Editorial

Warm greetings to all from the International Journal of Paediatric Orthopaedics Editorial Team. We are pleased to present the 3rd POSI issue of IJPO. Thanks to the overwhelming response to our invitation for submissions, our team of reviewers and editors have been kept busy in the past few months. We would like to express our gratitude to the entire POSI family from around the world and to all the authors for their submissions. With your continued support, the journal will reach great heights in the years to come. This issue has an informative and exhaustively researched symposium on lateral condyle fractures of the humerus. The articles in the symposium will provide a comprehensive and updated overview about this condition that poses significant challenges to the treating surgeon. The authors are acknowledged experts in paediatric trauma from India and around the world. It has been specially designed to supplement the material available in orthopaedic textbooks for the benefit of trainees, in addition to providing treatment pearls for the practising orthopaedic surgeon. We have original articles and interesting case reports from India, United Kingdom, Portugal, Senegal on a wide variety of paediatric orthopaedic conditions including DDH, infection and its sequelae and clubfoot managed in diverse healthcare systems. Due to the unprecedented increase in submissions, we call upon the POSI fraternity to help the society journal by joining our team of reviewers. This will help us to complete the peer review process in a timely manner. Being a part of our team will help also young surgeons to better understand the review process and develop their writing skills. We look forward to hearing from you with suggestions for further improvement. Sincerely Jayanth S Sampath FRCSEd (Tr & Orth) Editor, International Journal of Paediatric Orthopaedics [email protected]

Should We Continue to Screen for Developmental Dysplasia of the Hip in Clubfoot? Our Experience and Review of the Literature

Objective: The association between clubfoot and developmental dysplasia of the hip (DDH) remains uncertain, with only a few studies linking both. However, clubfoot is considered as a risk factor for DDH. The aim of this study was to determine the incidence of DDH and evaluate the need for routine hip imaging in our population of children with clubfoot. Methods: Retrospective analysis of all patients treated for clubfoot in our center between 2010 and 2019. We included patients with hip imaging for DDH in the first 12 months of life. Results: There were 108 children with clubfoot who underwent DDH screening. 92 had idiopathic clubfoot and 16 had syndromic clubfoot. Of the patients with idiopathic clubfoot, 2 (2.2%) had DDH; one had a clinically unstable hip and the other patient underwent hip screening on account of the clubfoot alone. Among patients with syndromic clubfoot, 3 (18.8%) had developmental dysplasia of the hip. Two of them had an abnormal hip examination while the other had normal hip clinical examination but other established risk factors for DDH. Conclusion: A targeted ultrasound or radiological screening programme for DDH in idiopathic clubfoot diagnosed hip dysplasia in only 1 child that would have otherwise been missed by clinical examination alone. We conclude that hip imaging is not warranted in children with idiopathic clubfoot and regular clinical screening may suffice. In syndromic clubfoot, due to the higher incidence of DDH, we recommend specific ultrasound screening even in the presence of a normal hip examination. Keywords: Clubfoot, Screening, Developmental dysplasia of the hip.

Bilateral Septic Hip Epiphyseal Detachment in Children: A Case Report and Review of the Literature

Background: Diagnosed and treated fairly early, children’s septic arthritis of the hip has few or no complications. Septic epiphyseal detachment of the hip in children is a rare complication due to delayed treatment. Unilateral forms have been reported, but bilateral involvement has never been described in the literature. Case presentation: We report the case of an 8-year-old girl who presented with hip pain associated fever and diminished lower limb movements, approximately 4 months after the onset of symptoms. The diagnosis of bilateral septic epiphyseal detachment of the hips was made and computerized tomography (CT) scan revealed osteonecrosis of both femoral heads. The necrotic epiphyses required removal in order to control the infection. Conclusion: This report highlights the importance of early diagnosis of septic arthritis of the hip in the neonatal period. Any delay in presentation, diagnosis or management can result in irrecoverable sequelae for the developing hip and seriously impact long-term function. Keywords: Septic arthritis, Bilateral, Epiphysis detachment, Hip, Ablation.

The Evaluation of Deformity Correction in Idiopathic Clubfoot During Ponseti Casting Sessions: Two Scoring Methods Depicted Graphically

Background We graphically analyzed the correction of total Pirani and Dimeglio scores and their subcomponents at sequential casting sessions for children with idiopathic clubfeet. Methods Correction of scores at weekly sessions was represented graphically. The tenotomy effect was accounted for separately. We classified 1st to 3rd casts as early, 4th and 5th cast midlevel, and beyond 5 as final casts to describe casting treatment. Results A total of 88 clubfeet (34 bilateral) in 54 patients were studied. Both total Pirani and Dimeglio graphs were characterized by a steep fall in early casts; subsequent minimal improvement in midlevel and final casts; later marked correction with tenotomy. Equinus in both scores stood as the most resistant deformity, showed full correction only following tenotomy. Dimeglio graphs captured coupling of various foot motions better over early casts than Pirani graphs. Conclusions Both Pirani and Dimeglio scores can adequately guide caregivers to progressive deformity correction in clubfoot. Keywords: Clubfoot, CTEV, Pirani, Dimeglio, Scores, Graphs

Neglected Lateral condyle Humerus Fractures: Current Concepts and Practices

Neglected lateral condyle fractures present varied and difficult challenges to the treating orthopaedic surgeon. They have the potential to cause long term problems like deformities, stiffness, instability and tardy ulnar nerve palsy. The treatment of lateral condyle non-unions depend on the presence or absence of deformity, the duration of non-union, skeletal maturity of the child and the presence or absence of ulnar nerve palsy. Accordingly the treatment ranges from conservative management in neglected fractures with no deformity and no ulnar nerve palsy at one end, Open/mini-open or closed in-situ fixation for established non-unions with instability and corrective osteotomy with fixation of non-union and ulnar nerve transposition at the other end. In this article, the authors have endeavoured to go through the various aspects of clinical presentations and treatment modalities for this difficult fracture. Keywords: Neglected lateral condyle fractures, Cubitus valgus, Tardy ulnar nerve palsy, Instability.

