Treatment perspective after failed open reduction of congenital hip dislocation. A systematic review.

Background: Failure of open reduction of developmental hip dislocation is a serious complication and revision surgery appear to be technically demanding with high complication rates. Little attention has been given in literature to patients in whom open reduction of developmental hip dislocation has failed. We present a systematic review about current perspectives and timing when to perform surgical revision after failed open reduction of developmental hip dislocation in children. Methods: Following the recommendations of the "Preferred Reporting Items for Systematic Reviews and Meta-Analyses" (PRISMA) statements we performed a comprehensive search of the PubMed and Google Scholar bibliographic database in order to select all studies published between 1980 and 2022. Studies were screened for the reasons for failure of open reduction, timing when revision surgery was performed, and for the surgical techniques used for revision. Results: A total of 10 articles including 252 patients and 268 hips has been recorded. The most common causes of re-dislocation after open reduction are inadequate exposure and failure to release the obstructing soft tissues inside and around the hip. In 90% of the cases the anterolateral approach was performed for revision surgery. Avascular necrosis occurred in 5%-67% of cases and was the most encountered complication. Conclusion: Redislocation of developmental hip dislocation after an open reduction has poor long-term outcomes mainly due to a high rate of avascular necrosis of the femoral head. It is mandatory to obtain a stable reduction at the second surgery combining soft tissue release, capsulorrhaphy, pelvic and femoral osteotomies.

Functional and Patient-related Outcomes of Total Hip Arthroplasty in Patients Younger Than 20 Years.

Background: Total hip arthroplasty (THA) in adolescent and young adults represent only about 10% of all THAs. Despite the advances in hip conservation surgery, there are still adolescents and young adults who progress to severe joint degeneration. THA seems to be the last solution in these cases. We aimed to assess the clinical and patient-related outcomes at short-term to midterm follow-up for THAs performed before the age of 20 years. Material and methods: We performed a retrospective monocentric study including all patients that underwent a THA before the age of 20 years between January 2008 and December 2018 at our tertiary orthopaedic center with a minimum follow-up of 2 years. Demographic data were recorded. The Harris and Oxford hip scores were used to assess clinical and patient-related outcomes. Results: A total of 11 patients (12 THAs) were included. Juvenile inflammatory arthritis and avascular necrosis due to slipped capital femoral epiphysis were the most commonly encountered etiologies. The mean age at surgery was 16 years (minimum 13, maximum 19 years). The mean follow-up duration was 6 years (minimum 2, maximum 9 years) without any revision. Regarding the Harris and Oxford hip scores, the mean score were 81 and 39.5 for clinical and patient-related outcomes respectively. The Spearman correlation test revealed a statistically significant positive correlation between the 2 scores of ρ = 0.811 with a P value < .001. Conclusions: THA in adolescents and young adults suffering from end-stage osteoarthritis due to pediatric hip disorders provides improved hip function and notable pain relief at short-term to midterm follow-up.

Myositis ossificans in the pediatric population: a systematic scoping review.

Introduction: Circumscribed or pseudomalignant myositis ossificans (MO) is a rare and benign condition characterized by heterotopic bone formation in soft tissues. The clinical presentation of MO, imaging investigations, histological findings, and treatment strategies are unclear, especially in the pediatric population. Materials and methods: A literature search was conducted in PubMed, Scopus, and Google Scholar electronic databases to identify original articles and reviews in English or French of traumatic and non-traumatic MO. Studies were selected by 2 independent reviewers following the PRISMA recommendation and descriptive data were extracted. We harvest in each case the sex, age at diagnosis, location, presence of initial trauma, pre-emptive diagnosis, modalities of imagery used, realized biopsy, treatment performed, and type of follow-up. Results: Sixty pediatric cases of MO were identified between 2002 and 2023. Twenty-three patients (38.3%) were diagnosed with idiopathic/pseudomalignant and 37 patients (61.7%) with circumscribed. The mean age at diagnosis was 9.5 years (range 0.2-17 years), with a male-to-female ratio of 1:1. The initial pre-emptive diagnosis was neoplasia in 13 patients (21.7%). The biopsy was percutaneous in 9 patients (15%) and incisional in 7 patients (11.7%). Histological analysis was achieved in 35 cases (57%). Surgical excision was the first line treatment in 46.7% of patients, and non-surgical in the remaining patients. The follow-up strategy was clinical in 16 patients (26.7%) or based on imaging investigation in 23 patients (38.3%). Discussion: Although MO in children is described as a rare pathology, identifying the benignity of the condition is essential to avoid unnecessary invasive treatment and to avoid delaying the treatment of a potentially life-threatening entity. It seems that there is no consensus established concerning the proper imaging for diagnosis. Clinicians should acknowledge that the absence of a triggering trauma tends to direct the investigation and the management toward a surgical attitude. Conservative management is key, however, surgical excision can be proposed on matured lesions on a case-by-case basis. The absence of recurrence is not excluded. Therefore, a close clinical follow-up is suggested for all cases. The true benefit of a radiological is questioned in a question known to be self-resolving.

