Correction of anterior bowing complicating tibial osteofibrous dysplasia in preadolescents by osteotomy and telescopic nailing without lesional resection: a preliminary study of four-case reports.

BACKGROUND: Osteofibrous dysplasia (OFD) occurs most frequently in the tibia and may result in deformity and pathological fracture. Surgical treatment such as curettage or segment excision has been performed but remains controversial due to high complication rates and surgical burden. This study introduces a new method to manage OFD with anterior bowing of the tibia using minimally invasive tibial osteotomy and telescopic rod (TR) osteosynthesis without extensive lesion resection. METHODS: A retrospective study of 4 children with OFD and tibia bowing deformity treated with minimally invasive tibial wedge osteotomy and TR fixation between January 2015 and November 2020 was performed. Results including bone healing, complications, function based on MSTS score, and recurrance of deformity were assessed. RESULTS: The median follow-up was 29 months. Radiographs showed the median time for union was 3 months. There were no instances of refracture or recurrence of deformity. The mean post-operative MSTS score was significantly higher than preoperative score. CONCLUSIONS: This method avoids large bone defects and reconstructive procedures. It is an effective and minimally invasive approach for managing anterior bowing deformity secondary to OFD while improving function and quality of life. LEVEL OF EVIDENCE: Level IV; Case Series; Treatment Study.

New bone formation accelerates during lower limb lengthening and deformity correction in children with Ollier's disease.

BACKGROUND: Ollier's disease can cause severe length discrepancy of the lower extremities and deformity in children. Osteotomy and limb lengthening with external fixation can correct the limb deformity. This study evaluated (1) whether the duration of external fixation was reduced in patients with Ollier's disease, and (2) the incidence of complications such as pin tract infection, external fixation loosening, and joint stiffness. METHODS: Two groups were compared with respect to age, angular correction (AC), lengthening gap (LG), distraction index (DI), lengthening length (LL), lengthening length percentage (L%), lengthening index (LI), bone healing index (BHI), and external fixation index (EFI). Group 1 (Ollier's disease) comprised nine patients undergoing 11 lower limb lengthening procedures using external fixators; group 2 (control, normal lengthened bone) comprised 28 patients undergoing 29 lengthening procedures with external fixators. RESULTS: In patients with Ollier's disease, full correction of the deformity and full restoration of length were achieved in all cases. In the femur, the mean AC (15.97° vs. 6.72°) and DI (1.11 mm/day vs. 0.78 mm/day) were significantly larger, while the LI (9.71 days/cm vs. 13.49 days/cm), BHI (27.00 days/cm vs. 42.09 days/cm), and EFI (37.86 days/cm vs. 56.97 days/cm) were all significantly shorter in group 1 than in group 2 (p < 0.05). In the tibia, the mean AC and L% were larger, while the LG, LI, BHI, and EFI were all shorter in group 1 than in group 2. There was no significant difference between the two groups in the incidence of complications. CONCLUSION: In children with Ollier's disease, new bone formation accelerated and the healing speed of the lengthened segments was faster throughout the whole lengthening period with external fixation, and full correction of the deformity and full restoration of length could be achieved.

Clinical outcomes of closed, displaced phalangeal neck fractures in children with different types of kirschner wire fixation: A retrospective observational study.

