Axial alignment of the lower limbs affects foot progression angle, knee biomechanics, patellofemoral joint instability, and hip impingement, although a standardized method of reference has not yet been described. An understanding of torsional malalignment is critical in many subspecialty areas of orthopaedics including paediatric orthopaedics, deformity correction, sports medicine, hip and knee surgery, as well as trauma. This article aims to provide a reference system to objectively classify axial plane malalignment of the femur and tibia using the 'axial malalignment test' (AMAT). A cohort of patellofemoral dislocators and control subjects underwent bilateral lower limb MRI scans as part of a research protocol. Their femoral and tibial torsion were calculated on axial slices, and femoral torsion for each patient was plotted with respect to their tibial torsion. The resulting scatterplot was divided into a matrix based on normal values constructed from the dataset. Normal, simple, and complex torsional profiles were defined based on whether there was torsion greater than normal in neither, one, or both bones respectively. Measurements of foot progression angle were also compared in selected patients, with extension of the algorithm to include assessment of any soft tissue contribution to finalize descriptive and quantitative values for the AMAT. The AMAT offers a structured approach that incorporates both bony anatomy and soft tissue function to support systematic assessment of torsional deformities. Validation in a larger cohort is needed to confirm these preliminary findings, given the small sample size.
In pediatric orthopedics, the physis functions as an ally, allowing for remodeling of fractures. However, when physeal bars occur, they can cause leg length discrepancy (LLD) and malalignment. 3D guided techniques can be used to guide the treatment of those physeal bars to achieve a precise resection while protecting the surrounding tissues, allowing growth to resume, and correcting angular deformity. The objective is to describe a 3D imaging-guided technique for excision of partial physeal bars and to report the results of a series of patients who have undergone this procedure. This is a retrospective chart review of five patients treated at a level 1 pediatric tertiary care center by a fellowship-trained pediatric orthopedic surgeon. Inclusion criteria were: (1) Pediatric patients aged 2-18 diagnosed with a partial physeal arrest with resulting deformity, (2) treatment with partial physeal excision using 3D imaging guidance between January 2008 and December 2022, and (3) appropriate radiographic follow-up of at least 6 months. Preoperative 3D imaging demonstrated physeal bar size and location for each patient and was utilized for operative planning. Descriptive statistics were used. The use of 3D imaging guidance for physeal bar excision resulted in improved radiographic angular deformities and LLD. Our cohort had an average physeal bar size of 6.7 ± 3.6% of the physis with no complications reported. A 3D guidance system can help achieve a precise and safe physeal bar resection and is a valuable tool to consider.
Pediatric femoral neck fractures result primarily from high-energy trauma. Common treatment methods include screw fixation and the placement of a proximal femoral locking plate. However, there is limited biomechanical evidence favoring one method over another for the treatment of unstable fractures. This study aimed to evaluate the biomechanical properties of screws and proximal femoral locking plates for the treatment of unstable pediatric femoral neck fractures using a synthetic bone model. Fourteen synthetic composite femurs were divided into two groups that included screw fixation (S) and locking plates (P). All specimens were prepared using a vertically oriented osteotomy to simulate unstable Delbet type II femoral neck fractures. Fixation in Group S employed three 6.5 mm cannulated screws, while Group P utilized a proximal femoral locking plate with 5.0 mm screws. The axial stiffness, cyclic elongation, and ultimate failure load were assessed using a universal material testing machine under standardized loading conditions. Statistical analyses were performed to compare biomechanical properties between the groups. Group P exhibited significantly greater axial stiffness (763 ± 212 N/mm) compared to that of Group S (547 ± 93 N/mm, P  = 0.026). Following cyclic loading, elongation was significantly smaller in Group P (0.42 ± 0.2 mm) vs. Group S (0.88 ± 0.4 mm, P  = 0.002). The ultimate failure load was also higher in Group P (2511 ± 321 N) than it was in Group S (2036 ± 256 N, P  = 0.007). The failure modes differed, with Group S exhibiting screw bending and femoral neck collapse and Group P exhibiting subtrochanteric fractures. Proximal femoral locking plates offer superior biomechanical performance compared to that of screw fixation in unstable pediatric femoral neck fractures. These findings suggest that locking plates are a viable alternative to enhance stability and potentially reduce postoperative complications.
