Management of Open Pediatric Fractures: Proposal of a New Multidisciplinary Algorithm.

BACKGROUND: An algorithm for managing open fractures in children is still being debated; the present study suggests an evidence-based way to manage these patients in the emergency department. METHODS: The literature on "Open fractures in children" was carefully analyzed using keywords. The primary sources were The Cochrane Library, PubMed, and Researchgate. CONCLUSION: We proposed an evidence-based algorithm for managing open fractures in children to standardize clinical practice and improve the care of these patients.

Vertebral Rotation in Functional Scoliosis Caused by Limb-Length Inequality: Correlation between Rotation, Limb Length Inequality, and Obliquity of the Sacral Shelf.

BACKGROUND: Scoliosis is a structured rotatory deformity of the spine defined as >10° Cobb. Functional scoliosis (FS) is a curve < 10° Cobb, which is non-rotational and correctable. FS is often secondary to leg length inequality (LLI). To observe vertebral rotation (VR) in functional scoliosis due to LLI, one must demonstrate a correlation between LLI, sacral shelf inclination (SSI), and VR and discover a predictive value of LLI capable of inducing rotation. METHODS: We studied 89 patients with dorso-lumbar or lumbar curves < 15° Cobb and radiographs of the spine and pelvis. We measured LLI, SSI, and VR. The patients were divided into VR and without rotation (WVR) groups. Statistical analysis was performed. RESULTS: The mean LLI value was 6.5 ± 4.59 mm, and the mean SSI was 2.8 ± 2.53 mm. The mean value of LLI was 5.2 ± 4.87 mm in the WVR group and 7.4 ± 4.18 mm in the VR group. The mean SSI value for WVR was 1.4 ± 2.00 and that for VR was 3.9 ± 2.39. For each mm of LLI, it was possible to predict 0.12° of rotation. LLI ±5 mm increased the probability of rotation (R2.08 p < 0.0016), while this was ±2 mm for SSI (R2 0.22 p < 0.01). Each mm of LLI corresponded to 0.3 mm of SSI (R2 0.29, p < 0.01). CONCLUSIONS: FS secondary to LLI can cause VR, and 5 mm of LLI can cause SSI and rotation.

Long-term outcome after brace treatment of Scheuermann's kyphosis: an observational controlled cohort study.

BACKGROUND: In the literature, there are several papers on Scheuermann's kyphosis. It is a structural deformity of the spine that is characterized by anterior wedging of 5° or more of 3 adjacent thoracic vertebral bodies with kyphosis measuring greater than 45° between T5 and T12. Bracing treatment is able to obtain, during skeletal growth, remodeling of the deformed vertebrae. AIM: The aim of this study was to evaluate the effectiveness of conservative treatment in Scheuermann's kyphosis at a minimum follow-up of 10 years. DESIGN: This is an observational controlled cohort study nested in a prospective clinical on-going database in patients with Scheuermann kyphosis. SETTING: Inpatients and outpatients in Rome. METHODS: From a consecutive series of patients included in a prospective database, we selected 158 patients with thoracic Scheuermann's kyphosis who were treated using an anti-gravity brace: 93 males and 65 females. The mean age at the beginning of the treatment was 14 years. The time bracing prescribed was a max of 20 hours daily and a min of 16 hours daily. Weaning was started when a full recovery of vertebral geometry was seen on a lateral radiograph view or when growing was ended. Radiographical measurements were performed on radiographs from a lateral projection at baseline (t1), at the end of the treatment (t2) and at 10 years of minimum follow-up (t3). To avoid the great variance in the range of curve angles in thoracic kyphosis (TK) that rely on the radiological position, X-rays were performed observing the following position: standing with head straight, arms bent at 45° and hands lightly placed on a support. The anterior wedging angle (Alpha) of the apex vertebra and the degrees of the curve (Cobb methods) were analyzed using statistical analysis. RESULTS: The results from our study showed that in 158 patients with TK curves, the mean Cobb angle was 57.6±6.3 SD at baseline, 43.3±7.8 SD at the end of treatment and 44.49±7.4 SD at ten years of follow-up. The alpha angle was 14.43±2.535 SD at baseline and 8.571±3.589 SD at the end of treatment, and after ten years of follow-up, it was 8.654±3.57 SD. The mean duration of treatment was 28.42±12.07 months, and the mean follow-up was 128.3±11.07 months. The difference between baseline and end of treatment, tested with the one-way ANOVA comparisons test, was significant (P<0.0001) for both Cobb angle and alpha; instead, the difference between the end of treatment and follow-up was not significant (P=0.3277). CONCLUSIONS: The results confirm that conservative treatment in Scheuermann's kyphosis during skeletal growth is effective. Bracing treatment can remodel the deformed vertebrae. CLINICAL REHABILITATION IMPACT: At the 10-year follow-up after bracing, kyphosis curve correction was stable over time.

