Distinguishing risk of curve progression in adolescent idiopathic scoliosis with bone microarchitecture phenotyping: a 6-year longitudinal study.

Low bone mineral density and impaired bone quality have been shown to be important prognostic factors for curve progression in adolescent idiopathic scoliosis (AIS). There is no evidence-based integrative interpretation method to analyze high-resolution peripheral quantitative computed tomography (HR-pQCT) data in AIS. This study aimed to (1) utilize unsupervised machine learning to cluster bone microarchitecture phenotypes on HR-pQCT parameters in girls with AIS, (2) assess the phenotypes' risk of curve progression and progression to surgical threshold at skeletal maturity (primary cohort), and (3) investigate risk of curve progression in a separate cohort of girls with mild AIS whose curve severity did not reach bracing threshold at recruitment (secondary cohort). Patients were followed up prospectively for 6.22 ± 0.33 years in the primary cohort (n = 101). Three bone microarchitecture phenotypes were clustered by fuzzy C-means at time of peripubertal peak height velocity (PHV). Phenotype 1 had normal bone characteristics. Phenotype 2 was characterized by low bone volume and high cortical bone density, and phenotype 3 had low cortical and trabecular bone density and impaired trabecular microarchitecture. The difference in bone quality among the phenotypes was significant at peripubertal PHV and continued to skeletal maturity. Phenotype 3 had significantly increased risk of curve progression to surgical threshold at skeletal maturity (odd ratio [OR] = 4.88; 95% CI, 1.03-28.63). In the secondary cohort (n = 106), both phenotype 2 (adjusted OR = 5.39; 95% CI, 1.47-22.76) and phenotype 3 (adjusted OR = 3.67; 95% CI, 1.05-14.29) had increased risk of curve progression ≥6° with mean follow-up of 3.03 ± 0.16 years. In conclusion, 3 distinct bone microarchitecture phenotypes could be clustered by unsupervised machine learning on HR-pQCT-generated bone parameters at peripubertal PHV in AIS. The bone quality reflected by these phenotypes was found to have significant differentiating risk of curve progression and progression to surgical threshold at skeletal maturity in AIS.

Adolescent idiopathic scoliosis (AIS) is an abnormal spinal curvature that commonly presents during puberty growth. Evidence has shown that low bone mineral density and impaired bone quality are important risk factors for curve progression in AIS. High-resolution peripheral quantitative computed tomography (HR-pQCT) has improved our understanding of bone quality in AIS. It generates a large amount of quantitative and qualitative bone parameters from a single measurement, but the data are not easy for clinicians to interpret and analyze. This study enrolled girls with AIS and used an unsupervised machine-learning model to analyze their HR-pQCT data at the first clinic visit. The model clustered the patients into 3 bone microarchitecture phenotypes (ie, phenotype 1: normal; phenotype 2: low bone volume and high cortical bone density; and phenotype 3: low cortical and trabecular bone density and impaired trabecular microarchitecture). They were longitudinally followed up for 6 years until skeletal maturity. We observed the 3 phenotypes were persistent and phenotype 3 had a significantly increased risk of curve progression to severity that requires invasive spinal surgery (odds ratio = 4.88, p = .029). The difference in bone quality reflected by these 3 distinct phenotypes could aid clinicians to differentiate risk of curve progression and surgery at early stages of AIS.

Novel Use of the Wide-Awake Local Anesthesia No Tourniquet Technique for Release of Spastic Upper Limbs.

Wide-awake local anesthesia no tourniquet procedures allow the patient to remain conscious and cooperative during surgery, allowing intraoperative assessments of hand function. This is useful in spastic hand surgeries, allowing an instant assessment of the muscle releases and residual power, thus guiding an optimal balance with the best possible functional outcomes. We describe the novel use of wide-awake, local anesthesia, no tourniquet surgery in spastic upper-limb surgery in forearm flexor-pronator release, thumb-in-palm and intrinsic-plus deformity correction, and elbow flexor release.

Vitamin D levels among pediatric tuberculosis patients - Does it alter following antitubercular treatment? A prospective study in 19 children.

