Quantitative computed tomography assessment of bone mineral density in adolescent idiopathic scoliosis: correlations with Cobb angle, vertebral rotation, and Risser sign.

Background: Adolescent idiopathic scoliosis (AIS) is a prevalent spinal disorder that can potentially influence bone mineral density (BMD), thereby increasing the susceptibility to osteoporosis and fractures. Early identification of reduced bone mass in AIS patients is crucial for clinicians to develop effective preventive strategies against fractures. This study aims to elucidate the correlation between BMD, as measured by quantitative computed tomography (QCT), and various clinical parameters in AIS, including the Cobb angle, vertebral rotation, and the Risser sign. By revealing the potential influences of these factors on BMD, our findings aim to assist clinicians in making informed and timely decisions regarding AIS management, particularly in situations where QCT is unavailable. Methods: A cross-sectional study was conducted on 129 adolescents with AIS who were enrolled at The Third People's Hospital of Chengdu, Sichuan, China, between 2021 and 2023. QCT was employed to assess BMD and vertebral rotation. The Cobb angle and Risser sign were determined through radiographic evaluation, while anthropometric and biochemical data were also collected. Statistical analyses, including Pearson and Spearman rank correlation and regression models, were used to investigate the associations between BMD and clinical measures. Results: A significant negative correlation was found between BMD and Cobb angle (coefficient =-0.663; P<0.001), as well as between BMD and vertebral rotation angle (coefficient =-0.442; P<0.001) in patients with AIS. BMD was positively correlated with increased height (coefficient =0.355; P<0.001) and BMI (coefficient =0.199; P=0.02). A significant association was detected between BMD and the Risser sign (P=0.002). No significant sex-based differences in BMD were observed (P=0.052). No significant correlations were observed between BMD and levels of potassium (K), calcium (Ca), inorganic phosphate (P), and iron (Fe) (P>0.05 all). The binary logistic regression analysis identified Cobb angle as a risk factor of lower BMD presence in AIS patients (coefficient =0.072; OR=1.075; P<0.001). Furthermore, the receiver operating characteristic (ROC) analysis of the combined model for predicting low BMD in AIS patients yielded an area under the curve (AUC) value of 0.900, with an optimal threshold determined as 0.398. The sensitivity and specificity were calculated as 0.816 and 0.900, respectively, indicating a robust predictive capacity. Conclusions: This study highlights the significant inverse correlation observed between BMD measured by QCT and both Cobb angle and vertebral rotation angle in patients with AIS. Furthermore, a notable variation in BMD was found across different Risser sign categories, with BMD values generally increasing as Risser sign levels increased. Additionally, our findings indicate that Cobb angle serves as a risk factor for low BMD presence. Moreover, a combined model was developed to predict the likelihood of low BMD occurrence in AIS patients.

Treatment and Outcome of Supracondylar Humeral Fractures in Children Over 10 Years of Age at the Time of Injury: A Review of 60 Cases.

OBJECTIVES: To assess the treatment and outcomes of supracondylar humeral fractures (SHFs) in children older than 10 years of age at the time of injury. METHODS: The study analyzed clinical data from 60 patients who sustained SHF, all over the age of 10 years, were analyzed. The patients included 49 males and 11 females with a mean age of 10.9 ± 0.9 years (range, 10 to 14.5). All patients underwent surgical treatment under general anesthesia. Closed reduction (CR) and percutaneous fixation were the primary treatment, with open reduction and internal fixation being employed only in cases CR was unsuccessful. The study assessed the healing of fractures by measuring the radiographic angles, including the carrying angle (RCA), Baumann's angle (BA), and metaphyseal-diaphyseal angle (MDA) on anteroposterior radiographs of the elbow joint. In addition, the study evaluated whether the anterior humeral line (AHL) appropriately passed through the middle third of the capitellum. The final follow-up visit used the Mayo Elbow Performance Index score (MEPI) and Flynn's criteria to analyze the recovery of elbow function. RESULTS: There were 15 (25%) SHF type II, 17 (28.3%) type III and 28 (46.7%) type IV. Of the 60 patients, 56 (93.3%) underwent successful CR, whereas 4 (6.7%) required open reduction and internal fixation because of an unsuccessful CR. The final follow-up showed the average BA as 72° ± 5.3°, the average MDA as 88.3° ± 2.8°, and the average RCA as 9.6° ± 3.9°. The AHL bisected accurately the capitellum in 59 cases (98.3%). The average range of elbow flexion-extension was 146.6° ± 8.6°, whereas the average MEPI score was 99.9 ± 0.6; 98.3% (n=59) were rated as excellent and 1.7% (n=1) were rated as good. According to Flynn's criteria, 86.7% had an excellent outcome (n=52), 10% had a good outcome (n=6), and 3.3% had a poor outcome (n=2). Only 1 patient (1.7%) experienced redisplacement. Eight cases of nerve injury were reported, with 7 involving the radial nerve and 1 involving the ulnar nerve; all resolved spontaneously. CONCLUSIONS: CR and percutaneous fixation have been shown to be effective in treating SHF in 93.3% of children aged 10 years old and older at the time of injury, with favorable radiographic and functional outcomes and a low risk of secondary displacement. Open reduction should only be considered when CR is ineffective.

