaedic and Traumatology. The survey comprised 34 questions about hardware removal after the treatment of long bone fractures, epiphyseal growth plate injuries, slipped capital femoral epiphysis (SCFE), and flat foot. Of the 3500 orthopaedic surgeons who received the questionnaire, 5.5% responded. The leading indications for implant removal were the patient's intolerance, pain, ROM limitations, and hardware breakage. Removal of elastic nails for long bone fractures, cannulated screws for growth plate injuries, and SCFE and screws for arthroereisis for flat foot correction were analysed in detail. The consensus among Italian Orthopaedic Surgeons is to remove elastic nails and cannulated screws in cases of pain, intolerance, or breakage and to reduce further risks during patient growth. An increasing number of physicians, however, are endorsing and advocating the growing trend in the literature of not routinely removing the hardware.

Resilience Against COVID-19: How Italy Faced the Pandemic in Pediatric Orthopedics and Traumatology.

BACKGROUND: We aimed to investigate the variation of medical and surgical activities in pediatric orthopedics in Italy, during the year of the COVID-19 pandemic, in comparison with data from the previous two years. The differences among the first wave, phase 2 and second wave were also analyzed. METHODS: We conducted a retrospective multicenter study regarding the clinical and surgical activities in pediatric orthopedics during the pandemic and pre-pandemic period. The hospital databases of seven tertiary referral centers for pediatric orthopedics and traumatology were queried for events regarding pediatric orthopedic patients from 1 March 2018 to 28 February 2021. Surgical procedures were classified according to the "SITOP Priority Panel". An additional classification in "high-priority" and "low-priority" surgery was also applied. RESULTS: Overall, in 2020, we observed a significant drop in surgical volumes compared to the previous two years. The decrease was different across the different classes of priority, with "high-priority" surgery being less influenced. The decrease in emergency department visits was almost three-fold greater than the decrease in trauma surgery. During the second wave, a lower decline in surgical interventions and a noticeable resumption of "low-priority" surgery and outpatient visits were observed. CONCLUSION: Our study represents the first nationwide survey quantifying the impact of the COVID-19 pandemic on pediatric orthopedics and traumatology during the first and second wave.

Diagnostic and infection control strategies for Clostridioides difficile infections in a setting of high antimicrobial resistance prevalence.

Clostridioides difficile (CD) is a major nosocomial pathogen and the leading cause of antibiotic-associated diarrhoea. In light of the strong association between antimicrobial use and CD infections (CDI), it may be hypothesised that areas at higher prevalence of antimicrobial resistance, like the region of Campania in southern Italy, could also have a higher rate of CDI. In this multicentre, region-based, prospective study, we analysed such issues, exploiting CDI incidence data collected from local hospitals. In 2016, the Italian National Centre for Disease Control supported a project involving three Italian regions: Friuli Venezia Giulia, Lazio and Campania. In Campania, a network of 49 hospitals willing to participate in the project was created. The project consisted of two phases: a survey on practice patterns concerning CDI and an epidemiological surveillance study. We identified a stringent need to improve awareness about CDI among the regional health-care community, as a widespread lack of surveillance programmes for CDI control was observed (existing in only 40% of participating facilities). Moreover, almost half of the participating hospitals (n=16, 43%) had no standardised procedures or protocols to control and prevent CDI. In the second phase of the study, we collected data of CDI cases during a six-month surveillance programme. In all, 87 CDI cases were observed, for a total of 903,334 patient bed-days and 122,988 admissions. According to the above data, CDI incidence was 0.96 cases/10000 patient bed-days, much lower than expected based on prior studies conducted elsewhere. The results of our study suggest CDI remains a rather neglected clinical issue in Campania. Despite a high burden of antimicrobial resistance and antimicrobial use in our geographic setting, we observed a very low incidence of CDI. Such a low incidence could be explained by underdiagnosis, but could also be related to actual diet, the lower patient age or the specific genetic background. However, further studies are warranted to either confirm or rebut the above hypotheses.

Recommendations from the Italian Society of Pediatric Orthopaedics and Traumatology for the management of pediatric orthopaedic patients during the COVID19 pandemic and post-pandemic period in Italy.