Objectives: Inappropriate treatment of Closed displaced phalangeal neck fractures (CDPNF) in children usually leads to poor outcomes.This study was to evaluate the clinical outcomes of closed/open reduction, age, and different types of fracture and Kirschner wire (K-wire) fixation in the treatment of CDPNF. Materials and methods: Participants: Sixty patients (male, 46 and female,14; right-handed, 35 and left-handed, 25; mean age, 7.9-years-old [range, 1.0-14.5 years]) who had CDPNF were included. Preoperative x-rays showed that the fractures were displaced and exhibited obvious deformities. Interventions: First, reduction (four cases of open reduction and 56 cases of closed reduction) was performed followed by percutaneous K-wire fixation (cross fixation, 24 cases; longitudinal and slanting fixation, 17 cases; homolateral fixation, four cases; and single longitudinal fixation, 15 cases,) and immobilized by cast. x-ray examination following removal of the K-wires showed that the fractures were healed; the criteria for fracture healing were callus formation and the absence of fracture lines. Clinical outcome and radiographs between groups were compared. Results: According to the visual analogue scale, the pain scores were excellent. According to the Al-Qattan Grade system(AGS),all the patients presented with closed, type II phalangeal neck fractures,the results were excellent in 36 cases (36/60, 60%), good in 15 cases (15/60, 25%), fair in 5 cases (5/60, 8.3%) and poor in 4 cases (4/60, 6.7%). There were significant differences in different fracture type groups (P = 0.013*), operation age groups (P = 0.025*) and open/closed reduction groups (P = 0.042*). There was no significant difference in K-wire fixation type groups (P > 0.05). Conclusions: Patients with open reduction, the more serious fracture type, the older at the operation, were more likely to have poor AGS result. Different K-wire fixation types for CDPNF in children had the same satisfactory results.

Displaced supracondylar femoral fractures: Clinical and radiographic outcomes in children aged 4-10 years treated with Kirschner wires and hip spica cast.

Background: Supracondylar femoral fractures (SFFs) are uncommon in children but can cause several abnormalities. Although several methods have been employed to treat these fractures, no accepted standard has been established. Objectives: To investigate the clinical and radiographic outcomes of displaced SFFs treated with Kirschner wires (K-wires) and hip spica casts in children aged 4-10 years. Methods: We retrospectively reviewed 22 displaced SFFs (mean age, 6.7 years; range, 4-10 years) in patients who underwent surgical treatment with K-wires and hip spica casts. The patients were followed-up frequently, radiographically and clinically between January 2014 and February 2019. Postoperative healing and functional results were elevated according to the radiographic and clinical measures. Results: Fifteen boys and seven girls were included in this study. All patients except two (91%), underwent closed reduction and stabilization of the fractures. The mean follow-up duration was four years (range, 2-5 years). All fractures showed clinical and radiological evidence of union 4-8 weeks after surgery. At the most recent check-up, all patients reported being pain-free and had returned to normal activities. The mean Knee Society Score was 95.41 at the final follow-up. According to the radiologic criteria, 18 of the 22 patients (81.8%) obtained excellent results, 3 (13.6%) had good results, 1 (4.5%) had a fair result, and none had poor results. Conclusion: Satisfactory clinical and radiological results can be expected in children aged 4-10 years using a combination of K-wires and hip spica cast fixation.

Characteristics of the length of the radius and ulna in children.

Objectives: Congenital malformation, trauma, tumor, or metabolic disease can cause length deformity of the radius or ulna, affecting the appearance and function of the forearm. Osteotomy and lengthening with external fixation can obviously improve the length of the radius and ulna (LRU). However, the extent of lengthening required is still unclear. This study analyzed the LRU in children, to provide suggested standards for various orthopedic treatments. Methods: Normal LRUs were measured on X-ray images in children who came to hospital for emergency treatment, with measurements including anterior-posterior (AP) radiographs, lateral (LAT) radiographs, full LRU (total length), and LRU without the epiphysis (short length). Any cases of fracture or deformity affecting measurement were excluded. Three hundred twenty-six cases were divided into 16 groups according to age from 1 year old to 16 years old. Results: The earliest epiphyseal plate and ossification center were observed in the distal part of the radius at 1 year old, and in the proximal part at 3 years old in both boys and girls. In the ulna, at the distal end it was 6 years old in girls and 7 years old in boys, while in the proximal part ossification was observed at 9 years old in both boys and girls. The proximal epiphyseal plate of the ulna began to close on X-ray images at 12 years old in girls and 13 years in boys. LRU increased with age, and there was a strong positive correlation and consistent ratio between radius, ulna and age. In short length, the ratio of the length of radius to ulna (RLRU) ranged from 0.8941 to 0.9251 AP, from 0.8936 to 0.9375 LAT. In total length, RLRU ranged from 0.9286 to 0.9508 AP, and 0.9579 to 0.9698 LAT. Conclusions: The length and epiphyseal ossification of the radius and ulna are associated with age. RLRU is also limited to a certain range and tends to remain stable with age. These characteristics have clinical significance for deformity correction of the forearm.