OBJECTIVES: It is still unknown whether altered vitamin D levels observed with osteoarticular tuberculosis change during treatment in a child or modify the disease course. To find a possible answer to the above query, we investigated serial serum 25 hydroxy vitamin D concentrations in children suffering from osteoarticular tuberculosis treated with multidrug antitubercular drugs. METHODS: The prospective study enrolled 19 untreated immunocompetent children with an established diagnosis of osteoarticular tuberculosis. None of the patients were offered any therapeutic vitamin D supplementation at initiation or during the treatment. The patients were followed for response to multidrug antitubercular therapy (DOTS) at 2 months interval. Mean values of vitamin D were calculated at 0, 2, and 6 months and statistically compared. The following laboratory references for defining the vitamin D status were used: <30 nmol/L = deficiency; 30-75 nmol/L = insufficiency; >75 nmol/L = sufficiency. RESULTS: All the patients responded to antitubercular therapy. Out of the enrolled children, 73.67% had low vitamin D levels at initial presentation. There was no statistically significant difference in vitamin D levels in affected children at either 0-2 (p = 0.452), 2-6 (p = 0.240), or 0-6 months (p = 0.854) following antitubercular treatment. Although the mean vitamin D levels were higher in male patients when compared to female patients at all times, there was no statistically significant difference in vitamin D levels during treatment stages in either sex. CONCLUSIONS: Vitamin D levels were low at initiation of treatment and did not significantly improve during multidrug antitubercular treatment. Further, tuberculosis healed well with antitubercular therapy despite persistence of low serum levels of vitamin D.

The foot abduction characteristics following Steenbeek foot abduction brace.

PURPOSE: We prospectively investigated the foot abduction characteristics following Steenbeek foot abduction brace (SFAB) use in corrected clubfeet. The foot abduction achievable in SFAB with knee flexion and extension was calculated to find the effectiveness and stretch exerted by it. METHODS: Only children with corrected idiopathic clubfeet using SFAB for greater than 3 months were enrolled. The foot abduction with and without brace in knee extended and flexed positions was measured. Hip range of motion (ROM) with and without brace was also recorded. RESULTS: The average age of 42 children ( 62 feet) was 24.25 months (range: 5-48 months). There was difference in foot abduction of 22.2° in knee extension and flexion with SFAB on. A significant change in foot stretch of 25.5° observed when the knee was moved from extended to flexed position indicated SFAB dynamicity. The SFAB was found to be an effective orthosis as it brought the corrected clubfoot into maximum abduction permissible in the foot during the phase of knee flexion. The tibial rotation accounted for a major component (61%) of apparent foot abduction with the brace on. A hip ROM of 52.2° was required for SFAB function. CONCLUSION: SFAB is a dynamic brace that functions better in flexed knee position. It is able to induce a near equivalent actual abduction available in the foot in flexed position of knee. There is a significant component of tibial external rotation in SFAB-induced foot abduction. SFAB function is also dependent on hip mechanics.

Nail changes in casted and braced clubfoot: A preliminary study.

BACKGROUND: The study aimed at finding whether there are any nail changes specific to treatment in clubfoot. METHODS: Sixty new, 26 undergoing serial corrective casting, and 247 clubfoot patients using foot abduction braces were prospectively studied. The casted and braced group formed the basis of the study to observe nail changes, if any. The new patients and opposite normal foot (in unilateral casted cases) were taken as controls. OBSERVATIONS: Acute paronychia, ingrown toe nail, onychoshizia, onychorrhexis, nail plate concavity, latent onychomadesis, and distal onycholysis were observed in feet undergoing corrective casting and bracing. Micronychia, malalignment and thinning of nail plate were the observed congenital nail anomalies. CONCLUSIONS: Nail changes in clubfeet are not infrequent. Certain nail changes might be etiologically linked to casting and bracing. Some of nail changes might require urgent medical care.

The Problems Encountered in a CTEV Clinic: Can Better Casting and Bracing Be Accomplished?

BACKGROUND: The aim of the study is to create awareness in the practicing health care workers toward the problems encountered during casting and bracing of clubfoot following Ponseti method, and in turn avoid them. MATERIAL AND PATIENTS: Retrospective audit of 6 years' clubfoot clinic records to analyze problems associated with Ponseti method. OBSERVATIONS: Problems were encountered in 26 cast and in 6 braced patients. Just 4 patients out of 71 syndromic (5.6%) experienced problems during casting compared with 3% overall incidence. The common problems encountered in casted patients were moisture lesions, hematoma, dermatitis due to occlusion, pressure sores, and fractures. There was excessive bleeding in 1 patient at time of tenotomy. In braced patients, pressure sores and tenderness at tenotomy site were major problems. None of the syndromic patients experienced difficulties during bracing. CONCLUSIONS: Problems were encountered with Ponseti method during casting, tenotomy, or bracing. Syndromic children had lesser complication rate than idiopathic clubfeet. It is important to be aware of these problems so that appropriate intervention can be done early. LEVELS OF EVIDENCE: Level IV: Retrospective.

