A Perspective on Management of Limb Fractures in Obese Children: Is It Time for Dedicated Guidelines?

Limb fractures are the most common injuries in pediatric orthopedics. Early and late complications are often not preventable, even when providing the best treatment; furthermore, these injuries are largely implicated in medico-legal claims. The development of evidence-based guidelines is one of the main goals of medical research. Approved guidelines for diagnosis, treatment, and follow up are fundamental to obtain the best results in medical practice. Guidelines in pediatric traumatology have been developed, even though specific conditions, like obesity, could influence their drafting. The cast and fixation systems usually applied in pediatric fractures provide a growth plate sparing, a satisfying reduction, and good stress resistance, mostly because of a lower bodyweight compared to adults. Several studies suggest that obesity influences the bone quality, the management, and the outcomes in cases of fracture. High body weight increases the risk of trauma, modifies fracture characteristics, and increases the risk of incomplete reduction. Fractures in obese children have a higher rate of complications, regardless of conservative or surgical treatment. In obese children, surgical treatment is often used more frequently than with non-obese children. Such considerations are valid both for lower and upper limb fractures. The aim of this paper is to discuss recent scientific literature and provide a perspective on the benefits of a dedicated approach in the management of obese children. Guideline updates could improve healthcare quality in a pediatric setting, and also reduce medico-legal implications.

Double hindfoot arthrodesis technique for the treatment of severe equino-plano-valgus foot deformity in cerebral palsy: long-term results and radiological evaluation.

The aim of this study was to evaluate the clinical and radiological results of a double arthrodesis technique for the treatment of equino-plano-valgus foot deformity in pediatric patients affected by cerebral palsy. A retrospective evaluation was performed on 175 feet surgically treated with a talonavicular and calcaneocuboid joint fusion technique. The average age at surgery was 14.7 years (range: 12-20 years). Visual analogue scale for pain score, Gross Motor Function Classification System scale, talonavicular angle, Costa-Bertani angle, and Kite's angle on standard weight bearing radiographs were evaluated preoperatively and postoperatively. The mean clinical follow-up was 62.4 months (range: 12-112 months). The mid Gross Motor Function Classification System scale value did not show a significant improvement in any of the subgroups considered. A significant improvement in the visual analogue scale for pain score value was evident 6 months after surgery. Radiological examination showed a statistically significant improvement in the talonavicular angle (average 7.4°) and the Costa-Bertani angle (average 128.5°). Complications occurred in 8.6% of cases. The described surgical technique is safe and efficacious, and could represent a useful option of treatment of equino-plano-valgus severe deformity in cerebral palsy patients older than 12 years of age.

Modified Roux-Goldthwait Procedure for Management of Patellar Dislocation in Skeletally Immature Patients with Down Syndrome.

BACKGROUND: Patellar instability is a common problem in Down syndrome patients since their childhood. Several treatment have been proposed, but relapses are frequent and not all surgeries are suitable for growing patients. The aim of the present study is to evaluate the clinical and radiographic outcomes of a modified Roux-Goldthwait technique, for the management of patellar instability in children with Down syndrome at minimum 5-year followup. MATERIALS AND METHODS: 19 patients (23 knees) affected by Down syndrome surgically treated for patellar dislocation, between 2000 and 2012 were included in this study. The mean age of patients was 9.5 years (range 3.7 - 15 years) and had a Dugdale Grade III, IV, and V patellar dislocation. Trochlear groove dysplasia was present in 15 patients. Each patient was clinically evaluated considering relapse rate, pre- and postoperative range of motion (ROM), Kujala score, and modified Lysholm score. Radiographic examination was performed on standard X-ray considering patellar height, trochlear angle, and patellofemoral congruence angle. RESULTS: The mean followup was 134 months (range 62-206 months). No case of relapse of dislocation was registered with an improved ROM (significant for knee extension, P < 0.05). The Kujala score showed significant improvement from a mean preoperative value of 39 ± 6.3 to a mean postoperative value of 92.7 ± 3.4 (P < 0.05) at final followup such as the modified Lysholm score (from mean preoperative 55.6 ± 6.3 to mean postoperative of 94.2 ± 2.6). Radiographs performed at latest followup showed a tendency to normalization of all the parameters considered, with a restored patellofemoral congruence and trochlear groove shape and without signs of osteoarthritis. CONCLUSION: The present study showed that the Roux-Goldthwait procedure is a valid surgical option for the treatment of patellar dislocation in children with Down syndrome.

Titanium elastic nailing in diaphyseal femoral fractures of children below six years of age.