Pioneering a chick embryo model to explore the intrauterine etiology of developmental dysplasia of the hip in oligohydramnios conditions.

OBJECTIVE: To explore the impact of oligohydramnios on fetal movement and hip development, given its association with developmental dysplasia of the hip (DDH) but unclear mechanisms. METHODS: Chick embryos were divided into four groups based on the severity of oligohydramnios induced by amniotic fluid aspiration (control, 0.2 mL, 0.4 mL, 0.6 mL). Fetal movement was assessed by detection of movement and quantification of residual amniotic fluid volume. Hip joint development was assessed by gross anatomic analysis, micro-computed tomography (micro-CT) for cartilage assessment, and histologic observation at multiple time points. In addition, a subset of embryos from the 0.4 mL aspirated group underwent saline reinfusion and subsequent evaluation. RESULTS: Increasing volumes of aspirated amniotic fluid resulted in worsening of fetal movement restrictions (e.g., 0.4 mL aspirated and control group at E10: frequency difference -7.765 [95% CI: -9.125, -6.404]; amplitude difference -0.343 [95% CI: -0.588, -0.097]). The 0.4 mL aspirated group had significantly smaller hip measurements compared to controls, with reduced acetabular length (-0.418 [95% CI: -0.575, -0.261]) and width (-0.304 [95% CI: -0.491, -0.117]) at day E14.5. Histological analysis revealed a smaller femoral head (1.084 ±â€¯0.264 cm) and shallower acetabulum (0.380 ±â€¯0.106 cm) in the 0.4 mL group. Micro-CT showed cartilage matrix degeneration (13.6% [95% CI: 0.6%, 26.7%], P = 0.043 on E14.5). Saline reinfusion resulted in significant improvements in the femoral head to greater trochanter (0.578 [95% CI: 0.323, 0.833], P = 0.001). CONCLUSIONS: Oligohydramnios can cause DDH by restricting fetal movement and disrupting hip morphogenesis in a time-dependent manner. Timely reversal of oligohydramnios during the fetal period may prevent DDH.

Total hip arthroplasty in patients with common pediatric hip orthopedic pathology.

Purpose: Literature regarding total hip arthroplasty for pediatric hip diseases is scarce. This review aims to portray the various orthopedic conditions of childhood that can lead to significant impairment of the hip joint and, ultimately, to total hip arthroplasty in adolescence and adulthood. Methods: In total, 61 out of 3666 articles were selected according to (1) the diagnosis of one of the 12 pediatric hip pathologies (Legg-Perthes-Calvé disease, developmental dysplasia of the hip, slipped capital femoral epiphysis, neuromuscular hip dysplasia, post-traumatic avascular necrosis of the proximal femur, juvenile rheumatoid arthritis, achondroplasia, spondyloepiphyseal dysplasia, mucopolysaccharidosis, mucolipidosis, hip infections, and tumors) that required total hip arthroplasty; (2) minimum follow-up of 16 months; (3) assessed outcome with a clinical or radiologic score; (4) Methodological Items for Non-Randomized Studies quality score of 9 or higher. The following information for each pathology was retrieved: mean age at total hip arthroplasty, reason for total hip arthroplasty, type of total hip arthroplasty, surgical technique, mean follow-up, and outcomes. Results: Overall, the mean age at total hip arthroplasty for pediatric hip disease is in the sixth and seventh decade, except for tumors and skeletal dysplasias. The reason for performing total hip arthroplasty is often osteoarthrosis and abnormal anatomy. Prosthesis types change based on patient's conditions and technological advances; custom-made implants are used for tumors, juvenile rheumatoid arthritis, and skeletal dysplasias; for other diseases, the most frequent are modular cementless implants. Outcomes are generally good, and all studies portray functional and pain improvements. Conclusion: Total hip arthroplasty is performed more frequently than in the past in patients with pediatric hip pathologies; it enhances patients' quality of life by reducing pain and improving function. However, revision rate in these patients is not negligible.

