Session 7: Pediatrics
Torsdag den 27. oktober
9:30 – 10:30
Lokale: Reykjavik
Chairmen: Peter Buxbom / Christian Færgeman
Christian Wong, Johanna Hall, Kasper Gosvig
Department of Othopedics, University hospital of Hvidovre; Department of Radiology, University hospital of Hvidovre; Department of Othopedics, University hospital of Hvidovre
Background: The importance of vertebral rotation as well as measurement of vertebral rotation in the development and management of scoliosis is recognized as important. The common radiological method of evaluating scoliosis by Cobb's angle is biased by measurement variation
Purpose / Aim of Study: To examine the effect of vertebral axial rotation on Cobb's angle as an indicator of the potential and inherent bias of truncal rotation in the normal or slight scoliotic spine
Materials and Methods: This study was conducted as a cross-sectional study, where 40 anonymized patients were included and scanned by CT consecutively. Coronal reconstructions covering the whole pelvis and spine executed in an angle of -15, -10, -5, 0 ,5,10 and 15 degrees (dg). Cobb's angle was measured from TH4-TH11 in the thoracic part and TH12-L4 for the lumbar part. All measurements were performed blinded by three experienced doctors separately. The data were evaluated by mixed effect model, including fixed effects for reconstructions and parts and a random slope effect for reconstructions within each patient. all analysis was perform in SPSS (ver 22)
Findings / Results: Measurements of Cobb's angle ranged from 0.05 dg to 36.3 dg with at average of 5.5 dg for the thoracic spine and from 0.3 dg to 29.1 dg with an average of 3.8 dg in the lumbar spine. There was a significant effect for vertebral rotation (< 0.001) with an estimated effect of 4.2 dg for every 5 dg vertebral rotation (SE = 0.6 dg)
Conclusions: Vertebral rotation has a significant effect on Cobb's angle. This indicates, that there seem to be a clinical implication, where truncal rotation under radiological examination bias Cobbs angle in the slightly scoliosis and normal spine, thus causing potential misdiagnosis of scoliosis (> 10 degrees of Cobb's angle) and initiation of monitoring and management of early scoliosis
Department of Othopedics, University hospital of Hvidovre; Department of Radiology, University hospital of Hvidovre; Department of Othopedics, University hospital of Hvidovre
Background: The importance of vertebral rotation as well as measurement of vertebral rotation in the development and management of scoliosis is recognized as important. The common radiological method of evaluating scoliosis by Cobb's angle is biased by measurement variation
Purpose / Aim of Study: To examine the effect of vertebral axial rotation on Cobb's angle as an indicator of the potential and inherent bias of truncal rotation in the normal or slight scoliotic spine
Materials and Methods: This study was conducted as a cross-sectional study, where 40 anonymized patients were included and scanned by CT consecutively. Coronal reconstructions covering the whole pelvis and spine executed in an angle of -15, -10, -5, 0 ,5,10 and 15 degrees (dg). Cobb's angle was measured from TH4-TH11 in the thoracic part and TH12-L4 for the lumbar part. All measurements were performed blinded by three experienced doctors separately. The data were evaluated by mixed effect model, including fixed effects for reconstructions and parts and a random slope effect for reconstructions within each patient. all analysis was perform in SPSS (ver 22)
Findings / Results: Measurements of Cobb's angle ranged from 0.05 dg to 36.3 dg with at average of 5.5 dg for the thoracic spine and from 0.3 dg to 29.1 dg with an average of 3.8 dg in the lumbar spine. There was a significant effect for vertebral rotation (< 0.001) with an estimated effect of 4.2 dg for every 5 dg vertebral rotation (SE = 0.6 dg)
Conclusions: Vertebral rotation has a significant effect on Cobb's angle. This indicates, that there seem to be a clinical implication, where truncal rotation under radiological examination bias Cobbs angle in the slightly scoliosis and normal spine, thus causing potential misdiagnosis of scoliosis (> 10 degrees of Cobb's angle) and initiation of monitoring and management of early scoliosis
Ahmed Abdul-Hussein Abood, Bjarne Møller-Madsen, Juan Manuel Shiguetomi-Medina, Casper Bindzus Foldager, Ole Rahbek
Paediatric Ortopaedics, Aarhus University Hospital; Paediatric Ortopaedics, Aarhus University Hospital; Paediatric Ortopaedics, Aarhus University Hospital; Ortopaedics, Aarhus University Hospital; Paediatric Ortopaedics, Aarhus University Hospital
Background: Fractures involving the growth plate can cause bone bridge formation leading to leg length discrepancy, angular bone deformities, and early secondary arthrosis. The gold standard treatment is to remove the bone bridge surgically and replace it with fat.
