BACKGROUND CONTEXT The emergence of drug resistance has complicated the management of spinal tube... more BACKGROUND CONTEXT The emergence of drug resistance has complicated the management of spinal tuberculosis (TB). While it is well known that the medical management of drug-resistant spinal TB is more difficult, the surgical outcomes of the same have not been studied sufficiently, particularly in children. PURPOSE To analyze the surgical outcomes in a cohort of children treated for spinal TB, and to thus assess whether drug resistant (DR) disease is associated with poorer surgical outcomes. STUDY DESIGN/SETTING Retrospective observational study. PATIENT SAMPLE All children diagnosed and treated for tuberculous spondylodiscitis at a single center between January 2014 and June 2017. OUTCOME MEASURES Surgical outcomes in terms of neurological status and kyphosis angle at final follow-up, and complication rates. METHODS Radiographic and clinical data of children treated for spinal TB with minimum two-year follow-up were retrospectively analyzed. Data gathered included age, gender, level of spine affected, number of vertebrae involved, neurology (Frankel grade), microbiological reports, duration and type of anti-tuberculous therapy (ATT), details of Orthopaedic management and complications during treatment. In DR cases, the time from presentation to starting of second-line ATT was also assessed. Radiographs were reviewed to note the pre- and post-operative degree of kyphosis as well as the angle at final follow-up. Patients that developed major complications were compared statistically with those that did not. RESULTS Forty-one consecutive children (mean age 8.5±4.2 years, 20 boys, 21 girls) were treated for spinal TB with a mean follow-up of 31.2±6.4 months. Fifteen were managed conservatively, of which only one had DR-TB. Of the 26 managed surgically, 13 were managed with first-line ATT and 13 required second-line ATT. Of this latter group, eight had microbiologically proven drug resistance, whereas five were switched to second-line therapy presumptively because of failure to show an adequate response to first-line regimen. At last follow-up, all children had completed the prescribed course of ATT and had been declared cured. Neurological improvement was seen in all but one patient; and at last follow-up, 18 children were Frankel E, seven were Frankel D, and one was Frankel B. The immediate post-operative Kyphosis angle averaged 24.38° ± 15.21°. However, six children showed a subsequent worsening of kyphosis, and the Kyphosis angle at last follow-up averaged 30.96° ± 23.92°. Five children had major complications requiring revision surgery; complications included wound dehiscence, vertebral collapse, screw pull-out and implant breakage. Significantly higher number of patients in the group with complications had required second-line ATT (p<0.05). CONCLUSIONS In a cohort of children treated surgically for spinal tuberculosis, a higher complication rate, and thus poor surgical outcomes, were found to be associated with drug resistant disease.
Journal of Foot and Ankle Surgery (Asia Pacific), 2021
Children with clubfoot often present after the walking age, especially in low- and middle-income ... more Children with clubfoot often present after the walking age, especially in low- and middle-income countries where approximately 80% of children with clubfoot are born. With advancing age, there is increased stiffness of the soft tissue structures and decreased remodeling potential of the bones of the foot. Not all clubfeet in older children are rigid—some are flexible and amenable to stretching and conservative treatment. Hence, the initial evaluation of the deformity must include an assessment of correctability. The treatment of clubfoot in the older child is challenging and was traditionally performed using complex soft tissue and bony surgeries, often with poor outcomes in the long term. Recent literature has focused on the role of conservative treatment utilizing Ponseti principles of serial manipulation and casting, combined with limited surgery. The purpose of this review is to report the changing trends in the management of clubfoot in the walking child, to review the current ...
Background The Edinburgh Visual Gait Score (EVGS) is a comprehensive measure of gait abnormalitie... more Background The Edinburgh Visual Gait Score (EVGS) is a comprehensive measure of gait abnormalities in children with cerebral palsy (CP) and has good psychometric properties. However, it is cumbersome to administer and requires multiple devices to record and measure its various components. We conducted this study to determine if a smartphone video protocol could be used to improve the usability and reliability of the EVGS for daily use in a clinic setting. Methods We used a handheld smartphone camera with slow-motion video technology and a motion analysis application to record and measure the EVGS of 30 ambulatory children with spastic CP. We tested the inter- and intra-rater reliability of various components of the EVGS between two observers. Results Average age was 7 years 3 months (range 4-14 years). The mean (range) EVGS scores for the trunk, pelvis, hip, knee, ankle, and foot were 1.18 (0-3), 0.68 (0-3), 1.1 (0-4), 3.95 (1.5-7.5), 1.87 (0-4) and 4.13 (2-6.5) respectively. Total ...