Simultaneous subtalar arthroeresis, midfoot soft tissue release, and talo-navicular arthrodesis in children with planovalgus neurologic foot.

PURPOSE: Planovalgus foot deformity (PVFD) is common in children with neuromuscular conditions and severe deformity may require surgical correction. This study aims to assess clinical and radiological outcomes of PVFD secondary to neuromuscular disease managed by subtalar arthroeresis (SuAE), midfoot soft tissue release and talo-navicular arthrodesis (TNA). METHODS: A retrospective analysis of children with neuromuscular disease and nonreducible PVFD who underwent SuAE, midfoot soft tissue release, and TNA and with a minimum follow-up of 5 years was performed. A total of 60 patients with neuromuscular disease (108 feet) including cerebral palsy were reviewed. Mean age at surgery was 12.7 ± 4.6 years (6-17). Mean follow-up was 7 ± 2.9 years (5-10). Clinical outcomes and radiologic correction at final follow-up were compared with preoperative values. Statistical analysis was performed and significance was set at P < 0.01. RESULTS: Statistically significant radiological improvements between pre- and postoperative values were found for all angle values. At final follow-up, there was a significant improvement in VAS score (4.8 vs. 2; P < 0.01). There was also a positive trend in the improvement of walking ability. No cases of pseudoarthrosis were reported at final follow-up. Screw removal was required in 5 out of 108 feet (4.6%) and 2 feet (3.3%) had delayed medial wound healing. CONCLUSIONS: SuAE combined with TNA and midfoot soft tissue is a safe and feasible procedure that can provide good clinical and radiologic results in patients with neuromuscular disease and nonreducible PVFD; the procedure can improve foot stability, and has a limited number of complications. LEVEL OF EVIDENCE: IV.

Are Generative Pretrained Transformer 4 Responses to Developmental Dysplasia of the Hip Clinical Scenarios Universal? An International Review.

OBJECTIVE: There is increasing interest in applying artificial intelligence chatbots like generative pretrained transformer 4 (GPT-4) in the medical field. This study aimed to explore the universality of GPT-4 responses to simulated clinical scenarios of developmental dysplasia of the hip (DDH) across diverse global settings. METHODS: Seventeen international experts with more than 15 years of experience in pediatric orthopaedics were selected for the evaluation panel. Eight simulated DDH clinical scenarios were created, covering 4 key areas: (1) initial evaluation and diagnosis, (2) initial examination and treatment, (3) nursing care and follow-up, and (4) prognosis and rehabilitation planning. Each scenario was completed independently in a new GPT-4 session. Interrater reliability was assessed using Fleiss kappa, and the quality, relevance, and applicability of GPT-4 responses were analyzed using median scores and interquartile ranges. Following scoring, experts met in ZOOM sessions to generate Regional Consensus Assessment Scores, which were intended to represent a consistent regional assessment of the use of the GPT-4 in pediatric orthopaedic care. RESULTS: GPT-4's responses to the 8 clinical DDH scenarios received performance scores ranging from 44.3% to 98.9% of the 88-point maximum. The Fleiss kappa statistic of 0.113 (P = 0.001) indicated low agreement among experts in their ratings. When assessing the responses' quality, relevance, and applicability, the median scores were 3, with interquartile ranges of 3 to 4, 3 to 4, and 2 to 3, respectively. Significant differences were noted in the prognosis and rehabilitation domain scores (P < 0.05 for all). Regional consensus scores were 75 for Africa, 74 for Asia, 73 for India, 80 for Europe, and 65 for North America, with the Kruskal-Wallis test highlighting significant disparities between these regions (P = 0.034). CONCLUSIONS: This study demonstrates the promise of GPT-4 in pediatric orthopaedic care, particularly in supporting preliminary DDH assessments and guiding treatment strategies for specialist care. However, effective integration of GPT-4 into clinical practice will require adaptation to specific regional health care contexts, highlighting the importance of a nuanced approach to health technology adaptation. LEVEL OF EVIDENCE: Level IV.