Ponseti Casting Technique: Using the Flags.

Ponseti casts for congenital clubfoot are generally removed in the clinics by soaking and unwrapping them. It is often difficult to find the plaster bandage edge for unwrapping it. The use of flags at cast ends can ease this problem.

Fibula regeneration following non-vascularized graft harvest in children.

BACKGROUND: A peculiarity of non-vascularized fibular harvest is that the donor site regenerates new bone provided periosteum is preserved. We prospectively investigated the regenerated fibula quantitatively and studied clinical implications of non-regeneration. MATERIAL AND METHODS: The fibula was harvested using a periosteum preserving technique. Only fibulae from healthy legs were harvested. X-rays were done pre- and post-operatively at three and six months. Clinical assessment of donor limb included pain, gait, motor and sensory examination. Fibular regeneration was quantified using defined length and width criteria. RESULTS: There were 16 children with 21 harvested fibula. About 65 % of total fibular length was available for use as graft. There was regeneration of fibula similar to the pre-operative dimensions as early as six months in 71 % of cases. There were no clinical morbid findings as assessed at six months follow up despite non-continuity being observed in 29 % of cases. The predominant site for non-continuity was middle third-distal third junction. CONCLUSIONS: Periosteal preserving non-vascularized fibula grafting was a low morbidity procedure. In two-third of the cases, there was regeneration of fibula comparable to pre-operative dimensions as early as six months. The non-continuous regeneration had no clinical implications.

The Dynamicity of Steenbeek Foot Abduction Brace for Clubfoot in Dorsiflexion and Pronation: A Pilot Study.

PURPOSE: Steenbeek foot abduction brace (SFAB) has been widely used in various national clubfoot programs. The aim of the study was to define effectiveness and dynamicity of SFAB in terms of dorsiflexion and pronation for the corrected clubfoot. METHODS: Differences in foot dorsiflexion and pronation measurement with brace in knee flexed and extended position were recorded as dynamicity1 and dynamicity2, respectively. The residual soft tissue stretch lag despite brace use was calculated by determining the difference between maximum foot dorsiflexion (stretchlag1) and pronation (stretchlag2) achievable without and with brace in knee flexed. Statistical difference between measurements were calculated using paired t tests. RESULTS: There were a total of 63 feet in 40 patients. The mean foot dorsiflexion with brace on in knee extension was 7.57° and in flexion was 15.20°. The foot pronation with brace on in knee extension was 9.46° and in flexion was 16.77°. Thus, SFAB exerted statistically significant differences in foot dorsiflexion and pronation between the knee extended and flexed positions. Dynamicity1 and dynamicity2 were 7.63° and 7.31°, respectively. Stretchlag1 was 18.47° and stretchlag2 was 17.63°. CONCLUSIONS: SFAB demonstrates effective dynamicity in maintaining corrected foot dorsiflexion and pronation. There is a residual soft tissue stretch lag both in dorsiflexion and pronation in corrected clubfoot despite use of SFAB. LEVELS OF EVIDENCE: Therapeutic, Level IV: Case series.

Role of Foot Abduction and Heel Angle in Equinus Correction in Idiopathic Clubfoot: A Pilot Study.

UNLABELLED: Introduction The purpose of this study was to determine whether foot abduction and heel angles have any influence on resultant equinus correction and whether hindfoot dorsiflexion can be predicted based on these parameters.Material and Methods Twenty-four children with 39 unintervened idiopathic clubfeet who completed Ponseti's casting and percutaneous Achilles tenotomy with satisfactory equinus correction (≥15°) were included. Measurements included foot abduction and heel angle at the beginning of cast treatment, pre-tenotomy, and post-tenotomy along with post-tenotomy hindfoot dorsiflexion. Statistical relationships were calculated using Pearson's coefficients.Results The changes in heel angle correlated better with post-tenotomy dorsiflexion achieved than changes in foot abduction. Pre-tenotomy foot abduction or heel angle did not have any statistically significant correlation with post-tenotomy dorsiflexion. Furthermore, there was a significant relationship between post-tenotomy foot abduction and post-tenotomy dorsiflexion.Conclusions Changes in foot abduction and heel angle (from initial casting to pre-tenotomy measurement) statistically correlated to post-tenotomy hindfoot dorsiflexion achieved. Absolute degree measurements of pre-tenotomy abduction or heel valgus did not correlate with the post-tenotomy hindfoot dorsiflexion achieved. There was also significant correlation between post-tenotomy abduction and post-tenotomy hindfoot dorsiflexion. Correlation between post-tenotomy heel valgus and post-tenotomy hindfoot dorsiflexion was weak. LEVELS OF EVIDENCE: Prognostic, Level II: Prospective study.

