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Gyula Domos Department of Orthopaedics, Semmelweis University, Budapest, Hungary
Centre for Translational Medicine, Semmelweis University, Budapest, Hungary

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Szilárd Váncsa Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
Institute of Pancreatic Diseases, Semmelweis University, Budapest, Hungary

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Csenge Szeverényi Department of Orthopaedics, University of Debrecen, Debrecen, Hungary

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Gergely Agócs Department of Biophysics and Radiation Biology, Semmelweis University, Budapest, Hungary

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Péter Hegyi Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
Institute of Pancreatic Diseases, Semmelweis University, Budapest, Hungary

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Anna Perge Department of Orthopaedics, Semmelweis University, Budapest, Hungary

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Krisztina Békési Klinik Chirurgie, Spital Bülach, Bülach, Switzerland

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Csaba Varga Department of Orthopaedics, Semmelweis University, Budapest, Hungary
Centre for Translational Medicine, Semmelweis University, Budapest, Hungary

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György Szőke Department of Orthopaedics, Semmelweis University, Budapest, Hungary

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Objective

  • In developmental dysplasia of the hip (DDH), concentric reduction of dislocated hips cannot be achieved by closed reduction in many cases, and open reduction is required (‘failure of reduction’). The incidence of cases requiring open reduction and the significance of risk factors for unsuccessful reduction remain unclear. We investigated the overall rate and the risk factors for failed closed reduction in DDH.

Methods

  • We followed the Cochrane recommendations in our systematic review and meta-analysis. We performed a systematic search in three medical databases to identify all studies reporting on pediatric patients with hip dislocation in DDH on 2 July 2022. Eligible studies reported on the rate of failure in children younger than 36 months. We calculated odds ratios (ORs) with 95% CIs from two-by-two tables (event rate in risk group, event rate in non-risk group).

Results

  • We identified 13 316 studies and included 62 studies (5281 hips) for failure rate and 34 studies (3810 hips) for risk factor analysis. The overall rate of failure in closed reduction was 20%. The risk of failure of reduction increased with the grade of dislocation and was significantly higher for high dislocations (group 0–24: IHDI 4 vs IHDI 2 OR: 17.45, CI: 9.26–32.92; Tönnis 4 vs Tönnis 2 OR: 14.67, CI: 1.21–177.37; Graf IV vs Graf III OR: 3.4, CI: 2.27–5.09). Male gender was also a significant risk factor (OR: 2.27, CI: 1.13–4.56) in group 0–36.

Conclusion

  • Higher grade dislocations and male gender are significant risk factors for failure of reduction in closed reduction in hip dislocation in DDH.

Open access
Marta Salom Department of Pediatric Orthopedic, La Fe University and Polytechnique Hospital, Valencia, Spain

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Inês Balacó Department of Pediatric Orthopedic, Hospital Pediátrico de Coimbra, Unidade Local de Saúde de Coimbra, Portugal

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  • Bone tumours are frequent in children but most of them are benign. Moreover, the incidence and type of tumours differ from those of adults.

  • As an orthopaedic surgeon, we will likely encounter a bone lesion in a child and we must be able to distinguish if it is a benign lesion or has malignant characteristics and it is necessary to refer it to a centre specialized in tumours.

  • We will discuss the key points we would have to ask in the medical history, look at the physical examination and the radiological characteristics that will allow us to distinguish between a benign and a malignant bone lesion in a child.

  • When there are doubts about the malignancy of a bone lesion or if the diagnosis is not clear, a biopsy should be performed following certain rules in a specialized centre.

Open access
Djandan Tadum Arthur Vithran Department of Orthopaedics, Xiangya Hospital of Central South University, Changsha, China
National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China

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Xu Liu Department of Orthopaedics, Xiangya Hospital of Central South University, Changsha, China

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Miao He Department of Orthopaedics, Xiangya Hospital of Central South University, Changsha, China

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Anko Elijah Essien Department of Orthopaedics, Xiangya Hospital of Central South University, Changsha, China

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Michael Opoku Department of Orthopaedics, Xiangya Hospital of Central South University, Changsha, China

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Yusheng Li Department of Orthopaedics, Xiangya Hospital of Central South University, Changsha, China

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Ming-Qing Li Department of Orthopaedics, Xiangya Hospital of Central South University, Changsha, China

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  • The cavovarus deformity is a pathological condition characterised by an anomalous elevation of the longitudinal arch. This condition results from a significant hindfoot varus and forefoot equinus deformity. This phenomenon comprises diverse anomalies and therapies and exhibits a prevalence of 25% within the populace.