Epidemiology and distribution of cruciate ligament injuries in children and adolescents, with an analysis of risk factors for concomitant meniscal tear.

Introduction: To investigate the epidemiological features and prevalence of cruciate ligament injuries (CLI) in children and adolescents, and to examine the potential risk factors associated with concomitant meniscal tear (MT) among this population. Methods: The demographic data and injury details of children and adolescents with CLI from Southeast China were analyzed to describe their distribution characteristics, alongside an analysis of the prevalence of MTs, the most frequent complication. In addition, binary logistic analysis was employed to ascertain the risk factors linked to MT in individuals suffering from CLI. Results: A total of 203 patients with CLI (n = 206) met the inclusion criteria, with a male-to-female ratio of 2.3:1. Notably, a higher proportion of females were aged ≤16 years old compared to males, who predominated in patients aged >16 years (P = 0.001). Among children and adolescents, anterior cruciate ligament (ACL) injuries were the primary type of CLI, accounting for 88.18% (179/203) of all cases. The majority of cases (132/203, 65.02%) were sustained during sports activities, and sprains were the predominant mechanism of injury (176/203, 86.7%). Additionally, the most common associated injury was an MT (157/203, 77.34%). The posterior horn is the most frequently affected site for both medial MT (62.93% out of 73 cases) and lateral MT (70.19% out of 73 cases). Moreover, vertical tears constituted the majority of medial MTs (59.48% out of 116 cases). Furthermore, patients with a higher BMI faced an increased risk of associated MT in comparison to non-overweight patients (88% vs. 73.86%; P = 0.038). Each increase in BMI unit was linked with a 14% higher probability of associated MT occurrence in children and adolescents with CLI (OR = 1.140; P = 0.036). Discussion: ACL injuries are a common form of knee ligament injury among children and adolescents, especially those over the age of 16, and are often the result of a sprain. Meniscal posterior horn injury is the most commonly associated injury of youth with CLI. Additionally, overweight or obese people with CLI are at a greater risk of developing MT.

Cast versus Kirschner wire fixation in type II paediatric phalangeal neck fractures.

PURPOSE: To compare the outcomes of type II pediatric phalangeal neck fractures (PPNFs) treated with closed reduction and cast immobilization (CRCI) versus closed reduction percutaneous pinning (CRPP), and evaluated the clinical efficacy of conservative versus surgical treatment of type II PPNFs via meta-analysis. METHODS: Patients aged ≤ 14 years with type II PPNFs were divided into conservative (CRCI) and operative (CRPP) groups. Radiographs measured angulation and translation; hand function was assessed with total active range of motion (TAM) and Quick-DASH. Complication rates were also compared between the groups. A meta-analysis of conservative versus operative treatment confirmed the clinical results. Statistical analysis was performed using SPSS 26.0 and R studio 3.0 with two-tailed, chi-squared, and Mann-Whitney U or t-tests, P < 0.05. Meta-analysis used fixed or random effects models, calculating mean differences and odds ratios for outcomes, and assessing heterogeneity with I2 and Q tests. RESULTS: Final angulation (3.4° ± 3.7° and 4.9° ± 5.4° vs. 3.6° ± 3.7° and 4.2° ± 4.3°) and displacement (6.3% ± 5.8% and 5.7% ± 4.7% vs. 5.8% ± 5.5% and 3.2% ± 4.2%) in the coronal and sagittal planes were not different statistically between the conservative and surgical groups (P > 0.05), but improved significantly compared to preoperative values (P < 0.05). Although Quick-DASH scores were comparable in both groups (P = 0.105), conservatively treated patients had a significantly better TAM at the last follow-up visit (P = 0.005). The complication rates were 24.2% and 41.7% in the surgical and conservatively treated groups respectively (P = 0.162). However, the latter primarily experienced imaging-related complications, whereas the former experienced functional complications (P = 0.046). Our meta-analysis (n = 181 patients) also showed comparable functional (P = 0.49) and radiographic (P = 0.59) outcomes and complication rates (P = 0.21) between the surgical (94 patients) and conservative (87 patients) groups. CONCLUSIONS: Conservative and surgical treatments are both reliable and safe approaches for managing type II PPNF in children. However, conservatively treated patients generally experience similar radiographic outcomes, lower complication rates, and better functional outcomes than surgically treated ones.

