Deep vein thrombosis screening in pediatric orthopedic patients.

Background: Deep vein thrombosis (DVT) is an important clinical condition that leads to subsequent morbidity and mortality in children, particularly those who involved operative procedures. The preoperative assessment for DVT in children may vary among different population risk factors and types of surgery. This study aimed to evaluate the screening methods for DVT in pediatric orthopedic patients. Method: We performed a retrospective cohort study of orthopedic patients aged <18 years at Ramathibodi Hospital, Bangkok, Thailand, from 2015 to 2019. The inclusion criteria were children scheduled for orthopedic surgery; who performed a D-dimer test, Wells score, and Caprini score; and who underwent Doppler ultrasonography for DVT screening. The exclusion criteria were incomplete data or inconclusive ultrasonographic results. Age and results of the D-dimer test, Wells score, and Caprini score were collected from all patients. The outcome assessment was ultrasound-proven DVT. The screening abilities of each test were analyzed in terms of sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), likelihood ratio (LR) for positive and negative tests, and area under the receiver operating characteristic curve (AUC). Results: A total of 419 children were included in the study. Five (1.19%) patients were diagnosed with DVT. The mean age was 10.16 ± 4.83 years. D-dimer ≥500 ng/mL had a sensitivity of 100% (95% CI: 47.8%-100%), a specificity of 36.7% (95% CI: 32.1%-41.6%), a PPV of 1.9% (95% CI: 0.6%-4.3%), and an NPV of 100% (95% CI: 97.6%-100%). Wells score ≥3 demonstrated a sensitivity of 0% (95% CI: 0%-52.2%), a specificity of 99.3% (95% CI: 97.9%-99.9%), and an LR for a negative test of 1.00 (95% CI: 1.00-1.01). Caprini score ≥11 had a sensitivity of 0% (95% CI: 0%-52.2%) and a specificity of 99.8% (95% CI: 98.7%-100%). The parallel test included D-dimer ≥500 ng/mL, Wells score ≥3, or Caprini score ≥11 points, generating a sensitivity of 100% (95% CI: 47.8%-100%), a specificity of 36.7% (95% CI: 32.1%-41.6%), an LR for a positive test of 1.58 (95% CI: 1.47-1.70), and an AUC of 0.68 (95% CI: 0.66-0.71). Conclusions: The D-dimer test exhibited moderate ability in predicting the development of DVT among pediatric orthopedic patients requiring surgery. The Wells score and Caprini score had low performance in identifying hospitalized children at increased risk of DVT events.

Factors for selective ultrasound screening in newborns with developmental dysplasia of the hip (DDH).

Background: Hip ultrasound screening for DDH provides better sensitivity compared to physical examination. Due to a lower prevalence and limited resources, selective hip ultrasound in newborns at risk could be considered a proper screening protocol in Thailand and Asian countries. Objective: This study was aimed to evaluate risk factors and define criteria for selective screening. Methods: A case-control study was conducted in 2020. All newborns with hip ultrasound screening were included. Cases were defined as newborns with abnormal hip ultrasounds, while controls were those with normal studies. Inter and intra-rater reliability were evaluated. All factors were analyzed using univariate and multivariate logistic regression. The model performance was tested by Hosmer-Lemeshow goodness of fit. Internal validity was performed by the split data method. Area under the receiver operating characteristic (ROC) curve was estimated. Results: Ninety-five newborns (29 cases and 66 controls) were included. Eighty percent of cases and 58% of controls were female. The gestational age was 36.6 and 37.7 weeks in case and control, respectively. Female, breech presentation, positive Ortolani test, positive Barlow test, and limited hip abduction were significant factors with odds ratio of 2.82, 5.12, 34.21, 69.64, and 5.48, respectively. The final model included breech presentation, positive Ortolani test, and positive Barlow test. The model cut-off value 15.02 provided sensitivity (93.10%) and specificity were (80.30%). The area under the ROC curve was 0.9308. The split data remained significant internal validity for all factors with p-value < 0.05. Conclusion: Careful history taking and physical examination are essential to identify the risk factors for DDH. Newborns with breech presentation, positive Ortolani test and positive Barlow test should be screened by hip ultrasound.