AIM: To report the clinical and radiographic results of titanium elastic nail (TEN) in diaphyseal femoral fractures of children below age of six years. METHODS: A retrospective analysis of 27 diaphyseal femoral fractures in children younger than six years treated with TEN between 2005 and 2015 was conducted. Patients were immobilized in a cast for 5 wk and the nails were removed from 6 to 12 wk after surgery. Twenty-four cases were clinically and radiographically re-evaluated using the Flynn's scoring criteria, focusing on: Limb length discrepancy, rotational deformity, angulation, hip and knee range of motion (ROM), functional status, complications, and parent's satisfaction. RESULTS: Sixteen males and eight females with a mean age of 3.2 years at the time of treatment were re-evaluated at an average follow-up of 58.9 mo. No cases of delayed union were observed. The mean limb lengthening was 0.3 cm. Four cases experienced limb lengthening greater than 1 cm and always minor than 2 cm. Twelve point five percent of the cases showed an angulation < 10°. Complete functional recovery (hip and knee ROM, ability to run and jump on the operated limb) occurred in 95.7% of cases. Complications included two cases of superficial infection of the TEN entry point, one case of refracture following a new trauma, and one TEN mobilization. According to the Flynn's scoring criteria, excellent results were obtained in 79.2% of patients and satisfactory results in the remaining 20.8%, with an average parent's satisfaction level of 9.1/10. CONCLUSION: TEN is as a safe, mini-invasive and surgeon-friendly technique and, considering specific inclusion criteria, it represents a useful and efficacy option for the treatment of diaphyseal femoral fractures even in patients younger than six years of age.

Infective complications in tumour endoprostheses implanted after pathological fracture of the limbs.

INTRODUCTION: Pathological fractures represent an adverse prognostic factor in primary and metastatic bone tumours. The purpose of this study was to evaluate the results of tumour silver-coated prosthesis implanted after pathological fractures. MATERIALS AND METHODS: A retrospective analysis was conducted on 30 patients with pathological limb fracture after primary or metastatic bone tumours treated by the same surgeon with wide margin resection and tumour prosthesis implant between 2005 and 2015. Silver-coated prostheses were implanted in 17 patients and uncoated prostheses were implanted in 13 patients. The primary outcome of the study was to evaluate the infective risk, the secondary outcomes were survival and functional level (visual analogue scale [VAS], 36-Item Short Form Health Survey [SF 36], and Musculoskeletal Tumour Society [MSTS] score) obtained at the longest follow-up available. A multivariate analysis was performed considering age, sex, tumour histology, grading and location, resection size, concomitant radiotherapy/chemotherapy, use of mesh for soft tissue reconstruction and local complications (dislocation, relapse, implant breakage). Scanning electron microscopy (SEM) analysis of explanted prosthesis was performed to study the residual silver-coating. RESULTS: The average age of patients in the study was 56.2 years (range 12-78 years). Silver-coated prostheses were implanted in 56.7% of patients, and uncoated tumour prostheses were used in the remaining 43.3%. The mean follow-up was 40.7 months. A total of 26.7% of patients died at a median time of 28.6 months after surgery. The overall rate of complications was 30%, with 16.7% due to infection. A total of 11.8% of the patients treated with silver-coated implants developed infection compared with 23.1% of the patients treated with uncoated tumour prostheses. There were no cases of early infection in the silver-coated prosthesis group, whereas early infection occurred in 66.7% of patients in the uncoated prosthesis group. All the functional outcomes were significantly improved after surgery. None of the other parameters analysed can be considered a significant negative prognostic factor for infection. The SEM analyses showed severe silver-coating degradation 2 years after first implant. No case of silver toxicity was demonstrated. DISCUSSION: There are few papers in the literature about infective complications in tumour prosthesis after pathological fracture. Silver-coated implants showed a protective action against early infection. Late infection rate was similar between the groups, thereby indicating a reduction of antimicrobial activity for the silver-coating over time. CONCLUSIONS: Silver-coated prostheses are a protective factor against early infections in limb salvage surgery after pathological fractures, so may represent the first-choice of implants in this type of surgery.

Intraspinal extradural benign fibrous histiocytoma of the lumbar spine in a pediatric patient. Case report and literature review.

INTRODUCTION: Benign fibrous histiocytoma (BFH) is a rare skeletal tumor. Spinal localizations have been previously described in 17 cases, and this is the first report of BFH occurring at the lumbar spine in a pediatric patient. CASE REPORT: A 13-year-old male complained lower limb motor and sensory impairment with severe claudication and urination disorders. A huge intraspinal, extradural mass at L4-L5 level, clearly evident on a preoperative MRI, caused dislocation and severe compression of the cauda equina nerve roots. After a biopsy, confirming BFH, a tumor resection and L4-S1 vertebral arthrodesis was carried out. At 1 year follow-up, no recurrence was detached on postoperative MRI, with complete neurological recovery. DISCUSSION AND CONCLUSION: Review of the literature is discussed. Histological examination is mandatory for a correct diagnosis and plan of treatment. None of the pediatric patients treated for BFH have ever shown local relapse.

Prognostic factors influencing the outcome of rotator cuff repair: a systematic review.