Learning Curve of Closed Reduction and Internal Fixation for Supracondylar Fractures of the Humerus in Children.

Background: This study aimed to identify the threshold for success in supracondylar humeral fracture surgery by describing the learning curve for beginners and exploring the relationship between the learning curve and the prognosis of supracondylar fractures of the humerus. Methods: Surgical information was collected of the first 100 humeral fractures treated by four pediatric orthopedic surgeons. The relationship between operation time, wire placement success rate, and surgical experience was determined using the restricted cubic strip (RCS). The inflection point in the curve and other risk factors that may affect fracture prognosis were collected and subjected to multiple logistic regression to clarify the relationship between the learning curve and prognosis of supracondylar fractures of the humerus. After the training, the four fresh surgeons were interviewed in the form of questionnaires to get feedback from the trainees. Results: A total of 400 supracondylar fractures of the humerus from four pediatric orthopedists were included in the study. On an RCS analysis, 65 surgical experiences were the inflection point of the learning curve. Before and after these 65 surgical experiences, there were significant differences in the patients' anatomical reduction (186 vs. 122, P < 0.001), conversion to incision (33 vs. 6, P = 0.008), and supervising physician guidance (28 vs. 2, P < 0.001). In the multiple logistic regression analysis, functional recovery after supracondylar fractures of the humerus was significantly associated with surgical experience, intraoperative conversion to incision, and post-operative infection. Four surgeons and a supervisor were interviewed. They believed that self-confidence establishment requires the experience accumulation of about 30 operations. The most critical surgical technique is the reduction of fractures. Conclusions: Although the accumulated experience of 30 operations can establish the self-confidence of trainers, fresh surgeons must accumulate experience with 65 operations to master closed reduction and internal fixation for supracondylar fractures. Surgical experience significantly impacts the post-operative recovery of patients with fractures. Level of Evidence: Level III.

Teardrop and sourcil line (TSL): a novel radiographic sign that predicts residual acetabular dysplasia (RAD) in DDH after closed reduction.

Background: Residual acetabular dysplasia (RAD) is a major problem of developmental dysplasia of the hip (DDH) after closed reduction (CR). Several parameters have been investigated as ways of predicting RAD; however, prediction of RAD remains controversial. The purpose of this study was to evaluate the radiographic sign of teardrop and sourcil line (TSL) in pediatric patients with DDH to enable prediction of RAD after CR. Methods: One hundred and twenty-five hips with DDH treated with CR and followed up for at least 2 years were included in this study. The mean age at CR was 18.3 months (range, 9 to 32 months) and the average follow-up time was 50.2 months (range, 24 to 89 months). The acetabular index (AI) was measured at different time points. The cases were divided into two groups according to whether TSL became continuous or not. The relationships among TSL, AI and RAD were analyzed. Results: The RAD incidence was 73.6% (92/125) at the last follow-up. AI at CR and TSL were the prognostic factors for RAD (P=0.017 and 0.001, respectively). Thirty-four hips showed a continuous TSL. There was a lower RAD rate in the TSL continuous group (P<0.001). There was no statistical difference in the AI at CR between the TSL continuous and discontinuous groups; however, the level of AI after CR was lower in the TSL continuous group. The TSL of 74% (20/27) hips became continuous after acetabular osteotomy surgery. Conclusions: The TSL continuous group had a lower AI and incidence of RAD than the discontinuous group. The TSL can be a predictive factor of RAD in DDH after CR and restore the continuous of TSL maybe a potential parameter that can help surgeons to make a judgment intra-operation.

Modified Langenskiöld procedure for congenital patella dislocations in pediatric patients.

