Good short-term results following arthroscopic deepening trochleoplasty combined with medial patellofemoral ligament reconstruction: surgical technique and outcomes.

PURPOSE: To report short-term results and clinical outcomes of arthroscopic deepening trochleoplasty combined with medial patellofemoral ligament (MPFL) reconstruction utilizing standard arthroscopic instruments in patients of recurrent patellar dislocation and trochlear dysplasia. METHODS: This is a case series of 13 patients between the ages of 14 and 20 years who presented with recurrent patellar dislocation and severe trochlear dysplasia (Dejour grade D). They were treated surgically using an arthroscopic technique from February 2017 to January 2019 and were followed for 18 months. Patients were assessed preoperatively and postoperatively (at 6, 12, and 18 months) with clinical scores (Tegner Activity Score, Lysholm Knee Score, and Kujala Score). RESULTS: There were 69.2% females, and the mean age was 16.4 â€‹± â€‹2.0 years. There were statistically significant improvements in the mean Lysholm and Kujala scores when comparing pre-operative and post-operative scores at every follow-up landmark (p â€‹< â€‹0.05). Comparing the preoperative and 18-month postoperative scores-the Lysholm score improved from 68.2 â€‹± â€‹10.3 to 98.7 â€‹± â€‹2.1 (p â€‹< â€‹0.001), and the Kujala score improved from 50.3 â€‹± â€‹12.0 to 95.4 â€‹± â€‹4.8 (p â€‹< â€‹0.001). Five patients were able to achieve premorbid Tegner activity levels at 12 months, with an additional 5 patients achieving the same premorbid Tegner activity at the 18-month mark. The remaining 3 patients were able to attain >90% of their activity level at 18 months' follow-up. No complications were observed during the follow-up period. CONCLUSIONS: This proposed arthroscopic deepening trochleoplasty technique combined with MPFL reconstruction has demonstrated excellent and reproducible early clinical outcomes. LEVEL OF EVIDENCE: IV.

A pilot study on the "ScoliBrace" in the treatment of adolescent idiopathic scoliosis.

PURPOSE: Bracing for adolescents with idiopathic scoliosis (AIS) is a treatment option to prevent curve progression to surgical level. This study aimed to assess the efficacy of a 3D fully customized over corrective brace, "ScoliBrace," an orthosis treatment for AIS. METHODS: This was a prospective pilot study of AIS female patients with inclusion criteria followed recommended Scoliosis Research Society (SRS) Guidelines. Cobb angles measured at: baseline (T0), 21 months (T5-2), skeletal maturity (T6), 6 months post-brace (T7), along with hours of brace wear using a thermal sensor and health-related quality of life (HRQoL) using the SRS-22r questionnaire. RESULTS: A total of 30 female AIS patients with mean age 11.85 ± 0.68 years, predominantly Risser 0 (70%), and median Cobb angle 29° were recruited; 21 patients were included for the final analysis. Results showed significant difference in Cobb angle between T0 and T5-2 (median = 22.5° vs. 28.5°, p = 0.0082). 57.14% had reduction in Cobb angle by ≥ 5° at skeletal maturity. Cobb angle reduced 0.794° for each additional hour of dosage (p = 0.036, 95% CI = - 1.532°, - 0.056°). Although pain level was increased at T6 (4.37 ± 0.51vs.4.70 ± 0.41, p = 0.014), patients reported significantly greater satisfaction with management of their condition (3.90 ± 0.90vs.3.29 ± 0.88, p = 0.020). CONCLUSION: Results show similar findings to the BRAIST study, whereby curves remained under surgical threshold and showed improvement. More than half had curve reduction of ≥ 5° at skeletal maturity. Increased dose was also associated with improved outcomes. Using "ScoliBrace" as a non-surgical treatment, maintained curves below surgical threshold and showed curve reduction, improving patient satisfaction with management.

Can the Lower Extremity Functional Scale Be Used in Children and Adolescents? A Validation Study.