Intoeing is a common reason for pediatric orthopedic consultations. Families increasingly use YouTube for medical information, but the reliability and quality of this content are unclear, and no previous study has evaluated videos on intoeing. This study assessed the reliability, educational quality, and popularity of YouTube videos on intoeing using validated scoring systems and a novel disease-specific tool. YouTube was searched using the terms 'intoeing', 'pigeon toe', and 'toeing in'. After applying inclusion and exclusion criteria, 48 videos were analyzed. Video characteristics were recorded, and reliability and quality were evaluated using the Journal of the American Medical Association score, Global Quality Score, DISCERN instrument, and the Intoeing Specific Score (ISS) developed for this study. Popularity was measured using the Video Power Index. Interobserver and intraobserver reliability were calculated, and statistical analyses examined associations between scores, video sources, and content. Overall quality was low: 76.4% of videos scored less than or equal to 2 on the Journal of the American Medical Association score, and 54% were rated poor or very poor by DISCERN. According to the ISS, 43.8% were very poor. Academic and physician-generated videos had higher educational quality but lower popularity than nonprofessional sources. Videos from YouTube-verified uploaders scored significantly higher in all quality measures, yet popularity did not correlate with educational quality. YouTube videos on intoeing are generally low quality, revealing a gap between popularity and reliability. Although academic and physician-generated content is more accurate, it is less represented among popular videos. The ISS showed strong reliability and may be useful for future evaluations of disease-specific online content.
The aim of this research was to evaluate clinical and radiographic outcomes in patients with Ogden type IV and V tibial tubercle fractures treated at two tertiary hospitals. We conducted a retrospective review of patients with Ogden type IV and V tibial tubercle fractures treated between 2010 and 2024. Demographic data, fracture characteristics, mechanism of injury, treatment modality, and fixation method were recorded. Radiographic parameters were measured before and after treatment, and at final follow-up. Clinical outcomes included range of motion, return to sports and complications. Forty-one patients met the inclusion criteria; 95.1% were male, with a median age of 14 years and a mean follow-up of 3 years and 8 months. Sports-related trauma accounted for 80.4% of injuries. Forty fractures were Ogden type IV and one type V. Conservative treatment was used in four (9.7%) patients, whereas 37 (90.3%) patients underwent surgical fixation, mostly with 7.0-mm cannulated screws. Fracture union was achieved in all cases. Complications occurred in eight (19.5%) patients, including screw prominence, infection, varus deformity, limb-length discrepancy, and transient peroneal neuropraxia. No cases of compartment syndrome were observed. At final follow-up, 95.2% of patients returned to their preinjury level of sports participation, and 92.6% regained full knee range of motion. Radiographic evaluation demonstrated restoration and maintenance of tibial alignment. We conclude that Ogden type IV tibial tubercle fractures and the only one Ogden type V demonstrated favorable clinical, functional, and radiographic outcomes, with high union rates and a low incidence of severe complications.
