Acetabular volume and femoral coverage change following Dega-like osteotomy in treatment of developmental dysplasia of the hip.

Although Dega's acetabuloplasty has become a commonly used osteotomy, there is still an ongoing debate regarding its impact on the volume and depth of the acetabulum. The purpose of our study was to assess the postoperative images of the transverse acetabular plane and version obtained from developmental dysplasia of the hip (DDH) patients after a modified Dega osteotomy. We performed a retrospective study of the morphologic indices obtained from the pelvic X-rays and computer tomography (CT) scans of patients with DDH, who were operated in our institution between July 2005 and October 2013, using the modified Dega osteotomy. Preoperative and postoperative pelvic X-rays were used to measure the acetabular index and the acetabular (ACM) angle. The postoperative CT scans were used to measure the acetabular anteversion angle (AAA), acetabular depth and depth of acetabular coverage [total acetabular index (TAI)]. The contralateral unaffected hips served as control. The postoperative acetabular indices and ACMs showed a significant improvement, with near-normal values measured 1 year after the surgery. Comparing the CT scan parameters (AAA, TAI and the depth of acetabulum) showed that TAI and the depth of acetabulum were not significantly different between the groups (TAI: P = 0.423; depth of acetabulum: P = 0.132), whereas AAA comparison implied a slight advantage of the DDH hips (17.6° DDH vs. 13.3° contralateral, P = 0.001). On the basis of images set of acetabular morphometric parameters, our study substantiates previous reports on an increase of acetabular volume and a significant improvement of femoral head coverage for patients with DDH who underwent Dega acetabuloplasty. Level of evidence: Level III - retrospective comparative study.

Early Opiate Analgesic Requirements Following Nonsurgically Managed Tibial Fractures in Children.

BACKGROUND: Many children with tibial fractures are currently being managed as outpatients. It is unclear how much opiates should be prescribed to ensure adequate analgesia at home without overprescription. This study aimed to evaluate the risk factors for requiring opiates following admission for tibial fractures and to estimate opiate requirements for children being discharged directly from the emergency department (ED). METHODS: All children aged 4 to 16 years admitted with closed tibial fractures being treated in a molded circumferential above-knee plaster cast between October 2015 and April 2020 were included. Case notes were reviewed to identify demographics, analgesic prescriptions, and complications. Risk factors were analyzed using logistic regression. RESULTS: A total of 75 children were included, of which 64% were males. The mean age was 9.5 (SD 3.4) years. Opiates were required by 36 (48%) children in the first 24 hours following admission. The median number of opiate doses in the first 48 hours was 0 (range: 0 to 5), with 93% of children receiving ≤3 doses. The odds of requiring opiates in the first 24 hours were unchanged for age above 10 years [odds ratio (OR)=0.85, 95% confidence interval (CI): 0.33-2.23], male sex (OR=1.58, 95% CI: 0.59-4.19), high-energy injury (OR=1.65, 95% CI: 0.45-6.04), presence of a fibula fracture (OR=2.21, 95% CI: 0.72-6.76), or need for fracture reduction in the ED (OR=0.57, 95% CI: 0.20-1.65). No children developed compartment syndrome, and the mean length of stay was 1.4 (SD 1.2) days. No children were readmitted following discharge. CONCLUSIONS: We have found no cases of compartment syndrome or extensive requirement for opiates following closed tibial fractures treated in plaster cast. These children are candidates to be discharged directly from the ED. We have not identified any specific risk factors for the targeting of opiate analgesics. We recommend a guideline prescription of 6 doses of opiates for direct discharge from the ED to ensure adequate analgesia without overprescription. LEVEL OF EVIDENCE: Level IV-case series.

Treatment of completely displaced distal radial fractures with a straight plaster or manipulation under anaesthesia.

AIMS: The management of completely displaced fractures of the distal radius in children remains controversial. This study evaluates the outcomes of surgical and non-surgical management of 'off-ended' fractures in children with at least two years of potential growth remaining. METHODS: A total of 34 boys and 22 girls aged 0 to ten years with a closed, completely displaced metaphyseal distal radial fracture presented between 1 November 2015 and 1 January 2020. After 2018, children aged ten or under were offered treatment in a straight plaster or manipulation under anaesthesia with Kirschner (K-)wire stabilization. Case notes and radiographs were reviewed to evaluate outcomes. In all, 16 underwent treatment in a straight cast and 40 had manipulation under anaesthesia, including 37 stabilized with K-wires. RESULTS: Of the children treated in a straight cast, all were discharged with good range of mo (ROM). Five children were discharged at six to 12 weeks with no functional limitations at six-month follow-up. A total of 11 children were discharged between 12 and 50 weeks with a normal ROM and radiological evidence of remodelling. One child had a subsequent diaphyseal fracture proximal to the original injury four years after the initial fracture. Re-displacement with angulation greater than 10° occurred for 17 children who had manipulation under anaesthesia. Four had a visible cosmetic deformity at discharge and nine had restriction of movement, with four requiring physiotherapy. One child developed over- granulation at the pin site and one wire became buried, resulting in a difficult retrieval in clinic. No children had pin site infections. CONCLUSION: Nonoperative management of completely displaced distal radial fractures in appropriately selected cases results in excellent outcomes without exposing the child to the risks of surgery. This study suggests that nonoperative management of these injuries is a viable and potentially underused strategy. Cite this article: Bone Joint J 2021;103-B(5):902-907.

Preoperative antibiotics for septic arthritis in children: delay in diagnosis.