Purpose / Aim of Study: The purpose was to evaluate bone bridge formation using the gold standard compared with no treatment using MRI in a porcine model.
Materials and Methods: In five immature female pigs the distal femoral growth plate was identified using fluoroscopy. The medial part of both growth plates was injured in a standardised procedure using a 6 mm cannulated drill bit operated manually. The injury included the metaphyseal and epiphyseal part of the bone to simulate a gap after excision of a bone bridge. The defects were rinsed sterile saline. Defects in both hind legs were randomized to filling of subcutaneous fat (group A, n = 5) or no filling (group B, n = 5). The animals were followed for 14 weeks. Three-dimensional MRI including water- content were performed at 14 weeks and followed by euthanasia. Presence or absence of a bone bridge was determined on MRI.
Findings / Results: Bone bridge formation was confirmed in 60% of the animals for group A and 100% for group B. Water-content MRI shows less water-content in the injured part of the growth plate compared to the uninjured all the animals in both groups.
Conclusions: Bone bridge formation was seen less frequently in the group treated with the current gold standard, nevertheless a bone bridge still occurred in 60% of the animals. Hence, there is a need for further investigation of alternative treatment options for bone bridge formation.
Paediatric Ortopaedics, Aarhus University Hospital; Paediatric Ortopaedics, Aarhus University Hospital; Paediatric Ortopaedics, Aarhus University Hospital; Ortopaedics, Aarhus University Hospital; Paediatric Ortopaedics, Aarhus University Hospital
Background: Fractures involving the growth plate can cause bone bridge formation leading to leg length discrepancy, angular bone deformities, and early secondary arthrosis. The gold standard treatment is to remove the bone bridge surgically and replace it with fat.
Purpose / Aim of Study: The purpose was to evaluate bone bridge formation using the gold standard compared with no treatment using MRI in a porcine model.
Materials and Methods: In five immature female pigs the distal femoral growth plate was identified using fluoroscopy. The medial part of both growth plates was injured in a standardised procedure using a 6 mm cannulated drill bit operated manually. The injury included the metaphyseal and epiphyseal part of the bone to simulate a gap after excision of a bone bridge. The defects were rinsed sterile saline. Defects in both hind legs were randomized to filling of subcutaneous fat (group A, n = 5) or no filling (group B, n = 5). The animals were followed for 14 weeks. Three-dimensional MRI including water- content were performed at 14 weeks and followed by euthanasia. Presence or absence of a bone bridge was determined on MRI.
Findings / Results: Bone bridge formation was confirmed in 60% of the animals for group A and 100% for group B. Water-content MRI shows less water-content in the injured part of the growth plate compared to the uninjured all the animals in both groups.
Conclusions: Bone bridge formation was seen less frequently in the group treated with the current gold standard, nevertheless a bone bridge still occurred in 60% of the animals. Hence, there is a need for further investigation of alternative treatment options for bone bridge formation.
Polina Martinkevich, Maiken Stilling , Bjarne Møller-Madsen, Ole Rahbek
Pediatric Orthopedics, Aarhus University Hospital; Clinical Medicine, Aarhus University; Pediatric Orthopedics, Aarhus University Hospital; Pediatric Orthopedics, Aarhus University Hospital
Background: Subluxation in the calcaneo-cuboid joint (CCJ) with dorsal displacement of the anterior calcaneal fragment following a calcaneal lengthening osteotomy in children is a frequently observed finding. Various methods to quantify the displacement have been proposed using conventional X-rays. However these methods are unprecise and only allow for uniplanar measurement.
