Results of the Italian Pediatric Orthopedics Society juvenile flexible flatfoot survey: diagnosis and treatment options.

The objectives of this study were to collect and analyze current diagnosis and treatment options of symptomatic flexible flatfoot (FFF), as well as to identify treatment expectations, among the members of the Italian Pediatric Orthopedics Society (SITOP). Diagnosis and treatment preferences were recorded according to a web-based survey. The survey was divided into six main sections: (1) general clinical parameters; (2) foot aspects; (3) X-ray angles (or lines); (4) expectations; (5) standard clinical assessment; (6) treatment options. One hundred and ten out of 248 SITOP members answered to the questionnaire. Age (85.5%), pain at the level of the plantar arch or fascia (61.8%), fatigue (59.1%) were the clinical parameters of crucial importance. Heel valgus (85.4%), flexibility (61.8%) and forefoot supination (47.3%) were identified as the most important foot aspects. Ninety-two responders (83.6%) identified the 'improved ability to walk longer without symptoms or discomfort' as the principal treatment expectation. Pain evaluated through the visual analog scale (VAS) was considered crucial in 31.8% of cases. All respondents confirmed they also treat patients with FFF surgically; in particular, 97.3% of SITOP affiliates declare to perform arthroereisis followed by lateral column lengthening (29.1%) and medializing calcaneal osteotomy (9.1%). Although in this survey heterogeneous findings for diagnosis and treatment of patients with symptomatic FFF within SITOP members were found, a large preference for age, heel valgus, flexibility as clinical aspects and parameters, as well as nonoperative treatment and arthroereisis, was reported.

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.

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.

Osteonecrosis in Children and Adolescents With Acute Lymphoblastic Leukemia: Early Diagnosis and New Treatment Strategies.

BACKGROUND/AIM: In the last few decades, treatment strategies for acute lymphoblastic leukemia (ALL) have been associated not only with improvement of prognosis, but also with an increasing rate of late complication as osteonecrosis (ON). Herein, the cumulative incidence, risk factors, new conservative therapeutic strategies as hyperbaric oxygen therapy (HBO), and outcome of symptomatic ON were studied in pediatric patients with ALL. PATIENTS AND METHODS: Between 2000 and 2017, 495 children and young adolescents with a diagnosis of ALL were evaluated. All the symptomatic patients underwent magnetic resonance imaging (MRI) to detect bone vascularization and structure. RESULTS: Twenty-three out of 495 patients presented ON (4.6%). ON was associated with an older age (p<0.0001) and a higher steroid dose (p=0.0013). All the patients underwent standard therapies and HBO was performed in 8 of 23 patients. During the follow-up, 15 patients were stable: 6 were totally asymptomatic, 5 complained of pain during activity, and 4 presented mild function limitation. CONCLUSION: Our data highlight the importance of early diagnosis of ON by screening MRI in asymptomatic patients, in order to start conservative treatment strategies. Moreover, HBO could have beneficial effects on ON patients.

Proposal of an innovative casting technique for correction of clubfoot according to Ponseti method: a pilot study.

A total of 70 clubfeet were treated by a posterior above-knee cast (pressure points on the talus and on the first metatarsal) according to Ponseti method. At diagnosis, average Pirani score was 4.44, and mean time of treatment was 50.32 days. Overall, 27 (38.6%) clubfeet had only conservative treatment (5.29 casts) and 43 (61.4%) also had Achilles tenotomy (6.38 casts). At the end 61/70 feet (87.14%) had Pirani score 0; 10/70 feet (5.71%) had Pirani score 0.5. The Pirani score gain/cast was ß=-0.432 (P<0.001). This new casting technique is safe and effective at avoiding some adverse issues related to the removal of the conventional cast.

Desepiphysiodesis and Reconstruction of the Distal Radial Growth Plate with an Autologous Iliac Crest Cartilage Graft: A Case Report and Review of Literature.