Comparison of treatment outcomes of stable and unstable developmental dysplasia of the hip with the Tübingen splint.

Background: The Tübingen splint was initially developed for the treatment of stable developmental hip dysplasia (DDH). Later on, some authors expanded its include for the treatment of unstable DDH, but there remain some controversies in the literature. This study aims to compare the outcome between stable and unstable DDH treated with a Tübingen splint. Methods: Epidemiological data and ultrasonographic data of all infants diagnosed with DDH and initially treated with a Tübingen splint at our institution between May 2017 and February 2020 were assessed retrospectively. We divided the population into stable and unstable hips using the Graf classification. Age at treatment initiation, duration of treatment, complications, and radiological outcome between 12 and 24 months were investigated. Results: We included a total of 45 patients (57 hips) affected by DDH treated with the Tübingen splint. Treatment has been successful in 93% of stable hips and only 40% of unstable hips. Radiological outcome at 1-year follow-up significantly correlated with initial Graf classification (p < 0.001). Conclusion: The Tübingen splint is a safe and effective treatment for stable hips, nevertheless, for unstable hips, closed reduction, and spica cast remains the gold standard.

Pediatric phalanx fractures: A retrospective study and review of the literature.

Purpose: Conventional radiography is frequently performed in pediatric patients in whom finger fractures are suspected. However, until now, the rate of positive findings of finger radiographic examinations in pediatric patients is unknown. This study aimed to evaluate the number of positive findings in the standard radiographic examinations of finger injuries in pediatric patients in a Level 1 trauma center systematically. Methods: We conducted a retrospective study on all children 0-16 years old admitted for acute finger injury in the Emergency Department of a University Hospital during the first semester of 2019 and received a radiographic examination. Their demographic characteristics, fracture pattern, and treatment were then analyzed and interpreted. Results: Out of 478 finger injuries reviewed in this cohort, 160 X-rays revealed positive for a fracture giving a fracture rate of 33.5%. More than half of them (51.9%) occurred in the age group of adolescents (11-16 years). Among all finger fractures, only 3.8% of them treated surgically. Conclusion: In this study, a relevant amount of standard finger radiographs revealed a low fracture rate and a rare operative indication of 3.8%. Therefore, indications for X-rays should be reviewed properly and alternative procedures should be discussed. Clinical decision rules should be developed and the necessary pathways must be implemented to minimize radiation exposure, waiting time, and costs.Level of evidence: level IV.

Epidemiology of paediatric lower extremity fractures in a tertiary care center in Switzerland.

PURPOSE: About 20% of all fractures in children occur at the lower extremity. This study aims to investigate the epidemiology and injury pattern of lower extremity fractures within the pediatric population consulting a tertiary referral hospital in Switzerland. METHODS: Study population included all patients up to 16 years presenting with a lower extremity fracture over a period of one year. Recorded data were age, gender, side, season of the year, mechanism, type of fracture and applied treatment. RESULTS: Fractures of the lower extremity represent 23% of all fractures with a mean age of 9 years and 6 months. The tibia, with 94 fractures (38%), represents the most frequently injured bone. Peak incidence is seen in winter and 24% of tibia shaft fractures were due to board sports. Overall, 82% of fractures were treated by cast with or without closed reduction, and only 18% requested surgery. CONCLUSION: Board sports seems to be a leading cause of tibial shaft fracture in our region. Nevertheless, only 18% of fractures had recourse to an orthopedic surgeon, hence the importance of the teaching quality of pediatric residents for conservative fracture treatment.

Epidemiology of Pediatric Upper Extremity Fractures in a Tertiary Care Center in Switzerland.

OBJECTIVE: Fractures in children are common and account for 10% to 25% of injuries in children with considerable effects on activity restriction and subsequent high socioeconomically impact. Eighty percent of all fractures in children occur at the upper extremity. The article investigates the epidemiology and fracture pattern of the upper extremity within a pediatric population consulting a tertiary referral hospital in Switzerland. METHODS: Study population included all patients younger than 18 years presenting with an upper extremity fracture. Recorded data were age, sex, side, season of the year, mechanism, type of fracture, and applied treatment. RESULTS: Fractures of the upper extremities represented 76% with a mean age of 9 years and 7 months. Compared with girls, boys had a risk ratio of 1.35 (1.14-1.6) of having a traumatic injury. The radius, with 298 fractures (37%), was the most injured bone. Overall simple fall from his or her height and soccer represented the main injury mechanisms accounting for 26% and 9%, respectively. Eighty-six percent of fractures were treated by cast with or without closed reduction, 11% (92) by closed reduction and pinning or elastic stable intramedullary, and only 3% of fractures were treated by open reduction and internal fixation. CONCLUSIONS: Eighty-six percent of all fractures could be treated by conservative methods. Only 17% need surgical treatments by orthopedic surgeons. This shows how important it is to train residents in pediatrics for the treatment of upper limb fractures in children.