BACKGROUND: Great difficulty and more failures were the descriptions of the treatment of congenital patella dislocation in pediatric patients. This study aims to evaluate the outcomes of patients with congenital patellar dislocations treated with the modified Langenskiöld procedure. METHODS: The medical records of 16 knees in 11 patients with a diagnosis of congenital patella dislocation were collected from September 2016 to March 2019. They were treated with the modified Langenskiöld procedure. The mean follow-up period was 37.8 months. The outcome measures were the Lysholm score, Kujala score, patellar stability, and knee range of motion. RESULTS: Eleven patients, namely, eight girls and three boys, with 16 knees were enrolled. The mean age at the time of operation was 3.1 years. The post-operative mean Lysholm score was 94.8 (SD 5.1; 87-100), whereas the Kujala score was 95 (SD 5.9; 86-100). There were no recurrent dislocations, and all patients had full extension postoperatively. CONCLUSION: The modified Langenskiöld procedure is a promising solution for the treatment of congenital patella dislocations. LEVEL OF EVIDENCE: Level IV; Case Series; Treatment Study.

Clinical and epidemiological features of tibial tubercle avulsion fracture in Chinese adolescents.

Background: Tibial tubercle avulsion fracture is rare in children. Accumulated knowledge on clinical and epidemiological features of this fracture is of practical significance for clinical colleagues to deal effectively with such fractures. Methods: Clinical and epidemiological parameters were reviewed retrospectively in 29 patients with tibial tubercle avulsion fracture that was treated in our hospital in the past 7 years. Results: Totally, 29 children with 30 tibial tubercle fractures were enrolled. They were all boys; the average age was 13.8 (12-15) years, and the average Body Mass Index (BMI) was 26.4 (19.2-34.3). Statistically, 41.4% of injuries occurred during jumping activities, and 1 (3.4%), 12 (41.4%) and 16 (55.2%) patients were injured bilaterally, on the right and left sides, respectively. The patients were classified into type I (4), II (3), III (13) and IV (10) fractures. Two patients (three knees) with fractures of type IV received close reduction and cast immobilization for 6 weeks. One patient with fracture of type IV underwent close reduction and was fixed with two cannulated screws. The remaining 26 patients underwent open reduction and were fixed with two or three cannulated screws. The average follow-up time was 38 (14-98) months; no complication was noted. Twenty-seven patients had an excellent outcome. Conclusion: In Chinese adolescents, the tibial tubercle avulsion fracture predisposes to boys with higher body weight; jumping is the most common cause of injury; treatments show satisfactory outcome regardless of fracture types.

Recommendations for control and prevention of infections for pediatric orthopedics during the epidemic period of COVID-19.

The outbreak of Coronavirus Disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged and spread rapidly throughout the world. As of February 29, 2020, 79 389 cases of COVID-19 have been reported, and the outbreak is linked to 2838 deaths. The population is generally susceptible to the disease, and differences in incubation periods after infection exist among individuals. These two aspects of COVID-19 pose significant challenges to pediatric orthopedic diagnosis and treatment. As a dedicated center for managing pediatric cases of SARS-CoV-2 in Shanghai, our hospital has mobilized all branches and departments to undertake joint actions for scientific prevention and control, precise countermeasure and comprehensive anti-epidemic efforts. Combined with our experience, we have consulted the relevant national regulations and the latest research advances and have formulated the prevention and control measures of SARS-CoV-2 infection, including outpatient, emergency, inpatient and surgical cares, for clinical practices of pediatric orthopedics according to the physicochemical properties of SARS-CoV-2. It may serve as practical references and recommendations for managing SARS-CoV-2 infection in other pediatric specialties and in other hospitals.

Guided bone regeneration using a bone tissue engineering complex consisting of a poly-dl-lactide membrane and bone mesenchymal stem cells.