Supplemental Digital Content is available in the text. Background: The coronavirus disease 2019 (... more Supplemental Digital Content is available in the text. Background: The coronavirus disease 2019 (COVID-19) pandemic required rapid, global health care shifts to prioritize urgent or pandemic-related care and minimize transmission. Little is known about impacts on pediatric orthopaedic surgeons during this time. We aimed to investigate COVID-19-related changes in practice, training, and research among pediatric orthopaedic surgeons globally. Methods: An online survey was administered to orthopaedic surgeons with interest in pediatrics in April 2020 and a follow-up was administered in February 2021. The surveys captured demographics and surgeons’ self-reported experiences during the pandemic. Participants were recruited from web media and available email lists of orthopaedic societies over a 2-month period. Descriptive statistics were used to analyze results, stratified by the severity of local COVID-19-related measures. Results: A total of 460 responses from 45 countries were collect...
Objective Ponseti method is suitable to treat neglected clubfoot after the walking age. However, ... more Objective Ponseti method is suitable to treat neglected clubfoot after the walking age. However, limited evidence exists on its effectiveness, outcomes and rate of relapse. Methods: 429 clubfeet in 303 patients with no previous treatment and older than one-year were treated with the Ponseti method in 15 centers from seven countries. The median age at treatment onset was three years, and the median follow-up of 1.3 years. Standard Ponseti Method was applied. Bilateral abduction brace was recommended after casting. Patients were classified according to group ages (<2 years, 2-4 years, >4-8years, >8 years). Feet were evaluated by Pirani score and a clinical outcome classification. Relapses were described in a subset of 103 clubfeet with minimal follow-up of two years. Results Ponseti method was able to correct the deformity in 87% (373 of 429) of neglected clubfeet, after a mean of 6.8 casts. Residual equinus was treated with percutaneous sectioning of the Achilles tendon in 3...
CASE A full-term neonate presented with right lower extremity ischemia at birth because of sponta... more CASE A full-term neonate presented with right lower extremity ischemia at birth because of spontaneous thrombosis of the right common iliac artery. He was initially managed with supportive treatment, anticoagulation, and dressings; however, advanced gangrenous changes precluded salvage of the ischemic limb. A guillotine amputation was performed at day 15 of life, and the stump went on to heal well by secondary intention. CONCLUSION Thromboembolic events occurring in infancy are well-recognized phenomena; however, it is far rarer to encounter a neonate born with "congenital gangrene". We discuss the etiology, approach to diagnosis, and treatment of this rare but devastating condition.
Purpose In India and other Global South countries, developmental dysplasia of the hip (DDH) is of... more Purpose In India and other Global South countries, developmental dysplasia of the hip (DDH) is often diagnosed after walking age, leading to more invasive surgeries and long-term disability. DDH care pathways aim to enhance early detection and must be tailored to meet a country’s needs and diverse practice settings. We describe a multi-phase methodology for context-specific DDH care pathway development, demonstrating its use in India. Methods In Phase I, Orthopaedic surgeons, Pediatricians/Neonatologists, and Radiologists in India were surveyed regarding DDH screening. Seven relevant Indian organizations partnered together and assembled a multidisciplinary working group, which then met fortnightly to establish an evidence base and prepare for the subsequent consensus-building phase. During Phase II, panelists participated in a modified Delphi process to reach consensus on a list of DDH screening statements. Phase III applied the statements to develop the care pathway. Results The De...
BACKGROUND CONTEXT The emergence of drug resistance has complicated the management of spinal tube... more BACKGROUND CONTEXT The emergence of drug resistance has complicated the management of spinal tuberculosis (TB). While it is well known that the medical management of drug-resistant spinal TB is more difficult, the surgical outcomes of the same have not been studied sufficiently, particularly in children. PURPOSE To analyze the surgical outcomes in a cohort of children treated for spinal TB, and to thus assess whether drug resistant (DR) disease is associated with poorer surgical outcomes. STUDY DESIGN/SETTING Retrospective observational study. PATIENT SAMPLE All children diagnosed and treated for tuberculous spondylodiscitis at a single center between January 2014 and June 2017. OUTCOME MEASURES Surgical outcomes in terms of neurological status and kyphosis angle at final follow-up, and complication rates. METHODS Radiographic and clinical data of children treated for spinal TB with minimum two-year follow-up were retrospectively analyzed. Data gathered included age, gender, level of spine affected, number of vertebrae involved, neurology (Frankel grade), microbiological reports, duration and type of anti-tuberculous therapy (ATT), details of Orthopaedic management and complications during treatment. In DR cases, the time from presentation to starting of second-line ATT was also assessed. Radiographs were reviewed to note the pre- and post-operative degree of kyphosis as well as the angle at final follow-up. Patients that developed major complications were compared statistically with those that did not. RESULTS Forty-one consecutive children (mean age 8.5±4.2 years, 20 boys, 21 girls) were treated for spinal TB with a mean follow-up of 31.2±6.4 months. Fifteen were managed conservatively, of which only one had DR-TB. Of the 26 managed surgically, 13 were managed with first-line ATT and 13 required second-line ATT. Of this latter group, eight had microbiologically proven drug resistance, whereas five were switched to second-line therapy presumptively because of failure to show an adequate response to first-line regimen. At last follow-up, all children had completed the prescribed course of ATT and had been declared cured. Neurological improvement was seen in all but one patient; and at last follow-up, 18 children were Frankel E, seven were Frankel D, and one was Frankel B. The immediate post-operative Kyphosis angle averaged 24.38° ± 15.21°. However, six children showed a subsequent worsening of kyphosis, and the Kyphosis angle at last follow-up averaged 30.96° ± 23.92°. Five children had major complications requiring revision surgery; complications included wound dehiscence, vertebral collapse, screw pull-out and implant breakage. Significantly higher number of patients in the group with complications had required second-line ATT (p<0.05). CONCLUSIONS In a cohort of children treated surgically for spinal tuberculosis, a higher complication rate, and thus poor surgical outcomes, were found to be associated with drug resistant disease.