Mid- and long-term outcome of Salter's, Pemberton's and Dega's osteotomy for treatment of developmental dysplasia of the hip: a systematic review and meta-analysis.

INTRODUCTION: Early diagnosis and early treatment have become the gold standard for management of developmental dysplasia of the hip. Surgery is required in case of failed initial treatment. Innominate pelvic osteotomy of Salter (SIO), Pemberton's pericapsular osteotomy (PPO) and Dega's acetabuloplasty (DA) are among the most used procedures.We performed a systematic review and meta-analysis of the past 57 years in order to assess the mid- and long-term outcome of these techniques. METHODS: Studies met inclusion criteria if they: (1) reported at least 5 cases treated by 1 of the abovementioned surgical techniques; (2) included children aged between 1 and 8 years; (3) surgical indication was late detected DDH or a failed initial treatment; (4) presented a minimal follow-up of 24 months; (5) reported the radiological score of Severin and/or the clinical score of McKay.Clinical and radiological outcomes were dichotomised into favourable and unfavourable outcome and weighted summary rates were determined using meta-analysis models. RESULTS: From a total of 7391 articles, 48 level of evidence grade IV articles were included in our review. A total of 2143 cases with a mean follow up of 112.4 months were included.Pooled Severin score indicated a statistically better outcome for PPO and DA compared to SIO (p = 0.0003 and p = 0.002, respectively). By dichotomising the results in favourable and unfavourable outcome, PPO showed the best results (p = 0.0002 vs. SIO, p = 0.01 vs. DA).Pooled McKay score showed a statistically better outcome for PPO and DA compared to SIO (p < 0.0001 and p = 0.03, respectively) as well as better outcomes for PPO compared to DA (p = 0.01). By dichotomising the results in favourable and unfavourable, PPO showed the best results. CONCLUSIONS: Even if our review demonstrates slightly better radiological and clinical results with the PPO, the currently available and limited data do not allow for clear recommendation towards one of these techniques.

Double-plate compound osteosynthesis for pathological fractures of the proximal femur: high survivorship and low complication rate.

INTRODUCTION: Management of pathological fractures of the proximal femur is often challenging. Compound double-plate osteosynthesis has been specifically developed for surgical treatment of these pathological fractures. To our knowledge, this study represents the largest series to date of double-plate compound osteosynthesis with the longest follow-up. MATERIALS AND METHODS: Using our institutional digital database, we identified 61 procedures in 53 patients at the proximal femur. Patients were divided into two groups. A 'primary' group with all cases in which a double-plate compound osteosynthesis was performed as initial procedure (n = 46) and a 'revision' group with all cases in which a double-plate compound osteosynthesis was performed as revision procedure after failed previous attempts of internal fixation (n = 15). (1) The survivorship of the hip was calculated using the Kaplan-Meier survivorship analysis. (2) Complications were graded using Sink's classification. (3) The functional outcome was quantified with the Merle d'Aubigné and Postel score. (4) Risk factors were identified based on a multivariate Cox-regression analysis. RESULTS: The cumulative Kaplan-Meier survivorship of the primary group was 96% at 6 months, 90% at 1 year, 5 years and thereafter and 83% at 6 months, 74% at 1 year, 53% at 2 years for the 'revision' group (p = 0.0008). According to the classification of Sink et al., the rate of grade III and IV complications was significantly lower in the primary group (p < 0.0001). The mean Merle d'Aubigné score was 14 ± 7 at 0-3 months, 13 ± 3 at 3-6 months, 15 ± 3 at 6-12 months and 15 ± 4 thereafter (p = 0.54). The only multivariate negative predictor was previous surgery with a hazard ratio of 9.2 (p < 0.006). CONCLUSION: Double-plate compound osteosynthesis is a valuable treatment option for pathological fractures in proximal femur with good functional results.

Residual hip dysplasia in children: osseous and cartilaginous acetabular angles to guide further treatment-a pilot study.