Purpose / Aim of Study: We investigated the feasibility of using marker-based radiostereometric analysis (RSA) for measurements of the CCJ in pediatric patients who underwent calcaneal lengthening surgery for flexible flatfoot.
Materials and Methods: Eight patients diagnosed with flexible flatfoot (8 feet; 1 male, 7 females) with mean age 12.3 years (range 8.2-14.2) were examined one year after calcaneal lengthening osteotomy (CLO). Supine and standing stereoradiographs were obtained. The Oxford ankle foot questionnaire (OxAFQ) was used to assess the affect of the foot on the quality of life of the child.
Findings / Results: Precision of the RSA measurements of the CCJ ranged between 0.14-0.58 mm for translations and 2.08-4.26 degrees for rotations. In response to loading we find the cuboid to translate (mean; range) distally by -0.92 mm(-1.78;-0.12), dorsally by 2.13 mm(0.58;4.07), laterally by -1.94 mm(-3.94;-0.17) and rotate medially around the x-axis by 7.23 degrees (-1.05;17.06) with reference to the distal calcaneal fragment. Based on the OxAFQ scores children were asymptomatic.
Conclusions: This is the first in vivo study describing the CCJ kinematics in children one year after CLO using RSA. This is the first step towards understanding the CCJ before and after CLO, and to examine the clinical consequences of this motion. In the future, model-based RSA and fluoroscopy can allow for obtaining preoperative models of the foot and provide a complete kinematic analysis of the CCJ during motion.
Pediatric Orthopedics, Aarhus University Hospital; Clinical Medicine, Aarhus University; Pediatric Orthopedics, Aarhus University Hospital; Pediatric Orthopedics, Aarhus University Hospital
Background: Subluxation in the calcaneo-cuboid joint (CCJ) with dorsal displacement of the anterior calcaneal fragment following a calcaneal lengthening osteotomy in children is a frequently observed finding. Various methods to quantify the displacement have been proposed using conventional X-rays. However these methods are unprecise and only allow for uniplanar measurement.
Purpose / Aim of Study: We investigated the feasibility of using marker-based radiostereometric analysis (RSA) for measurements of the CCJ in pediatric patients who underwent calcaneal lengthening surgery for flexible flatfoot.
Materials and Methods: Eight patients diagnosed with flexible flatfoot (8 feet; 1 male, 7 females) with mean age 12.3 years (range 8.2-14.2) were examined one year after calcaneal lengthening osteotomy (CLO). Supine and standing stereoradiographs were obtained. The Oxford ankle foot questionnaire (OxAFQ) was used to assess the affect of the foot on the quality of life of the child.
Findings / Results: Precision of the RSA measurements of the CCJ ranged between 0.14-0.58 mm for translations and 2.08-4.26 degrees for rotations. In response to loading we find the cuboid to translate (mean; range) distally by -0.92 mm(-1.78;-0.12), dorsally by 2.13 mm(0.58;4.07), laterally by -1.94 mm(-3.94;-0.17) and rotate medially around the x-axis by 7.23 degrees (-1.05;17.06) with reference to the distal calcaneal fragment. Based on the OxAFQ scores children were asymptomatic.
Conclusions: This is the first in vivo study describing the CCJ kinematics in children one year after CLO using RSA. This is the first step towards understanding the CCJ before and after CLO, and to examine the clinical consequences of this motion. In the future, model-based RSA and fluoroscopy can allow for obtaining preoperative models of the foot and provide a complete kinematic analysis of the CCJ during motion.
Nina Hardgrib, Ole Rahbek, Bjarne Møller-Madsen, Rikke Maimburg
of pediatrics, Aarhus University Hospital; of orthopaedic surgery, Aarhus University Hospital; of orthopaedic surgery, Aarhus University Hospital; of Obstetrics and Gynaecology, Aarhus University Hospital
Background: Congenital muscular torticollis (CMT) is an orthopedic diagnosis seen in childhood and presents within months after birth. In general the etiology remains unknown. However medical textbooks suggest trauma at birth as a main reason.