BACKGROUND: The lower extremity functional scale (LEFS) is a patient-reported outcome measure for assessment of lower extremity function. It has been validated in adults but not in children or adolescents. METHODS: Patients 8 to 18 years of age who were treated for a lower limb fracture, injury, or other conditions were invited to join the study. LEFS and Pediatric Quality of Life Inventory 4.0 Generic Core Scales (PedsQL) were administered. Reliability and validity of the LEFS were determined for the entire cohort and for 2 age groups (children: 8 to 12 years; adolescents 13 to 18 years) using PedsQL as comparison. RESULTS: A total of 178 patients were recruited into this study. In the entire cohort, internal consistency of LEFS was excellent (0. 972) with acceptable floor (0%) and ceiling (12%) effects. Correlation between LEFS and PedsQL physical functioning component was high ( r =0.859). Construct validity was acceptable, with all 8 hypotheses demonstrating statistical significance. Factor analysis showed that item 15 (sitting for 1 hour) may contribute to measurement error in the pediatric population. Results remained similar when comparing the 2 age groups. CONCLUSIONS: The LEFS is overall an acceptable patient-reported outcome assessment of children and adolescents with various lower limbs disorders. LEVEL OF EVIDENCE: Level II.

Improved Comfortability and Satisfaction of Hybrid-mesh Casts in the Conservative Management of Pediatric Supracondylar Humeral Fractures: A Randomized Controlled Trial.

BACKGROUND: Cast immobilization is the mainstay of treatment for stable pediatric supracondylar humeral fractures (SCHFs). In recent years, a waterproof and breathable hybrid-mesh (HM) cast has emerged and been marketed to address common complaints such as itch, skin irritation, and malodor. Hence, this randomized controlled trial seeks to assess the overall satisfaction, comfort, and clinical outcomes of using HM casts in the conservative treatment of stable pediatric SCHF. METHODS: Seventy-nine patients (age range: 1 to 10 y) with modified Gartland's classification Type I and Type IIa SCHF were recruited and randomized for immobilization with either fiberglass or HM long-arm cast for 3 weeks. During follow-up visits, patients were assessed for any loss of reduction and skin rash. The weight of casts, the presence of cast breakage, the duration of cast application, and removal were recorded. A self-reported patient comfort and satisfaction questionnaire was also administered during the same visit. RESULTS: The final analysis included 38 patients immobilized with fiberglass casts and 39 patients with HM casts. Despite the significantly longer duration required for HM cast removal (4.18±1.25 min vs. 2.25±0.55 min, P <0.001), the HM cast was significantly lighter than its fiberglass counterpart (162.82±23.94 g vs. 203.95±36.52 g, P <0.001). The HM casts have better comfort (4.05±0.887 vs. 3.47±0.951, P =0.007) and satisfaction (3.69±1.055 vs. 3.11±0.953, P =0.012) scores as compared to fiberglass casts for immobilizing pediatric SCHF without compromising clinical outcome. CONCLUSIONS: HM casts have better comfort and overall satisfaction as compared to conventional fiberglass casts for immobilizing pediatric SCHF without compromising clinical outcomes. LEVEL OF EVIDENCE: Level II-therapeutic studies-investigating the results of treatment.

The machine-vision image guided surgery system reduces fluoroscopy time, ionizing radiation and intraoperative blood loss in posterior spinal fusion for scoliosis.

PURPOSE: To determine if the novel 3D Machine-Vision Image Guided Surgery (MvIGS) (FLASH™) system can reduce intraoperative radiation exposure, while improving surgical outcomes when compared to 2D fluoroscopic navigation. METHODS: Clinical and radiographic records of 128 patients (≤ 18 years of age) who underwent posterior spinal fusion (PSF), utilising either MvIGS or 2D fluoroscopy, for severe idiopathic scoliosis were retrospectively reviewed. Operative time was analysed using the cumulative sum (CUSUM) method to evaluate the learning curve for MvIGS. RESULTS: Between 2017 and 2021, 64 patients underwent PSF using pedicle screws with 2D fluoroscopy and another 64 with the MvIGS. Age, gender, BMI, and scoliosis aetiology were comparable between the two groups. The CUSUM method estimated that the MvIGS learning curve with respect to operative time was 9 cases. This curve consisted of 2 phases: Phase 1 comprises the first 9 cases and Phase 2 the remaining 55 cases. Compared to 2D fluoroscopy, MvIGS reduced intraoperative fluoroscopy time, radiation exposure, estimated blood loss and length of stay by 53%, 62% 44%, and 21% respectively. Scoliosis curve correction was 4% higher in the MvIGS group, without any increase in operative time. CONCLUSION: MvIGS for screw insertion in PSF contributed to a significant reduction in intraoperative radiation exposure and fluoroscopy time, as well as blood loss and length of stay. The real-time feedback and ability to visualize the pedicle in 3D with MvIGS enabled greater curve correction without increasing the operative time.

