Session 8: Pediatrics

Juan Manuel Shiguetomi-Medina, Ahmed Abood, Ole Rahbek, Hans Stødkilde-Jørgensen, Bjarne Møller-Madsen
Department of Children's Orthopaedics / Orthopaedics Research Laboratory, Aarhus University Hospital; Orthopaedics Research Laboratory, Aarhus University Hospital; Departiment of Children's Orthopaedics, Aarhus University Hospital; The MR Research Center, Aarhus University Hospital; Departmen of Children's Orthopaedics, Aarhus University Hospital

Background: Epiphysiodesis made with RFA has resulted, in animal models, an effective procedure that disrupts the growth plate and induces LLD. This procedure involves an increase of temperature (>92°C) of the targeted region causing thermal damage. To our knowledge, no study that investigates the effect of this procedure in the adjacent joint articular cartilage has been reported
Purpose / Aim of Study: Proof of concept that epiphysiodesis made with RFA is a safe procedure that disrupts the growth plate without damaging the adjacent joint articular cartilage
Materials and Methods: RFA Epiphysiodesis RFA was done for 8 minutes in vivo in 40 growing pig tibia physis. In addition, three tibiae were ablated for 16 minutes, and three more for 24 minutes. As a damage reference, 6 tibiae were ablated on the joint articular cartilage for 8 minutes. MRI was done ex vivo after the procedure to evaluate the joint articular cartilage in all samples using T1-weighted, T2-weighted and water content sequences under a 1.5 T magnetic field
Findings / Results: The intentionally-damaged articular cartilage showed intensity changes on the MR. This images were used as reference for damage. We found no evidence of articular cartilage damage on the 40 8 mins procedures. The tibiae ablated for 16 mins showed a larger lesion on the physis but the articular joint cartilage was intact. No articular cartilage damage was found on the tibiae ablated for 16 mins
Conclusions: Epiphysiodesis using RFA is safe for the adjacent articular joint cartilage. This study resembles possible results of RFA epiphysiodesis on humans. Previous studies suggest that an 8 min ablation is enough to disrupt the growth plate. This study shows that RFA can be done safely in the growing physis even on triple-long procedures. It is important to highlight that all this evidence was obtained on an animal model

Louise Klingenberg, Klaus Hindsø, PhD, Andreas Balslev-Clausen
Orthopedic Department, Rigshospitalet

Background: Persistent dysplasia in developmental dysplasia of the hip leads to early osteoarthritis in the adult. Secondary procedures may therefore be necessary to correct residual dysplasia after initial treatment for late presenting hip dislocation. Timing of secondary procedures can be difficult as some hips normalize spontaneously
Purpose / Aim of Study: To identify early prognostic radiografical markers for residual dysplasia
Materials and Methods: A consecutive series of 60 patients with late presenting hip dislocation treated with reduction under anesthesia from 2002 to 2005 were identified in the hospital database (GS- open). Patients with neuromuscular dislocations or septic arthritis (8) or insufficient radiological records (5) were excluded leaving 47 children and 52 hips in the study group. X-rays were evaluated with respect to acetabular index (AI), center-edge-angle (CEA), Shentons line and the sharpness of the lateral corner.
Findings / Results: There were 37 closed and 15 open reductions at a mean age of 16.5 months. 22 hips had secondary procedures at an average age of 55 months. The procedures were proximal femoral osteotomy(3), Salter osteotomy (15) and combined Salter and femoral osteotomies (4). The AI-index declined from 38.1 postreduction to 17.1 at final follow up. At six months after initial reduction AI>35 degrees equaled a relative risk of 2.8 (95.5%CI 1.6-4.8) for secondary procedures. All hips with AI>40 had secondary procedures whereas one hip with an AI<30 had a secondary procedure. CEA, Shentons line and quality of the lateral corner did not correlate to secondary procedures at 6 months.
Conclusions: If the AI does not show significant improvement within six months after primary reduction, the need for secondary procedures are very likely and may be performed at an early stage to improve hip function and avoid residual dysplasia.