INTRODUCTION: The term "desepiphysiodesis" consists of removing a partial premature epiphyseal closure due to the formation of an osseous bridge and replacing it by interpositional inert material; in spite of the experimental evidence supporting the efficacy of autologous cartilage as interposition material into resection cavity to permit the remaining growth, this option, curiously, is not found in clinical practice and literature. Indeed, surgical treatment for partial growth injury, autogenous, fat, and non-biological grafts is most frequently transplanted after physeal bar resection to prevent and/or correct angular deformities. CASE REPORT: This is a case report of a 10-year-old boy with an angular defect of the right distal radial growth plate which was the result of a post-traumatic lesion. The bone bridge was resected and replaced with an autologous block from the apophyseal cartilage of iliac crest. CONCLUSION: We are aware of this is the second case reported, in which autologous physeal graft was successfully used, observing a satisfactory long-term evolution of the patient. This research shows that the treatment of growth arrest with autologous iliac crest apophyseal cartilage graft is an effective method that can yield excellent results.

Transphyseal separation of the distal humerus in newborns.

Obstetric traumatic separation of the distal humeral epiphysis is a very uncommon injury, which presents a diagnostic challenge. These case serials reviewed the functional outcomes of 5 patients who had sustained a fracture-separation of the distal humeral epiphysis at birth. The diagnosis was made at a mean time of 40.8 h after delivery. All the patients were treated with gentle close manipulation, reduction under fluoroscopy and above-elbow cast application. After discharge, the patients were followed up for a mean of 30 months. Clinico-radiological results were excellent in four patients. One case necessitated closed reduction and percutaneous K-wire fixation at one week follow-up due to failed reduction. Cubitusvarus deformity was the only complication noted in 1 case. Good functional outcome can be expected in newborns with fracture-separation of the distal humeral epiphysis wherein the physis is anatomically reduced.

Focal Myositis in paediatric age.

BACKGROUND: Focal Myositis is a rare pseudotumor of unknown aetiology that is often difficult to diagnose and treat. Typically afflicting people in adulthood, it has occasionally been reported also among children. PURPOSE: the aim of this study is to review the literature of Focal Myositis in paediatric age in order to compare the clinical manifestation and the various treatment suggested by different authors. METHODS: this article describes a 6-year-old boy with focal myositis in gracilis muscle successfully treated by conservative methods, including nocturnal leg traction, intensive physiokinesi therapy and articulated knee orthosis guided to progressive extension. Furthermore a systematic review of literature concerning focal myositis in paediatric age is reported. CONCLUSION: our case and the review of literature suggests that conservative methods should be the first-choice treatment for FM in paediatric age and that surgery should be strictly reserved for selected cases where non-invasive methods have previously failed.

Comparison of musculoskeletal and urological functional outcomes in patients with bladder exstrophy undergoing repair with and without osteotomy.

It is controversial as to whether osteotomy, by restoring a more normal pelvic anatomy, might improve the final outcome of bladder exstrophy (BE) repairs. We compared the functional orthopaedic and urological outcomes in BE patients treated with and without osteotomy. Orthopaedic and urological outcomes were compared in eight BE patients treated with osteotomy and six BE patients treated without osteotomy. Orthopaedic evaluation included an assessment of pubic bones dissymmetry, bending of the spine, presence of Trendelenburg or Thomas sign, and presence of out-toeing. Pubic diastasis was ruled out on a plain X-ray of the pelvis. A Pediatric Orthopedic Society of North America (POSNA) questionnaire was administered to every child or his/her caregiver to assess functional outcome. Urological evaluation included an assessment of required continence surgeries and of contemporary continence status. All patients presented a pubic diastasis. This was in median 49 (24-66) mm in patients treated without osteotomy and 42 (25-101) mm in those treated with osteotomy (p = 0.3). There was no difference either in the orthopaedic outcome or in any features of the POSNA questionnaire between groups. Neither was there a difference in the final continence rate nor in the number of additional continence procedures required. Although osteotomy is an essential step in the treatment of many BE patients in order to achieve a tension-free closure of the abdominal wall and bladder, our preliminary results suggest that it does not improve the eventual orthopaedic or urological outcomes of BE.

Musculoskeletal manifestations in pediatric acute leukemia.