  • A thorough clinical evaluation is required to identify deformities in the cavovarus foot. Weight-bearing radiographs play a crucial role in identifying the apex of deformity and quantifying the required extent of correction.

  • Cavus feet are frequently linked with neurological conditions affecting sensory and motor nerves. Identifying the optimal treatment for individual patients necessitates the performance of clinical and radiographic evaluations. Inaccurate diagnosis of a neurological disorder can lead to inappropriate surgical intervention, relapse, and inadequate reconstruction. When faced with progressive anomalies, it is crucial to implement a phased surgical protocol promptly to avoid exacerbating malalignment. Various surgical procedures have been recorded, including soft tissue releases, tendon transfers, osteotomies, and arthrodesis, which are selected based on the nature and extent of the deformity assessment findings, with the ultimate goal of reaching a foot that is both plantigrade and balanced.

  • Due to a lack of research on this topic, the present review aims to furnish the most recent literature update on the manifestation, imaging evaluation, and optimal therapeutic interventions currently accessible for individuals afflicted with cavovarus deformities and to assist healthcare providers in selecting the most suitable therapy for paediatric patients with this condition in their routine clinical practice.

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Valeria Pintar St George’s Hospital, London, UK

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Charlotte Brookes St George’s Hospital, London, UK

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Alex Trompeter St George’s Hospital, London, UK
St George’s University of London, UK

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Anna Bridgens St George’s Hospital, London, UK

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Caroline Hing St George’s Hospital, London, UK
St George’s University of London, UK

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Yael Gelfer St George’s Hospital, London, UK
St George’s University of London, UK

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Purpose

  • Tourniquets are commonly used intraoperatively in orthopaedic surgery to control bleeding and improve visibility in the surgical field. Recent evidence has thrown into question the routine use of tourniquets in the adult population resulting in a British Orthopaedic Association standard for intraoperative use. This systematic review evaluates the evidence on the practice, benefits, and risks of the intraoperative use of tourniquets for trauma and elective orthopaedic surgery in the paediatric population.

Methods

  • A prospectively registered systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (PROSPERO: CRD42022359048). A search of MEDLINE, Embase, the Cochrane Library and a Grey literature search was performed from their earliest record to 23 March 2023. Studies reporting tourniquet data in paediatric patients undergoing orthopaedic surgery were included. Data extracted included demographics, involved limb, trauma versus elective use, tourniquet use as primary or secondary measure, and tourniquet parameters and complications.

Results

  • Thirty-nine studies were included. Tourniquet practices and information reporting varied considerably. Tourniquets were used uneventfully in the majority of patients with no specific benefits reported. Several physiological and biochemical changes as well as complications including nerve injury, compartment syndrome, skin burns, thrombosis, post-operative limb swelling, and pain were reported.

Conclusions

  • Tourniquets are routinely used in both trauma and elective paediatric orthopaedic surgery with no high-quality research affirming benefits. Severe complications associated with their use are rare but do occur. High-quality studies addressing their benefits, the exact indication in children, and the safest way to use them in this population are necessary.

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Marco Gupton MountainView Regional Medical Center, Orthopaedic Surgery Residency, Las Cruces, New Mexico, USA

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Jessica Burns Department of Orthopaedic Surgery, Phoenix Children’s Hospital, Phoenix, Arizona, USA

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  • Osteoarticular infections (OAI) are a significant cause of morbidity and mortality. Cultures and serology are some of the gold standards for identifying infection but are often unable to provide a timely diagnosis or a diagnosis at all.

  • Genetic testing offers capabilities that other modalities lack. Polymerase chain reaction has multiple versions with various costs and turnaround times. This technology has become implemented in multiple pediatric center OAI diagnostic protocols. There is sufficient literature documenting effectiveness in certain clinical situations, especially with fastidious organism diagnosis, but significant limitation still exists.

  • Metagenomic next-generation sequencing is an unbiased or hypothesis-free modality with the capability to detect the genetic material of bacteria, viruses, parasites, fungi, and humans from a single sample.

  • Potential benefits include pathogen identification unaffected by antimicrobial administration, detection of fastidious organisms more quickly, delineation of pathogens in polymicrobial infections, antimicrobial susceptibility, and avoidance of invasive procedures.

