Study to determine the Results of Femoral Shaft Fractures among Children managed with Immediate Hip Spica Cast

This prospective descriptive study aims to assess the importance of the immediate hip spica in a fracture of the femoral shaft in children at the Orthopedic Department of Liaqat University of Medica and Health science Jamshoro, Pakistan, for a one-year duration from June 2019 to June 2020. All children 1 to 5 years of age with femoral fractures who were admitted to the Orthopedic department within seven days of injury were included in the study. A total of 35 children, 24 (68.6%) boys and 11 (31.42%) girls, with a mean age of 3.8 years, were treated with an immediate hip spica cast. Their ages ranged from 1 to 5 years. The time of immobilization of the Spica cast ranged from 4 to 6 weeks (mean 5.4 weeks). In the second week, seven (22.85%) children had spica wetting, and breakage and reinforcement of spica was done, and 5 (14.28%) children had a spica wedging, and casting was applied to fix the angulation. No extension or hypertrophy was observed in the fractured limb. We concluded that immediate hip spica casting is a safe, inexpensive and definitive treatment of femoral shaft fractures in children aged 1-5 years.

Outcomes of Early Hemivertebrectomy in Children with Congenital Scoliosis: A Prospective Follow-up Study

Background and Aims: Posterolateral hemivertebrectomy with monosegmental instrumentation at an early age is an established method to correct congenital scoliosis but is associated with a relatively high risk of instrumentation failure and health-related quality of life outcomes are not available. We aimed to investigate the effects hemivertebrectomy with postoperative hip spica cast on complications and health-related quality of life in small children with congenital scoliosis. Materials and Methods: A follow-up study of 30 children (at mean age = 3.4 years, range = 1.0–8.5 years) undergoing posterolateral hemivertebrectomy and short pedicle instrumentation. Children were immobilized postoperative with hip spica cast for 6 weeks and immobilization for 4 months using a rigid thoracolumbosacral orthosis. The Caregivers filled out Scoliosis Research Society 24 outcome questionnaire preoperatively, at 6 months, and at final follow-up visit on behalf of their child. Standing radiographs were obtained preoperatively, postoperatively in the cast, and standing at final follow-up. Results: Mean major curve was 41° (range = 26°–87°) preoperatively and was corrected to 14° (4.0°–35°) at final follow-up. Eight (27%) children had postoperative complications, including three (10%) deep surgical site infections. The Scoliosis Research Society 24 back domain showed an improvement from a mean of 3.8 preoperatively to 4.4 at final follow-up ( p < 0.001). Function from back condition domain showed a significant deterioration from 4.2 preoperatively to 3.7 at 6 months ( p = 0.020) but improved back to baseline at final follow-up (4.2, p = 0.0022 6 months vs final follow-up). Conclusion: Hemivertebrectomy with short instrumentation resulted into 64% correction of scoliosis and improved health-related quality of life in back pain and function domains.

Preliminary results of rigid fixation (locking plate/screw) after triple pelvic osteotomy without a hip spica cast: A modified fixation method in 21 patients

Objectives: The aim of this study is to investigate whether rigid fixation after triple pelvic osteotomy (TPO) utilizing a 3.5-mm locking plate and screws without hip spica cast can provide enough stability and prevent correction loss in pediatric patients with developmental dysplasia of the hip (DDH) and Legg-Calvé-Perthes disease (LCPD). Patients and methods: A total of 21 hips of 21 pediatric patients (9 males, 12 females; mean age: 9.3±2.0 years; range, 6 to 14 years) who underwent rigid fixation with locking plate/screws after TPO for DDH and LCPD between June 2015 and October 2018 were retrospectively analyzed. Preoperative, immediate postoperative, and six-month follow-up anteroposterior radiographs were compared for the Wiberg’s center-edge angle (CE), Sharp angle, acetabular coverage of the femoral head (ACFH), and center-head distance discrepancy (CHDD). The patient demographics, surgery time, perioperative complications were evaluated. Results: Underlying diagnosis were DDH in 14 patients and LCPD in seven patients. In patients with DDH, postoperative evaluation showed significant increase in the mean CE angle (5.6±16.1° vs. 30.5±9.3°, respectively) and ACFH (46.4±16.8% vs. 84.5±12.1%, respectively), and a significant decrease in the mean Sharp angle (55.3±6.2° vs. 35.6±7.8°, respectively) and CHDD (14.6±10.7% vs. 6.2±5.6%, respectively). The final follow-up revealed that there was no correction loss in these parameters. In the patients with LCPD, postoperative evaluation showed a significant increase in the mean CE (20.1±11.1° vs. 38.3±9.6°, respectively) and ACFH (62.9±18% vs. 91.4±10.1%, respectively), and a significant decrease in the mean Sharp angle (46±3.6° vs. 25.2±5.5°, respectively). The final follow-up revealed that there was no correction loss in radiological parameters. No perioperative complications were noted. Conclusion: Our study results suggest that rigid fixation construct with a 3.5-mm locking plate and screws without hip spica cast can provide adequate stability to allow early mobilization following TPO in children without any loss of correction, until bony healing at the osteotomy sites.