Developmental dysplasia of the hip (DDH) represents a wide range of abnormalities affecting the acetabulum and femoral head. Traditional diagnostic tools such as anteroposterior pelvic radiographs are limited in evaluating the three-dimensional morphology of the acetabulum, especially in pediatric populations. This study introduces novel measurement parameters that include both angular and dimensional metrics for a comprehensive assessment of acetabular morphology. It also compares these parameters between normal and dysplastic hips in pediatric population. Computed tomography scans of 35 children with unilateral DDH, aged between four and 48 months, were analyzed, comparing dysplastic and normal hips. Parameters measured included anterior and posterior acetabular indexes and lengths, anterior and posterior coverage angles, lengths, and posterior coverage area, dome length and dome coverage. Statistical analyses evaluated differences between groups. Dysplastic hips exhibited higher anterior and posterior acetabular index values and reduced anterior and posterior acetabular lengths, reflecting global elongation and shallowness. Anterior coverage angle was significantly greater, while posterior coverage angle and posterior coverage parameters were reduced, highlighting posterior wall deficiencies. Dome coverage was also significantly decreased. All measurements showed good to excellent interobserver and intraobserver reliability (0.68-0.94 and 0.76-0.92, respectively). Our findings suggest that DDH involves global acetabular deficiencies, including posterior insufficiency, challenging the traditional focus on anterolateral deficiencies. The introduced parameters provide a reproducible method for evaluating pediatric acetabular morphology, offering valuable insights for diagnosis and treatment planning. Future studies should validate these findings and explore MRI for enhanced diagnostic accuracy.
We examined how clinical experience relates to use of contralateral comparison radiographs in pediatric elbow/ankle trauma and quantified diagnostic change, additional-imaging requests, and observer agreement. In this multicenter, two-stage observer study, 12 anonymized pediatric trauma cases (six elbows and six ankles) were retrospectively selected (anteroposterior/lateral; mortise added for ankles) and reviewed by 120 orthopedic clinicians (residents, general orthopedic surgeons, and pediatric orthopedic specialists). Observers first assessed unilateral radiographs and later the same cases with bilateral comparison radiographs. Outcomes were comparison-radiograph requests, postcomparison diagnostic change, additional-imaging requests, and inter-/intra-observer agreement. Across 1440 assessments, comparison radiographs were requested in 47.2% overall - highest in junior residents (54.5%) and lowest in pediatric orthopedic specialists (33.0%; P = 0.003). Inter-observer agreement increased with experience (κ junior → pediatric: 0.44 → 0.82; P < 0.01); intra-observer stability likewise improved (junior κ = 0.32 vs. pediatric κ = 0.84; P < 0.001). Diagnostic change after comparison decreased with experience (P = 0.002). Additional-imaging requests peaked in senior residents and then declined across specialist levels (P < 0.001). Soft-tissue presentations and Salter-Harris I scenarios generated the highest additional-imaging demand. Increasing experience was associated with fewer comparison-radiograph requests, fewer diagnostic revisions, and higher agreement. Findings support selective comparison imaging and targeted training. The study evaluates practice patterns and reliability rather than diagnostic accuracy or outcomes.
Atlantoaxial instability (AAI) is a common but potentially severe complication in pediatric patients with Down syndrome, while its surgical characteristics and outcomes remain understudied compared with non-Down syndrome populations. To compare the clinical presentation, radiological features, surgical strategies, and postoperative outcomes of AAI between pediatric patients with Down syndrome and matched non-Down syndrome controls. A retrospective case-match study was conducted, including 15 patients with Down syndrome along with AAI who underwent surgical atlantoaxial arthrodesis between 2009 and 2022. Each case was matched with two non-Down syndrome controls by age, sex, and AAI severity. The patients were divided into two groups: the Down syndrome group (group DS) and the control group (group C). Data included clinical presentation, radiographic parameters [atlantodental interval (ADI) and space available for the spinal cord (SAC)], surgical approach, complications, and fusion rates were compared between the two groups. Patients with Down syndrome exhibited a higher incidence of neurological symptoms (12/15, 80%) compared with controls (5/30, 16.7%) (P < 0.05). Os odontoideum was more common in patients with Down syndrome (10/15, 66.7%), while rotatory dislocation was more common in patients with non-Down syndrome (9/30, 30%); nine (60%) in group DS and one (2.9%) in group C had a high-signal area on MRI. Preoperative ADI was larger for group DS compared with group C (9.0 vs. 7.4 mm; P < 0.01). The ADI and SAC were significantly corrected and were comparable at the last follow-up. Preoperative Japanese Orthopaedic Association scores were significantly smaller in group DS compared with group C (13.3 vs. 16.5; P < 0.01). Neurological symptoms were significantly improved in all patients at the last follow-up. All included patients underwent posterior atlantoaxial screw-rod fixation and fusion. Only two patients suffered superficial wound infection at the iliac bone area, and another patient in the neck (20%), and no complications occurred in group C. Solid fusion was shown in all patients by the time of the last follow-up. Pediatric patients with AAI often have os odontoideum and hypoplasia of the dental process. Posterior atlantoaxial screw-rod fixation can result in good fusion and neurological function recovery.