Aspects of Patient Experience Associated With Improved Scoliosis Research Society-22 Revised (SRS-22R) and European Quality of Life Five-Dimension Five-Level (EQ-5D-5L) Scores in Patients With Adolescent Idiopathic Scoliosis Managed With Observation or Bracing.

STUDY DESIGN: Prospective cohort study. OBJECTIVE: The purpose of this study was to evaluate the relationship between patient-reported experience measures (PREMs) and patient-reported outcome measures (PROMs) in adolescent idiopathic scoliosis (AIS) managed nonsurgically with bracing or observation. SUMMARY OF BACKGROUND DATA: PREMs and PROMs are increasingly used to assess the effectiveness of patient-centered health care provision. To date, no study has attempted to study the relationship between PREMs and PROMs in AIS. METHODS: All patients who visited our one-stop, tertiary center for AIS between 2020 and 2021, were asked to complete pairs of PREMs and PROMs questionnaires. PREMs were evaluated using our institution's outpatient experience survey adapted from Hospital Consumer Assessment of Healthcare Providers and Systems survey. PROMs were determined via the Scoliosis Research Society-22 revised (SRS-22r) and European Quality of Life Five-Dimension Five-Level (EQ-5D-5L) forms. RESULTS: In total, we included 730 patients who completed pairs of PREMs and PROMs questionnaires. 451 patients were treated by observation and 279 were braced. In the observation group, there was no association between patient experience and SRS-22r or EQ-5D-5L scores. In the brace group, improved SRS-22r were associated with higher PREM scores. In particular, having confidence and trust in treating physicians ( r =0.34), reporting that their worries and concerns were addressed during treatment ( r =0.34) and being taught self-care ( r =0.33, P <0.0001 for all) were most highly correlated with better SRS-22r scores. CONCLUSIONS: In patients with AIS treated with bracing, improved patient experience was positively correlated with better patient reported outcomes, especially if patients' concerns were addressed during treatment and they received supportive care and education on self-care. In contrast, patient experience did not correlate with PROMs in children and adolescents with AIS who were under observation.

Osteomyelitis in Immunocompromised children and neonates, a case series.

BACKGROUND: Osteomyelitis in immunocompromised children can present differently from immunocompetent children and can cause devastating sequelae if treated inadequately. We aim to review the aetiology, clinical profile, treatment and outcomes of immunocompromised children with osteomyelitis. METHODS: Retrospective review of all immunocompromised children aged < 16 years and neonates admitted with osteomyelitis in our hospital between January 2000 and January 2017, and referred to the Paediatric Infectious Disease Service. RESULTS: Fourteen patients were identified. There were 10 boys (71%), and the median age at admission was 70.5 months (inter-quartile range: 12.3-135.0 months). Causal organisms included, two were Staphylococcus aureus, two were Mycobacterium bovis (BCG), and one each was Mycobacterium tuberculosis, Pseudomonas aeruginosa, Stenotrophomonas maltophilia, Burkholderia pseudomallei and Rhizopus sp. One patient had both Clostridium tertium and Clostridium difficile isolated. Treatment involved appropriate antimicrobials for a duration ranging from 6 weeks to 1 year, and surgery in 11 patients (79%). Wherever possible, the patients received treatment for their underlying immunodeficiency. For outcomes, only three patients (21%) recovered completely. Five patients (36%) had poor bone growth, one patient had recurrent discharge from the bone and one patient had palliative care for underlying osteosarcoma. CONCLUSIONS: Although uncommon, osteomyelitis in immunocompromised children and neonates can be caused by unusual pathogens, and can occur with devastating effects. Treatment involves prolonged administration of antibiotics and surgery. Immune recovery also seems to be an important factor in bone healing.

