The popliteal artery runs along the posterior surface of the distal femur. An exostosis on the posteromedial aspect of the distal femur can potentially affect the course of this artery, depending on its position and shape. This study aimed to clarify the relationship between distal femur exostoses and the course of the popliteal artery in patients with multiple cartilaginous exostoses. This study included 10 patients who underwent exostosis resection in the posteromedial aspect of the distal femur between April 2002 and March 2022. Sex, age, operated side, course of the popliteal artery relative to the exostosis, exostosis shape, recurrence rate, and perioperative complications were analyzed. Exostosis shape was classified as pedunculated or sessile based on the lateral radiographic view. The patients were divided into three groups based on the course of the popliteal artery relative to the exostosis: lateral, over, and medial. The study included eight male patients and two female patients. The mean age at operation was 12.8 years. Three patients had pedunculated lesions, and seven had sessile lesions. The popliteal artery ran laterally in six cases, over in three, and medially in one. The median follow-up period was 1.1 years. There were no cases of recurrence or major complications. The course of the popliteal artery may vary depending on the location and shape of the exostosis. Understanding this relationship preoperatively and paying attention to the artery intraoperatively are essential to prevent vascular damage.

We evaluated the imaging and clinical outcomes of posterior thoracic-pelvic corrective fixation (TP-PCF) for nonambulant neuromuscular scoliosis (NA-NMS), including the Caregiver Priorities and Child Health Index of Life with the Japanese version of the Disabilities Questionnaire (J-CPCHILD), and analyzed the J-CPCHILD and preoperative and postoperative radiographic parameters to determine whether sagittal and coronal alignment correlate with preoperative and postoperative quality of life (QoL) in NMS, respectively. Twenty-five patients (nine males and 16 females) with a mean age of 14.3 ± 2.0 years, who had TP-PCF and were followed up for >2 years postoperatively, were included. Sitting radiographs and the J-CPCHILD were evaluated preoperatively, at 1 year postoperatively, and at the final visit. Preoperative major curve and pelvic obliquity (PO) were 102.4 ± 22.2 ° and 21.5 ± 9.9 °, which significantly improved to 51.4 ± 18.8 ° and 10.9 ± 7.6 °, respectively, at the final visit. At the final visit, lumbar lordosis and sacral slope showed a significant increase of 46.6 ± 18.5 ° and 30.2 ± 17.5 ° compared with preoperative values of 25.8 ± 33.2 ° and 24.4 ± 31.0 °, respectively. Sagittal vertical axis showed a significant decrease of 2.2 ± 35.3 mm at the final visit compared with 37.1 ± 36.5 mm preoperatively. However, iliac screw (IS)-related implant failure was observed in four (16%) patients. Significant improvement from 37.1 ± 20.8 to 51.2 ± 25.2 points and from 49.6 ± 12.6 to 59.1 ± 14.9 points was observed in the positioning domain ( P  = 0.047) and total score ( P  = 0.032) of the J-CPCHILD, respectively, at 1 year postoperatively compared with preoperatively. However, no correlations were identified between the respective domains of the J-CPCHILD and the magnitude of the major curves, PO, or sagittal plane vertical axis, either preoperatively or postoperatively. According to caregivers, improvement in comprehensive trunk stability with better global balance, similar to that of the ambulant patient, contributed to overall QoL after TP-PCF for NA-NMS. However, IS-related implant failure occurred in approximately 16% of the patients.

