Search Results (102)

Background/Objectives: The prevalence of developmental dysplasia of the hip (DDH) in adolescent idiopathic scoliosis (AIS) remains unclear, partly because of differences in diagnostic criteria and measurement accuracy. Additionally, spinopelvic alignment and skeletal maturation may affect radiographic assessment of acetabular morphology in patients with AIS. This study aimed to clarify the prevalence of DDH in Japanese patients with AIS using standardized radiographic assessment and to compare conventional and age-adjusted diagnostic criteria for DDH. Methods: This cross-sectional study included 602 Japanese patients aged 10–18 years with AIS. Patients with inadequate radiographs, including those with pelvic rotation and lateral inclination, were excluded to improve measurement accuracy. DDH was defined using two criteria: (1) conventional (lateral center-edge angle <20°) and (2) age-adjusted thresholds (<15° for <15 years and <18° for ≥15 years). Radiographic parameters were compared between patients with and without DDH. A multivariate logistic regression analysis was performed to identify factors independently associated with DDH. Results: The prevalence of DDH in AIS was 5.6% (34/602) using the conventional criterion and 1.5% (9/602) using the age-adjusted criteria. Patients with DDH showed significantly lower acetabular coverage, with a lower lateral center-edge angle and acetabular head index and higher Sharp and Tönnis angles than those without DDH (all p < 0.01). No significant difference in the main curve Cobb angle was observed between the groups. A younger age was independently associated with DDH, whereas sex and the main curve Cobb angle were not. Conclusions: The prevalence of DDH in Japanese patients with AIS varies substantially depending on the diagnostic criteria. Standardized radiographic evaluation with exclusion of pelvic rotation provides a reliable estimate. These findings highlight the importance of evaluating acetabular morphology on standing whole-spine radiographs in patients with AIS while considering skeletal maturation and spinopelvic alignment. Full article

Background: Clubfoot represents a prevalent congenital deformity of the foot and ankle complex that may significantly compromise a child’s walking ability. Contemporary treatment protocols encompass serial manipulations and casting procedures designed to achieve gradual correction of the deformity. Various casting materials have been employed in this therapeutic approach, with plaster of Paris and fiberglass constituting the two predominant options. This study aimed to evaluate the comparative effectiveness of these casting materials and determine whether material selection influences the rate of correction and the clinical indications, specifically regarding the number of casts required before percutaneous Achilles tenotomy. Methods: We conducted a retrospective analysis of prospectively collected data on paediatric patients treated at our tertiary-level institution with both plaster of Paris (POP) and semirigid fiberglass (SRF) by a single orthopaedic surgeon between 2010 and 2020. Treatment was initiated within the first 30 days of life (median age 12 days, range 0–28 days). To reduce confounding bias related to baseline aetiology (e.g., rigid syndromic feet), the primary comparative analysis was restricted to the idiopathic clubfoot subgroup. The Pirani score was used to assess deformity severity at each clinical visit. Results: A cohort of 84 patients (137 feet) was enrolled and treated, comprising patients with a Pirani score ≥ 4.5, excluding non-idiopathic cases. The mean number of casts required was 5.8 ± 1.0 for POP and 5.7 ± 1.2 for SRF, with no statistically significant difference (p = 0.91). Conclusions: Both plaster of Paris and semirigid fiberglass are highly effective casting materials for the initial phase of Ponseti treatment. Both achieve comparable correction sufficient to proceed with Achilles tenotomy. Accordingly, material selection should be guided by clinician proficiency, institutional cost-effectiveness, and patient comfort. Further investigation is needed to evaluate long-term outcomes and the relative benefits of each material in clubfoot management. Full article