Magnetically Controlled Growing Rods: Influence on Intraoperative Fluoroscopic Imaging: A Case Report.

CASE: A 7-year-old boy with severe congenital scoliosis and impending thoracic insufficiency syndrome underwent uneventful single magnetically controlled growing rod (MCGR) insertion and removal of his ipsilateral rib-based distraction implants at our institution. Intraoperative fluoroscopy imaging revealed an artifactual bend (S-distortion) of the rod actuator after placement. This artifact was eliminated by moving the image intensifier further from the patient. CONCLUSION: We attributed the S-distortion to influences of magnetic fields within the MCGR actuator onto the image intensifier. Surgeons should be aware of such implications which can lead to misleading imaging artifacts. This is a first reported case of such incident with MCGR.

Retained foreign objects in casts in children.

Cast immobilization is a noninvasive and effective option in the treatment of fractures in children. However, its use can be associated with complications, such as pressure sores, skin infections, thermal injuries, and joint stiffness. In clinical practice, retained foreign objects in casts are not uncommon. This study aims to ascertain reasons for foreign objects being retained in casts and their effects on the skin. Eighteen children with retained foreign objects in their casts were identified and interviewed. Patient demographics, type of fracture and cast applied, nature of foreign body, and medical complications caused directly by the foreign object were also recorded for analysis. The foreign objects retained included coins, stationery, toy parts, cutlery, and hygiene items. The most common reason for their retention was to relieve itch, followed by accidental insertion and deliberate play. More than half of the children did not suffer complications, and the rest were all skin complications, with the most severe one being an infected skin ulcer that required oral antibiotics. Although the complications of retained foreign bodies are limited to the skin, they can worsen with delayed treatment. Cast care and itch reduction advice must be clearly communicated to patients and their caregivers. Foreign objects in casts must be emergently removed. Level of Evidence: Level 4 Evidence.

The utility of mini C-arm in the fixation of unstable paediatric supracondylar humeral fractures.

BACKGROUND: Pediatric supracondylar humerus fractures have traditionally been reduced and fixed with conventional C-arm (CCA) fluoroscopy guidance. With the increase in popularity of the newer mini C-arm (MCA) system within other fields of surgery due to its ease of use and lower radiation emission, the same adoption should be explored in pediatric orthopedic surgeries. The purpose of this study is to compare the MCA and CCA primarily in reduction and fixation outcomes and secondarily in other perioperative parameters. METHODS: Retrospective analysis of 193 patients who underwent surgical fixation for displaced supracondylar humerus fractures. 44 and 149 cases were performed with the MCA and CCA respectively. Baumann's angle and the intersection of anterior humeral line (AHL) were assessed on postoperative anterior posterior and lateral radiographs and adequate reduction was defined by an angle between 64 and 81˚, and AHL intersecting middle third of the capitellum. Surgical time, fluoroscopy duration, number of images and radiation exposure were obtained from the surgical notes. RESULTS: Amongst the CCA cases, there were greater satisfactory coronal plane reduction (p < 0.05), while no difference in sagittal plane accuracy (p > 0.05) was seen. In MCA group, longer surgical (p < 0.05) and fluoroscopy times (p < 0.05), and greater number of shots (p < 0.05) was noted. However overall radiation exposure in the MCA group was still lower (p < 0.05). CONCLUSION: The MCA system is potentially less accurate in coronal plane reduction and more challenging to use. However, pitfalls can easily be avoided. Usage should be advocated as overall radiation exposure can be reduced. LEVEL OF EVIDENCE: Level III retrospective comparative study.

A novel Ser40Trp variant in IFITM5 in a family with osteogenesis imperfecta and review of the literature.