Reconstructive hip surgery is essential for managing hip displacement in nonambulatory children with cerebral palsy (CP); however, its impact on health-related quality of life (HRQoL) and caregiver burden remains unclear. This study evaluates postoperative changes in HRQoL and caregiver burden. This prospective observational study included 19 nonambulatory children with spastic CP classified as Gross Motor Function Classification System (GMFCS) levels III-V undergoing reconstructive hip surgery. HRQoL and caregiver burden were assessed using the Pediatric Quality of Life Inventory (PedsQL 4.0) and the Zarit Burden Interview (ZBI), respectively, at baseline and during a 12-month follow-up. Subgroup analyses were performed based on Reimers' migration index, GMFCS levels, and age. PedsQL scores showed a continuous improvement over 12 months, with a significant increase from baseline to 1 year ( P  < 0.001). Caregiver burden (ZBI) slightly increased at 3 months but progressively declined thereafter, with significant reductions at 9 months ( P  = 0.010) and 12 months ( P  = 0.002). Subgroup analyses by Reimers' migration index, GMFCS level, and age revealed no significant between-group differences in outcome scores ( P  > 0.05). Reconstructive hip surgery enhances HRQoL and reduces caregiver burden over time in nonambulatory children with CP. These findings highlight the long-term benefits of surgical intervention.

Level IV.

This study investigated the impact of preoperative vertebral rotation (VR) on the surgical outcomes in spinal muscular atrophy (SMA) scoliosis. A retrospective analysis of 27 SMA patients (mean age 13.4 ± 4.3 years) who underwent scoliosis surgery between 2015 and 2019 was conducted. Preoperative VR was measured using Aaro-Dahlborn's and Ho's methods on computed tomography images. Surgical outcome prediction was evaluated using the Pearson correlation coefficient, linear stepwise regression, receiver operating characteristic (ROC) curve, and logistic regression analyses. Ho's method yielded significantly higher VR measurements than Aaro-Dahlborn's ( P  < 0.001). Postoperative Cobb angles correlated positively with preoperative Cobb angles ( r ² = 0.425, P  = 0.0002), Ho's method VR ( r ² = 0.449, P  = 0.0001), and Aaro-Dahlborn's method VR ( r ² = 0.4352, P  = 0.0002). Stepwise regression identified preoperative Ho's method VR and Cobb angles as independent predictors of postoperative Cobb angles. Postoperative Cobb angles >30 ° indicated increased risk of deformity progression in SMA. ROC curve analysis showed preoperative Ho's method VR significantly predicted postoperative Cobb angles >30 ° (area under the curve: 0.813, P  = 0.006), with an optimal cutoff of 35 °. Logistic regression analysis revealed patients with preoperative Ho's method VR > 35 ° had a higher risk of postoperative Cobb angles >30 ° (odds ratio: 10.36, 95% confidence interval: 1.050-102.261, P  = 0.045). This study demonstrated that Ho's method better predicted surgical outcomes, with preoperative Ho's method VR > 35 ° at the apex associated with higher initial residual scoliosis curves after surgery. These findings could enhance surgical planning and improve outcome predictions in SMA scoliosis correction.

This article aims to introduce a novel growth-guidance technique for early onset scoliosis (EOS) surgery, utilizing closed multiaxial screws (CMAS) as an alternative to Shilla trolley screws. We report clinical and radiographic outcomes from five EOS patients treated between 2021 and 2024, who underwent active apex correction using CMAS. This method provided an effective alternative for anchoring in the cephalad and caudad regions. Our analysis shows a significant reduction in the major coronal Cobb angle from an average of 71.2 to 19.6° postoperatively, with a 22.8% increase in truncal height maintained at the final follow-up. Importantly, no neurological changes were observed, and patients were braced for the initial 3 months after surgery. In conclusion, CMAS offers a user-friendly and effective alternative for growth guidance in EOS treatment, demonstrating reliable outcomes.