  • It is a resource-intensive modality with little standardization of the complex processes. Appropriate use and definitive clinical impact have yet to be determined.

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Christiaan J A van Bergen Department of Orthopedic Surgery, Amphia, Breda, the Netherlands

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Pieter Bas de Witte Department of Orthopedic Surgery, LUMC, Leiden, the Netherlands

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Floor Willeboordse Knowledge Institute of Medical Specialists, Utrecht, the Netherlands

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Babette L de Geest Knowledge Institute of Medical Specialists, Utrecht, the Netherlands

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Magritha (Margret) M H P Foreman-van Drongelen Department of Hip Sonography, Diagnostiek voor U, Eindhoven, the Netherlands

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Bart J Burger Department of Orthopedic Surgery, North West Hospital Group, Alkmaar, the Netherlands

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Yvon M den Hartog Department of Orthopedic Surgery, Medisch Spectrum Twente, Enschede, the Netherlands

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Joost H van Linge Department of Orthopedic Surgery, Reinier Haga Orthopedic Center, Zoetermeer, the Netherlands

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Renske M Pereboom Dutch Hip Patient Association, Vereniging Afwijkende Heupontwikkeling, Nijkerk, the Netherlands

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Simon G F Robben Department of Radiology, Maastricht University Medical Center, Maastricht, the Netherlands

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M Adhiambo Witlox Department of Orthopedic Surgery, CAPHRI Care and Public Health Research Institute, Maastricht University Medical Center, Maastricht, the Netherlands

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Melinda M E H Witbreuk Department of Orthopedic Surgery, OLVG, AUMC, Amsterdam, the Netherlands

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  • Despite the high incidence of developmental dysplasia of the hip (DDH), treatment is very diverse. Therefore, the Dutch Orthopedic Society developed a clinical practice guideline with recommendations for optimal and uniform treatment of DDH. This article summarizes the guideline on centered DDH (i.e. Graf types 2A–C).

  • The guideline development followed the criteria of Appraisal of Guidelines for Research and Evaluation II. A systematic literature review was performed to identify randomized controlled trials and comparative cohort studies including children <1 year with centered DDH. Articles were included that compared (1) treatment with observation, (2) different abduction devices, (3) follow-up frequencies, and (4) discontinuation methods. Recommendations were based on Grading Recommendations Assessment, Development, and Evaluation, which included the literature, clinical experience and consensus, patient and parent comfort, and costs.

  • Out of 430 potentially relevant articles, 5 comparative studies were included. Final guideline recommendations were (1) initially observe 3-month-old patients with centered DDH, start abduction treatment if the hip does not normalize after 6–12 weeks; (2) prescribe a Pavlik harness to children <6 months with persisting DDH on repeated ultrasonography, consider alternative abduction devices for children >6 months; (3) assess patients every 6 weeks; and (4) discontinue the abduction device when the hip has normalized or when the child is 12 months.

  • This paper presents a summary of part 1 of the first evidence-based guideline for treatment of centered DDH in children <1 year. Part 2 presents the guideline on decentered DDH in a separate article.

Open access
Matías Sepúlveda Universidad Austral de Chile, Valdivia, Chile
Hospital Base de Valdivia, Valdivia, Chile
AO Foundation, PAEG Expert Group, Davos, Switzerland

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Cecilia Téllez Universidad Austral de Chile, Valdivia, Chile
Hospital Base de Valdivia, Valdivia, Chile

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Víctor Villablanca Universidad Austral de Chile, Valdivia, Chile
Hospital Base de Valdivia, Valdivia, Chile

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Estefanía Birrer Universidad Austral de Chile, Valdivia, Chile
Hospital Base de Valdivia, Valdivia, Chile

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  • The physis of the distal femur contributes to 70% of femoral growth and 37% of the total limb growth; therefore, physeal injury can lead to important alterations of axes and length.

  • Distal metaphyseal corner-type fracture prior to walking is classically associated with child abuse. In children aged >10 years, sports-related fractures and car accidents are significant contributors.

  • Imaging includes a two-plane radiographic study of the knee. It is recommended to obtain radiographs that include the entire femur to rule out concomitant injuries. In cases of high suspicion of distal metaphyseal fractures and no radiographic evidence, CT or MRI can show the existence of hidden fractures.

  • Fractures with physeal involvement are conventionally classified according to the Salter–Harris classification, but the Peterson classification is also recommended as it includes special subgroups.

  • Conservative and surgical management are valid alternatives for the treatment of these fractures. Choosing between both alternatives depends on factors related to the fracture type.