PURPOSE: To review the records of 50 children who underwent open joint washout for septic arthritis with (n=25) or without (n=25) preoperative antibiotics. METHODS: Records of 50 children who underwent open joint washout for presumed septic arthritis with (n=25) or without (n=25) preoperative antibiotics were reviewed. 17 boys and 8 girls aged 3 weeks to 16 years (median, 1.5 years) who were prescribed preoperative antibiotics before joint washout were compared with 12 boys and 13 girls aged one month to 14 years (median, 2 years) who were not. Following arthrotomy and washout, all patients were commenced on high-dose intravenous antibiotics. Patients were followed up for 6 to 18 months until asymptomatic. RESULTS: Patients who were referred from places other than our emergency department were twice as likely to have been prescribed preoperative antibiotics (p=0.0032). Patients prescribed preoperative antibiotics had a longer median (range) time from symptom onset to joint washout (8 [2-23] vs. 4 [1-29] days, p=0.05) and a higher mean erythrocyte sedimentation rate (93.1 vs. 54.3 mm/h, p=0.023) at presentation. Nonetheless, the 2 groups were comparable for weight bearing status, fever, and positive culture, as well as the mean (range) duration of antibiotic treatment (4.9 [4-7] vs. 4.7 [1-8] weeks, p=0.586). CONCLUSION: Preoperative antibiotics should be avoided in the management of septic arthritis in children. Their prescription delays diagnosis and definitive surgery, and leads to additional washouts and complications. A high index of suspicion and expedite referral to a specialist paediatric orthopaedic unit is needed if septic arthritis is suspected.

[Assessment of absolute knee joint linear and angular velocity in patients with spastic cerebral palsy after operative treatment of lever arm disfunction deformities--prospective study]. / Ocena calkowitej predkosci liniowej i katowej stawu kolanowego u chorych z postacia spastyczna mózgowego porazenia po operacyjnym leczeniu tzw. "deformacji dzwigniowozaleznych" konczyn dolnych--badanie prospektywne.

INTRODUCTION: Lever arm dysfunction (LAD) deformities in patients with CP are based on imbalanced forces acting in lower limbs during gait. Muscle imbalance results in bone axial deformities, simultaneously magnifying biomechanical disturbances. Goal. Analysis of knee joint velocity in patients with spastic dipegia treated with use of single event multi level surgery (SEMLS). MATERIAL: 15 patients (21 limbs), mean age--15 years (12-23) at operation, with spastic CP treated with use of SEMLS were included. In all ceases the distal derotational femoral osteotomy, combined with various additional operative correction were performed. Patients were divided into two groups depending on distal RF transfer as a single criteria. METHOD: Patients were examined with use of VICON 460 motion analysis system: before and 12 months after operative treatment. Lower limb joints ROM, with changed parameters of coronal and sagittal plane moments, was subjected to detailed analysis, with assessment of influence of mentioned moments on knee joint absolute LV and AV during terminal stance (TS), toe off (TO) and initial swing (IS). RESULTS: The statistically significant increase in knee joint LV in TS, TO, IS, p < 0,001, before (mean: TS--536.3 mm/s; TO--668.7 mm/s; 826.1 mm/s) and after (mean: TS--828 mm/s; TO--1007.5 mm/s; 174.5 mm/s) treatment was observed and compared to normal healthy adults. The difference in knee joint AV was statistically significant in TS p = 0.018 (mean: before: 82.2 deg/s; after: 81.2 deg/s) and IS p = 0.023 (mean: before: 53 deg/s; after: 20.2 deg/s). CONCLUSIONS: Joints moments improvement, as an outcome of operative treatment, resulted in increase of absolute LV and AV of knee joint towards values of healthy adults, consequently improving CP patients gait.

[Idiopathic toe walking (ITW)--normal or pathological?]. / Idiopatyczne chodzenie na palcach--norma czy patologia?

UNLABELLED: Idiopathic toe walking ITW appears to be a clinical problem in otherwise healthy children after 3 years of age. The definitions includes patients walking on toes permanently and temporally. Goal. definition of kinematical and kinetic determinants of ITW and the use of gait analysis determinants of ITW according to Alvarez. Material and methods. 8 patients, mean age 7 (4-11), were assessed in Motion Analysis Laboratory with clinical examination use of Vicon 460 (Vicon U.K.) and force plates AMTI (Newton USA). Presence of 1st rocker, early 3rd rocker, and predominance of first ankle dorsal flexion moment was assessed. RESULTS: 1st rocker was observed in 2 patients--group I, early 3rd rocker in 2 patients group II, and predominance of ankle flexion moment in 3 patients--group III, 1 patient was not classified due to presence of 1st rocker combined with predominance of dorsal flexion moment. CONCLUSION: thanks to motion analysis we have a tool to differentiate between behavioral and fixed deformities and adjust treatment--physiotherapy, BTX, serial casting or surgical orthopaedic treatment.

[Pedobarographic evaluation of the foot after Keller's procedure for Hallux valgus and Hallux rigidus]. / Ocena pedobarograficzna stopy po operacji palucha koslawego i sztywnego metoda Kellera.

Hallux valgus and hallux rigidus are common foot deformities. One of possible procedures is Keller's surgery. The purpose of this study is to evaluate the use of pedobarography for postoperative evaluation of the foot. Group. We examined 54 patients aged 48 to 82 (average 60.4) after surgical treatment of Hallux valgus (78 feet) or Hallux Rigidus (15 feet). Methods. Retrospective pedobarographic evaluation 1 to 11 years after surgery was performed using PEL-38 system. Clinical results. All patients had markedly increased pressure under the 2nd and 3rd metatarsal heads comparing to other forefoot regions. Only 17% of feet had distal dynamic transverse arch during stance phase of gait. There was severe impairment of function of the great toe in entire group. In 82.7% of feet there was no ground contact of the great toe in dynamic evaluation of the stance phase. Conclusion. Pedobarographic examination has good value in postoperative functional assessment of the foot. It's a valuable addition to physical and radiological examination.