Docking phenomenon and subsequent acetabular development after gradual reduction using overhead traction for developmental dysplasia of the hip over six months of age

Purpose This study aimed to explore the docking of the femoral head into the acetabulum after gradual reduction (GR) using traction for developmental dysplasia of the hip (DDH) and the impact on subsequent acetabular development. Methods A total of 40 patients with DDH (42 hips) undergoing GR using overhead traction and spica casting were retrospectively reviewed. The presence of inverted labrum and the coronal and axial femoral-acetabular distances (FADs) were compared between MRI immediately and five weeks after spica casting. The change in the acetabular index on anteroposterior pelvic radiographs were compared between hips with inverted labrum (residual group) and with normally-shaped labrum (normalized group) on follow-up MRI. Results The mean age at reduction was 13.1 months (7 to 33) and the mean follow-up duration was 7.7 years (4 to 11). The rate of inverted labrum and the FADs significantly decreased between the MRI scans (all p-values < 0.001), and previous Pavlik harness failure had no negative effect on these decreases. The acetabular indices at the ages of three and five years in the residual group were significantly larger than those in the normalized group (both p-values < 0.001). Residual acetabular dysplasia was seen in 84.2% of the residual group compared with 34.8% of the normalized group (p = 0.002). Conclusion The docking phenomenon can occur during spica casting following GR using traction in children with DDH between the ages of six months and three years. The remaining inverted labrum at the cast removal may negatively affect subsequent acetabular development. Level of evidence III - retrospective comparative study

Treatment of closed femoral shaft fractures in children aged 2–10 years: a systematic review and meta-analysis

Objective To review current literature on treatment of closed femoral shaft fractures in children of 2–10 years old, with subgroup analysis of children aged 2–6 years, comparing intramedullary nailing (IMN) to conservative treatment modalities. Methods We included clinical trials and observational studies that compared traction and subsequent casting (TSC), spica casting and IMN for treatment of femur shaft fractures in children of 2–10 years of age. Subgroup analysis of children aged 2–6 years was performed. Results Compared to treatment with immediate spica casting, IMN led to significantly less coronal angulation (mean difference (MD): 2.03 degrees, confidence interval (CI) 1.15–2.90), less sagittal angulation (MD: 1.59 degrees, CI 0.82–2.35) and lower rates of LLD (Risk difference (RD): 0.07, CI 0.03–0.11). In terms of rehabilitation, IMN leaded to shorter time until walking with aids (MD: 31.53 days, CI 16.02–47.03), shorter time until independent ambulation (MD: 26.59 days, CI 22.07, 31.11) and shorter time until full weight bearing (MD: 27.05 days, CI 6.11, 47,99). Compared to TSC, IMN led to a lower rate of malunion (RD: 0.31, CI 0.05–0.56), shorter hospital stays (MD: 12.48 days, CI 11.57, 13.39), time until walking with aids (MD: 54.55, CI 40.05–69.04) and full weight bearing (MD: 27.05 days [6.11, 47,99]). Conclusion Although a lack of quality evidence, this systematic review showed a clear tendency to treatment with elastic intramedullary nails of femoral shaft fractures in children of 2–10 years of age. Level of evidence 3.

Follow-up of an Elongation Bending Derotation Brace in the treatment of infantile scoliosis

Since 2013, an elongation bending derotation brace (EBDB) has been developed and applied to EOS in our institution. The goals of the study were: 1) to compare radiographic changes before the use of EBDB (Pre-B), in brace (IB), and after the use of EBDB (Post-B) in a minimal two year follow-up; 2) to determine the compliance with the EBDB. Thirteen children diagnosed with an infantile scoliosis (IS) were retrospectively recruited. Under general anesthesia in the OR, child was placed on a Spica casting table, and the spine was manipulated by stockinet straps. Then 3D child’s torso was scanned, the EBDB was designed and manufactured for exact fitting to the torso in the corrected position using CAD/CAM technology.1 Mean age at start of EBDB was 2 years and 6 months. Average follow-up was 36 months. Compliance showed a mean 19 hours per day (14 to 23 hours). Pre-treatment Cobb angle was 40°, in brace 22°, and out of brace 28° (p<0.05). Axial vertebral rotation (AVR) by Nash-Moe method improved from 30% before treatment to 21% in brace and 19% at the end of visit (p<0.05). Kyphosis was significantly increased from 16° (Pre-B) to 32° (Post-B) (P<0.05). However, there was reduction of Rib-vertebral angle difference (RVAD) from 23° (Pre-B) to 11° (Post-B) (P>0.05). A cascade of EBDB effectively corrects and stabilizes the 3D spinal deformities in infantile. Thus the EBDB is considered as a successful modality in the treatment of IS children.

Treatment of femoral fractures in children aged two to six

Aims Current American Academy of Orthopaedic Surgeons (AAOS) guidelines for treating femoral fractures in children aged two to six years recommend early spica casting although some individuals have recommended intramedullary stabilization in this age group. The purpose of this study was to compare the treatment and family burden of care of spica casting and flexible intramedullary nailing in this age group. Methods Patients aged two to six years old with acute, non-pathological femur fractures were prospectively enrolled at one of three tertiary children’s hospitals. Either early closed reduction with spica cast application or flexible intramedullary nailing was accomplished under general anaesthesia. The treatment method was selected after discussion of the options by the surgeon with the family. Data were prospectively collected on patient demographics, fracture characteristics, complications, pain medication, and union. The Impact on Family Scale was obtained at the six-week follow-up visit. In all, 75 patients were included in the study: 39 in the spica group and 36 in the nailing group. The mean age of the spica group was 2.71 (2.0 to 6.9) years and the mean age of the nailing group was 3.16 (2.0 to 6.9) years. Results All fractures healed without evidence of malunion or more than 2.0 cm of shortening. The mean Impact on Family score was 70.2 for the spica group and 63.2 (55 to 99) for the nailing group, a statistically significant difference (p = 0.024) in a univariate analysis suggesting less impairment of the family in the intramedullary nailing group. There was no significant difference between pain medication requirements in the first 24 hours postoperatively. Two patients in the spica group and one patient in the intramedullary nailing group required additional treatment under anaesthesia. Conclusion Both early spica casting and intramedullary nailing were effective methods for treating femoral fractures in children two to six years of age. Intramedullary stabilization provides an option in this age group that may be advantageous in some social situations that depend on the child’s mobility. Fracture treatment should be individualized based on factors that extend beyond anatomical and biological factors. Cite this article: Bone Joint J 2020;102-B(8):1056–1061.

A comparative study of the management of pediatric femoral shaft fractures treated conservatively with traction or spica casting

<p class="abstract"><strong>Background:</strong> Femoral shaft fractures, though not very common, are of major concern for orthopedic surgeons. the management for infants and older children is generally universal but the young patients still offer a management dilemma.</p><p class="abstract"><strong>Methods:</strong> We present a prospective study conducted at a tertiary care hospital in India of 37 children between 1 year and 6 years to compare the two conservative methods most commonly used i.e. spica casting and traction application.<strong></strong></p><p class="abstract"><strong>Results:</strong> We found that though both the methods are similar in the time for union, shortening was better controlled with traction and angulation with spica casting. The frequency of other complications was also comparable.</p><p class="abstract"><strong>Conclusions:</strong> Both the methods give acceptable results and given the feasibility of such procedures in developing countries, both may be recommended. However, the choice thus depends on the surgeon treating the patient keeping in mind the drawbacks and limitations of each.</p>