Is posterior vertebral arthrodesis at the end of the electromagnetic rod lengthening program necessary for all patients? Comparative analysis of sixty six patients who underwent definitive spinal arthrodesis and twenty four patients with in situ lengthening rods.

PURPOSE: Magnetically controlled growing rods (MCGR) should be removed or changed at most two years after their implantation in the treatment of patients with early-onset scoliosis (EOS) (Safety notice July 2021). However, in the face of patients at high risk of intraoperative complications and relying on the principle of auto-fusion of the spine, some surgeons would prefer a more wait-and-see attitude. The aim of this study was to report on patients who did not undergo final fusion at the end of the lengthening program with MCGR and to compare them with those who did. METHODS: This was a multicenter study with ten centres. We collected all graduate patients with EOS who had received MCGR between 2011 and 2022. RESULTS: A total of 66 patients had final fusion at the end of the lengthening program and 24 patients kept MCGRs in situ. The mean total follow-up time was 66 months (range, 25.3-109), and the mean follow-up time after final lengthening was 24.9 months (range, 3-67.7). Regarding the main curve and thoracic height, there was no significant difference in the percentage of correction over the whole follow-up between the two groups (p = 0.099, p = 0.176) although there was a significant difference between the end of lengthening and the last follow-up (p < 0.001). After completion of the lengthening program, 18 patients who had final fusion developed 24 of the 26 recorded complications (92.3%). CONCLUSION: Contrary to the manufacturer's published safety notice, not all patients systematically benefited from the removal of the MCGRs. Although arthrodesis significantly improved the scoliotic deformity, no significant difference was found in terms of radiographic outcome between patients who underwent spinal fusion and those who kept the MCGRs in situ.

Epidemiological characteristics and distribution of pediatric supracondylar fractures in South China: a retrospective analysis of 760 cases.

To evaluate demographic characteristics and distribution of pediatric supracondylar fractures (SCFs) at a tertiary hospital in South China. A retrospective observational study was conducted on children aged 15 years or younger with a diagnosis of SCFs during the period from January 2016 to December 2018. Patients' medical records and radiographs were retrospectively analyzed for age at the time of injury, sex, site and mechanism of traumatic injury. A total of 760 patients with 761 SCFs were reviewed (453 males, 59.6%, and 307 females, 40.4%). There were 748 extension-type fractures (98.3%) and 13 flexion-type fractures (1.7%). Associated injuries were identified in 30/760 (3.9%) patients: associated fracture ( n  = 15; 2%), nerve injury ( n  = 12; 1.6%), open fracture ( n  = 2; 0.2%) and compartment syndrome ( n  = 1; 0.1%). Age at the time of fracture has a bimodal pattern with a first peak around the age of 1 year and a second peak around the age of 4-5 years. The fractures occurred mostly around 11 a.m. and between 4 and 9 p.m. in the evening. Most fractures occurred at home (50.7%), and falling down (62.2%) was the most frequent mechanism of injury. SCFs occurred most frequently in children aged 1 and 4-5 years, and during daylight hours. In about 96% of cases, these were isolated injuries, and falling down was found to be the most frequent traumatic mechanism. Based on our findings, targeted educational efforts and interventions can be set up in order to prevent the occurrence of SCFs in South China. Level of evidence: III.

Radiologic, clinical, and functional evaluation of children with displaced T-condylar fractures treated by closed reduction and percutaneous fixation using the Mayo Elbow Performance Score.