Background/Objectives: Wrist fractures are common paediatric injuries, yet some remain radiographically occult. The Pronator Quadratus Sign (PQS), defined by displacement or alteration of the fat stripe overlying the pronator quadratus muscle (PQm), remains a debated radiologic diagnostic marker. This study evaluated whether PQS can serve as a diagnostic adjunct for wrist fractures and whether specific PQS morphological types are associated with different fracture patterns. Methods: This retrospective study included paediatric patients presenting with wrist trauma. Radiographs were categorized into three groups: no fracture, torus fracture, and other non-displaced distal radius fractures. PQS morphology was classified using a six-tier system. Quantitative assessment included measurement of the anterior distance from the distal radius to the external border of the pronator quadratus muscle (X) and radial width (R), expressed as the X/R ratio to standardize comparisons. Results: A total of 247 patients were included. The X/R ratio differed significantly among groups (p < 0.001), with higher values observed in patients with fractures. ROC analysis demonstrated good discrimination performance between no fracture and non-displaced distal radius fractures (AUC = 0.80), but limited performance for torus fractures (AUC = 0.62). Although PQS morphology alone was not a reliable indicator of fracture presence, the distribution of PQS types—representing distinct patterns of pronator quadratus fat stripe appearance and displacement—differed significantly across fracture groups (p < 0.001). Conclusions: Quantitative PQS assessment using the X/R ratio is associated with improved discrimination for non-displaced distal radius fractures, while PQS morphology alone shows limited diagnostic utility. Further prospective studies incorporating magnetic resonance imaging are warranted to clarify its role in occult fracture detection. Full article

Background: Cerebral palsy (CP) is the leading cause of permanent physical disability in children. Although hip surveillance is a global standard, spinal surveillance remains inconsistent, often leading to reactive rather than proactive management of neuromuscular scoliosis. This study aims to establish an international consensus on a risk-based spinal surveillance protocol. Methods: A three-round modified Delphi process was conducted in 2024 with 15 international pediatric spine surgeons, identified through purposive sampling. The process adhered to CREDES standards and focused on establishing standards for timing, frequency, and radiographic surveillance. Consensus thresholds were defined a priori as excellent (≥80%) and good (≥73%) agreement. Results: The panel reached excellent consensus (93%) on a “Traffic Light” system based on the Gross Motor Function Classification System (GMFCS) levels. Green Group (Walkers, GMFCS I–II): Clinical surveillance. Amber Group (Poor Walkers, GMFCS III, and asymmetric hemiplegic GMFCS I–II): Annual radiographs starting at ages 3–8. Red Group (Non-Walkers, GMFCS IV–V): Six-monthly radiographs starting at ages 3–5. There was 100% consensus on the mandatory use of sitting radiographs for non-ambulatory patients to prevent masking true pelvic decompensation. Critical referral triggers were identified as a Cobb angle >20°, pelvic obliquity ≥5°, or a progression rate ≥1° per month. Conclusions: The “Traffic Light” protocol helps identify the “window of opportunity” for intervention before reaching the 90° “point of no return,” where surgical risks increase nonlinearly. This proactive approach aims to reduce surgical complications and systemic delays in specialized care. Full article

Background/Objectives: Slipped Capital Femoral Epiphysis (SCFE) is a common, serious hip disorder in children and adolescents. Two-dimensional (2D) radiography is the gold standard for diagnosis but may not fully capture the deformity’s complexity, and it is vulnerable to positioning errors. Advances in three-dimensional (3D) imaging, such as computed tomography and magnetic resonance imaging (MRI), enable more accurate assessments. This study aimed to (1) assess the inter-rater reliability of 2D radiographic and 3D MRI measurements, and (2) evaluate the correlations and agreements between these outcomes. Methods: Patients were randomly selected from a cohort of patients aged under 16 years old and diagnosed with SCFE between January 2000 and December 2024. Southwick angles and posterior epiphyseal slip angles on 2D radiographs were independently measured by two orthopaedic surgeons. Posterior epiphyseal slip angles on 3D MRI were independently measured by two orthopaedic surgeons and two paediatric radiologists. Relationships between the three outcomes were evaluated using the Pearson correlation coefficient (r). Inter-rater reliability and agreements between the three outcomes were evaluated using the intraclass correlation coefficient (ICC) and the standard error measurement (SEM). Results: A total of 35 patients (35 hips) were recruited, with a mean age of 11.8 (1.2) years old and 19/35 (54%) females. Radiographic outcomes were moderately correlated (r < 0.75, p < 0.01) with MRI posterior epiphyseal slip angles. MRI posterior epiphyseal slip angles were systematically greater (16° on average) than both radiographic outcomes, regardless of whether contralateral correction was applied. The inter-rater reliability of radiographic outcomes was excellent (ICC > 0.85, SEM > 5.0°) and almost perfect (ICC > 0.95, SEM = 2.5°) for the MRI posterior epiphyseal slip angles measured by the paediatric radiologists. Conclusions: Findings suggest that while both diagnostic methods are reliable, radiographic measurements systematically underestimate epiphyseal slip severity by approximately 16° compared to MRI. This discrepancy could impact the accuracy of disease staging, leading to potential misclassifications. This highlights the need for a more standardised approach to evaluating SCFE, especially regarding the type of imaging used for angle measurement. Full article