Helen Latifi, Bodil Moltesen, Christian Wong
Almen Praksis introlæge, Region Hovedstaden; Pædiatrisk afd., Herlev Hospital; Ortopædkirugisk afd., Hvidovre Hospital

Background: Internationally, a high percentage of children with non-accidental injuries (NAI) are treated in the emergency room (ER) not detected. NAI is found to be connected with severe physical- and psychological health consequences, and can even be fatal in some cases.
Purpose / Aim of Study: In this study we wanted to examine whether Danish physicians in an ER setting can identify and document NAI adequately.
Materials and Methods: This study was a retrospective review of all ER charts from Glostrup Hospital from May 2009. All children from 0-3 years of age with treated injuries were included. A new score system was developed to assess the history documentation (HD) sufficiency; with this system, we were able to evaluate to which extent the HD included the 6 relevant HD variables necessary to rule out potential NAI: The place of accident, time of accident, context of injury, presence of witnesses, mechanism of injury (MI) and the accompanying caregiver.
Findings / Results: A total of 155 ER charts fulfilled the inclusion criteria. The results showed that 85 % documented the place of accident, the time of accident in 97 %, the context of injury in 20%, the presence of witnesses in 7 % and the accompanying caregiver in 35 % of the ER charts. The MI was adequately documented in 25%, partially documented in 31% and undocumented in 44% of the ER charts. The overall HD score used to assess whether or not a possible NAI had taken place, was only estimated sufficient in 17% of the ER charts.
Conclusions: A majority of the ER charts HD in this study was insufficient. The physicians are therefore at risk of missing out on the opportunity to identify the children victimized by NAI. In light of the serious health risks and future psychosocial consequences, that they entail, focusing on how to screen NAI in an ER setting is highly recommended.

Polina Martinkevich, Ole Rahbek, Kjeld Søballe, Bjarne Møller-Madsen, Maiken Stilling
Dept. of Children's Orthopaedics, Aarhus University Hospital; Dept. of Orthopedic Surgery, Aarhus University Hospital

Background: RSA is a precise method in measurements of migration in hip and knee artroplasty and in assessment of fracture stability. Lengthening osteotomies of the calcaneus in children’s orthopaedics are in general grafted with iliac crest bone. Artificial structural bone grafts have been introduced. The durability has not been documented by RSA. RSA has not previously been used in clinical studies of calcaneal osteotomies. Prior to a clinical study we performed an RSA study on lateral calcaneal lengthening osteotomy (LCLO) in cadaver feet.
Purpose / Aim of Study: To determine the feasibility and precision of marker-based RSA on LCLO with focus on the osteotomy and the calcaneal-cuboid (CC) joint.
Materials and Methods: The LCLO was performed in three fixed adult cadavers (six feet). Tantalum markers were inserted in the anterior and posterior fragment of calcaneus and the cuboideum. Lengthening was done with a plexiglas wedge. A total of 24 double radiographic examinations were obtained with the osteotomy in zero distraction, 1 cm, 1.25 cm and 1.5 cm distraction to mimic clinical situations. One foot was excluded from the study due to loose markers/osteotomy fracture. Precision was assessed as systematic bias and 95% repeatability limits.
Findings / Results: Systematic bias was generally below 0.09mm for translations and 1° for rotations. Precision of LCLO measurements was below 0.2mm for translations (x,y,z) and below 3° for rotations. Precision of migrations measurements in the CC joint was below 0.4mm for translations and below 2° for rotations about the x,y and z-axes. Mean condition number for anterior and posterior calcaneus and the cuboid was 153, 53 and 192.
Conclusions: RSA is a feasible and precise method to assess migration in LCLO and in the CC joint, though less precise for rotation.