PURPOSE: T-condylar (T-C) fractures of the distal humerus are rare in children. There is no accepted treatment for such an injury, and there is a lack of reports evaluating the outcome of T-C fractures treated by closed reduction and percutaneous fixation. The aim of this study was to evaluate the feasibility of closed reduction and percutaneous K-wire and screw (CRPKS) fixation in patients with type II and III T-C fractures according to the Toniolo-Wilkins classification modified by Canavese et al. (TWC classification). METHODS: The clinical data of 12 consecutive patients (8 males, 4 females) who were younger than 14 years of age and who had a T-C fracture that was managed by CRPKS were retrospectively evaluated. Fractures were classified according to the TWC classification. The baseline information of the patients, carrying angle (CA) and Mayo Elbow Performance Score (MEPS) were used to evaluate clinical and functional outcomes; related complications were recorded. Statistical analysis was performed. RESULTS: The mean age at the time of injury was 11.6 ± 1.8 years (range, 8-14). The time from injury to surgical treatment was 1.5 ± 1.0 days (range, 0-3), and the mean follow-up duration was 33.7 ± 12.3 months (range, 18-61). Surgery lasted 45.7 ± 7.6 min on average (range, 35-58). All fractures healed in 4.9 ± 1.0 weeks on average (range, 4-7). At the last follow-up visit, the CA was 12.6° ± 5.8° on the injured side and 13.8° ± 1.8° on the uninjured side (p=0.432). The MEPS was 100 (95, 100) on the injured side and 100 (100, 100) on the uninjured side (p=0.194). Three complications were recorded. CONCLUSION: Good functional and radiological outcomes can be expected in pediatric patients with type II and III T-C fractures treated by CRPKS. The technique is relatively simple to perform and has a lower rate of complications.

The Duration of Hardware Retention After Radiologic Union of Surgically Treated Femoral Neck Fractures in Children May Predict the Aggravation or Occurrence of Avascular Necrosis of the Femoral Head or Neck After Hardware Removal.

BACKGROUND: The incidence of aggravation or occurrence of avascular necrosis (AVN) following hardware removal in surgically treated pediatric femoral neck fractures who achieved radiologic consolidation is unknown. This study aimed to investigate the risk factors for this complication. METHODS: Seventy-one pediatric (mean age: 9.8±3.9 y) were retrospectively analyzed. Risk factors (age, sex, laterality, severity of initial displacement, type of fracture, time from trauma to reduction, reduction and fixation method, quality of reduction, time required to achieve radiologic union, duration of hardware retention, presence of AVN before hardware removal and follow-up time) were recorded. The severity of AVN was assessed based on radiographs with Ratliff's classification. RESULTS: Following hardware removal, the aggravation/occurrence of AVN was detected in 11 hips (15.5%). Among the 5 hips (7%) with aggravation of AVN, 1 (1.4%) with type II AVN and 3 (4.2%) with type III AVN exhibited aggravation of type I AVN, while the remaining hip (1.4%; type I) showed enlargement of the involved AVN area. Six hips (8.5%) developed AVN following hardware removal: 2 (2.8%) were classified as type I and 4 (5.6%) as type III. Receiver operating characteristic curve analysis indicated that hardware retention >7 months after union is associated with a decreased rate of aggravation or occurrence of AVN of the femoral neck or head following hardware removal. CONCLUSIONS: The incidence of aggravation or occurrence of AVN following hardware removal in surgically treated pediatric femoral neck fractures is 15.5%; hardware retention >7 months after radiologic union may reduce the risk of aggravation or occurrence of AVN of the femoral neck or head postimplant removal. LEVEL OF EVIDENCE: Level III.

Is there an alternative to the Delbet-Colonna classification? Introduction and reliability assessment of a new classification system for paediatric femoral neck fractures: preliminary results.