Steenbeek Brace: Patterns of Wear.

UNLABELLED: Steenbeek foot abduction brace (SFAB) is an essential orthotic for maintaining correction in congenital talipes equinovarus treated with Ponseti method. As the brace is used up to 3 to 4 years of age, we examined the brace wear pattern according to a child's development and age. We studied 100 SFABs that were rendered unusable or returned by parents due to advanced brace wear. SFABs returned due to other reasons such as foot outgrowing shoe size were excluded. Each part of the brace (outer sole, insole, upper leather, abduction bar, shoe laces) was carefully inspected to observe any pattern of damage. We grouped the pattern of brace wear as per the probable causative factors into 3 broad categories: due to general use in all age groups, sitters and crawlers, and walking children. Shredded tongue, elongated/torn shoelace hole, peeled paint of metal abduction bar, shredded outer sole, and frayed shoelace were due to general use. Due to sitting and crawling with the brace on, shoe wore on its anteromedial, anterolateral, and posterolateral parts at the junction of the upper leather and outer sole. The commonest area of shoe wear in walkers was the abduction bar, which either broke from the welded junction between bar and metal or was bent at midpoint. The SFAB wear pattern was related to the age of the child and his/her activities. The reusability of the brace can probably be extended with simple improvisations and instructing parents about the correct use of the brace. LEVELS OF EVIDENCE: Prognostic, Level IV: Case series.

Lymphocyte/monocyte ratio in osteoarticular tuberculosis in children: a haematological biomarker revisited.

INTRODUCTION: *Work attributed to Department of Pediatric Orthopaedics, Chacha Nehru Bal Chikitsalaya, Geeta Colony, Delhi-110031(India)This study tested the hypothesis whether the lymphocyte/monocyte ratio (L/M ratio) altered significantly during treatment of paediatric osteoarticular tuberculosis (OATB) for it to be a useful monitor of the response to therapy. MATERIAL AND METHODS: Thirty immunocompetent paediatric patients with OATB treated with 6 months of uninterrupted multidrug anti-tubercular treatment with resultant clinical and radiological healing of the lesion were included. Haemoglobin, total leucocyte, monocyte and lymphocyte count, and erythrocyte sedimentation rate (ESR) were collected at 0, 2 and 6 months, and were analysed. RESULTS: The L/M ratio altered from high (11) at the start of treatment towards normalisation (9) at 2 months and (7.7) at 6 months. There was no correlation with declining ESR levels. CONCLUSIONS: The L/M ratio may have potential as an effective biomarker response.

Shoulder tuberculosis in children: a report of two cases.

We report 2 children who underwent multidrug antituberculous therapy with rifampicin, isoniazid, ethambutol, and pyrazinamide followed by dedicated physiotherapy for tuberculosis of the shoulder. Both patients regained a range of motion comparable with the contralateral side after 9 to 10 months.

One-year multidrug treatment for tuberculosis of the cervical spine in children.