Martin Gottliebsen, Line Kjeldgaard Pedersen, Ivan Hvid, Michael Davidsen, Ole Rahbek, Bjarne Møller-Madsen
Department of Children`s Orthopaedics, Aarhus University Hospital

Background: Calcaneal lengthening osteotomy can be used to correct painful pes planovalgus but it requires the use of graft material to be inserted as a bone wedge at the osteotomy site. Obtaining autologous graft material from the iliac crest in children is a painful procedure and puts the child at risk for growth arrest and iliac wing deformity. New structural bone graft materials consisting of a mixture of porous hydroxyapatite (HA) and tricalcium phosphate (TCP) are being developed which could prove useful in paediatric orthopaedic surgery.
Purpose / Aim of Study: We hypothesized that a structural artificial graft could be used for calcaneal lengthening osteotomy.
Materials and Methods: A prospective cohort study with ethical approval was conducted from October 2010 – September 2011. Calcaneal lengthening was performed in 8 children and adolescents (9 feet) with mean age 13.1 years (range 6.6-19.2) using wedge shaped HA/TCP graft material (ReproBone). A cast was applied for 6-7 weeks after surgery. Internal fixation of the osteotomy was not used. Follow up was performed using radiographs, computed tomography (CT) and paedobarography.
Findings / Results: Healing of the osteotomy was obtained in all cases on radiographs and CT images. At one year follow-up clinical examinations and paedobarography showed satisfying results of surgery. No graft failure or wound related infections were observed.
Conclusions: Harvesting of autologous graft from the iliac crest may be avoided for calcaneal lengthening procedures using HA/TCP graft material. We report satisfying short term results from a small prospective study with healing of the osteotomy achieved in all cases.

Silas Hinsch Gylvin, Martin Gottliebsen, Christian Wong
Orthopaedics, Nordsjællands Hospital; Children's Orthopaedics , Aarhus University Hospital; Children’s Orthopaedics, Hvidovre Hospital

Background: Partial epiphysiodesis using unilateral eight Plates (EP) is indicated for correction of angular deformities. Permanent epiphysiodesis has traditionally been used for correction of leg length discrepancy (LLD) ranging from 2-5 cm. However, it has become part of clinical practise to perform temporary growth arrest (GA) by inserting bilateral EP for correction of LLD. Only sparse documentation exists to back up this clinical practise.
Purpose / Aim of Study: To evaluate the results of temporary GA using bilateral EP technique for correcting LLD.
Materials and Methods: 14 patients from 2 centers were identified. All had GA performed using bilateral EP in femur or femur and tibia. Follow-up data and radiographs were retrieved and analysed. Information regarding age at surgery, gender, comorbidity, complication rate, amotio atellae and LLD before and during treatment was registered.
Findings / Results: 14 patients received surgery from 2008 to 2011 with an average age of 13,1 (range 11-15, F=12,M=13,7) at surgery. Most patients had idiopathic LLD, whilst clubfoot was the only reoccurring comorbidity. 10 Patients were operated on femur alone, and 4 patients on tibia and femur. They had an average LLD of 2,65cm and 3,75cm, respectively. All had temporary growth arrest with an average GA of 1,84cm, with 0,89cm first year, 0,7cm second year and 0,25cm third year. Average GA for patients operated on femur alone was 1,98cm, while GA was 1,5cm on patients with EP in femur and tibia. 8 patients had implants removed after mean 29,3 months (range 22-37 months). Boy:girl ratio was 6:4 with an average GA of 1,94cm and 1,66cm respectively. The only complication was postoperative pain, in one case prolonged.
Conclusions: Bilateral EP seems to be an effective method to obtain temporary GA and correct moderate LLD in children with remaining growth potential.

Kirsten Nordbye-Nielsen, Ole Rahbek, Bjarne Møller-Madsen
Dept. of Children`s Orthopaedics and Orthopaedic Research Laboratory, Aarhus University Hospital; Dept. of Children`s Orthopaedics , Aarhus University Hospital