Complications of Lateral Humeral Condyle Fractures in Children

Lateral humeral condyle fractures in children are easily missed and often associated with complications. These complications include malunion, delayed union or nonunion, lateral spur formation, fishtail deformity and growth disturbances. There is also controversy related to best treatment options including closed vs open reduction and K-wire vs screw fixation. Though some complications like malunion are avoidable, others like lateral spur formation are inevitable. Knowledge about these complications would help in counseling patients and their families. The purpose of this article was to review common complications related to these fractures and suggest tips to avoid some of them. Keywords: Paediatric, Lateral condyle fracture, Internal oblique X-ray, Arthrogram, Anatomical reduction, Complications, Tips to overcome

ABCD of Lateral Condyle Humerus Fracture in Children: Anatomy, Biomechanics, Classification and Diagnosis

The lateral condyle fractures which form less than 20% of paediatric elbow fractures are seen at average 6 years age and have less severity of signs and symptoms which may lead to delayed diagnosis. Internal rotation view of X-ray of elbow is important in addition to standard AP and Lateral views. Jakob, Weiss and Song are commonly used classification systems in decision making. Keywords: Lateral condyle fracture, Children, Classification, Anatomy, Diagnosis.

Iliopsoas Abscess in Children – A Forgotten Diagnosis

Iliopsoas abscess is a rare diagnosis in children. We recently encountered two cases which were managed at our institution. A 11-year female presented with thigh and inguinal swelling while 3-year male child presented with limp and fixed flexion deformity of right leg. Due to the differing presentation, imaging studies are often important before management is planned. Ultrasound scan is the most common investigation followed by computerized tomography (CT) scan in a selected few. The girl underwent a CT scan followed by incision and drainage (I&D) of the iliopsoas abscess while the boy underwent ultrasound-guided pigtail catheter insertion. Both cases were successfully treated. Atypical presentation of iliopsoas abscess makes the diagnosis difficult and requires a high degree of clinical suspicion for making correct diagnosis. Imaging studies help with diagnosis in such cases. Less invasive techniques like image-guided aspiration and catheter drainage can be helpful in carefully selected cases. Keywords: Iliopsoas abscess, Atypical presentation, Percutaneous drainage, Pediatric.

Surgical Treatment of Pathological Developmental Dysplasia of the Hip: A 12-Year Study

Aim: We aimed to assess outcomes of a 12-year longitudinal observational study of developmental dysplasia of the hip (DDH) requiring surgical intervention. Method: We conducted a prospective study from 2004 to 2015 of all cases of DDH undergoing surgical intervention. In addition to clinical examination, Tönnis acetabular index (AI) method and International Hip Dysplasia Institute (IHDI) grading used. Avascular necrosis of the femoral head (AVN) was assessed by the Kalamchi method. Results & Discussion: There were 81 hips in 72 patients (12 male, 60 female). Mean age of the first operative procedure was 16.4 months (95% CI, 13.66 to 19.14). Mean follow up was 47.6 months (95% CI, 41.8 to 53.4). 31 children underwent closed reductions, 48 required open reduction; 17 femoral and 39 pelvic osteotomies were performed during the course of the study. Overall, post-surgery 96.3 % were noted to have an acceptable AI (< 2 SD of the mean). Five hips were considered to have poor results due to residual subluxation/ dislocation (6.2%). Evidence of avascular necrosis was present in 16 of the 81 hips (19.8%).Higher grades of hip pathology were generally associated with a later age of diagnosis and likely to require more extensive surgical interventions. Conclusion: Operative intervention for DDH results in acceptable clinical and radiographic outcomes in the vast majority of children. Keywords: DDH, Developmental Dysplasia of the hip, Surgery.

Management of Acute Lateral Condyle Fractures of Humerus

Background: Diagnosed and treated fairly early, children’s septic arthritis of the hip has few or no complications. Septic epiphyseal detachment of the hip in children is a rare complication due to delayed treatment. Unilateral forms have been reported, but bilateral involvement has never been described in the literature. Case presentation: We report the case of an 8-year-old girl who presented with hip pain associated fever and diminished lower limb movements, approximately 4 months after the onset of symptoms. The diagnosis of bilateral septic epiphyseal detachment of the hips was made and computerized tomography (CT) scan revealed osteonecrosis of both femoral heads. The necrotic epiphyses required removal in order to control the infection. Conclusion: This report highlights the importance of early diagnosis of septic arthritis of the hip in the neonatal period. Any delay in presentation, diagnosis or management can result in irrecoverable sequelae for the developing hip and seriously impact long-term function. Keywords: Septic arthritis, Bilateral, Epiphysis detachment, Hip, Ablation.