We evaluated the imaging and clinical outcomes of posterior thoracic-pelvic corrective fixation (TP-PCF) for nonambulant neuromuscular scoliosis (NA-NMS), including the Caregiver Priorities and Child Health Index of Life with the Japanese version of the Disabilities Questionnaire (J-CPCHILD), and analyzed the J-CPCHILD and preoperative and postoperative radiographic parameters to determine whether sagittal and coronal alignment correlate with preoperative and postoperative quality of life (QoL) in NMS, respectively. Twenty-five patients (nine males and 16 females) with a mean age of 14.3 ± 2.0 years, who had TP-PCF and were followed up for >2 years postoperatively, were included. Sitting radiographs and the J-CPCHILD were evaluated preoperatively, at 1 year postoperatively, and at the final visit. Preoperative major curve and pelvic obliquity (PO) were 102.4 ± 22.2 ° and 21.5 ± 9.9 °, which significantly improved to 51.4 ± 18.8 ° and 10.9 ± 7.6 °, respectively, at the final visit. At the final visit, lumbar lordosis and sacral slope showed a significant increase of 46.6 ± 18.5 ° and 30.2 ± 17.5 ° compared with preoperative values of 25.8 ± 33.2 ° and 24.4 ± 31.0 °, respectively. Sagittal vertical axis showed a significant decrease of 2.2 ± 35.3 mm at the final visit compared with 37.1 ± 36.5 mm preoperatively. However, iliac screw (IS)-related implant failure was observed in four (16%) patients. Significant improvement from 37.1 ± 20.8 to 51.2 ± 25.2 points and from 49.6 ± 12.6 to 59.1 ± 14.9 points was observed in the positioning domain ( P  = 0.047) and total score ( P  = 0.032) of the J-CPCHILD, respectively, at 1 year postoperatively compared with preoperatively. However, no correlations were identified between the respective domains of the J-CPCHILD and the magnitude of the major curves, PO, or sagittal plane vertical axis, either preoperatively or postoperatively. According to caregivers, improvement in comprehensive trunk stability with better global balance, similar to that of the ambulant patient, contributed to overall QoL after TP-PCF for NA-NMS. However, IS-related implant failure occurred in approximately 16% of the patients.
The reproducibility of radiographic parameters used to assess pediatric supracondylar fracture reduction, including Baumann angle, lateral capitellohumeral angle (LCHA), carrying angle, and anterior humeral line (AHL) crossing the capitellum, was evaluated. Two observers undertook a total of 2368 measures on 148 elbow radiographs from 107 patients aged 0-12 years. The observers, who were blinded to their own measurements and each other's measurements, performed the measurements twice with a 1-month interval using an electronic goniometer. The average value and reliability of the measurements were evaluated. Intraobserver and interobserver reliability were determined using intraclass correlation coefficients (ICCs). The mean LCHA of the 148 elbow population was 52.4° (range: 27-74°), the mean Baumann angle was 71.5° (range: 54-90°), and the mean carrying angle was 18° (range: 5-37°). 80% of the AHL was in the middle third of the capitellum. The ICCs for interobserver reliability were moderate to good for Baumann angle 0.71-0.78, for LCHA 0.72-0.72, for carrying angle 0.83-0.85, and for AHL 0.89-0.90. The ICCs for intraobserver reliability were moderate to excellent for Baumann angle 0.93-0.86, for LCHA 0.91-0.81, for carrying angle 0.71-0.92, and for AHL 0.94-0.90. This study demonstrated that Baumann angle, LCHA, carrying angle, and AHL are reliable measuring methods, with normal values reported in the Turkish population.