  • As there is a high risk of permanent physeal damage, long-term follow-up is essential until skeletal maturity is complete.

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Manuel Saavedra Universidad Austral de Chile, Valdivia, Chile

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Matías Sepúlveda Universidad Austral de Chile, Valdivia, Chile
AO Foundation, PAEG Expert Group, Davos, Switzerland
Hospital Base de Valdivia, Valdivia, Chile

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María Jesús Tuca Clinica Alemana, Santiago, Chile
Universidad del Desarrollo, Santiago, Chile
Hospital Clínico Mutual de Seguridad, Santiago, Chile

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Estefanía Birrer Universidad Austral de Chile, Valdivia, Chile
AO Foundation, PAEG Expert Group, Davos, Switzerland

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  • Discoid meniscus is the most frequent congenital malformation of the menisci, and primarily affects the lateral meniscus; it is highly prevalent in the Asian population.

  • The anatomic, vascular, and ultrastructural features of the discoid meniscus make it susceptible to complex tears.

  • Discoid meniscus anomalies are described according to their shape; however, there is consensus that peripheral stability of the meniscus should also be defined.

  • Initial workup includes plain X-rays and magnetic resonance imaging, while arthroscopic evaluation confirms shape and stability of the meniscus.

  • Clinical presentation is highly variable, depending on shape, associated hypermobility, and concomitant meniscal tears.

  • Treatment seeks to re-establish typical anatomy using saucerization, tear reparation, and stable fixation of the meniscus.

Cite this article: EFORT Open Rev 2020;5:371-379. DOI: 10.1302/2058-5241.5.190023

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Hakan Ömeroğlu TOBB University of Economics and Technology, Faculty of Medicine, Department of Orthopaedics and Traumatology, Ankara, Turkey

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Manuel Cassiano Neves CUF Descobertas Hospital, Department of Paediatric Orthopaedics, Lisbon, Portugal

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  • Results of numerous studies assessing the national or the local patient databases in several countries have indicated that the overall rate of operative treatment in fractures, as well as the rate in certain upper and lower limb fractures, has significantly increased in children. The most prominent increase in the rate of operative treatment was observed in forearm shaft fractures.

  • Results of several survey studies have revealed that there was not a high level of agreement among paediatric orthopaedic surgeons concerning treatment preferences for several children’s fractures.

  • The reasons for the increasing tendency towards operative treatment are multifactorial and patient-, parent- and surgeon-dependent factors as well as technological, economic, social, environmental and legal factors seem to have an impact on this trend.

  • It is obvious that evidence-based medicine is not the only factor that leads to this tendency. A high level of scientific evidence is currently lacking to support the statement that operative treatment really leads to better long-term outcomes in children’s fractures. Properly designed multicentre clinical trials are needed to determine the best treatment options in many fractures in children.

Cite this article: EFORT Open Rev 2020;5:347-353. DOI: 10.1302/2058-5241.5.200012

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Ignacio Rodriguez Universidad Austral de Chile, Valdivia, Chile

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Matías Sepúlveda Universidad Austral de Chile, Valdivia, Chile
AO Foundation, PAEG Expert Group, Davos, Switzerland
Hospital Base de Valdivia, Valdivia, Chile

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Estefanía Birrer Universidad Austral de Chile, Valdivia, Chile
Hospital Base de Valdivia, Valdivia, Chile

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María Jesús Tuca Clinica Alemana, Santiago, Chile
Universidad del Desarrollo, Santiago, Chile
Hospital Clínico Mutual de Seguridad, Santiago, Chile

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  • Fractures of the anterior tibial tuberosity during childhood are an infrequent pathology (around 3% of all proximal tibial fractures), but the incidence of this injury has risen over recent years, likely due to the increased involvement of this age group in sports activities.

  • This fracture is more commonly seen in children 12–14 years old.

  • It is vital to identify the anatomical structures associated with this type of fracture, along with the pathophysiological mechanisms involved.

  • Treatment includes non-operative and operative options, with the goal of achieving articular congruency, restoring the extensor mechanism function, and avoiding damage to the proximal tibial physis.

  • Understanding the management of this fracture, and the complications that might arise, is critical. The provision of an appropriate clinical management plan and the avoidance of complications are vital in the prevention of disability.

Cite this article: EFORT Open Rev 2020;5:260-267. DOI: 10.1302/2058-5241.5.190026

Open access