The rapid spread of the COVID-19 outbreak in Italy has dramatically impacted the National Healthcare System, causing the sudden congestion of hospitals, especially in Northern Italy, thus imposing drastic restriction of almost all routine medical care. This exceptional adaptation of the Italian National Healthcare System has also been felt by non-frontline settings such as Pediatric Orthopaedic Units, where the limitation or temporary suspension of most routine care activities met with a need to maintain continuity of care and avoid secondary issues due to the delay or suspension of the routine clinical practice. The Italian Society of Pediatric Orthopaedics and Traumatology formulated general and specific recommendations to face the COVID-19 outbreak, aiming to provide essential care for children needing orthopaedic treatments during the pandemic and early post-peak period, ensure safety of children, caregivers and healthcare providers and limit the spread of contagion.

An alternative to plaster cast treatment in a pediatric trauma center using the CAD/CAM technology to manufacture customized three-dimensional-printed orthoses in a totally hospital context: a feasibility study.

The aim of this study is to implement the clinical use of the three-dimensional (3D) design and printing technology in pediatric pathologies requiring immobilization. We describe the manufacturing process of the 3D device in place of the plaster cast usually applied to a child 48/72 h after the access to the Trauma Center Traumatology Hub. This procedure had already been performed at Level II, Trauma Center, Campania Region, Orthopaedic Division of Santobono Children's Hospital, Naples, Italy. The operative phase was performed by two 3D printers and a scanner in the bioengineering laboratory of the hospital's outpatient area. The phase of software elaboration requires close cooperation among physicians and engineers. We decided to use a model with a double-shell design and holes varying in width to ensure complete ventilation and lightness of the device. We chose to treat nondisplaced metaphyseal distal fractures of the radius in 18 patients enrolled from January 2017 to November 2017. The flow chart includes clinical and radiological examinations of every enrolled child, collecting information required by the program and its elaboration by bioengineers, and then transfer of the results to 3D printers. The child, immobilized by a temporary splint, wore his 3D device after 12/24 h. Then, he underwent serial check-ups in which the effectiveness and appropriateness of the treatment were clinically monitored and evaluated using subjective scales: visual analogue scale and patient-rated wrist evaluation. All the fractures consolidated both radiologically and clinically after the treatment, with no complications reported. Only one partial breakage of the device happened because of an accidental fall. The statistical analysis of the visual analogue scale and patient-rated wrist evaluation data shows that children's activities of everyday life improved during the immobilization thanks to this treatment. This first study shows that using a 3D device instead of a traditional plaster cast can be an effective alternative approach in the treatment of pediatric nondisplaced metaphyseal distal radius fractures, with high overall patient satisfaction. We believe that 3D technology could be extended to the treatment of more complex fractures; this will be the subject of our second study.

TEN versus external fixator in the management of pediatric diaphyseal femoral fractures: evaluation of the outcomes.

INTRODUCTION: Over the last 20 years, the incidence of pediatric diaphyseal femoral fractures was increased, due to changes in the children's daily activities. The healing times are different according to the chosen treatment and to other factors such as age, type of fracture, involvement of the soft tissues, and concomitance with other injuries. MATERIALS AND METHODS: From 2000 to 2015, 38 pediatric patients with diaphyseal femoral fractures were surgically treated and enrolled in the study. The average age of the patients was between 3 and 15 years. Twenty-two patients were treated with endomedullary titanium nails (TEN) and the other 16 with external axial fixators. Comparing the two groups, radiographic images were taken to assess the fracture reduction and consolidation. RESULTS: The average follow-up was 14 months. The average time needed to remove the TEN nails was 5 months; while 2.5 months was the time to remove the external fixator. At the final follow-up, there were no differences between two groups in term of significant rotation defects, angulation, growth, and/or nonunion. CONCLUSIONS: This study showed that TENS and external fixation have similar results in term of fracture healing and complication, even if patients treated with TENS are more satisfied.

"Three-in-One minimally invasive approach to surgical treatment of pediatric pathological fractures with wide bone loss through bone cysts: ESIN, curettage and packing with injectable HA bone substitute. A retrospective series of 116 cases.".