Is Surface Topography Useful in the Diagnosis of Scoliosis? Validation of the Biometrical Holistic of Human Body (BHOHB).

BACKGROUND: The concern around repeated exposure to X-rays has been motivating doctors involved in scoliosis to seek alternative solutions. Surface topography (ST) analysis is a modern system that has been shown to have good results. The purpose of the study is to validate the new BHOHB hardware for the investigation of scoliosis in adolescents by comparing it to X-ray examinations and to assess the reliability of intraoperator and interoperator tests. METHODS: Ninety-five patients were enrolled in our study. All the patients were analyzed via the BHOHB method 2 times by 2 independent physicians (t0) and for a second time 2 or 3 months later (t1). The Pearson correlation coefficient was used to evaluate the relationship between the measurements obtained by BHOHB and the gold standard. The intraclass correlation coefficient (ICC) was used to assess intra- and interoperator reliability. Statistical analysis was performed with the GraphPad Prism 8 software. RESULTS: The correlations between the first and second operators in the measurements and between the BHOHB method and X-ray showed a very good to excellent r for both. A very good correlation was also confirmed for prominence measured by operators and by the BHOHB machine. Intra- and interoperator reliability was found to be very positive for both the first and the second physicians. CONCLUSIONS: We can state that ST can be useful for diagnosing and treating scoliosis. The recommendation is to use it primarily to evaluate the evolution of the curve, as in this mode, you can reduce the patient's exposure to X-rays. The results indicate that BHOHB measures are comparable to radiographs and not influenced by the operator.

Surgical correction of valgus deformities of the knee in Polyostotic Fibrous Dysplasia.

Coxa vara and shepherd's crook deformity represent the most common femoral deformities in patients affected by polyostotic fibrous dysplasia (PFD) and McCune Albright syndrome (MAS). The tibia is also commonly affected, with antero-medial bowing and valgus deformity. Surgical treatment of these deformities are technically demanding and, in most cases, intramedullary nails are the preferred method to stabilize corrective osteotomies. Genu valgus may also be present, as a residual defect after the surgical correction of the aforementioned deformities. The aim of our study was to report the outcomes obtained in five patients with PFD or MAS operated on for complex deformities of the lower limbs with an associated residual genu valgum greater than 15°. It was surgically treated by distal femoral or proximal tibial osteotomy stabilized with a screw plate. The osteotomy was performed distal to the intramedullary nail in femurs, while it was performed after removing the intramedullary nail in the proximal metaphysis of the tibia. In latter cases, the intramedullary device was reinserted at least 6 months after surgery. At follow-up, the femoro-tibial angle was corrected in all cases and the patients were satisfied with the final result. Two patients showed mild limping, unrelated to the alignment of the knee. In our opinion, residual valgus deformities of the lower limb greater than 15 degrees should be corrected to improve function and cosmetic appearance of these patients. The osteotomy of the distal femur or of the proximal tibia stabilized by a screw-plate represent the treatment of choice for the correction of these deformities.

Clinical and Radiological Results after Fracture-Dislocations of the Ankle: A Medium- to Long-Term Followup Study.