A Rare Case of an Iliac Fracture at the Iliac Fossa Immediately after Salter Innominate Osteotomy

This report presents the unusual case of a 5-year-old girl with iliac fracture just after Salter innominate osteotomy for developmental dysplasia of the hip. The iliac fracture was diagnosed two days after Salter innominate osteotomy, and computed tomography (CT) revealed that it was at the extremely thin portion of the iliac wing called the “iliac fossa.” We were able to reduce the fracture by pulling the left leg distally, and after reducing the iliac bone, the ilium was fixed by Kirschner wire from the anteroinferior iliac spine and anterosuperior iliac spine. The patient was in a hip-spica cast for 6 weeks postoperatively and allowed to walk from 3 months after the surgery. At the last follow-up one year after the surgery, bone union was completely obtained, and she had no complications. The cause of the fracture seems to be the stress concentration on the iliac fossa due to the cranked iliac osteotomy line passing through the iliac fossa. The current case indicates the importance of careful evaluation by CT before surgery and ensuring that the osteotomy line does not extend near the iliac fossa.

Is Hip Spica an obsolete method for paediatric femur fractures ?-A retrospective analysis of 58 patients

Background- Diaphyseal femur fracture in paediatric age group are common in orthopaedics with treatment options varying from conservative methods such as hip spica to operative measures such as nailing/plating. We analyzed results of patients treated conservatively in a hip spica cast. Material and Methods- 58 patients, upto 5 years of age, with shaft femur fracture managed by hip spica cast were retrospectively analysed in terms of healing clinically and radiologically and complications noted, if any. Results- Fracture healed satisfactorily in all patients. Mean age of patients affected was 3.8 years. Males were more affected and road side accident was most common etiology. Mean hospital stay was 3.4 days. Most common complication was skin breakage (27.58%) followed by cast soiling or breakage (13.79%) while shortening was seen in 3 patients (5.1%) and angulation in 2 patients (3.44%). Conclusion- Despite newer and safer implants, hip spica remains safe and cost effective method for treatment of femur fracture in children.

Closed Reduction as Therapeutic Gold Standard for Treatment of Congenital Hip Dislocation

Background Congenital hip dislocation (luxation) has an incidence of 0.4 – 0.7% and is regarded as a prearthrotic deformity. Thus, if not being diagnosed and treated at a very early age, extensive surgical measures are inevitable in childhood and early adulthood. Methods In the time between 01/2013 and 02/2019 we performed 28 600 hips sonographies in babies as part of general screening measures at U2 or U3. There were 71 instable, dysplastic or dislocated hips diagnosed that were treated by arthrographic, closed reduction. After a hip spica cast was applied, reposition was controlled by MRI, estimating the acetabular head index (ACI), the head coverage index (HCI) as well as the femoral headʼs sphericity or by sonography using the Graf method. Results Overall success rate was 91.6% for primary closed reduction. Patients with primarily irreducible hips were significantly older (p < 0.003) than patients with primarily successful reducible hips. Congenital dislocated hips had significantly higher ACIs (p < 0.001) and HCIs (p = 0.03) as well as significantly less well rounded femoral heads (sphericity; p < 0.001) compared to stable hips. Conclusion Early diagnosis and treatment of congenital dislocated hips by closed reduction is essential for a sufficient and regular maturation of the hips without further surgical interventions.

Anatomic three-dimensional model-assisted surgical planning for treatment of pediatric hip dislocation due to osteomyelitis

Management of pediatric septic coxarthritis and osteomyelitis of the femur is challenging, and the sequelae of multiplanar hip joint deformity with instability are difficult to reconstruct. The inadequacy of a suitable device for fixing small bones during pediatric osteotomy is a hindrance to the correction of subluxated hip joints and deformed femurs in children. Two-dimensional axial images and three-dimensional (3D) virtual models representing the patient’s individual anatomy are usually reserved for more complex cases of limb deformity. 3D printing technology can be used for preoperative planning of complex pediatric orthopedic surgery. However, there is a paucity of literature reports regarding the application of 3D-printed bone models for pediatric post-osteomyelitis deformity. We herein present a case of a 4-year-old boy who underwent treatment for post-osteomyelitis deformity. We performed corrective surgery with Pemberton osteotomy of the right hip, multilevel varus derotation osteotomy of the right femur, and immobilization with a hip spica cast. A 3D-printed bone model of this patient was used to simulate the surgery, determine the proper osteotomy sites, and choose the appropriate implant for the osteotomized bone. A satisfactory clinical outcome was achieved.

PAEDIATRIC FEMUR FRACTURE

Objectives: To evaluate the outcome of retrograde flexible intramedullary nailsin treatment of paedriatic diaphyseal fractures in comparison with the traditional treatment ofimmediate hip spica cast. Hypothesis: We hypothesised that in children with femur fracturewho are managed with flexible intramedullary nails have better outcome in comparison tothose managed with immediate hip spica cast. Study Design: Randomized control trail. Place& Duration of Study: Lady Reading Hospital, Peshawar from June 2016 to October 2017.Methods: A group of forty-eight children aged 6-12 were randomly allocated either elasticintramedullary nail or immediate hip spica casting and were followed up to six months. Fracturealignment (coronal and sagittal angulation, leg length discrepancy), time for fracture union,recovery mile stones (time to start weight bearing with aids, independent walking, knee rangeof movement) and the presence of complications including surgical site infection were recordedand compared between two groups. Results: Children treated with elastic intramedullary nailsin comparison with those treated with immediate hip spica had early union (p<0.001), shortertime to start weight bearing with support or independently (p<0.001). Leg Length discrepancy(p<0.001), coronal and sagittal angulation (p<0.001 and p=0.02) was significantly higher in hipspica group. Difference observed between the two groups regarding knee range of movement(p=0.085) and surgical site infection (p=0.076) was not significant. Conclusion: Children aged6-12 years treated with elastic intramedullary nail for femoral diaphyseal fracture had earlierunion, reduced rate of shortening, malunion and allowed earlier rehabilitation.