This research aims to investigate femoral neck anteversion (FNA) on the less involved side in unilateral cerebral palsy (CP) and examine its impact on hip rotation during gait. Sixty-nine patients with unilateral CP, with a mean of 21 years, were included study. Static and dynamic hip rotation ranges were quantified via physical examination and three-dimensional motion analysis. Patients were stratified into five levels of involvement according to modified Winters' classification. FNA differences between modified Winters' classification types and correlation with static and dynamic hip rotation were analyzed. Hip morphology was classified based on the Melbourne Cerebral Palsy Hip Classification Scale E&R. Regarding FNA, our analysis suggested a moderate correlation ( r  = 0.61, P  < 0.05) between both sides. Hip dysplasia was found in 20.5 and 23.1% of the less involved and more involved sides, respectively, in 39 patients. Increased FNA was associated with increased static hip internal and decreased external rotation for both sides ( P  < 0.05). A positive correlation was observed between FNA and dynamic hip rotation on the more involved side ( P  < 0.05). Conversely, on the less involved side, FNA showed no significant correlation with pelvic, hip, or knee rotation. This study demonstrates that in unilateral CP, the less involved side is also significantly affected, a moderate correlation exists between the two sides, and both hips may exhibit dysplasia. These findings underscore the necessity for a comprehensive bilateral clinical assessment. Long-term surveillance of both hips and consideration of the less involved side for surgical planning may be warranted.

Studies suggest that vitamin D may be protective against upper extremity low-energy (LEn) fractures. We hypothesized that there may be a similar effect in lower extremity long bone (LLB) fractures. We prospectively enrolled pediatric patients (ages 3 to 18) with LLB fractures. Exclusion criteria were pathologic, vertebral or pelvic fracture, or patients with metabolic and neuromuscular disorders. The 25-hydroxyvitamin D (25OH vit D) in the LEn group (18.3 ± 6.6 ng/ml, n = 48) was significantly lower than that in the high-energy group (HEn) (23.5 ± 7.4 ng/ml, n = 22) (P = 0.0086). As ankle fractures were predominantly in the higher 25OH vit D range, a subgroup analysis of 25OH vit D in LEn above ankle fracture group (LEnAA) (16.8 ± 5.5 ng/ml) was significantly lower than that in the HEn above ankle fracture group (HEnAA) (22.6 ± 6.3 ng/ml) (P = 0.011). Defining vitamin D deficiency, insufficiency, and sufficiency as 25OH vit D < 20, 20-29, and ≥ 30 ng/ml respectively, the percentage of patients with vitamin D sufficiency in LEnAA (0%) was significantly less than that in HEnAA (19%); vitamin D deficiency in LEnAA (68%) was significantly greater than that in HEnAA (38%). A greater percentage of patients with vitamin D deficiency were treated operatively compared to those with vitamin D insufficiency and sufficiency (P = 0.02). Our study found that LEn and LEnAA had significantly lower 25OH vit D compared to HEn and HEnAA and supported the hypothesis that vitamin D may be protective against LLB LEn fractures. Our recommendation is to obtain 25OH vit D in LLB LEn.

Hip joint morphology varies by sex and age. Computed tomography (CT) provides excellent evaluation of acetabular morphology; however, a description of the normal range of CT measurements in healthy children is lacking. This study aimed to describe the acetabular morphology on CT in healthy children by sex and at specific ages. Children who underwent pelvic CT from February 2016 to 2022 were retrospectively studied. The anterior pelvic plane was the basis for measuring lateral center-edge angle (LCEA), acetabular angle, anterior center-edge angle (ACEA), acetabular version (AcetV), anterior acetabular sector angle (AASA), and posterior acetabular sector angle (PASA). This study included 55 females and 55 males. The mean age was 12.5 years (range: 1-18 years). Patients were grouped by age: 2-7 years (n = 50 hips), 8-11 years (n = 50 hips), and 12-18 years (n = 120 hips). Mean AcetV was 16.5° (range: 5.8-29.5°), mean AASA was 58.38° (range: 40.0-69.4°), mean PASA was 90.6° (range: 68.8-111.00°), mean LCEA was 27.9° (range: 19.0-40.4°), mean acetabular angle was 45.1° (range: 33.6-55.9°), and mean ACEA was 47.6° (range: 23.0-64.4°). The AcetV, AASA, PASA, LCEA, and ACEA increased with age, while the acetabular angle decreased (P < 0.001). AcetV and PASA were highest in females (P < 0.001). Hip joint development varies by sex across specific ages. The measurements reported provide descriptive reference data that may be used as an assessment tool for early identification of pediatric hip deformities and aid surgical planning.