Background: Children with severe cerebral palsy (CP) are at risk of secondary deformities as dislocated hips which often leads to asymmetry, loss of mobility, pain and difficulties into daily activities and personal care. It has been shown that the Swedish follow- up programme, CPUP can identify children at risk of hip dislocation, leading to early interventions and prevention of hip dislocation.
Purpose / Aim of Study: To determine the prevalence of children with hips at risk identified in a cohort of children between 0-6 years, with the aim of early intervention and prevention of hip dislocations.
Materials and Methods: 37 children aged 0-6 years, GMFCS level I-V. 18 girls and 19 boys have been included in the follow-up programme in the Central Region Denmark from September 2012 until June 2013. According to the protocol conventional X-ray of the hips were obtained. Migration Percentage (MP) measure was done by the orthopedic surgeon. Migration Percentage >33 was defined as a hip with dislocation or in risk for dislocation.
Findings / Results: We analyzed 37 children (74 hips) GMFCS level I-IV. In the study group four children were identified with MP>33,GMFCS level V-IV, two girls and two boys. Percentage of hips with MP>33 was 8.1%, 6 of 74 hips.
Conclusions: CPOP seems to be a useful tool identifying hip pathology at an early stage leading to early prevention and interventions by the multidisciplinary team. Dislocation of hips in cerebral palsy remains a serious problem and these data underlines the need of a national screening programme.

Jesper Holbeck-Brendel, Line Kjeldgaard Pedersen, Ole Rahbek, Michel Bach Hellfritzsch , Peter Dalsgaard Nielsen, Bjarne Møller-Madsen
Department of Children’s Orthopedics, Aarhus University Hospital; Department of Radiology, Aarhus University Hospital

Background: Ludloff’s approach for open reduction of congenital hip joint dislocation first described in 1908 is commended for its minimal tissue damage, but is criticized for the risk (9%-42,9%) of late avascular necrosis (AVN) of the femoral head.
Purpose / Aim of Study: To evaluate the clinical and radiographic outcome after treatment of congenital hip dislocation by Ludloffs approach at the Department of Children’s Orthopedics, Aarhus University Hospital.
Materials and Methods: 19 patients underwent Ludloffs approach from 1997 to 2005 and were invited to follow- up. 14 children accepted and a clinical and radiographic examination of the hip and pelvis were performed. In total 17 hips were treated with Ludloffs approach. Radiographic outcome measures were acetabular angle, migration index (MI) and signs of late complications in form of both distinct and subtle signs of AVN. The clinical outcome measures were range of motion (ROM) of the hip joints, individual orthopedic complaints and the HAGOS hip questionnaire.
Findings / Results: Mean age at surgery was 12 months. Mean follow-up time was 11,2 years. Radiographic evaluation showed signs of AVN in 5 of 17 operated hips (29,4%). Six operated hips have required additional surgery. A significant correlation was found between both MI and AVN (p<0,05) and follow-up time (p<0,01). Difference in ROM for unilateral treated hips was only significant for flexion (p<0,02). Two of five questions of quality of life in the HAGOS hip questionnaire showed a significant worse outcome for patients with AVN (p<0,01, p<0,01).
Conclusions: Ludloffs approach is relevant in the treatment of congenital hip dislocation. This study indicates an acceptable rate of late AVN and a general good clinical and radiographic outcome.

Peter Buxbom, Derek Curtis, Stig Sonne-Holm, Christian Wong
Orthopedic Department, Hvidovre Hospital; Gait Laboratory, Hvidovre Hospital

Background: No validated questionnaire assessing health-related quality of life (HRQL) in children with severe cerebral palsy (CP) has yet existed. However, the Canadian CPCHILD questionnaire meets this deficiency, but has not yet been translated to Danish.
Purpose / Aim of Study: The purpose of the study was to achieve a qualitative validated Danish translation of CPCHILD, in order to be able to assess quality of life in Danish children with severe CP and to be able to examine treatment impact in HRQL and to be able to convey clinical outcome of treatments internationally.
Materials and Methods: Bilingual persons performed stepwise translations, both forward and backward without looking at the original questionnaire. The two versions were discussed in the research group, and summarized to a temporary Danish translation. Caregivers of 12 CP children were asked to fill out the questionnaire and were afterwards interviewed about any problems or misunderstandings. The feedback was discussed in our research group and incorporated in the final Danish version.
Findings / Results: The CPCHILD questionnaire underwent the stepwise translation process. The preliminary Danish version was found easy understandable by caregivers, and parental feedback led to only minor changes. The qualitative Danish translation can be acquired from the authors.
Conclusions: A qualitative validated Danish version of the CPCHILD questionnaire is now available. We are now able to asses HRQL in children with severe CP (GMFCS IV-V) in Danish. As soon as a quantitative validation has been performed we will apply for making this Danish version of CPCHILD the official CPCHILD© Project version; this could best be done on an national basis due to the large number of ‘patients needed to treat’.