Venous thromboembolism (VTE), comprising deep vein thrombosis and pulmonary embolism, is an important but under-recognised complication in neuromuscular diseases. In adults, emerging epidemiological data suggests increased VTE occurrence in conditions such as Amyotrophic Lateral Sclerosis, myotonic dystrophy, myasthenia gravis, inflammatory neuropathies, inflammatory myopathies, and POEMS syndrome. This heightened risk reflects not only disease-related immobility but also disorder-specific biological mechanisms, including inflammation, endothelial dysfunction and cardiomyopathy-related stasis. Therapies such as corticosteroids, IVIG-related hyperviscosity, long-term central venous access, perioperative immobility, critical illness, and complex orthopaedic procedures have prothrombotic effects. Despite this multifactorial risk profile, disease-specific guidance for thromboprophylaxis is lacking, and current practice relies heavily on extrapolation from general medical and surgical recommendations rather than data derived from neuromuscular cohorts. In children and adolescents, the VTE burden is less well-characterised, but events have been reported in Duchenne and Becker muscular dystrophy, congenital myopathies, and spinal muscular atrophy particularly with advanced motor impairment, severe cardiomyopathy, ventilatory insufficiency, and prolonged hospitalisation. Beyond venous events, selected neuromuscular disorders also exhibit increased arterial thrombosis risk. Myotonic dystrophy and dystrophinopathies are associated with cardiomyopathy and arrhythmia that predispose to systemic embolism and stroke, while inflammatory myopathies may demonstrate arterial events related to vasculitic or endothelial processes, although overall evidence remains limited. This review summarises available empirical and epidemiological evidence on venous and arterial thrombosis across adult and paediatric neuromuscular disorders, outlines disease-specific mechanistic pathways, examines treatment-related contributors, and highlights key evidence gaps that must be addressed to guide rational and targeted prophylaxis strategies in this complex, heterogeneous population. Full article

Paediatric osteoarticular infections (OAIs) encompass a heterogeneous group of musculoskeletal infections associated with acute septic complications, prolonged morbidity and potentially long-term sequelae. Over the past two decades, advances in microbiological diagnostics—particularly nucleic acid amplification assays—have refined the aetiological understanding of OAIs and started a new therapeutic debate regarding the most appropriate routes of antibiotic administration. Clinicians now evaluate which children can be treated safely using oral antibiotics from the outset (oral-first), which require an initial intravenous (IV) phase before a step-down to oral therapy, and which will need IV therapy all along their care pathway. Treatment debates are particularly relevant in contexts involving constrained healthcare resources and limited hospital bed availability. This narrative review summarises the essential prerequisites for prescribing oral antibiotic therapy for paediatric OAIs and proposes a pharmacokinetic/pharmacodynamic (PK/PD) framework for guiding clinical decision-making. Key considerations include: pathogen identification and resistance profiling; contemporary bacteriological epidemiology; the comparative effectiveness of IV versus oral therapy; the availability of active oral antibiotics and their penetration into bone and joint compartments; achieving adequate systemic exposure and hitting PK/PD targets after oral administration; and the clinical limitations of oral antibiotic therapy, including patient selection criteria. We argue that oral-first and early-switch strategies are best framed as structured selection processes that integrate clinical severity and source control, pathogen/minimal inhibitory concentration constraints, the feasibility of attaining PK/PD targets orally and the reliability of follow-up. No single strategy should be seen as a universal default strategy. Full article