Residual Deformity and Outcome of Ambulatory Adults With Cerebral Palsy: A Long-term Longitudinal Assessment.

BACKGROUND: Advances in pediatric orthopaedic care have improved mobility and function for children with cerebral palsy (CP) as mobility declines from adolescence into adulthood. The long-term effectiveness of modern orthopaedic care is not widely reported. This study aimed to report the pediatric orthopaedic surgical burden, residual deformities, and outcomes using objective evidence of mobility in ambulatory adults with CP. METHODS: An institutional review board-approved prospective cohort study was performed in ambulatory adults with CP between 25 and 45 years, who had an adolescent gait analysis. Orthopaedic interventions were reviewed, and adolescent and adult gait analyses were compared using paired 2-tailed t tests. Adults were categorized by the presence of no, mild, or severe residual deformities in rotation, crouch, stiff knee, equinus, and foot deformity. RESULTS: Of 106 adults with CP, Gross Motor Function Classification System (GMFCS) distribution was grade I (22%), II (50%), III (23%), and IV (5%). Sixty-one males and 45 females were tested. The average age was 30±4 years with follow-up of 13±4 years since previous analysis; 279 surgical events (1165 procedures) were performed with a mean per patient of 2.6 events and 11 procedures. Comm on procedures were gastrocsoleus complex (88%) and hamstring lengthening (79%). The mean gait deviation index at adolescent and adult visit were 72.7±13 and 72.3±13 (P=0.78). Mean gait velocity at the adolescent visit was 85±27 and 79±31 cm/s at adult visit (P=0.02). Both gait deviation index and gait velocity change were clinically insignificant. Fifty-seven adults (81 limbs, 54%) had mild residual deformities. Residual hip internal rotation, pes planovalgus, and crouch gait were common. Severe deformities impacting function or causing pain were present in 11 participants (14 limbs, 10%). Seven of the 11 adults with severe deformities were worse compared with their adolescent evaluation; 4 were unchanged. CONCLUSIONS: Correcting deformities before adulthood has lasting stability with little functional loss in most ambulatory young adults with CP. Increasing deformity after adolescence can occur in young adults but is uncommon. LEVEL OF EVIDENCE: Level III.

The impact of asymmetry on the radiographical outcomes following hip reconstruction in patients with cerebral palsy.

PURPOSE: The purpose of this study was to evaluate the impact of asymmetric hip dysplasia on the outcome of hip reconstruction in patients with cerebral palsy according to preoperative migration percentage (MP). METHODS: This study was institutional review board-approved for retrospective cohort review. From 2008 to 2018, 65 patients met inclusion criteria: Gross Motor Function Scale Classification (GMFSC) III to V with spastic hips (MP > 30%) who underwent bilateral hip reconstruction, with a follow-up > 24 months. Main exclusion criteria: children with associated syndromes or chromosomal disorders. The cohort was subdivided into three groups according to preoperative MP difference between hips: Group A > 50%, group B 20% to 50% and Group C < 20%. Subsequently, the groups were analyzed individually and then compared. The asymmetry of extended abduction of the hip was also evaluated and separated into three groups: no asymmetry (< 20° difference), mild asymmetry (20° to 50° difference) and severe (> 50° difference). RESULTS: In total, 65 patients underwent bilateral bony reconstructive surgery (130 hips). Mean age at surgery was 10.1 years (sd 3.6; 3.6 to 18.4). Mean age at follow-up was 14.7 years (sd 3.8; 8 to 21). Preoperative GMFSC distribution was grade III (four, 6%), IV (15, 23%) and V (46, 71%). In all, 21 symmetric hips (< 20% MP difference) had a preoperative MP difference of 9% and a follow-up MP difference of 18% (p > 0.05); 32 had a preoperative MP difference of 34% and a follow-up MP difference of 16% (p < 0.0001); 12 had a preoperative MP difference of 80% and a follow-up difference of 6% (p < 0.0001). According to pre- and postoperative abduction values, the mean high hip abduction preoperatively was 34° (sd 17°), whereas low hip abduction was 23° (sd 17°). CONCLUSION: Hips with asymmetrical dysplasia and/or abduction undergoing bilateral reconstructive surgery focused on symmetric abduction, and corrected dysplasia in patients with cerebral palsy has improved symmetry in hip abduction and MP. Obtaining this goal immediately postoperatively is maintained to medium-term follow-up. LEVEL OF EVIDENCE: IV.