Osteogenesis imperfecta, is a genetically and clinically heterogeneous connective tissue disorder that disrupts bone architecture, making it fragile and more prone to fractures. While more than 85% of cases are due to variants in COL1A1 and COL1A2, variants in noncollagen genes have been identified in the remaining cases. The recurring heterozygous variant in IFITM5 (c.-14C>T) leads to osteogenesis imperfecta type V, a second missense variant in IFITM5 (c.119C>T, p.Ser40Leu) leads to phenotype resembling osteogenesis imperfecta type VI. In this report, we describe the first patient with Ser40Trp variant in IFITM5, who presented with multiple fractures in the prenatal period. She remained fracture free after birth (except for trauma-related fractures during puberty) with normal bone mineral densitometry. Her mother, who did not have a history of fracture, was noted to have somatogonadal mosaicism for this variant and became pregnant with a second child with multiple prenatal fractures, found to have the same variant. To our knowledge, this is the first case of somatogonadal mosaicism in IFITM5. In addition, we have summarized the literature on patients presenting with variant in codon 40 (serine) of IFTIM5 protein.

Ingrowing toenails in children and adolescents: is nail avulsion superior to nonoperative treatment?

INTRODUCTION: Ingrowing toenail (IGTN) or onychocryptosis is not uncommon in children and adolescents. However, there is a dearth of evidence in the literature on the management of IGTN in this age group. This study aimed to compare the results of nonoperative treatment for IGTN with that of operative treatment among children and adolescents. METHODS: All children and adolescents who were treated for IGTN at our institution between 2010 and 2014 were included for this retrospective study. Demographic data, treatment prescribed and outcome at six months after presentation were analysed. RESULTS: Overall, 199 patients were recruited. There were 123 (61.8%) boys and 76 (38.2%) girls. Median age was 14 years. Among 199 toes, 162 (81.4%) were treated nonoperatively, with nail care advice, topical antibiotics and daily cleansing. Only 37 (18.6%) toes were treated operatively. In the operative group, 23 (62.2%) patients underwent wedge resections, while the remaining 14 (37.8%) had total nail avulsions; for all patients, germinal matrices were preserved. At the six-month follow-up, there were 5 (3.1%) cases of recurrence in the nonoperative group when compared to 3 (8.1%) recurrences in the operative group. CONCLUSION: We recommend that IGTN in children and adolescents be treated in the first instance by nonoperative methods. Operative options can be considered for resistant cases or in case of recurrence of IGTN.

Cast immobilisation for the treatment of paediatric distal radius fracture: fibreglass versus polyolefin.

INTRODUCTION: Stable distal radius fractures in children are frequently treated by immobilisation with a cast and heal readily without complications. This randomised clinical trial aimed to assess patient satisfaction and casting-related clinical outcomes when using polyolefin cast, a new cast material, compared to the conventional fibreglass cast. METHODS: A total of 80 patients (age range 7-16 years) with radiograph-confirmed stable distal radius fractures were recruited. They were randomised to either the fibreglass group or polyolefin group, with short arm cast immobilisation for 20-30 days. After cast removal, the incidence of skin rash, growth of hair and cast breakage was recorded along with the administration of patient satisfaction questionnaires. Mann-Whitney U test or Fisher's exact test was applied to compare results. RESULTS: Overall, 34 patients from the fibreglass group and 31 patients from the polyolefin group were included in the final analysis. Significantly fewer patients from the polyolefin group reported itchiness during the casting period (p = 0.038). However, significantly more cast breakages were observed for the polyolefin group in the palmar bar region (p = 0.009). Patients from the polyolefin group were overall more satisfied (fibreglass group = 3.15/5 vs. polyolefin group = 3.74/5; p = 0.002). CONCLUSION: Polyolefin cast reduces itchiness during casting and provides higher overall patient satisfaction during the treatment of stable distal radius fractures in children in tropical climates. However, patients should be counselled regarding potential cast breakage, which did not compromise safety, and the higher costs involved.

A Case of Tuberculosis Spondylodiscitis With Paraspinal Abscess in a 2-Year-Old Child.

In this article, we report a case of tuberculosis spondylodiscitis in a 2-year-old child. Imaging of her spine showed a paraspinal abscess. The diagnosis of spinal tuberculosis remains difficult, and we discuss its salient features and current management within the pediatric population.

Paediatric supracondylar humeral fractures: a technique for safe medial pin passage with zero incidence of iatrogenic ulnar nerve injury.