Developmental dysplasia of the hip (DDH) is one of the most common diseases encountered in pediatric orthopedic departments. Current treatment strategies seek to improve acetabular coverage, the principal defect of acetabular dysplasia, but are not very successful. We developed a guided bone regeneration (GBR) strategy to improve acetabular coverage via bone tissue engineering (BTE). Poly-dl-lactide (PDLLA) membranes were seeded with bone marrow mesenchymal stem cells (BMSCs) to form a BTE complex, which was then implanted into the superior margin of the acetabulum in a rabbit DDH model. Twelve weeks later, a small amount of high-density shadowing was evident on X-rays of the superior margin of the acetabulum, specimens of which exhibited new bone formation. Micro-computed tomography yielding three-dimensional images revealed that new bone had formed in the superior acetabulum, the basal part of which had fused with (and thus reconstructed) the autogenous bone, and new trabecular bone featuring transverse interlacing was evident in the interior of the hip. No clear evidence of bone formation was observed in rabbits that underwent sham operations or that were implanted with PDLLA only. Thus, it may be possible to improve acetabular coverage via BTE-based bone regeneration.

Leverage application on Gartland type IV supracondylar humeral fracture in children.

PURPOSE: Although the most complex management of Gartland type IV supracondylar humeral fracture (SCHF) due to instability, the gold standard of initial treatment remains closed reduction and percutaneous pinning. However, open reduction was inevitable in most published studies. This study reports the outcome of treatment by leverage-assisted closed reduction. METHOD: Twenty-seven patients were diagnosed as Gartland type IV SCHF during surgery in 214 preoperative Gartland type III fractures. Leverage-assisted reduction with percutaneous lateral pinning was done in these patients after failure of close reduction. Evaluations were performed with radiographic examination, clinical assessment and Flynn's criteria by interview and physical examination. RESULT: All 27 patients obtained acceptable reduction by leverage-assisted close reduction and percutaneous pinning. The average follow-up was 23.6 (18-30 months). There was no neurovascular complication, infection, nonunion, myositis ossificans or Volkmann's contracture. Evaluation of Baumann's angle was towards varus (74-74.2°). There was no significant difference (p = 0.1876). Flynn's criteria were excellent in 22 (81.5 %) patients, good in four (14.8 %) and fair in one (3.7 %). The rate of excellent and good outcome was 96.3 % and of satisfactory 100 %. CONCLUSION: We recommend leverage-assisted closed reduction as an option before open reduction in type IV SCHF, not only for gold standard management but also because of satisfactory outcomes and the low incidence of major complications.

The role of TGFß1 stimulating ROCK I signal pathway to reorganize actin in a rat experimental model of developmental dysplasia of the hip.

Importance of actin organization in control of chondrocyte phenotype is well established, but little is known about the role of transforming growth factor-ß1 (TFGß1) in regulating of ROCK I signal pathway. Here, we investigated the role of the TGFß1, a well-studied member of the TGF-ß superfamily, in chondrogenesis. Newborn Rats were randomly assigned to developmental dysplasia of the hip (DDH) group and control group. The isolated hips were performed with HE staining and immunohistochemistry. The chondrocytes was isolated and stained by immunofluorescence. The relative quantification of TGFß1 on mRNA level was determined using real-time RT-PCR, and its secretion in culture supernatant in each well was detected by means of ELISA. The expression of ROCK I and ROCK II was detected by means of Western Blot. The relative amounts of actin in detergent-soluble and insoluble fractions were determined. Furthermore, TGFß1 were employed to stimulate normal primary culture chondrocytes in vitro. We found TFGß1 significantly changed in acetabulum chondrocytes after mechanical overloading. Over expression of TFGß1 was observed by means of RT-PCR and ELISA assay. The expression of ROCK I was significantly increased in DDH acetabulum chondrocytes compared with normal cells. The detergent-soluble actin was confirmed reorganization in DDH chondrocytes. Furthermore, TFGß1 can stimulate the ROCK I signaling to modulate actin location in vitro. In conclusion, our data suggested that TFGß1 expression suppresses chondrogenesis through the control of ROCK signaling and actin organization.