PURPOSE: The purpose of this study was to introduce a new classification system for paediatric femoral neck fractures (PFNFs) and to evaluate its reliability. METHODS: Two hundred and eight unilateral PFNFs (mean patient age: 9.0 ± 4.8 years) were included. Based on preoperative radiographs, the new classification system distinguished PFNFs without anterior or posterior translation (Type I), PFNFs with anterior (Type II) or posterior (Type III) translation, PFNFs with a comminuted medial or posterior column (Type IV), and subtrochanteric femoral fractures (SFFs; Type V). Radiographs were evaluated twice with an interval of two weeks by 19 raters with different specialties, experiences and geographical origins. The results were compared with a selection of 50 patient age-matched unilateral PFNFs and SFFs (mean patient age: 9.1 ± 4.9 years). These were graded twice by the same graders according to the Delbet-Colonna (D-C) classification. RESULTS: Four radiologists and 15 paediatric orthopaedic surgeons from Europe and Asia graded the radiographs. Fair agreement was found between radiologists (κ = 0.296 ± 0.01) and surgeons (κ = 0.3 ± 0.005) (P = 0.17), although more experienced surgeons performed better than less experienced ones; a similar fair assessment was found for raters from Europe (κ = 0.309 ± 0.021) and Asia (κ = 0.3 ± 0.006) and for type II, III and IV fractures; the κ value in the first evaluation (0.309) was similar to that in the second evaluation (0.298). The overall κ value of the D-C classification subtypes was significantly higher (0.599 ± 0.217) than that of the new classification, 0.326 ± 0.162 (t = 3.190 P = 0.005). CONCLUSIONS: The new classification system showed fair reliability relative to the D-C classification. The reliability of the new classification system was not affected by the specialty or geographic origin of the rater or the evaluation round, only by rater experience level. The concordance was worse for PFNFs with anterior or posterior translation or with a comminuted medial or posterior columns.

Does enhanced cognitive performance reduce fracture risk? a Mendelian randomization study.

OBJECTIVE: While observational studies have suggested a link between cognitive performance and fracture risk, the causality and site-specific nature are unclear. We applied Mendelian randomization (MR) to elucidate these associations. METHODS: 147 single-nucleotide polymorphisms (SNPs) tied strongly to cognitive performance (p< 5e-8) were selected. We performed MR analysis to investigate the causal relationship between cognitive performance and fractures at specific sites, including the wrist, upper arm, shoulder, ribs, sternum, thoracic spine, lumbar spine, pelvis, femur, leg, and ankle. The primary estimate was determined using the inverse variance-weighted method. Additionally, we examined heterogeneity using the MR Pleiotropy RESidual Sum Outlier test and Cochran Q, and employed MR-Egger regression to identify horizontal pleiotropy. RESULTS: MR analysis identified a causal association between cognitive performance and fractures at the lumbar-spine-pelvis (odds ratio [OR] = 0.727, 95% CI = 0.552-0.956, p = 0.023), and ribs-sternum-thoracic spine sites (OR = 0.774, 95% CI = 0.615-0.974, p = 0.029). However, no causal association was found for fractures at other sites. CONCLUSIONS: This study provided evidence of a causal connection between cognitive performance and fracture risk at certain locations. These findings underline the potential of cognitive enhancement strategies as innovative and effective methods for fracture prevention.

Uninstrumented fusion in cervical kyphosis due to neurofibromatosis type I: report of two paediatric cases.

PURPOSE: Severe cervical kyphosis (CK) in neurofibromatosis type 1 (NF-1) is associated with a high risk for progression and neurologic impairment in children. We present our surgical technique and mid-term outcomes of uninstrumented anterior tibial strut grafting for severe CK secondary to NF-1. METHODS: Case report. The Consensus-based Clinical Case Reporting Guideline Development (CARE) guidelines were followed. RESULTS: Two paediatric patients (8- and 3-year-old) presented with severe CK secondary to NF-1. A halo body jacket (HV) allowed the progressive distraction of the cervical spine, avoiding neurological compromise and deformity progression. Circumferential fusion was obtained with anterior tibial strut autograft and posterior onlay bone graft. Cervical spine fusion was successfully maintained at a minimum 4-year follow-up in both patients. CONCLUSION: In children with severe CK secondary to NF-1, cervical distraction and immobilisation with a HV followed by uninstrumented anterior tibial strut grafting and posterior bone grafting, provided spinal fusion and stability without increasing the risk of neurological injury and donor site morbidity. The reported surgical technique appears to be a valuable tool in the armamentarium of the spinal surgeon.

Causal Link between Gut Microbiota, Neurophysiological States, and Bone Diseases: A Comprehensive Mendelian Randomization Study.