In pediatric orthopedics, the physis functions as an ally, allowing for remodeling of fractures. However, when physeal bars occur, they can cause leg length discrepancy (LLD) and malalignment. 3D guided techniques can be used to guide the treatment of those physeal bars to achieve a precise resection while protecting the surrounding tissues, allowing growth to resume, and correcting angular deformity. The objective is to describe a 3D imaging-guided technique for excision of partial physeal bars and to report the results of a series of patients who have undergone this procedure. This is a retrospective chart review of five patients treated at a level 1 pediatric tertiary care center by a fellowship-trained pediatric orthopedic surgeon. Inclusion criteria were: (1) Pediatric patients aged 2-18 diagnosed with a partial physeal arrest with resulting deformity, (2) treatment with partial physeal excision using 3D imaging guidance between January 2008 and December 2022, and (3) appropriate radiographic follow-up of at least 6 months. Preoperative 3D imaging demonstrated physeal bar size and location for each patient and was utilized for operative planning. Descriptive statistics were used. The use of 3D imaging guidance for physeal bar excision resulted in improved radiographic angular deformities and LLD. Our cohort had an average physeal bar size of 6.7 ± 3.6% of the physis with no complications reported. A 3D guidance system can help achieve a precise and safe physeal bar resection and is a valuable tool to consider.

Pediatric femoral neck fractures result primarily from high-energy trauma. Common treatment methods include screw fixation and the placement of a proximal femoral locking plate. However, there is limited biomechanical evidence favoring one method over another for the treatment of unstable fractures. This study aimed to evaluate the biomechanical properties of screws and proximal femoral locking plates for the treatment of unstable pediatric femoral neck fractures using a synthetic bone model. Fourteen synthetic composite femurs were divided into two groups that included screw fixation (S) and locking plates (P). All specimens were prepared using a vertically oriented osteotomy to simulate unstable Delbet type II femoral neck fractures. Fixation in Group S employed three 6.5 mm cannulated screws, while Group P utilized a proximal femoral locking plate with 5.0 mm screws. The axial stiffness, cyclic elongation, and ultimate failure load were assessed using a universal material testing machine under standardized loading conditions. Statistical analyses were performed to compare biomechanical properties between the groups. Group P exhibited significantly greater axial stiffness (763 ± 212 N/mm) compared to that of Group S (547 ± 93 N/mm, P = 0.026). Following cyclic loading, elongation was significantly smaller in Group P (0.42 ± 0.2 mm) vs. Group S (0.88 ± 0.4 mm, P = 0.002). The ultimate failure load was also higher in Group P (2511 ± 321 N) than it was in Group S (2036 ± 256 N, P = 0.007). The failure modes differed, with Group S exhibiting screw bending and femoral neck collapse and Group P exhibiting subtrochanteric fractures. Proximal femoral locking plates offer superior biomechanical performance compared to that of screw fixation in unstable pediatric femoral neck fractures. These findings suggest that locking plates are a viable alternative to enhance stability and potentially reduce postoperative complications.

Blood cultures are routinely performed for microbiological diagnostic purposes in acute hematogenous osteomyelitis (AHO); however, the blood culture positivity rate is less than 50%. This retrospective study aimed to identify indicators to distinguish blood culture outcomes in children with AHO from July 2017 to 2024. Patients were stratified based on the results of blood cultures. The age, sex, duration of symptoms, duration of antibiotic therapy before blood culture, location of the lesion, maximum temperature, and inflammatory indexes from admission were reviewed. The efficacy of each index in diagnosing negative blood cultures was also determined according to the receiver operator curves. Logistic regression analysis was used to determine the independent risk factors for blood culture negativity. Among 75 patients, 47 had negative and 28 had positive cultures. No significant differences were found in age, sex, symptom duration, or leukocyte count. However, maximum temperature, duration of antibiotic therapy before culture, neutrophil count, C-reactive protein, and erythrocyte sedimentation rate (ESR) showed significant differences. Logistic regression identified antibiotic therapy duration >2.5 days (OR = 6.383, 95% CI: 1.720-23.680) and ESR <41.5 mm/h (OR = 12.377, 95% CI: 2.042-75.015) as independent risk factors for negative cultures. AHO patients with either of these factors are more likely to have negative blood cultures. For such children, early invasive procedures to obtain pus or tissue for culture should be considered.