BACKGROUND: In children, acute leukemia (AL) at presentation can mimic several orthopaedic pathologies, so that a variable delay of the correct diagnosis is often reported. METHODS: To define more clearly the clinical and radiological musculoskeletal manifestations of leukemia in children, 122 affected children referred from 1984 to 1999 to our Pediatric Onco-Hematologic Clinic were retrospectively reviewed. Average age at diagnosis was 6.6 years (from 7 months to 17 years). Seventy-three (60%) were boys and adolescent boys, 49 (40%) were girls and adolescent girls. One hundred two (83.6%) had acute lymphoblastic leukemia, 20 (16.4%) had acute myeloid leukemia. The mean follow-up was 8.2 years for the 104 survivors and 2.5 years for the 18 nonsurvivors. The chi2 test was used to perform the statistical analyses. RESULTS: At presentation, complaints related to the musculoskeletal system were frequent (38.3%), including pain (34.4%), functional impairment (22.9%), limping (12.3%), swelling (10.6%), and joint effusion (5.7%). At presentation, 40.2% of children had at least 1 radiographic abnormality. In order, they were osteolysis (13.1%), metaphyseal bands (9.8%), osteopenia (9%), osteosclerosis (7.4%), permeative pattern (5.7%), pathological fractures (5.7%), periosteal reactions (4.1%), and mixed lysis-sclerosis lesions (2.5%). Different from previous reports, late radiographic lesions were uncommon (5.7%), probably because of milder newer medication protocols. They included avascular necrosis (3.3%), vertebral collapses (1.6%), and osteolysis (0.8%). CONCLUSIONS: Both clinical and radiological changes had various and no uniform localization. Poor correlation was found between symptoms and radiological lesions. Survival rates in children with AL were 95.8% at 1 year, 89.6% at 3 years, 85.8% at 5 years, and 83.4% at 10 and at 13 years. Radiographic abnormalities (P = 0.400), type of leukemia (P = 0.291), sex (P = 0.245), and white blood cell count at presentation (P = 0.877) were not prognostic factors. The presence of multiple bone lesions did not affect the survival rate (P=0.632). As early diagnosis significantly decreases morbidity and mortality of AL, the orthopaedist should suspect AL in any child with unexplained persistent skeletal pain or radiographic alterations. Accurate history, general physical examination, and complete blood cell count tests should address the suspicion, which is confirmed by a peripheral and/or iliac crest bone marrow biopsy.

Triplane fracture of the proximal tibial epiphysis.

Our purpose is to report a very rare case of proximal tibia triplane fracture, focusing the particular pattern of fracture and the long-term follow-up result. The triplane fracture is an exceptional fracture that occurs in the 3 planes (coronal, sagittal and transverse) close to the end of the growth period. A 15-year-old boy was admitted to our Center for a left femoral diaphyseal fracture and an ipsilateral lateral proximal tibia triplane fracture following a road accident. The femur was fixed with an intramedullary nail, the triplane fracture was anatomically reduced and percutaneously fixed. After 4 years follow-up, the knee was stable and with no complaints. Its range of motion was complete. Radiographs and MRI did not show any abnormality on the left leg and knee. In order to stabilize a proximal tibia triplane fracture a surgical internal fixation is usually required, with the possibility of a good long-term outcome also due to the growth potential remaining, if physeal arrest does not occur.

Polydactyly of the foot.

Fifty-six patients with 72 duplicated toes were analysed. Postaxial duplication accounted for 79%, and the most common anatomical pattern was duplication of the proximal phalanx with a wide metatarsal head. Forty-two patients with 55 duplications were clinically and radiographically evaluated at long-term follow-up (mean 22.5 years). Results were satisfactory in 91% of the patients. Poor results were often associated with preaxial polydactyly because of persistent hallux varus. Surgical treatment is usually straightforward but must be individualized, and some anatomical and surgical details should be considered to obtain a better result.

Is conservative treatment really effective for Legg-Calvé-Perthes disease? A critical review of the literature.

INTRODUCTION: The treatment of Legg-Calvé-Perthes Disease (LCPD) is controversial and not well defined. This literature review aimed to assess the quality of the evidence available to support the effectiveness of conservative LCPD treatment advocated by orthopaedic surgeons and(or) paediatricians. A secondary aim was to see if conservative treatments really modify the natural history of LCPD. MATERIALS AND METHODS: The review was performed mainly on the PubMed Database and based on the principles of Evidence Based Practice (EBP). Keywords used were Perthes disease, conservative treatment, containment treatment, review, and weight-relief. EBP is the integration of the best research evidence with clinical expertise and patient values of which there are five different levels of evidence: (1) Randomized Controlled Trials; (2) Prospective Cohort Study; (3) Case Control or Retrospective Cohort Study;(4) Case Series; 5) Expert Opinion or Individual Case Report. Results. Until 20th August 2005 there were 144 articles of clinical relevance about conservative treatment of LCPD: 16.7% of EBP level 5; 50.7% of level 4; 31.9% of level 3; none of level 2; and 0.7% of level 1. CONCLUSION: The quality of evidence that supports conservative treatment for children with LCPD is not of high quality. There is no scientific evidence that conservative treatments modify LCPD natural history. Containment, no containment and simple symptomatic treatment have comparable effectiveness. Prolonged weight-relief and(or) containment treatments are associated with social and psychological problems.