Increasing evidence highlights a robust correlation between the gut microbiota and bone diseases; however, the existence of a causal relationship between them remains unclear. In this study, we thoroughly examined the correlation between gut microbiota and skeletal diseases using genome-wide association studies. Linkage disequilibrium score regression and Mendelian randomization were used to probe genetic causality. Furthermore, the potential mediating role of neuropsychological states (i.e., cognition, depression, and insomnia) between the gut microbiota and bone diseases was evaluated using mediation analysis, with genetic colocalization analysis revealing potential targets. These findings suggest a direct causal relationship between Ruminococcaceae and knee osteoarthritis (OA), which appears to be mediated by cognitive performance and insomnia. Similarly, a causal association was observed between Burkholderiales and lumbar pelvic fractures, mediated by cognitive performance. Colocalization analysis identified a shared causal variant (rs2352974) at the TRAF-interacting protein locus for cognitive ability and knee OA. This study provides compelling evidence that alterations in the gut microbiota can enhance cognitive ability, ameliorate insomnia, and potentially reduce the risk of site-specific fractures and OA. Therefore, strategies targeting gut microbiota optimization could serve as novel and effective preventive measures against fractures and OA.

Diagnosis and treatment of "medial to lateral diagonal injury of the elbow" in children: Concomitant medial epicondylar and radial neck fractures.

Purpose: The simultaneous and ipsilateral occurrence of medial epicondylar and radial neck fractures is rare. This study evaluated the clinical and radiological outcomes of medial to lateral diagonal injury of the elbow (MELAINE). Methods: Six males and 6 females were diagnosed with MELAINE (left: 10, 83.3%; right: 2, 16.7%). Medial epicondylar and radial neck fractures were classified according to Papavasiliou's classification (seven type II, two type III, three type IV) and Judet's classification (three type I, four type II and five type III), respectively. All patients underwent surgery. The carrying angle, range of motion, and Kim et al. Elbow Performance Score were used to evaluate clinical and functional outcomes; related complications were recorded. Results: Mean age at injury and mean follow-up were 11.1 ± 2.5 (range, 6-14) and 40 ± 25.6 months (range, 13-90), respectively. All fractures consolidated in 6.3 ± 1.2 weeks on average (4-9). Outcomes were good (n = 1; 8.3%) to excellent (n = 11; 91.7%). The carrying angle of the injured and uninjured side was 15.5°± 2.6° and 14.7°± 2°, respectively (p = 0.218). The range of motion of elbow flexion-extension and forearm pronation-supination of the injured side was 144.2°± 10.4°, 4.6°± 5.4°, 76.7°± 9.1°, 80.4°± 9.2°, respectively, with no significant differences from the healthy side (p > 0.05). The Elbow Performance Score of the injured and uninjured side was 96.3 ± 5.3 and 98.8 ± 2.3, respectively (p = 0.139). No cases of infection, cubitus valgus, stiffness, or instability were recorded. Conclusion: Although uncommon, MELAINE should not be neglected. Surgery aims to stabilize the elbow and avoid valgus deformity. If diagnosed and treated, clinical and radiological results are excellent in most cases.

Factors influencing outcomes of pelvic osteotomy for residual acetabular dysplasia following closed reduction in patients with developmental dysplasia of the hip.

To investigate the factors influencing outcome of pelvic osteotomy (PO) for residual acetabular dysplasia (RAD) following closed reduction (CR) in patients with developmental dysplasia of the hip (DDH). We retrospectively reviewed 91 patients (95 hips) with DDH who underwent PO for RAD. Tönnis grade, Acetabular index, Center Edge Angle, Reimer's Index (RI), and avascular necrosis of the femoral head (AVN) were assessed. Hips were divided into satisfactory (Severin I/II) and unsatisfactory group (Severin III/IV). Finally, 87 hips (91.5%) had satisfactory and 8 (8.5%) unsatisfactory outcomes. The RI before PO was significantly higher in unsatisfactory (49.6 ± 9%) than in satisfactory group (30.6%±11.8%). All patients without AVN had satisfactory outcome, while it was 78.9% of patients with AVN. Logistic regression analysis showed that higher AVN grade and RI before PO were risk factors for unsatisfactory outcome. Satisfactory outcome was obtained in all hips with RI < 33% before PO, while it was 79.5% if RI > 33% before PO (79.5%). There was no difference in the satisfactory rate between patients undergoing open reduction (66.7%) and those not undergoing (83.3%). The rate of satisfactory outcome in patients undergoing femoral osteotomy (63.6%) was lower than those without it (100%). In patients with RAD following CR, good outcome can be expected after PO alone. AVN and preoperative RI > 33% are risk factors for poor outcome. Additional open reduction and femoral osteotomy do not significantly improve outcome of PO in patients with preoperative RI > 33%.