Purpose / Aim of Study: The aim of this study was to systematically describe obstetric outcomes in a population of children with a confirmed CMT diagnosis
Materials and Methods: Children with a validated diagnosis of CMT born at Aarhus University Hospital from 1993-2014 were included in the study. Information on perinatal, intrapartum and neonatal characteristic were obtained from databases and from medical records and systematically described.
Findings / Results: In this study, there were no differences in birth characteristics in children with left and right sided CMT, between boys and girls or between the conservatively treated and the children who needed surgery. Four children were in breech presentation, eighteen in vertex and two in unspecified cephalic presentation. Of those born vaginally, five children were delivered by vacuum extraction, and two children were assisted vaginal breech births. Five children were delivered by cesarean section. The mean second stage of labour for the vaginal deliveries was 32 minutes. Most of the children with CMT in this study were delivered at term without signs of birth complications or trauma. None experienced moderate or severe asphyxia.
Conclusions: The results of the present study suggests that complicated birth or birth trauma may not be the main cause of CMT and point towards intrauterine and prenatal reasons for developing Congenital muscular torticollis.
of pediatrics, Aarhus University Hospital; of orthopaedic surgery, Aarhus University Hospital; of orthopaedic surgery, Aarhus University Hospital; of Obstetrics and Gynaecology, Aarhus University Hospital
Background: Congenital muscular torticollis (CMT) is an orthopedic diagnosis seen in childhood and presents within months after birth. In general the etiology remains unknown. However medical textbooks suggest trauma at birth as a main reason.
Purpose / Aim of Study: The aim of this study was to systematically describe obstetric outcomes in a population of children with a confirmed CMT diagnosis
Materials and Methods: Children with a validated diagnosis of CMT born at Aarhus University Hospital from 1993-2014 were included in the study. Information on perinatal, intrapartum and neonatal characteristic were obtained from databases and from medical records and systematically described.
Findings / Results: In this study, there were no differences in birth characteristics in children with left and right sided CMT, between boys and girls or between the conservatively treated and the children who needed surgery. Four children were in breech presentation, eighteen in vertex and two in unspecified cephalic presentation. Of those born vaginally, five children were delivered by vacuum extraction, and two children were assisted vaginal breech births. Five children were delivered by cesarean section. The mean second stage of labour for the vaginal deliveries was 32 minutes. Most of the children with CMT in this study were delivered at term without signs of birth complications or trauma. None experienced moderate or severe asphyxia.
Conclusions: The results of the present study suggests that complicated birth or birth trauma may not be the main cause of CMT and point towards intrauterine and prenatal reasons for developing Congenital muscular torticollis.
Jens Svendsson, Ahmed Abood, Søren Harving, Anne-Sofie Jensen
Orthopaedic, Aalborg University Hospital; Orthopaedic, Aalborg University Hospital; Orthopaedic, Aalborg University Hospital; Orthopaedic, Aalborg University Hospital
Background: It has been suggested that breech presentation during pregnancy, family history of Hip Dysplasia (DDH) or twins have an increased risk of DDH. Different screening methods are applied in different regions with controversy.
Purpose / Aim of Study: The purpose of this study is to evaluate the current screening programme of DDH at Aalborg University Hospital (AAUH).
Materials and Methods: Patients were identified using registrations of patients screened for DDH at the department of paediatric orthopaedics AAUH from 2004 until 2014. Patients were divided into 5 groups according to referring cause: breech presentation, family history of DDH, twin birth, clinical hip instability and asymmetrical skinfolds. For each group the final clinical examination and treatment was determined. Patients with lower body deformities were excluded.
Findings / Results: 176 patients were included. The screening of 127 (72%) patients was completed after first examination. For the 5 groups the percentage of patients terminated in the programme after first examination ranged from 43% to 76%. Lowest for the patients referred due to unstable hips and highest for the genetically predisposed patients. 96% of the patients terminated the programme within the first 6 months. All patients included completed the programme with no treatment other than a Dennis Brown brace or instructions in spreading exercises.
Conclusions: The findings may suggest a to aggressive screening programme for children referred due to the 5 mentioned causes.
Orthopaedic, Aalborg University Hospital; Orthopaedic, Aalborg University Hospital; Orthopaedic, Aalborg University Hospital; Orthopaedic, Aalborg University Hospital
Background: It has been suggested that breech presentation during pregnancy, family history of Hip Dysplasia (DDH) or twins have an increased risk of DDH. Different screening methods are applied in different regions with controversy.