The authors report the long-term outcome in a series of 26 patients surgically treated for a fracture-dislocation of the ankle by open reduction and internal fixation (ORIF), reviewed after an average followup of 5.2 years. The average age of the patients was 46.8 years; 17 were female and 9 male; the right side was involved in 22 patients and the left side in 4; 10 patients had a unimalleolar fracture, 11 a bimalleolar fracture, and 5 a trimalleolar fracture. The quality of reduction was excellent in 14 cases and good in 12. The functional results were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) score, while radiographic results followed the Van Dijk classification. At followup, the AOFAS score ranged from 75 to 98 points with an average of 87.9, while the radiographic results were evaluated as grade 0 in 16 ankles and grade I in 10. Fracture-dislocations of the ankle occurred more frequently after high-energy traumas in younger patients on the right side, but they were also observed in older females after low-energy trauma. Excellent reduction was correlated with better radiographic results at long term followup. However, these injuries may lead to a poor functional outcome, despite an anatomical reduction and good radiographic results; in fact, in nine of our cases (34.6 percent), the AOFAS score was less than 90 points.

The effectiveness of preliminary traction in the treatment of congenital dislocation of the hip.

BACKGROUND: Historical papers on the treatment of congenital dislocation of the hip suggest the use of preliminary traction to facilitate closed reduction or to decrease the risk of avascular necrosis (AVN) of the femoral head. In the 1980s, some authors questioned the role of preliminary traction and suspended its use, yielding satisfactory results. Since then, several studies called into question this method, and some authors have continued to recommend preliminary traction while other authors have discouraged its use. MATERIALS AND METHODS: We reanalysed the full set of radiographs of 71 hips (52 patients) surgically treated by a medial approach after 4 weeks of preoperative longitudinal traction. The mean age at operation was 16 months. Before and after traction, the height of the dislocation was graded according to the Gage and Winter method. The hips were divided into two groups: group 1, in which the traction was effective, and group 2, in which the traction was not effective. These two groups were statistically analysed regarding the severity of the dislocation, the age of the patient at surgery and the incidence of AVN. RESULTS: Preliminary traction was effective in 48 hips (68%, group 1), while it was not effective in the remaining 23 (32%, group 2). The effectiveness of preliminary traction was statistically related to the height of the dislocation and to the age of the patient at surgery, with traction being less effective in more severe dislocations and in older children. The incidence of AVN was statistically lower in group 1 than in group 2. CONCLUSIONS: In our study population, despite not having a control group, preliminary traction-when effective-seemed to reduce the incidence of AVN in patients surgically treated for congenital dislocation of the hip. The effectiveness of the traction was influenced by the severity of the dislocation and the age of the patient; it worked better for less severe dislocations and in younger children. To reduce hospital costs, traction should be applied at home. LEVEL OF EVIDENCE: 3.

Surgical Treatment of Severe Idiopathic Flexible Flatfoot by Evans-Mosca Technique in Adolescent Patients: A Long-Term Follow-Up Study.

Flexible idiopathic flatfoot is very common in growing age and rarely causes pain or disability. Surgery is indicated only in severe symptomatic cases that are resistant to conservative treatment, and numerous surgical procedures have been proposed. Lateral column calcaneal lengthening as described by Evans and modified by Mosca is a widely used surgical technique for the correction of severe symptomatic flexible flatfoot. In the present study, we report the long-term clinical and radiographic results in 14 adolescent patients (mean age: 12.8 years) affected by severe symptomatic flexible flatfoot, surgically treated by Evans-Mosca procedure, for a total of 26 treated feet (12 cases bilateral and 2 unilateral). In all cases, surgery was indicated for the presence of significant symptoms resistant to nonsurgical management. Clinical evaluation was made according to the American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale, the Foot and Ankle Disability Index (FADI) Score, and Yoo et al.'s criteria. Radiographic evaluation was made using anteroposterior and lateral weight-bearing radiographs of the feet to evaluate Meary's angle and Costa-Bertani's angle and to evaluate possible osteoarthritic changes in the midtarsal joints. At follow-up (mean: 7 years and 7 months), we observed a satisfactory result in all patients. The mean average score of the AOFAS Ankle-Hindfoot Scale improved from 60.03 points to 95.26; the mean FADI score improved from 71.41 to 97.44; and according to Yoo et al.'s criteria, the average clinical outcome score was 10.96. At radiographic examination, nonunion of the calcaneal osteotomy was never observed. Meary's angle improved from an average preoperative value of 25° to 1.38° at follow-up; Costa-Bertani's angle improved from an average preoperative value of 154.2° to 130.9° at follow-up. In no case, significant radiographic signs of midtarsal joint arthritis were observed. According to our results, we believe that Evans-Mosca technique is a valid option of surgical treatment for severe idiopathic flexible flatfoot and allows a satisfactory correction of the deformity with a low rate of complications.