Lateral opening wedge osteotomy has been utilized in adolescent and adult deformity with the advantage of maintaining the length of the femur. Polyetheretherketone (PEEK) cage can be utilized to fill the opened wedge. Using the cage in opening wedge valgus osteotomy may not only help in bone on-growth healing but also makes the surgery more straightforward through immediate stability of the osteotomy site and allow for earlier mobilization. Between 2017 and 2021, 44 consecutive patients (14 males and 30 females, mean age: 20.8 years, range: 14-36 years) presented with knee valgus deformity. Their mean mechanical tibia-femoral angle (mTFA) at the center of rotation of angulation at the distal femur was 30.7 ° (± 2.74) of valgus. All patients were treated with lateral opening wedge osteotomy using a lumbar PEEK fusion cage designed for posterior lumber interbody fusion and fixed with a distal femoral locking plate. No postoperative casting was used. Modified Hospital for Special Surgery (HSS) knee score pre and postoperatively with a mean follow-up of 36.8 (± 2.8) months. All cases achieved bony union after a mean of 7.5 (± 1.7) weeks, presented with full range of motion, and maintained an mTFA of 7.5° (± 1.8) at the latest follow-up of 36.8 months that had been corrected from a preoperative mTFA of 30.7° (± 2.74). The modified HSS knee score improved from 58.4 (± 1.7) preoperatively to 85.7 (± 2.3) at final follow-up. A PEEK cage augmentation of the femoral lateral opening wedge gap resulted in successful healing and maintenance of the corrected limb axis at a ~3‑year follow‑up.
Pediatric open fractures present major challenges in wound management because of high infection risk and delayed healing. This study compared the clinical efficacy of vacuum sealing drainage (VSD) combined with moist exposed burn ointment (MEBO) versus VSD combined with hydrogel dressings in pediatric open fracture wounds. A retrospective analysis was performed in 222 pediatric patients with refractory fracture wounds, including 119 treated with VSD + MEBO and 103 treated with VSD + hydrogel dressings. Outcomes assessed included wound healing time, overall treatment efficacy, total treatment cost, pain intensity evaluated using the Visual Analogue Scale (VAS), serum inflammatory markers [high-sensitivity C-reactive protein (hs-CRP), procalcitonin (PCT), and interleukin-6 (IL-6)], and complication rates. Compared with the VSD + hydrogel group, the VSD + MEBO group demonstrated significantly faster wound healing and lower total treatment costs (both P < 0.001). VAS scores on days 3 and 5 after dressing application were also significantly lower in the VSD + MEBO group (P < 0.001). Moreover, serum levels of hs-CRP, PCT, and IL-6 on day 7 were significantly reduced in the VSD + MEBO group compared with the VSD + hydrogel group (P < 0.001). No significant differences were observed between the two groups in overall treatment efficacy or complication rates (P > 0.05), indicating comparable safety. In conclusion, VSD combined with MEBO accelerates wound healing, reduces inflammation and pain, and lowers treatment costs in pediatric open fracture wounds, demonstrating potential clinical advantages.