PURPOSE: To review the clinical and radiological features and treatment outcome in 22 children who underwent one-year antitubercular multidrug treatment for tuberculosis of the cervical spine. METHODS: Records of 13 boys and 9 girls aged 2 to 12 (mean, 9.1) years who underwent one-year antitubercular multidrug treatment for tuberculosis of the cervical spine were reviewed. Tuberculosis involved the atlantoaxial region (C1-C2) in 7 patients, mid-cervical region (C3-C7) in 8, cervicodorsal region (C6-T3) in 3, contiguous multilevels in 2, and non-contiguous multifocal areas in 2. The mean number of vertebrae involved was 2.8 (range, 1-8). The mean symptom duration was 2.5 (range, 0.25-6) months. Three patients had neurological deficits. Antitubercular multidrug treatment included an intensive phase for 2 months and a continuation phase for 10 months, using isoniazid, rifampicin, pyrazinamide, and ethambutol. RESULTS: At a mean of 2.25 (range, 0.5-5) years after treatment, no patient had recurrence, pain, or dynamic instability. Full range of movement was achieved after a mean of 2.7 (range, 1-4) months in all but 3 patients. In the 3 patients with neurological deficits, recovery was achieved after a mean of 8 (range, 5-14) weeks. Soft tissue swelling resolved after a mean of 11 (range, 8-12) weeks. Remineralisation of vertebrae occurred after a mean of 2 (range, 2-6) months. Spontaneous vertebral fusion occurred in only 6 of 22 patients after a mean of 36 (range, 18-72) months. Three patients developed kyphotic deformity. CONCLUSION: Antitubercular multidrug treatment is a viable option for children with tuberculosis of the cervical spine, even in the presence of neurological deficits. Development of deformity is not common; interbody fusion is usually delayed. Patients with contiguous multilevel involvement with vertebral erosion or collapse should be closely monitored for development of late deformity.

Scurvy in pediatric age group - A disease often forgotten?

Scurvy is caused by prolonged severe dietary deficiency of vitamin C. Being rare as compared to other nutritional deficiencies, it is seldom suspected and this frequently leads to delayed recognition of this disorder. Children with abnormal dietary habits, mental illness or physical disabilities are prone to develop this disease. The disease spectrum of scurvy is quite varied and includes dermatological, dental, bone and systemic manifestations. Subperiosteal hematoma, ring epiphysis, metaphyseal white line and rarefaction zone along with epiphyseal slips are common radiological findings. High index of suspicion, detailed history and bilateral limb radiographs aids physician in diagnosing this eternal masquerader. We searched Pubmed for recent literature (2009-2014) with search terms "scurvy" "vitamin C deficiency" "ascorbic acid deficiency" "scurvy and children" "scurvy and pediatric age group". There were a total of 36 articles relevant to pediatric scurvy in children (7 reviews and 29 case reports) which were retrieved. The review briefly recapitulates the role of vitamin C, the various disease manifestations and the treatment of scurvy to create awareness of the disease which still is reported from our country, although sporadically. The recent advances related to scurvy and its management in pediatric age group are also incorporated.

Clubfoot associated with congenital constriction band: the Ponseti method perspective.

BACKGROUND: The clubfoot and congenital constriction band is a known association in which the clubfoot is considered as being rigid, responding poorly to casting, and requiring surgical interventions. OBJECTIVE AND METHODS: The series describes 3 cases of clubfoot with deep ipsilateral congenital constriction bands managed with Ponseti method and immediate outcomes achieved. RESULTS AND CONCLUSIONS: The feet responded favorably to casting although equinus correction required more extensive surgical interventions. The preexisting edema in distal limb often precluded a snuggly fitting cast increasing the cast numbers. Careful monitoring of vascularity is essential. Simultaneous procedures of release of constriction bands, correction of hand anomalies and equinus can be combined to the advantage of the patient. LEVELS OF EVIDENCE: Case report, Level IV.

Lytic lesions of distal radius in children: a rare tubercular presentation.

INTRODUCTION: We report the presentation, management, and outcome in five children with osteoarticular tuberculosis of distal radius. PATIENTS: PATIENTS were recruited in a prospective study. All patients underwent an open biopsy, curettage and diagnosis confirmed by histopathological/microbiological examination. In cavitary lytic lesions, bone grafting was also undertaken. The multidrug anti-tubercular chemotherapy was given for one year. OBSERVATIONS: Five patients were included in the study. The average follow-up post-completion chemotherapy was 34.8 months. Bony lesions presented as a poorly defined radiolucent lytic area in metaphysis, cavitary lytic lesions with or without sequestrum or spanned the physeal plate. At final follow-up, except for one case, a full pain free range of movements was achieved in all cases. Fibular graft was used in two cases with cavitary lesions and incorporated well in both cases. CONCLUSIONS: Tuberculosis can involve the adjacent physis and can be multifocal. The presentation is usually lytic with minimal sclerosis. For smaller ill defined lesions, curettage and multidrug anti-tubercular chemotherapy results in excellent outcome. Cavitary lytic lesions should be bone grafted as there is a risk of pathological fractures.