Is there a role for arthroscopic synovectomy in oligoarticular juvenile idiopathic arthritis?

OBJECTIVE: To evaluate the longterm efficacy and safety of arthroscopic synovectomy (AS) in children with oligoarticular juvenile idiopathic arthritis (JIA). METHODS: Patients with oligoarticular JIA and persistent monoarticular involvement, refractory to nonsteroidal antiinflammatory drugs (NSAID) and/or intraarticular corticosteroid (IAC) treatment underwent AS followed, one month later, by IAC. The efficacy of AS was prospectively evaluated, and a good response was defined as absence of synovitis or > or = 60% decrease in articular score from baseline. Clinical, laboratory, and radiological variables (radiographs, ultrasound, magnetic resonance imaging) were noted to examine possible factors predictive of the result. RESULTS: Twenty-two patients with JIA (15 female, 7 male) entered the study. Age at disease onset was 77 months (range 13-168). Mean disease duration at the time of AS was 50 months (3-324). Nineteen knees, 2 temporomandibular joints, and one shoulder were treated; the mean followup was 57 months (12-168). Thirty-six percent of patients relapsed within 12 months of the procedure, 14% within 24 months, and 14% thereafter. Eight patients (36%) remain in remission after a mean 65 months' followup. Variables found to be predictive of good response were persistent monoarticular course (p = 0.004), short disease duration at the time of AS (p = 0.03), and normal erythrocyte sedimentation rate and C-reactive protein at baseline (p = 0.008 and 0.01, respectively). CONCLUSION: AS is a safe but only partially effective procedure in patients with oligoarticular JIA. Best results are achieved early in the disease course in children with persistent monoarticular involvement and no evidence of systemic inflammation.

Localized unresectable non-rhabdo soft tissue sarcomas of the extremities in pediatric age: results from the Italian studies.

BACKGROUND: Treatment of initially unresectable nonrhabdo soft tissue sarcomas (NRSTS) in pediatric age is debated, due to their different chemosensitivity. The authors objective was to evaluate clinical features and treatment results observed in a series of Italian patients over a 24-year period. METHODS: Fifty-two patients age 8-18 years (median 8 years) were observed (1979-2002). Primary sites were on the lower limbs in 41 and on the upper limbs in 11 cases. Clinical TNM and surgical Intergroup Rhabdomyosarcoma Staging systems were adopted. Therapeutic guidelines recommended an initial biopsy plus neoadjuvant chemotherapy. Aggressive delayed surgery of residual disease, including compartmental resections, was recommended. Radiotherapy was suggested only for patients age > 3 years when surgery was incomplete or not feasible. RESULTS: The evaluation was performed dividing the patients into two categories according to their chemosensitivity. Chemosensitive (CTs) sarcomas, 21: synovial sarcoma, 11; extraosseous Ewing sarcomas, 5; primitive peripheral neuroectodermic tumors, 5. Nonchemosensitive (CTns) sarcomas, 31: fibrosarcoma, 11; malignant peripheral nerve sheet tumors, 10; liposarcoma, 2; hemangiopericitoma adult type, 2; epithelioid sarcoma, 2; and alveolar soft part sarcoma, leiomyosarcoma, clear cell sarcoma, and sarcoma NOS, each 1. Nineteen of 21 patients with CTs-NRSTS were alive without disease: the 5-year overall survival (OS) and progression-free survival (PFS) were 94.4% and 79.3%, respectively; 23 of 31 patients with CTns-NRSTS were alive without disease: 5-year OS and PFS were 75.3% and 68.3%, respectively. Response to neoadjuvant chemotherapy was complete or partial in 10 of 20 evaluable CTs and in 8 of 26 evaluable CTns tumors. The achievement of complete delayed resection was particularly important for CTns-NRSTS. Tumor size < 5 cm, distal site, and tumor grading for CTns sarcomas were often linked to a favorable outcome; no conclusive results were detected concerning age of the patients or T status of the tumor. CONCLUSIONS: Multidisciplinary treatment without mutilating procedures allowed the cure of most patients with CTs and CTns-NRSTS. Relapses were cured in several cases of CTs tumors, whereas almost all patients with relapsed CTns tumors died due to the high rate of metastatic spread.