This study aimed to assess the determinants affecting parental satisfaction and trust in clinical care of children with clubfoot at a specialized clubfoot clinic in a tertiary care setting. In this cross-sectional study at Khyber Teaching Hospital, 306 attendants of children with clubfoot were recruited using consecutive sampling. Pirani score was used to evaluate the severity. Satisfaction levels were assessed using Short Assessment of Patient Satisfaction score. Data were analyzed using SPSS, with chi-square tests. The mean number of clinic visits was 8.52 ± 5.08; 55.6% of patients required more than eight clinical visits, and 82.7% underwent treatment for more than 8 weeks. Mean Short Assessment of Patient Satisfaction score was 23.37 ± 5.19; 82% of parents expressed satisfaction, whereas 18% showed variable levels of dissatisfaction. High dissatisfaction was correlated with greater than eight visits (P = 0.014), prolonged treatment duration (P = 0.008), Ponseti management with serial casting plus tenotomy versus serial casting only (very dissatisfied: 43.8% vs. 2.4%; P < 0.001), and unsatisfactory clinical outcome (P < 0.001). Significant concerns included lack of shared decision-making (19.3% dissatisfied), unclear explanations (10.2% dissatisfied), and overall dissatisfaction towards the health services (23.6% dissatisfied; 16.0% neutral). Even with high satisfaction and satisfactory outcomes with the Ponseti method, high frequency of visits, long treatment durations, inadequate parental participation and lack of effective communication compromise caregivers' trust. Enhancing patient-centered approach, proper counseling, and effective care delivery may influence follow-up and satisfaction in sustained pediatric orthopedic care and optimize compliance.
The purpose of this study is to describe the mid-term complication profile after limb salvage for pediatric bone sarcomas utilizing all reconstruction techniques. A retrospective review was performed on patients less than 18 years who underwent resection of a primary bone sarcoma with limb salvage reconstruction. The primary outcome measure was the all-cause postoperative complication rate. Complications were grouped into major or minor categories. Patients were stratified by reconstruction type (endoprosthetic, allograft, allograft-prosthetic composite, biologic). The timing of complications and reoperations was analyzed. Eighty-four patients were included (median follow-up 46 months). The overall complication rate was 75%, and the major complication rate was 36%. Twenty-five percent had two complications, and 18% had three or more complications. The reoperation rate was 55%, and 14% required three or more reoperations. Seventy-one percent of patients sustained their first complication within 1 year. Twenty-eight percent of patients underwent a reoperation within 12 weeks. Limb salvage for pediatric bone sarcomas is associated with a high rate of complications and reoperations, regardless of reconstruction technique. Despite the substantial complication rate, these procedures are essential to the multidisciplinary care of children with bone sarcomas, as limb salvage is commonly pursued. We hope to provide realistic postoperative expectations and argue that surgeons caring for these patients must be prepared to manage complications, as they tend to arise during the window of adjuvant chemotherapy.
This study aimed to evaluate the outcomes of guided growth - temporary hemiepiphysiodesis - in patients with fibular hemimelia (FH) and proximal femoral focal deficiency (PFFD), with a focus on treatment effectiveness, success rates, complications, and rebound phenomena. A retrospective review was conducted using medical records and standing radiographs from a prospective database of all FH and PFFD patients treated with guided growth for genu valgum deformity between 2007 and 2017. Forty-two children (28 with FH and 14 with PFFD) comprising 55 operated physes were included. The mean duration of follow-up was 51.11 ± 27.56 months from the first surgical intervention. Thirty-two physes were treated for pathological mechanical lateral distal femoral angle abnormalities, achieving a mean angular correction of 6.24° in the FH group and 6° in the PFFD group, with corresponding time-to-correction intervals of 14.07 months and 11.56 months. Twenty-three physes were operated on for pathological mechanical medial proximal tibial angle deformities, with mean angular corrections of 4.43° (FH) and 6.22° (PFFD), and time-to-correction of 17.95 months and 20.35 months, respectively. Among the 30 children in whom implants were removed, 12 (40%) developed recurrent deformity - 7 of 21 in the FH group and 5 of 9 in the PFFD group. Patients with first-episode rebound required repeat hemiepiphysiodesis. A second recurrence occurred in 3 of 21 (14%) FH patients and 2 of 9 (22%) PFFD patients. Temporary hemiepiphysiodesis is an effective method for correcting angular deformities around the knee in this congenital cohort, with a low complication rate but a notable risk of rebound.