Pernille Bovbjerg, Zaid Al-Aubaidi
Orthopeadic, Odense University Hospital

Background: Acute surgical procedures are an integrated part of the daily activity at any orthopedic department. Some of these have to be performed in the late hours of the night.
Purpose / Aim of Study: To analyze the outcome of surgically treated pediatric elbow fractures. We expected that the rate of reoperation is higher for those treated at night.
Materials and Methods: Data collected at a single institution by searching in the FPAS system using the ICD and the treatment code. We had three types of distal humerus fractures: supracondylar (SC), lateral condyle (LC) and medial epicondyle fractures (ME). Surgical timing was defined as day; 8:00 AM-22:59 PM and night 23:00 PM- 7:59 AM. Surgeons were classified into; 1 pediatric orthopedic surgeon, 2 consultant, 3 specialist, 4 resident and 5 unknown.
Findings / Results: In total 221 patients divided into 158 SC, 35 ME and 28 LC. 43 patients were operated at night. 10 out of the 43 operations were performed by 1 during the night (23%) and 17 of the 43 by 2 (40%).The remaining 37% are operated by 3, 4 or 5. At daytime 31% of the surgeries were performed by 1 and 36% by 2. For 37 SC operated at night 3 were reoperated (8%), while for surgery during day time 8 were reoperated (6.8%). Three elbow dislocations with ME were operated at night, but for two patients the fracture was not identified intraoperatively and needed extra intervention. For LC three were operated between 23:00 PM and 7:59 AM and no reoperation. There was no secondary surgery for ME and LC operated at day time, where 9 dislocated elbows were operated.
Conclusions: This study suggests that patients operated at the late night time, have slightly higher reoperation rate. Generally, surgical procedures should be performed during the day time, unless acute intervention is indicated due to neurovascular comprise.

Andreas Balslev-Clausen, Steffen Volkvardsen, Stig Sonne-Holm, Jens Krogh Christoffersen, Christian Wong
Dept. of Orthopaedic Surgery, Rigshospitalet; Dept. Of Orthopaedic Surgery, Hvidovre University Hospital; , Danish Patient Insurance Association; Dept. of Orthopaedi Surgery, Hviovre University Hospital

Background: Physeal injuries (PI) of the distal humerus account for 30% of fractures in the distal humerus. Radiographic diagnosis can be difficult due to the different ossifications center and treatment recommendations are not uniform. The Danish Patient Insurance Association (DPIA) decides compensation claims by patients injured in connection to treatment by the Danish Health Service
Purpose / Aim of Study: To identify patterns in suboptimal treatment of PI in the elbow in children.
Materials and Methods: The DPIA database was searched for case files with PI from 1996 to 2010 for patients 0 to15 years of age. The files were reviewed with respect to patient characteristics, treatment and insurance consequences.
Findings / Results: A total of 47 cases were identified. The boy:girl ratio was 6:4 and with an average age of 9 years. Distribution of fractures was 20 medial epicondylar, 3 medial condyle, 4 lateral epicondylar and 18 lateral condyle. Most frequent complaint was missed fracture at the initial x-ray (23) with a diagnostic delay of a median of 29 days. Junior doctors were responsible for the missed fracture in 17 cases and 15 of the cases were medial epicondylar fractures. 5 patients complained of malpractice due to insufficient surgery; all performed by senior doctors. Only two cases had a range of motion below 100 degrees and there was no significant varus/valgus deformity at final case closure. Half of the injuries were evaluated as a light injury by the DPI but over 2/3 of the complaints were acknowledged.
Conclusions: Medial epicondylar fractures are often missed in the emergency department. In order to optimize treatment and prevent doctors delay more awareness - especially by junior staff - are necessary to avoid missing these fractures. Radiographs of the opposite elbow for comparison or review by an experienced radiologist should be mandatory.