Purpose / Aim of Study: The purpose of this study is to evaluate the current screening programme of DDH at Aalborg University Hospital (AAUH).
Materials and Methods: Patients were identified using registrations of patients screened for DDH at the department of paediatric orthopaedics AAUH from 2004 until 2014. Patients were divided into 5 groups according to referring cause: breech presentation, family history of DDH, twin birth, clinical hip instability and asymmetrical skinfolds. For each group the final clinical examination and treatment was determined. Patients with lower body deformities were excluded.
Findings / Results: 176 patients were included. The screening of 127 (72%) patients was completed after first examination. For the 5 groups the percentage of patients terminated in the programme after first examination ranged from 43% to 76%. Lowest for the patients referred due to unstable hips and highest for the genetically predisposed patients. 96% of the patients terminated the programme within the first 6 months. All patients included completed the programme with no treatment other than a Dennis Brown brace or instructions in spreading exercises.
Conclusions: The findings may suggest a to aggressive screening programme for children referred due to the 5 mentioned causes.
Helle Sneftrup Poulsen, Niels Wisbech Pedersen
Rehabiliteringsafdelingen, Odense Universitets Hospital; Ortopædkirurgisk afdeling, Børnesektionen, Kvidovre Hospital
Background: CPOP is a combined follow-up program and a healthcare quality register for children with cerebral palsy. The professional treatments are coordinated at interdisciplinary consultations offered by the paediatric departments, at which the child, parents, neuropediatrician, paediatric orthopaedic surgeon, physio- and occupational therapist participate.
Purpose / Aim of Study: To evaluate parental satisfaction with the CPOP consultations in the Region of Southern Denmark.
Materials and Methods: A questionnaire was developed and validated by parents from the target group. The questionnaire consisted of five dimensions; staff, context, participation, information and overall impression. Answers were given on a scale from 1 to 5 (1= to a very small extent, 5= to a very large extent). Eight of the items were based on LUP (National survey of patient experiences). Inclusion criterion: Parents who attended a CPOP consultation in the period June 6th to Dec. 18th 2015. Parents, who cannot read Danish, were excluded. Descriptive statistics and confidence intervals were used in the analysis.
Findings / Results: 104 questionnaires are analyzed. Dimension scores range from 4.3 to 4.7. The highest rated questions are the ones concerning staff´s kindness and their professional relevance, where 75% answered 5 and 21-23% answered 4. The lowest-rated questions relate to the involvement of the child and to the information provided, where 6-8% answered 1 and 2. Comparing the eight items based on LUP with the corresponding LUP results, a statistically significant difference in satisfaction is found in seven out of eight items in favor of the CPOP study.
Conclusions: The study shows a high degree of parental satisfaction with the CPOP consultations in Southern Denmark. Furthermore, the study indicates areas where the quality can be improved.
Rehabiliteringsafdelingen, Odense Universitets Hospital; Ortopædkirurgisk afdeling, Børnesektionen, Kvidovre Hospital
Background: CPOP is a combined follow-up program and a healthcare quality register for children with cerebral palsy. The professional treatments are coordinated at interdisciplinary consultations offered by the paediatric departments, at which the child, parents, neuropediatrician, paediatric orthopaedic surgeon, physio- and occupational therapist participate.
Purpose / Aim of Study: To evaluate parental satisfaction with the CPOP consultations in the Region of Southern Denmark.
Materials and Methods: A questionnaire was developed and validated by parents from the target group. The questionnaire consisted of five dimensions; staff, context, participation, information and overall impression. Answers were given on a scale from 1 to 5 (1= to a very small extent, 5= to a very large extent). Eight of the items were based on LUP (National survey of patient experiences). Inclusion criterion: Parents who attended a CPOP consultation in the period June 6th to Dec. 18th 2015. Parents, who cannot read Danish, were excluded. Descriptive statistics and confidence intervals were used in the analysis.