Hereditary multiple exostoses (HME) represent a rare skeletal disorder characterized by multiple osteochondromas, often leading to angular deformities in the lower limbs as well as leg length discrepancy (LLD), managed with tension band plates (TBP) for deformity correction. However, the utility of both angular deformity and LLD in HME has not been comprehensively evaluated. In this study, we retrospectively reviewed 25 pediatric patients with HME who visited our institution and reached skeletal maturity between 2012 and 2024, assessing a total of 50 limbs. Surgical indications included patients aged greater than 10 years with an open growth plate, predicted LLD of greater than or equal to 20 mm at the skeletal maturity, and a mechanical axis zone (MAZ) greater than or equal to Zone 2. We categorized the outcomes into four groups: excellent [LLD < 10 mm; mechanical axis percentage (%MA) ≤ ±25%], good (LLD < 15 mm; %MA ≤ ±50%), fair (LLD < 20 mm or at least one limb classified as %MA ≤ ±100%), and poor (worse than the previous categories). We used paired t-tests for statistical analyses. Among the 17 surgically treated patients, TBP was performed on 27 limbs and 60 physes. In most cases, multisite and staged surgeries were required. Angular deformities improved significantly, with the mean hip-knee-ankle angle reduced from 7.8 to 2.7° (lower extremity < 0.01), and 92% of limbs achieved MAZ Zone 1. LLD was corrected from 17.6 to 5.6 mm (P < 0.01) at an average correction rate of 0.47 mm/month. The final outcomes were excellent, good, and fair or poor in 12, 11, and 2 patients, respectively. Major complications were not observed. TBP treatment is effective in correcting both angular deformity and LLD in patients with HME, offering a minimally invasive strategy for comprehensive correction of this complex skeletal dysplasia. Careful surgical planning and timing are essential and staged multisite procedures are often required.
Congenital talipes equinovarus (CTEV) is a common musculoskeletal entity that affects 1-2 per 1000 of live births worldwide. Most are idiopathic with a typical deformity of midfoot cavus, forefoot adductus, hindfoot varus, and equinus. Controversy exists whether CTEV results primarily from in-utero soft-tissue abnormality or the defect is in the osteocartilage anlagen. This fetus study aimed to elucidate the gross anatomical morphology and morphometry of bones, joints, and soft tissue in CTEV compared with the normal foot. This comparative cross-sectional study done on 12 normal feet and four CTEV (two bilateral and two unilateral) in nine fetuses without spinal defects, aborted between 16-18, 19-20, 22-24, 26-28, and 32-33 weeks, analyzed the morphological and morphometric parameters. In CTEV, the talus was plantarflexed with a short medially deviated neck, and the posterior facet was flat instead of the normal quadrilateral shape, with a less convex tibiotalar articular surface. Calcaneus in CTEV was slightly smaller, displaced into varus, equinus, and internal rotation, and the posterior articular surface was triangular and transversely flat. Angular measurements (α, β, γ, δ) of the talus were increased while the λ angle of the calcaneus was decreased to almost half. All morphometric measurements were statistically significant (P values 0.001 by Mann-Whitney U test). The soft tissues (muscle and tendon) were shorter in length compared to normal. Significant abnormalities were detected in multiple parameters in both osteocartilage anlagen as well as soft tissues in CTEV.