PURPOSE: To identify prognostic factors significantly associated with rotator cuff repair outcome and define the strength of these associations. METHODS: Search was performed using electronic databases. Studies reporting prognostic factors affecting rotator cuff repair outcome were included. Primary outcomes were: structural integrity, Disabilities of the Arm, Shoulder and Hand score, American Shoulder and Elbow Surgeons score, and Constant score. Each other outcome was considered as secondary outcome. Descriptive statistics was used. When possible, meta-analyses were performed. Methodological quality was assessed using the Quality In Prognosis Studies Tool. A best evidence synthesis was performed using the Grading of Recommendations Assessment, Development and Evaluation framework adapted to prognostic studies. RESULTS: Sixty-four studies were included. Methodological quality was high only for twelve studies. The overall quality of evidence was low to very low. Meta-analyses were possible only for seven studies. Older age and larger tears size were found to affect retear risk. Results were controversial for fatty infiltration, acromioclavicular joint or biceps procedures, acromiohumeral distance, delamination of tendon edges, musculotendinous junction position, number of tendons involved, and tendon length, quality and retraction. Baseline scores and workers compensation claim predicted functional outcomes. Subjective outcome was also affected by patient's expectations. CONCLUSIONS: Despite the large number of outcomes and prognostic factors evaluated by a relative small number of studies, almost not prognostic in design, it was not possible to reach any definitive conclusion regarding the most relevant predictors of outcome of rotator cuff repair. Moreover, the low methodological quality of the included studies and, subsequently, the low quality of evidence, seriously affected the strength of recommendation of the present review. Based on data available, retear risk is mainly affected by older age and larger tears size. Baseline scores and work compensation claim are the most significant predictors for functional outcomes. LEVEL OF EVIDENCE: Systematic review of level I-IV prognostic studies, Level IV.

Surgical versus conservative treatment of primary patellar dislocation. A systematic review and meta-analysis.

PURPOSE: The purpose of this study was to determine the efficacy of surgical and conservative treatment in the prevention of recurrence after primary patellar dislocation. METHODS: Studies were searched on MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials and CINHAL from their inception to April 2015. All randomized controlled clinical trials comparing surgical versus conservative treatment after first patellar dislocation were included. Primary outcomes were: recurrent dislocation, subluxation, overall instability and subsequent surgery. Secondary outcomes included imaging, and subjective and objective clinical assessment tools. Methodological quality of the studies was assessed using Cochrane Collaboration's "Risk of Bias" tool. Pooled analyses were reported as risk ratio (RR) using a random effects model. Continuous data were reported as standardized mean difference (SMD) and 95 % confidence intervals (CIs). Heterogeneity was assessed using I². RESULTS: Nine studies were included in the meta-analyses. Methodological quality of the studies was moderate to low. Meta-analyses showed that surgical treatment significantly reduces the redislocation rate (RR = 0.62; 95% CI = 0.39, 0.98, p = 0.04) and provides better results on Hughston VAS score (SMD = -0.32; 95% CI = -0.61, -0.03; p = 0.03) and running (OR = -0.52; 95% CI = 0.31, 0.88; p = 0.01). Conservative treatment showed less occurrence of minor complications (OR = 3.46; 95% CI = 2.08, 5.77; p = 0.01) and better results in the figure-of-8 run test (SMD = 0.42; 95% CI = 0.06, 0.77; p = 0.02) and in the squat down test (SMD = -0.45; 95% CI = -0.81, -0.10; p < 0.00001). No other significant differences could be found. CONCLUSIONS: Based on the available data, surgical treatment of primary patella dislocation significantly reduces the risk of patella redislocation.

Efficacy of intra-articular hyaluronic acid injections and exercise-based rehabilitation programme, administered as isolated or integrated therapeutic regimens for the treatment of knee osteoarthritis.

PURPOSE: To assess the efficacy of intra-articular hyaluronic acid (HA) injections and exercise-based rehabilitation (EBR) programme, administered as isolated or integrated for the treatment of knee osteoarthritis. METHODS: One hundred sixty-five patients affected by moderate degrees of knee OA were randomly divided into three groups. Group 1 (HA) underwent three HA injections (one every 2 weeks); group 2 (EBR) underwent 20 treatment sessions in a month of an individualized programme; and group 3 (HA + EBR) received both treatments simultaneously. Primary outcome was the Italian version of the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index; secondary outcome was the evaluation of active range of movement (AROM). All patients were evaluated before and 1, 3 and 6 months after treatment. Significance was set at p < 0.05. RESULTS: Two patients in each group were lost to follow-up. No adverse events occurred. All groups experienced improvements at 1-month follow-up. No further improvements could be detected within groups over time. At 1-month follow-up, WOMAC pain subscale showed significant improvement in group 3 compared to group 1 (p = 0.043). WOMAC pain, stiffness and function subscales showed that group 2 significantly worsened between 1 and 6 months after treatment (p = 0.004, p = 0.026 and p = 0.025, respectively). AROM revealed no significant differences between and within groups over time. CONCLUSIONS: Intra-articular HA injections and individualized rehabilitation programmes administered in isolation or in combination are effective in improving knee function and pain relief. The combined treatment showed the greatest pain relief at 1-month follow-up compared to either in isolation. Compared to the previous studies, this is the first study, which proposed an EBR programme tailored to the compartment of the knee joint most involved in the degenerative process. LEVEL OF EVIDENCE: I.