Pediatric pes planovalgus (flatfoot) is a prevalent musculoskeletal condition characterized by the flattening of the medial arch of the foot. Despite its common occurrence, there is a lack of standardized diagnostic and therapeutic protocols. This study aimed to conduct a comprehensive bibliometric analysis on the 100 most-cited papers on pediatric flatfoot to identify major research trends, including publication years, countries of origin, contributing institutions, prevalent keywords, common surgical treatments, and authorship patterns. This bibliometric analysis utilized the Web of Science Core Collection database by Clarivate Analytics to identify articles related to pediatric flatfoot using keywords. The 100 most-cited articles were manually selected and analyzed using the VOSviewer software to create network visualization maps. The 100 most-cited articles were published between 1951 and 2019, with the number of citations ranging from 26 to 299. The number of influential papers published increased in the 2000s, and the majority were published in the 2010s (57%). The USA was the most productive country (31 publications), the University of South Australia was the most productive institution (eight publications), and Evans AM was the most productive author (seven publications). Calcaneal osteotomy was the most studied procedure (14 publications, 782 citations), predominantly in North America. Subtalar arthroereisis was the focus of seven publications (462 citations), mostly coming from Europe. There was a notable expansion in research on pediatric flatfoot in recent years. There were major geographic differences in the approach to treatment for calcaneal osteotomy vs. subtalar arthroereisis.

Flatfoot is a common condition in children; surgical treatment should be reserved for severe and symptomatic cases. Calcaneal lengthening osteotomy (CLO) has been associated with good results; the original technique considers the use of allografts or autografts. This study aimed to evaluate advantages of a titanium trapezoidal wedge (TTW) in a pediatric population, compared with traditional grafts. At our knowledge, there are no studies in pediatric patients. This is a retrospective study of 11 patients (14 feet) with severe flatfoot treated with CLO and TTW and a control group of nine patients (13 feet) treated with CLO and traditional grafts. The mean age of TTW group was 13.4 years, and the mean follow-up was 15 months. The mean age in the control group was 13.7 years, and the mean follow-up was 36 months. Pre- and postoperative clinical and radiographic measures were evaluated, as well as operative time and radiation exposure. At follow-up, feet treated with TTW showed an improvement in all radiographic parameters measured on weight-bearing radiographs and also an improvement in the American Orthopedic Foot and Ankle Society Score, comparable to the control group. The use of TTW significantly reduced radiation exposure and operating time. No cases of graft fracture or migration were observed. All TTW appeared osteointegrated at the last follow-up. CLO using TTW is an effective procedure, allows correction to be maintained over time and reduces operative time and radiation exposure. Despite the promising results, our findings should be considered as a preliminary report; more data are needed to confirm our results.

To evaluate the effects of multidisciplinary team (MDT) intervention on perioperative management, functional recovery, and psychological well-being in adolescents aged 14-18 years with limb or pelvic fractures. One hundred adolescents aged 14-18 years with limb or pelvic fractures, admitted between January 2018 and December 2023, were retrospectively divided into an MDT group (n = 50) and a control group (n = 50) according to whether they received MDT intervention. The MDT group received comprehensive perioperative management involving orthopedics, emergency, anesthesiology, rehabilitation, pediatrics, psychology, and surgical intensive care; the control group received standard perioperative management. Perioperative outcomes, pain scores, functional recovery, and psychological status were compared at predetermined time points. The MDT group had significantly shorter hospital stays and lower postoperative pain scores than the control group (P < 0.05). Functional recovery was assessed using the short musculoskeletal function assessment (SMFA) and the CORE-Kids simplified score (CKSS), a 0-9 binary scale developed with reference to the CORE-Kids core outcome set. At 3 and 6 months, the MDT group showed significantly better SMFA and CKSS scores (P < 0.05). At 12 months, no significant differences were observed. The MDT group also had significantly lower hospital anxiety and depression scale anxiety and depression scores on postoperative day 3 and at 12 months (P < 0.05). MDT intervention improves perioperative pain control, promotes functional recovery, and enhances psychological well-being in adolescents with limb or pelvic fractures and may facilitate earlier return to daily life and school.