The study aimed to compare rates of recurrent toe walking following operative intervention between idiopathic toe walkers and toe walkers with autism or a similar sensory processing disorder (SPD). A retrospective review of all patients at a single institution who underwent surgical treatment for toe walking over a 12-year period was conducted. Children with neuromuscular disorders, congenital deformities, prior foot/ankle surgery, and those not managed with an isolated triceps surae procedure were excluded. The remaining patients were divided into those with idiopathic toe walking (ITW group) and toe walking associated with autism spectrum/SPDs (SPD group). Toe walking recurrence and need for additional surgery for recurrence were compared between cohorts. A total of 106 patients met inclusion criteria; 29 (27%) had a SPD and 77 comprised the ITW group. There were no differences between groups in follow-up length (average 1.2 years; P = 0.08) or type of index surgery (P = 0.48). SPD patients had significantly more male patients (76 vs. 48%; P = 0.01) and were younger at their index surgery (8.5 vs. 10 years; P = 0.03). SPD patients had significantly higher rates of recurrence than ITW patients (24 vs. 5%; P = 0.009) at an average of 2.6 years following the index procedure. Multivariate regression analysis revealed that an underlying SPD was an independent predictor of recurrence (P = 0.018, odds ratio = 7.5, 95% confidence interval: 1.5-45.2). Autism spectrum disorder/SPDs confer over a seven-fold increased risk of recurrence following the surgical treatment of toe walking when compared with idiopathic toe walkers. The level of evidence is therapeutic level III.
While opioid medications are commonly used to manage postoperative pain in patients undergoing posterior spinal fusion (PSF) for adolescent idiopathic scoliosis, their use is associated with negative short and long-term effects. There is a paucity of data evaluating the feasibility and efficacy of opioid-free pain regimens in this population. The purpose of this study was to compare a multimodal opioid-free with a traditional opioid-containing protocol in pediatric patients undergoing instrumented PSF for idiopathic scoliosis. We hypothesized that the opioid-free pain management pathway would result in equivalent length of stay (LOS) and fewer opioids prescribed at discharge compared with an opioid-containing pathway. This was a prospective case-control study comparing opioid-free versus opioid-containing pathways. Eligible participants included patients aged 10-20 years at time of surgery with idiopathic scoliosis who underwent primary instrumented PSF by a single, fellowship-trained pediatric orthopedic surgeon during a 2-year period. Total opioid use was recorded. Statistical analysis included Wilcoxon, Chi-square, and Fisher's exact tests for group comparisons. Patients in the opioid-free group had a greater number of levels fused ( P  = 0.036), had a similar inpatient LOS postoperatively ( P  = 0.917), and required fewer opioid prescriptions at discharge [10/36 patients (27.8%) vs. 55/56 patients (98.2%), respectively; P  < 0.0001]. A comprehensive, multimodal, opioid-free pain management pathway following instrumented PSF for idiopathic scoliosis results in equivalent LOS and fewer opioids prescribed at discharge compared with an opioid-containing pathway. Establishing patient/family expectations beforehand is crucial to the successful engagement and implementation of this opioid-free protocol.
The popliteal artery runs along the posterior surface of the distal femur. An exostosis on the posteromedial aspect of the distal femur can potentially affect the course of this artery, depending on its position and shape. This study aimed to clarify the relationship between distal femur exostoses and the course of the popliteal artery in patients with multiple cartilaginous exostoses. This study included 10 patients who underwent exostosis resection in the posteromedial aspect of the distal femur between April 2002 and March 2022. Sex, age, operated side, course of the popliteal artery relative to the exostosis, exostosis shape, recurrence rate, and perioperative complications were analyzed. Exostosis shape was classified as pedunculated or sessile based on the lateral radiographic view. The patients were divided into three groups based on the course of the popliteal artery relative to the exostosis: lateral, over, and medial. The study included eight male patients and two female patients. The mean age at operation was 12.8 years. Three patients had pedunculated lesions, and seven had sessile lesions. The popliteal artery ran laterally in six cases, over in three, and medially in one. The median follow-up period was 1.1 years. There were no cases of recurrence or major complications. The course of the popliteal artery may vary depending on the location and shape of the exostosis. Understanding this relationship preoperatively and paying attention to the artery intraoperatively are essential to prevent vascular damage.