Objective: The association between vitamin D status and paediatric fracture risk remains controversial, with inconsistent findings across existing studies. This study aimed to evaluate the relationship between serum 25(OH)D concentrations, vitamin D sufficiency, insufficiency and deficiency, vitamin D supplementation and fracture risk in a large Southeast Asian paediatric cohort. Methods: This retrospective cross-sectional study included children under 18 years whose serum 25(OH)D concentrations were measured between 2014 and 2022. One-way ANOVA determined statistical significance between 25(OH)D concentrations in fracture and non-fracture groups. Prevalence of vitamin D insufficiency, deficiency and supplementation was compared between the two groups. Chi-square tests evaluated the association between 25(OH)D concentrations and supplementation against fracture risk. Results: A total of 4530 children were included (157 fracture cases, 4373 controls). Mean serum 25(OH)D concentration was lower in the fracture group than in the controls (27.44 ± 12.26 vs. 30.75 ± 15.21 ng/mL; p = 0.007). Sub-sufficient vitamin D status (<30 ng/mL) was more prevalent among fracture patients (p = 0.001), and suboptimal (p = 0.001), insufficient (p = 0.001), and deficient (p = 0.014) categories were each significantly associated with fractures. An association between vitamin D supplementation and fracture risk was observed. However, the dataset did not permit the determination of causality and a protective effect cannot be inferred. Conclusions: Higher serum 25(OH)D concentrations were associated with lower fracture risk, suggesting that optimisation of vitamin D status may represent a modifiable factor in paediatric bone health. Healthcare institutions should aim to maintain adequate 25(OH)D concentrations (>30 ng/mL). An association between vitamin D supplementation and fracture risk was observed; however, causality cannot be inferred from this retrospective dataset. Full article

Osteomyelitis (OM), an inflammatory condition of the bone tissue, is a complex orthopedic condition marked by chronic inflammation, diagnostic uncertainty, and recurrent infections. Despite standard treatments—including surgical debridement, antimicrobial therapy, and bone reconstruction—many patients continue to experience recurrence and treatment failure. Growing molecular evidence indicates that host genetic factors play a crucial role in shaping immune responses and influencing disease progression in OM. This narrative review synthesizes current knowledge from candidate gene single-nucleotide polymorphism (SNP) association studies to illustrate how specific genetic variations contribute to OM pathogenesis, diagnostic refinement, and treatment outcomes. We examined key immunogenetic variants within genes involved in inflammatory signaling, pathogen recognition, and neutrophil regulation. Our synthesis identifies a landscape of pro-inflammatory SNPs, such as IL-1β rs16944 and NLRP3 rs10754558, that are associated with increased susceptibility to chronic or post-traumatic OM, as well as SNPs that are associated with protective effects that may favor infection resolution, such as within the NOS2 and VDR genes. These SNP-driven differences in inflammasome activity, cytokine pathways, and oxidative stress responses highlight emerging opportunities for individualized therapeutic strategies. This review consolidates these variants, providing a genetic framework to analyze host susceptibility and differentiating high risk from protective genetic profiles. Integrating genomic insights into OM management represents a promising shift toward personalized medicine, enhancing diagnostic precision, informing targeted interventions, and improving prognostic assessment. Continued large-scale validation of candidate SNPs and translational genomic models will be essential to support their future clinical application. Full article

Background/Objectives: Juvenile osteochondritis dissecans (JOCD) of the knee is commonly treated using conservative or joint-preserving surgical techniques. While clinical outcomes are generally favorable, the risk of early cartilage degeneration remains unclear. Joint space width (JSW) on weight-bearing radiographs serves as an indirect marker of cartilage health. Artificial intelligence (AI)-based JSW assessment may enable sensitive and reproducible detection of early degenerative changes. Methods: This cross-sectional feasibility study included 21 skeletally immature patients treated for JOCD of the distal femur between 2002 and 2017. Treatment modalities comprised conservative management, retrograde drilling, and fragment refixation. Fully automated JSW measurements were performed on standardized anteroposterior knee radiographs using a validated AI-based software IB Lab KOALA™, Version 2.4. JSW of the affected compartment was compared with the contralateral knee and between treatment groups. Clinical outcomes were assessed using the Lysholm Knee Scoring Scale and the International Knee Documentation Committee (IKDC) score. Additionally, a systematic review of the literature on post-treatment degenerative changes following OCD therapy was conducted according to PRISMA guidelines. Results: Compared with manually reviewing images, the software IB Lab KOALA™, Version 2.4 as easy to implement. AI-based analysis revealed no significant differences in JSW between the affected and contralateral knees, nor between treatment modalities. Average JSW exceeded 6 mm in all groups after a median follow-up of 64 (min. 27, max. 177) months. Clinical scores were high and comparable across treatments. A moderate positive correlation was observed between the JSW and Lysholm score, while increasing age and longer follow-up were associated with a reduced JSW. The systematic review identified ten relevant studies, reporting generally favorable long-term clinical outcomes with a low but present risk of osteoarthritis progression. Conclusions: Our AI-based analysis showed no differences in JSW between conservative and joint-preserving surgical treatments of JOCD in the follow-up. This technology can provide a valuable tool for standardized and sensitive radiographic monitoring in young patients. Full article