Network meta-analysis of management of trigger thumb in children.

To estimate and rank cure and recurrence rates between conservative and operative treatments for trigger thumb in children. A systematic review was conducted by searching PubMed and Scopus. Eligible criteria were comparative studies included non-syndromic trigger thumbs, aged up to 10 years, reported at least 20 thumbs and followed up at least 12 months. Two assessors independently extracted data and appraised for cure, recurrence rates among observation, stretching, splinting, open surgery, and percutaneous surgery. We assessed the risk of bias in non-randomized studies of interventions. A network meta-analysis, and probability of being the best outcomes were estimated with surface under the cumulative ranking curves (SUCRA). From 6853 searched articles, eight studies (799 children and 981 thumbs) were included. Mean age was 1.87-2.83 years and average followed up time was 1-5.7 years. Open surgery, percutaneous release, splinting, and stretching had higher cure rate than observation; pooled risk ratio (95% confidence interval) of 2.06 (1.53-2.78), 1.79 (1.26-2.53), 1.76 (1.30-2.36), and 1.37 (0.93-2.03), respectively. Percutaneous release increased risk of recurrence 3.29 times (1.42-7.60) when compared with open surgery. The best cure rates were open surgery (SUCRA = 95) followed by splint (SUCRA = 63.4), and percutaneous technique (SUCRA= 62.8). The highest recurrence rates were percutaneous (SUCRA = 97.3), and open surgery (SUCRA = 62.4). Splint is the most appropriate intervention for pediatric trigger thumb. After failed conservative methods, open surgery is considered for operative treatment. Level of evidence: Therapeutic study level II-III.

Using humeral nail for surgical reconstruction of femur in adolescents with osteogenesis imperfecta.

Osteogenesis imperfecta (OI) is a rare inherited connective tissue disorder caused by mutation of collagen which results in a wide spectrum of clinical manifestations including long bone fragility fractures and deformities. While the treatment for these fractures was recommended as using intramedullary fixation for minimizing stress concentration, the selection of the best implant in the adolescent OI patients for the surgical reconstruction of femur was still problematic, due to anatomy distortion and implant availability. We are reporting the surgical modification by using a humeral nail for femoral fixation in three adolescent OI patients with favorable outcomes.

Infantile hip arthroscopy: the relationship between neurovascular anatomy and the portal pathway.

OBJECTIVE: In the past, studies of hip arthroscopy portal path relate with extra-articular structures were done in adults. This study was investigated in the infantile group. MATERIAL AND METHOD: 10 hips of fresh infantile cadavers. K-wire diameter 2.4 mm. are representing scope pathway. Three portals (anterior, anterolateral and posterolateral) in supine position without traction were chose to used in this study. RESULTS: One cadaver was female and four were male. The mean age and weight when death occurred was 74 days and the mean weight was 3584.4 gm. At the anterior portal, the most lateral branch of LFCN was frequently injured. The average distant of femoral nerve to the K-wire was 11.2 (7-14) mm. Transverse branch of lateral femoral circumflex artery had an average distant 8.5(6-14) mm and the terminal branch could be identified in four hip and average distance was 1 mm. At the anterolateral portal two, greater trochanter were injured by K-wire. In the posterolateral portal the average distant from K-wire to sciatic nerve was 13.2 mm. CONCLUSION: From this pilot study, the distance of major neurovascular structure as related to hip scope path is nearly a centimeter on average.