PURPOSE: In case of residual hip dysplasia (RHD) in children, pelvic radiographs are sometimes insufficient to precisely evaluate the entire coverage of the femoral head, when trying to decide on the need for further reconstructive procedures. METHODS: This study retrospectively compares the bony and the cartilaginous acetabular angle of Hilgenreiner (HTE) of 60 paediatric hips on pelvic MRI separated in two groups. Group 1 included 31 hips with RHD defined by a bony HTE > 20°. Group 2 included 27 hips with a HTE < 20°. They were compared by introducing a new ratio calculated from the square of cartilaginous HTE above the bony HTE on frontal MRI. The normal upper limit for this acetabular angle ratio was extrapolated from the published normal values of cartilaginous HTE and bony HTE in children. RESULTS: The acetabular angle ratio was statistically significantly increased in the hips with RHD with a mean value of 7.1 ± 4.7 compared to the hips in the control group presenting a mean value of 2.1 ± 1.9 (p < 0.00001). CONCLUSIONS: This newly introduced ratio seems to be a helpful tool to orientate the further treatment in children presenting borderline RHD.

Acetabular Labral Tear Secondary to Repeated Lateral "Grand Écart" Split Exercises in an Adolescent Ballet Dancer: Case Report and Review of the Literature.

Due to frequent movements involving extreme hip amplitudes, ballet dancers often present with hip pain and chondrolabral lesions as seen in femoroacetabular impingement. The lesions appear even with normal anatomy. Diagnosis is often delayed, and treatment is challenging, especially in skeletally immature patients. This study reports the case of an adolescent ballet dancer suffering from a large symptomatic labral tear. The literature has also been reviewed for context regarding the pathophysiology and current therapeutic management of these injuries.

[Pediatrics - Perthes disease : current knowledges and treatment]. / Pédiatrie. Maladie de Perthes : connaissances actuelles et prise en charge.

Perthes's disease corresponds to an interruption of the vascularization of the epiphyseal nucleus of the femoral head followed by avascular necrosis. This necrosis weakens the bone and subchondral fractures associated with a deformation of the femoral head is seen. It is important not to miss an extrusion of the femoral head, which makes surgical treatment unavoidable. The loss of joint congruence causes functional limitations and represents an increased risk for early hip osteoarthritis. Non weight bearing limits the subchondral fractures, but requires an important adaptation from the patient and his entourage.

La maladie de Perthes correspond à une interruption de la vascularisation du noyau épiphysaire de la tête fémorale suivie d'une nécrose avasculaire. Cette nécrose fragilise l'os et des fractures sous-chondrales associées à une déformation de la tête fémorale en sont les conséquences. Il est important d'être vigilant quant à une excentration de la tête fémorale, ce qui rend une prise en charge chirurgicale incontournable afin d'éviter des séquelles trop importantes à l'âge adulte. La perte de congruence articulaire engendre une limitation fonctionnelle et représente un risque accru de coxarthrose précoce. La décharge permet de limiter les fractures sous-chondrales, mais demande une adaptation importante de la part du patient et de son entourage.

Unusual Complication after Intramedullary Nailing of an Intertrochanteric Fracture.

Intramedullary nails have gained popularity for the treatment of intertrochanteric fractures. Cephalic screw cutout, non-union, nail breakage, intraoperative fractures, and peri-implant fractures are complications of these implants and have been well described. This case report describes an unusual complication in an 89-year-old woman presenting with a femoral neck fracture with an intramedullary nail in place without implant failure or non-union after having been successfully treated three years previously for an intertrochanteric fracture.

Influence of anatomical variations on lumbar foraminal stenosis pathogenesis.

INTRODUCTION: Symptomatic foraminal stenosis has been observed in patients with degenerative disc disease, scoliosis, asymmetrical disc degeneration and spondylolisthesis. Nevertheless not all patients with the above pathologies will develop symptomatic foraminal stenosis. We hypothesised that symptomatic patients have anatomical predisposition to foraminal stenosis, namely a larger pedicle height (PH) to vertebral body height (VH) ratio, leaving less room below the pedicle for the exiting nerve root compared to asymptomatic patients. PATIENT SAMPLE: 66 Patients were divided in two groups. The surgical group consisted of 37 patients (average age of 61 years) who presented with severe radicular symptoms resisting to conservative measures and requiring decompression and transforaminal lumbar interbody fusion (TLIF). The control group consisted of 29 patients (average age of 51 years) presenting with low back pain (LBP) but with no radicular symptoms and who were treated conservatively. METHODS: We measured VH at the level of the posterior wall as well as PH on parasagittal images (CT or MRI) on all lumbar levels (L1 to L5). Statistical analysis was performed using Student's t test. RESULTS: No difference in PH was found between the two groups for L1 to L4 levels. By contrast, there was a highly statistically significant difference in VH between the two groups from L1 to L4 level. In the surgical group, the VH was smaller (p < 0.001). CONCLUSIONS: Symptomatic patients with foraminal stenosis have smaller VH leading to lesser space beneath the pedicle and putting the exiting nerve root at risk in cases of spondylolisthesis or disc degeneration.