Background/Objectives: Dalbavancin is approved for pediatric acute bacterial skin and skin structure infections (ABSSSIs), yet real-world practice frequently necessitates off-label use for deep-seated infections requiring prolonged suppression. While adult data support therapeutic drug monitoring (TDM)-guided maintenance, the pediatric evidence for repeated-dose pharmacokinetics (PK) is limited. We evaluated the efficacy, safety, multi-dose PK, and pharmacoeconomic impact of dalbavancin in a complex pediatric cohort. Methods: A retrospective study (2023–2025) of enrolled patients < 18 years treated with dalbavancin. A subgroup receiving ≥3 doses underwent PK analysis to assess concentration decay against conservative efficacy targets (4 and 8 mg/L). A pharmacoeconomic analysis compared resource utilization against the standard of care. Results: Sixteen patients (median age 12) were included, primarily treated for Staphylococcus aureus (S. aureus) osteoarticular infections (75%), and frequently device-associated (66.7%). Clinical success was 93.8% (15/16) with no adverse events. A PK analysis (n = 9; 78 samples) ruled out dangerous accumulation but revealed a significant concentration drop at week 4 (mean 6.06 mg/L; p = 0.005). Logistic regression identified the time since the previous dose as the sole predictor of sub-therapeutic levels, with >50% of the patients dropping below 8 mg/L by the fourth week. An analysis showed median net savings of EUR 3215.84 per patient (p = 0.004). Conclusions: Dalbavancin is effective and cost-saving for complex pediatric infections. However, due to distinct pediatric PK, dosing regimens extrapolated from adults may result in sub-therapeutic concentrations by week 4. We recommend TDM around week 3 to tailor dosing or limiting maintenance intervals to a maximum of 4 weeks. Full article

Purpose: Revision total hip arthroplasty (RTHA) in the presence of a well-fixed femoral stem is associated with increased risk, as stem removal often results in bone loss, prolonged operative time, and greater blood loss. This problem is particularly relevant for older implants with a 14/16 taper, which is incompatible with most modern femoral heads. The Bioball™ System, a modular head–neck adapter, allows for acetabular or head-only revision while preserving the femoral stem. This study aimed to evaluate long-term clinical and radiological outcomes of RTHA using the Bioball™ System in patients with 14/16 tapers. Methods: A total of 38 patients (23 women, 15 men; mean age 73.5 years) met the inclusion criteria. All procedures were carried out with a well-fixed femoral stem and a 14/16 taper. Revisions were limited to exchange of the acetabular component, liner, or both, avoiding stem removal. The primary indication was acetabular cup loosening (n = 29, 76.3%); liner-only exchange was performed in 9 patients (23.7%). Clinical outcomes were assessed using the modified Merle d’Aubigné and Postel (MAP) score, and radiological evaluation focused on fixation, migration, and loosening. Mean follow-up was 8.44 years. Results: Both the acetabular component and liner were replaced in 76.3% of patients, while 23.7% underwent liner and head exchange only. Longer adapter sizes were most frequently used, and a 7.5° offset adapter was applied in 57.9% of cases. The modified MAP score improved by a mean of 5.7 points (p < 0.05), and VAS pain scores decreased from 7.4 to 2.6 (p < 0.05). No radiological signs of loosening were observed at final follow-up. Conclusions: The Bioball™ System enables effective restoration of hip stability and offset without femoral stem removal, offering favorable long-term clinical and radiological outcomes in revisions involving older 14/16 tapers. Full article