INTRODUCTION: The outcome of pathological fracture due to large aggressive benign stage 3 Dormans and Flynn lesions [6] is often unsatisfactory and the rate of recurrence is high. No single technique has been considered safe and successful. Many Authors suggested curettage and bone grafting as the unique effective treatment in cases of large defect but, because of the invasive and complex nature of the operation (it needs a double-step procedure), it is not preferred. The purpose of this study is to examine the effectiveness of a minimally invasive treatment in one step through ESIN, curettage and packing with self-setting calcium phosphate cement. PATIENTS AND METHODS: This is a retrospective study of 116 children admitted at the Division of Pediatric Orthopaedics Surgery of Santobono Children Hospital between 2006 and 2014 with a diagnosis of pathological fracture due to large aggressive ostheolytic benign lesions (stage 3 Dormans and Flynn). The size of bone loss was measured on the AP and ML radiographs and all the cysts with a caudo cranial extension from 5 to 8cm and with a medio lateral extension from 3 to 5cm were included. Mean time follow up 24 months was performed. RESULTS: The three-in-one procedure was applied in all 116 patients. After two years of follow up, 113 patients were classified as healed and just 3 required 3 years to complete heal. No severe life threatening adverse effects or complications associated with the use of ESIN and injectable HA were recorded during the follow up period of 24-36 months. Fracture healing occurred in all cases within 4-6 weeks with adequate periosteal and endosteal callus formation. No second pathological fractures occurred in our series as well as no cysts reoccurred. Patients with humeral localizations showed a more rapid regain of muscular function and reestablishment of a complete range of motion. CONCLUSIONS: The proposed three-in-one procedure has shown to be efficient, cost-effective, associated to high rates of definitive bone healing and low incidence of adverse effects.

Prevalence of overweight in children with bone fractures: a case control study.

BACKGROUND: Children's fractures have been enlisted among orthopaedics complaints of childhood obesity. Unhealthy lifestyle behaviours may contribute to increased risk. This study described the prevalence of overweight/obesity in children and adolescents reporting a recent fracture in relation to gender, dynamic of trauma, and site of fracture. METHODS: Four-hundred-forty-nine children and adolescents with fracture and 130 fracture-free controls were recruited from a large children's hospital. The interaction between overweight and gender, dynamic of trauma, site of fracture was explored. Sports participation, television viewing, and calcium intake were also investigated. RESULTS: Overweight/obesity rate was increased in girls with fracture either at the upper or the lower limb (p= 0.004), while it was increased only in boys with fracture at the lower limb (p <0.02). Overweight/obesity rate did not differ between groups with low or moderate trauma. TV viewing ≥ 2 hrs was more frequent in children with fractures than controls (61.5% vs 34.5%, p =0.015) in the overweight/obese group. CONCLUSIONS: The increased prevalence of overweight/obesity in children with fractures is related to gender and site of fracture. Higher levels of sedentary behaviours characterize overweight children reporting fractures.

Pattern of fractures across pediatric age groups: analysis of individual and lifestyle factors.

BACKGROUND: Knowledge of the epidemiology of children's fractures is essential to develop preventive strategies. The aim of this study was to analyze the individual/lifestyle determinants of fractures across pediatric age groups. METHODS: A cross-sectional study was performed in the first six months of 2008 through questionnaire on a sample of children from an outpatient clinic for pediatric fractures. Differences in gender, anatomic site, circumstances and location of fracture occurrence, behavioural lifestyle, and calcium intake were investigated among three different age classes (pre-school children, school children, and adolescents). RESULTS: The sample consisted of 382 subjects (2-14 years of age) sustaining a fracture after low or moderate trauma. Males were at a higher risk of fractures than females; greater than two-thirds of injuries occurred after low-energy trauma and the upper limb was more frequently involved. With increasing age, the male/female ratio and time spent in sports participation increased (p < 0.001), while calcium intake and time spent in sedentary behaviors decreased (p < 0.001 and < 0.003, respectively). Gender discordance existed in pre-school children with respect to the anatomic location, and in school children and adolescents with respect to the dynamics. In the adolescent group, males were more physically active and also more sedentary than females. Fractures most frequently occurred in homes (41.6%), followed by playgrounds and footpaths (26.2%), sports facilities (18.3%), and educational facilities (13.9%), with gender differences existing only in adolescence. Twenty-three percent of the subjects sustained one or more fractures in the past. The percentage of recurrent fractures increased with age (p = 0.001), with a similar trend in both genders. CONCLUSIONS: Gender differences were shown in the prevalence of injuries, characteristics, and circumstances across ages. These differences may be explained by the related changes in behaviors, together with attending different places. Individual and lifestyle factors can in part explain the variability in the occurrence of fractures and can also address targeted preventive strategies.