INTRODUCTION: The cross Kirschner wire (K-wire) configuration in closed reduction and percutaneous pinning of paediatric supracondylar humeral fracture affords superior stability. However, medial pin placement presents a risk of iatrogenic ulnar nerve injury. This study describes, in step-by-step detail, another safe method of percutaneous medial pin insertion. METHODS: The technique involved placing the patient's arm in external rotation, with elbow flexed no more than 45° after closed reduction. The surgeon held the K-wire close to its sharp end to pass it percutaneously onto the medial epicondyle, then adjusted his grip toward the blunt end. After fluoroscopy check, the wire driver was engaged and an anteriorly directed force was applied to the distal humerus fragment using the thumb of the surgeon's free hand. The K-wire was inserted at a 45° angle to the longitudinal axis of the humerus shaft. Clinical notes and radiographs of patients who underwent surgery with this technique from 2006 to 2008 were reviewed. RESULTS: A total of 125 patients (84 boys, 41 girls) were included, with a mean age of 7.1 (range 2-14) years. Most injuries were left-sided (72.8%, n = 91, vs. right: 27.2%, n = 34). 72 (57.6%) patients had two-pin cross K-wire configuration, while 53 (42.4%) patients had an additional lateral pin inserted. No patient had postoperative ulnar neuropathy. There were no complications of non-union, malunion or infection. CONCLUSION: This safe method of medial pin placement for surgical stabilisation of paediatric supracondylar humeral fractures is easily learnt and reproducible, and produces excellent results.

The isolated medial humeral epicondyle fracture treated nonoperatively: does fracture displacement change over time?

This study explores the change in the position of the fragment in isolated, displaced, medial humeral epicondyle fractures in children. In this series, 34 patients (mean age 11.0 years) were treated nonoperatively by cast immobilization with no attempt at closed fracture reduction. A statistically significant association was found between the position of the fracture fragment at the time of initial fracture compared with 3 weeks after fracture (P=0.015). Twenty-six of 34 patients (76.5%) showed spontaneous improvement in fragment position. These findings support the practice of treating significantly displaced medial epicondyle fractures nonoperatively.

Percutaneous pin removal in the outpatient clinic--do children require analgesia?: a randomized controlled trial.

BACKGROUND: Percutaneous pins used in the surgical fixation of fractures in children are often removed in the outpatient clinic without the administration of analgesia. Pin removal can be a cause of anxiety for children, parents, and caregivers. Relatively little is known about the requirement of analgesia for this procedure. In a randomized controlled trial, we evaluated whether oral acetaminophen or ibuprofen reduced the pain experienced during pin removal. METHODS: Participating in the study were 240 children between the ages of five and twelve years who had two or three percutaneous pins in the elbow following treatment of a supracondylar humeral fracture or a lateral humeral condyle fracture with closed reduction and percutaneous pinning. The patients were randomized into one of three groups (n = 80) allocated to receive acetaminophen, ibuprofen, or vitamin C (placebo) an hour before pin removal. A pain score was obtained and heart rate measured before pin removal, immediately following the procedure, and ten minutes after pin removal. RESULTS: No significant differences were found among the study groups in terms of the demographic data of sex, age, side of injury, or number of pins. Pain score and heart rate did not exhibit differences that were either statistically significant or clinically relevant. The change from baseline did not differ significantly among the groups for either measure at either of the follow-up times post pin removal. Immediately after pin removal, the mean difference in pain score (and 95% confidence interval [CI]) between the acetaminophen group and the ibuprofen group was 0.10 (-1.03 to 1.23); between the acetaminophen group and the placebo group, 0.35 (-0.78 to 1.48); and between the ibuprofen group and the placebo group, 0.25 (-0.88 to 1.38). The CIs excluded a clinically relevant difference. Pain scores and heart rates returned to preprocedural baseline levels within ten minutes following pin removal. CONCLUSIONS: Neither acetaminophen nor ibuprofen significantly reduced the pain score or heart rate associated with percutaneous pin removal in children as compared with the placebo. The oral analgesics administered were clinically equivalent to the placebo. These results suggest that non-narcotic analgesia use does not significantly reduce pain or heart rate associated with percutaneous pin removal in children.