Background/Objectives: Childhood is marked by frequent musculoskeletal injuries, with fractures representing a major cause of pediatric trauma admissions. Unstable long-bone fractures often require surgical stabilization, commonly achieved using elastic stable intramedullary nailing (ESIN). Although this method ensures effective fixation and early mobilization, concerns remain regarding potential metal ion release in growing children. This study aimed to assess changes in calcium, magnesium, copper, zinc, titanium, and aluminum concentrations in blood and material from the medullary cavity of forearm fractures following intramedullary fixation. Methods: A prospective study was conducted on 40 patients aged 4–15 years treated with ESIN at the University Children’s Hospital in Lublin. Peripheral blood and material from the medullary cavity were collected before implantation and at implant removal. Elemental concentrations were determined using high-resolution ICP-OES, and statistical analyses included paired comparisons, delta values, and multivariate methods. Results: No significant systemic changes were found for calcium, magnesium, copper, zinc, or aluminum. A modest but significant increase in blood titanium levels was observed after treatment (p = 0.0075), especially in patients with two rods. Multivariate analysis confirmed overall stability of elemental profiles, with titanium contributing most strongly to post-treatment variation. Conclusions: Intramedullary titanium fixation in children does not significantly disrupt systemic mineral homeostasis. The slight increase in circulating titanium reflects implant exposure rather than toxicity, supporting the safety of ESIN, although continued monitoring of metallic elements may be warranted. Full article

Background: Trauma-related injuries are among the most common reasons for paediatric hospital presentations and represent a substantial component of orthopaedic care. Their management poses unique challenges due to ongoing skeletal development in children. While most reported fractures occur at home or during sports, prior studies have primarily used data from urban European populations, limiting the relevance of their findings for rural and regional settings. Urban-centred research often informs public healthcare guidelines, treatment algorithms, and infrastructure planning, introducing a bias when findings are generalised outside of metropolitan populations. This study addresses that gap by analysing fracture data from two rural trauma centres in New South Wales, Australia. This study assesses paediatric fractures resulting from severe injury mechanisms in rural areas, identifying common fracture types, underlying mechanisms, and treatment approaches to highlight differences in demographics. These findings aim to cast a light on healthcare challenges that regional areas face and to improve the overall cultural safety of children who live and grow up outside of the metropolitan trauma networks. Methods: We analysed data from two major rural referral hospitals in New South Wales (NSW) for paediatric injuries presenting between 1 January 2018 and 31 December 2022. This study included 150 patients presenting with fractures following severe mechanisms of injury, triaged into Australasian Triage Scale (ATS) categories 1 and 2 upon initial presentation. Results: A total of 150 severe fractures were identified, primarily affecting the upper and lower limbs. Males presented more frequently than females, and children aged 10–14 years old were most commonly affected. High-energy trauma from motorcycle (dirt bike) accidents was the leading mechanism of injury among all patients, and accounted for >50% of injuries among 10–14-year-old patients. The most common fractures sustained in these events were upper limb fractures, notably of the clavicle (n = 26, 17.3%) and combined radius/ulna fractures (n = 26, 17.3%). Conclusions: Paediatric trauma in regional Australia presents a unique and under-reported challenge, with high-energy injuries frequently linked to unregulated underage dirt bike use. Unlike urban centres where low-energy mechanisms dominate, rural areas require targeted prevention strategies. While most cases were appropriately managed locally, some were transferred to tertiary centres. These findings lay the groundwork for multi-centre research, and support the need for region-specific policy reform in the form of improved formal injury surveillance, injury prevention initiatives, and the regulation of under-aged off-road vehicular usage. Full article

The gender gap in drug use is narrowing in regions where access to criminalized substances, such as opioids, is increasing. While research shows that substance use is gendered, less is known about the cultural norms and values shaping women’s drug use, as most studies focus on men. Cross-national comparisons of cultural models of addiction are needed to better understand how addiction is perceived and to inform culturally responsive treatment approaches for women. This study examined cultural models of addiction among reproductive-aged women receiving treatment for substance misuse in London, Toronto, and Delhi. Participants completed a semi-structured questionnaire with open-ended and free-list prompts. Findings revealed shared cultural models attributing drug use to psychological factors, such as self-medicating to manage negative emotions or enhance positive ones, as well as relational, developmental, and biological influences. In conclusion, the study highlights the importance of incorporating cultural models into research and treatment. By using an inductive approach to explore meanings surrounding drug use among people in recovery, researchers can better understand how interventions are received and interpreted through existing internal frameworks. Full article