Findings / Results: 104 questionnaires are analyzed. Dimension scores range from 4.3 to 4.7. The highest rated questions are the ones concerning staff´s kindness and their professional relevance, where 75% answered 5 and 21-23% answered 4. The lowest-rated questions relate to the involvement of the child and to the information provided, where 6-8% answered 1 and 2. Comparing the eight items based on LUP with the corresponding LUP results, a statistically significant difference in satisfaction is found in seven out of eight items in favor of the CPOP study.
Conclusions: The study shows a high degree of parental satisfaction with the CPOP consultations in Southern Denmark. Furthermore, the study indicates areas where the quality can be improved.
Roshan Latifi, Johanna Hall, Silas Gylvin, Christian Wong
Department of Othopedics, University hospital of Hvidovre; Department of Radiology, University hospital of Hvidovre; Department of Othopedics, University hospital of Hvidovre; Department of Othopedics, University hospital of Hvidovre
Background: Bilateral 8-plates (B8P) has been introduced off-label for performing temporary total epiphysiodesis (ttE) for correction of moderate leg length discrepancy (LLD). Concerns has been raised of development of secondary distal femoral dysplasia
Purpose / Aim of Study: To study the efficacy and potential development of secondary femoral dysplasia after B8P for ttE for correcting moderate LLD
Materials and Methods: Fourteen patients were identified retrospectively and 8 were included. These were all treated with B8P. Mean follow-up time was 4.8 years and average initial LLD was 3.2 cm. Information of clinical assessments were retrieved. Long legs radiographs were obtained and measurements of bilateral leg length, knee alignment, femur and tibia length, femoral central, medial and lateral epiphyseal height for both legs were done by 3 doctors independently. Preoperative radiographs were also retrieved. Paired t-tests were performed in SPSS
Findings / Results: Knee alignment and leg and femoral length were not significant different between the operated leg and non-operated leg, but not tibial length. The three femoral epiphysial heights were significant larger from the preoperative height, but not compared to the opposite leg, indicating growth. The ratios between the central part divided with the lateral, medial side, respectively, had no significant difference when compared to the ratios of the non-operated leg at follow-up, and the preoperative operated side. This indicated no femoral dysplasia. Clinical assessments and the other retrieved data were in agreement with the above measurements
Conclusions: ttE with B8P for moderate LLD seems to be an effective treatment without secondary femoral dysplasia and with inconsiderable number and severity in complications when evaluated clinically and radiologically. This indicated no femoral dysplasia
Department of Othopedics, University hospital of Hvidovre; Department of Radiology, University hospital of Hvidovre; Department of Othopedics, University hospital of Hvidovre; Department of Othopedics, University hospital of Hvidovre
Background: Bilateral 8-plates (B8P) has been introduced off-label for performing temporary total epiphysiodesis (ttE) for correction of moderate leg length discrepancy (LLD). Concerns has been raised of development of secondary distal femoral dysplasia
Purpose / Aim of Study: To study the efficacy and potential development of secondary femoral dysplasia after B8P for ttE for correcting moderate LLD
Materials and Methods: Fourteen patients were identified retrospectively and 8 were included. These were all treated with B8P. Mean follow-up time was 4.8 years and average initial LLD was 3.2 cm. Information of clinical assessments were retrieved. Long legs radiographs were obtained and measurements of bilateral leg length, knee alignment, femur and tibia length, femoral central, medial and lateral epiphyseal height for both legs were done by 3 doctors independently. Preoperative radiographs were also retrieved. Paired t-tests were performed in SPSS
Findings / Results: Knee alignment and leg and femoral length were not significant different between the operated leg and non-operated leg, but not tibial length. The three femoral epiphysial heights were significant larger from the preoperative height, but not compared to the opposite leg, indicating growth. The ratios between the central part divided with the lateral, medial side, respectively, had no significant difference when compared to the ratios of the non-operated leg at follow-up, and the preoperative operated side. This indicated no femoral dysplasia. Clinical assessments and the other retrieved data were in agreement with the above measurements
Conclusions: ttE with B8P for moderate LLD seems to be an effective treatment without secondary femoral dysplasia and with inconsiderable number and severity in complications when evaluated clinically and radiologically. This indicated no femoral dysplasia