Ataxia telangiectasia AT), an autosomal recessive disorder due to mutations in the ATM gene, results in progressive cerebellar ataxia, oculocutaneous telangiectasia, immunodeficiency, pulmonary compromise, sensitivity to ionizing radiation, and increased risk of hematologic malignancies. Orthopedic manifestations such as scoliosis, hip displacement, gait abnormalities, and extremity contractures are common, but reports are scarce. This study aimed to evaluate and summarize the orthopedic manifestations associated with AT. A retrospective review was conducted of patients with AT. Reported outcomes included demographics, orthopedic manifestations and operative/nonoperative treatments, radiographic exposure, development of malignancy, and ambulatory status (using the Functional Mobility Scale at 50 m, FMS50). Twenty-four children were included [11 (45.8%) female] with a mean age at diagnosis of 5.5 (SD = 3.5) years. The most common reason for orthopedic consultation was ataxia; 12 (50%) were walkers (FMS50 = 4,5) and 12 nonwalkers (FMS50 = 1,2). Foot deformities were present in 10 (42%) including pes planovalgus (N = 6, 25%), Achilles tendon contracture (N = 1, 4%), hallux valgus (N = 1, 4%; underwent Akin osteotomy), equinovarus (N = 1.4%), and gastrocnemius contracture (N = 1, 4%). Six children (25%) developed scoliosis, and three underwent fusion. Other manifestations included hip flexion contracture (N = 2, 8%), hamstring contracture (N = 2, 8%), torticollis (N = 1, 4%), and osteomyelitis of the ischium (N = 1, 4). This report describes orthopedic manifestations associated with AT, most commonly foot deformities, followed by scoliosis. Since radiographic surveillance was not performed due to radiosensitivity, the frequency of hip displacement in AT could not be ascertained. Orthopedic surgical interventions, where required, were generally successful. Level of evidence: 3.

Plaster of Paris (POP) is traditional for Ponseti treatment of idiopathic congenital talipes equinovarus (CTEV), but semirigid fiberglass (SRF) is an alternative. This systematic review and meta-analysis compare POP and SRF outcomes. We searched PubMed, Scopus, Cochrane, and EMBASE up to 5th April 2025 for randomized controlled trials (RCTs) and quasi-RCTs comparing POP versus SRF for initial Ponseti treatment of idiopathic CTEV. Eligible studies reported on the number of casts, clinical scores (Dimeglio/Pirani), relapse or skin complications. Risk of bias was assessed using the Cochrane RoB tool. Data were pooled using random-effects meta-analysis [mean difference (MD) for continuous, risk ratio (RR) for binary outcomes]. Four studies (two RCTs, one prospective, one retrospective; 454 feet) met inclusion criteria. Study quality varied. No significant difference was found in the mean number of casts [MD: 0.34, 95% confidence interval (CI): -8.80 to 9.48; two studies, I² = 70.6%], relapse rates (RR: 1.41, 95% CI: 0.04-50.93; two studies, I² = 0.0%), or skin lesions (RR: 0.68, 95% CI: 0.31-1.50; two studies, I² = NA). Evidence certainty was low due to heterogeneity and limited studies. Clinical score analysis was limited by differing scales and missing data; SRF consistently received higher parental satisfaction ratings. Based on limited, low-certainty evidence, no significant difference in clinical efficacy (casts, relapse, skin lesions) was found between POP and SRF. SRF offers advantages in parental satisfaction. Limitations include heterogeneity, few studies per outcome, and inconsistent reporting. While POP is cost-effective, SRF is a viable alternative. Further high-quality RCTs are needed.