Lower limb lengthening over an intramedullary nail: a long-term follow-up study of 28 cases.

BACKGROUND: Limb lengthening using an external fixator requires a long period of external fixation and may be associated with several complications such as axial deformity, fracture of the regenerated bone, and joint stiffness. With the goal of reducing the time of external fixation as well as some of these complications, we performed femoral or tibial lengthening over an intramedullary nail, according to Paley's technique, in 28 patients, followed up after a mean period of 8 years. MATERIALS AND METHODS: Twenty-eight patients treated for lower limb discrepancy by limb lengthening over an intramedullary nail were reviewed from 5 to 11 years after healing of regenerated bone. There were 20 femurs and 8 tibiae, with average age at surgery of 14.2 years and average length inequality of 6.1 cm for femurs and 5.3 cm for tibiae. RESULTS: The mean lengthening was 5.8 cm for femurs and 4.8 cm for tibiae. The mean period of radiographic consolidation of the regenerated bone was 6 months for femoral lengthening and 4.5 months for tibial lengthening. At follow-up, we observed 8 excellent results, 15 good results, 4 fair results, and 1 poor result, based on Paley's evaluation criteria. The main complications were one deep infection, one nonunion of the distracted segment, one breakage of the distal fiche of the external fixator, and one breakage of both distal locking screws of the intramedullary nail. DISCUSSION: We believe that limb lengthening over an intramedullary nail still represents a good method to treat limb length discrepancy because it reduces the time of external fixation, prevents axial deformities and fractures of regenerated bone, and allows early rehabilitation. The new intramedullary lengthening nails, which theoretically are the ideal device for treating limb length inequality, are still very expensive and need longer follow-up for definitive evaluation. LEVEL OF EVIDENCE: 4.

Surgical treatment of primary trapezio-metacarpal osteoarthritis by trapeziectomy and ligament reconstruction without tendon interposition. Long-term results of 50 cases.

BACKGROUND: Primary trapezio-metacarpal osteoarthritis can be painful and disabling. Surgical treatment is used when conservative treatment, such as splinting or oral analgesics, fails. The purpose of this study was to report the long-term outcomes obtained in 40 patients (50 thumbs) surgically treated for thumb osteoarthritis by trapeziectomy and ligament reconstruction without tendon interposition. MATERIALS AND METHODS: Forty patients (50 thumbs), with severe trapezio-metacarpal osteoarthritis, surgically treated by trapeziectomy and ligament reconstruction without tendon interposition were reviewed after an average follow-up of 8 years. All patients were women. At follow-up, clinical results were evaluated on the basis of the DASH score, possible presence of pain and the following criteria: palmar abduction of the thumb, carpometacarpal joint opposition of the thumb (Kapandji), extension of the metacarpophalangeal joint and strength of the hand. RESULTS: The DASH score improved from 42.65 (preoperatively) to 16 (at follow-up), and most patients were asymptomatic. Palmar abduction of the thumb averaged 57 mm. Carpometacarpal joint opposition averaged 8.8. Metacarpophalangeal extension was abnormally increased in 86% of the cases. The strength of the operated hand was comparable to the contralateral side in 46 cases. Radiographic examinations showed a slight proximal migration of the first metacarpal bone (< 3 mm) in all cases but mild signs of carpometacarpal osteoarthritis in only 4 cases. CONCLUSIONS: Based on the reported experience, we believe that primary trapezio-metacarpal osteoarthritis surgically treated by trapeziectomy and ligament reconstruction without tendon interposition allows good long-term results. LEVEL OF EVIDENCE: Therapeutic IV.