Sonographic assessment of clubfoot.

PURPOSE: This study was performed to develop a standardized methodology for the sonographic assessment of clubfoot at birth and at the end of both conservative treatment and surgical correction. METHODS: Forty-two congenital clubfeet and 42 normal feet were examined sonographically in the position of spontaneous alignment and during passive manual correction. Scans along 4 planes provided information relevant to the assessment: sagittal posterior, sagittal anterior, coronal lateral, and transverse. RESULTS: Sagittal posterior sonograms demonstrated the progressive gain of dorsiflexion ability during the different steps of treatment for clubfoot. Sagittal anterior sonograms could not demonstrate the normal alignment of the navicular in clubfeet because of the bone's medial displacement. On transverse sonograms, the talar head and the medially displaced navicular may lie on the same plane, depending on the severity of the deformity. Coronal lateral sonograms provided for estimation of the relationships between the calcaneus and cuboid, which were described by the calcaneal-cuboid angle. CONCLUSIONS: Sonography is a promising technique for assessment and monitoring of clubfoot during treatment. The method described here yields accurate and reproducible information about the anatomy of the nonossified clubfoot, helping the orthopedic team decide on appropriate treatment steps.

Synovial involvement in hemangiomatosis.

BACKGROUND: Angiodysplastic lesions of the extremities are very often of great interest for the orthopedist, involving not only bones with length discrepancy, but also joints with hemarthrosis and synovial hypertrophy. METHODS: We describe 4 patients with cutaneous hemangiomatosis in the lower limb and a concomitant knee arthropathy. Like in other arthropathies, the articular damage is rapidly invasive and leads to progressive damage in the joint if not adequately diagnosed and treated. We treated the 4 patients at different ages, corresponding to different stages of intra-articular involvement. The preoperative management included MRI and diagnostic arthroscopy. All patients underwent an open synovectomy. All our patients were reviewed at a clinical and radiographic follow-up after 10 years. RESULTS: In all patients, the range of motion was improved or at least not worsened after surgery, in spite of a larger extent of cutaneous lesions. X-ray and MRI confirmed clinical data showing no recurrence of the lesion inside the joint and no progression of the articular damage. CONCLUSION: The clinical outcomes were very good or good in the patients treated early, poorer in the patient operated on at an adult age. The importance of an early and precise diagnosis and of an accurate preoperative planning must be underlined.

Prognostic value of Catterall and Herring classification in Legg-Calvé-Perthes disease: follow-up to skeletal maturity of 32 patients.

To compare the prognostic value of the Catterall and Herring classification, 32 patients, treated without surgery for unilateral Perthes diseases, were reviewed and classified at skeletal maturity according to Stulberg. The Catterall classification had no significant prognostic correlation with the final outcome. Only some head at-risk signs, such as lateral epiphyseal calcification and epiphyseal subluxation >4 mm, were prognostic. The Herring lateral pillar was not predictive when it was considered alone, but it became prognostic when related to age at onset. Moreover, in group C of the Herring classification (lateral pillar <50%), the final outcome was better in children younger than 6 years. This last observation strengthens the opinion that age and related residual skeletal moulding are also of prognostic value in Perthes disease.

SAPHO syndrome and transient hemiparesis in a child: coincidence or new association?

We describe a case of synovitis, acne, pustulosis, hyperostosis, osteitis (SAPHO syndrome) in an 8-year-old boy with an unusual presentation of acute transitory hemiparesis. SAPHO syndrome has been reported in association with inflammatory bowel diseases, chest complications, and pulmonary involvement. No patient with both SAPHO syndrome and neurologic complaints has been previously described. Further observations are needed to confirm if SAPHO syndrome and hemiparesis represent a coincidence or a new association.