Journal of Foot and Ankle Surgery (Asia Pacific), 2021
Children with clubfoot often present after the walking age, especially in low- and middle-income ... more Children with clubfoot often present after the walking age, especially in low- and middle-income countries where approximately 80% of children with clubfoot are born. With advancing age, there is increased stiffness of the soft tissue structures and decreased remodeling potential of the bones of the foot. Not all clubfeet in older children are rigid—some are flexible and amenable to stretching and conservative treatment. Hence, the initial evaluation of the deformity must include an assessment of correctability. The treatment of clubfoot in the older child is challenging and was traditionally performed using complex soft tissue and bony surgeries, often with poor outcomes in the long term. Recent literature has focused on the role of conservative treatment utilizing Ponseti principles of serial manipulation and casting, combined with limited surgery. The purpose of this review is to report the changing trends in the management of clubfoot in the walking child, to review the current ...
Background The Edinburgh Visual Gait Score (EVGS) is a comprehensive measure of gait abnormalitie... more Background The Edinburgh Visual Gait Score (EVGS) is a comprehensive measure of gait abnormalities in children with cerebral palsy (CP) and has good psychometric properties. However, it is cumbersome to administer and requires multiple devices to record and measure its various components. We conducted this study to determine if a smartphone video protocol could be used to improve the usability and reliability of the EVGS for daily use in a clinic setting. Methods We used a handheld smartphone camera with slow-motion video technology and a motion analysis application to record and measure the EVGS of 30 ambulatory children with spastic CP. We tested the inter- and intra-rater reliability of various components of the EVGS between two observers. Results Average age was 7 years 3 months (range 4-14 years). The mean (range) EVGS scores for the trunk, pelvis, hip, knee, ankle, and foot were 1.18 (0-3), 0.68 (0-3), 1.1 (0-4), 3.95 (1.5-7.5), 1.87 (0-4) and 4.13 (2-6.5) respectively. Total ...
Supplemental Digital Content is available in the text. Background: The coronavirus disease 2019 (... more Supplemental Digital Content is available in the text. Background: The coronavirus disease 2019 (COVID-19) pandemic required rapid, global health care shifts to prioritize urgent or pandemic-related care and minimize transmission. Little is known about impacts on pediatric orthopaedic surgeons during this time. We aimed to investigate COVID-19-related changes in practice, training, and research among pediatric orthopaedic surgeons globally. Methods: An online survey was administered to orthopaedic surgeons with interest in pediatrics in April 2020 and a follow-up was administered in February 2021. The surveys captured demographics and surgeons’ self-reported experiences during the pandemic. Participants were recruited from web media and available email lists of orthopaedic societies over a 2-month period. Descriptive statistics were used to analyze results, stratified by the severity of local COVID-19-related measures. Results: A total of 460 responses from 45 countries were collect...
Objective Ponseti method is suitable to treat neglected clubfoot after the walking age. However, ... more Objective Ponseti method is suitable to treat neglected clubfoot after the walking age. However, limited evidence exists on its effectiveness, outcomes and rate of relapse. Methods: 429 clubfeet in 303 patients with no previous treatment and older than one-year were treated with the Ponseti method in 15 centers from seven countries. The median age at treatment onset was three years, and the median follow-up of 1.3 years. Standard Ponseti Method was applied. Bilateral abduction brace was recommended after casting. Patients were classified according to group ages (<2 years, 2-4 years, >4-8years, >8 years). Feet were evaluated by Pirani score and a clinical outcome classification. Relapses were described in a subset of 103 clubfeet with minimal follow-up of two years. Results Ponseti method was able to correct the deformity in 87% (373 of 429) of neglected clubfeet, after a mean of 6.8 casts. Residual equinus was treated with percutaneous sectioning of the Achilles tendon in 3...
CASE A full-term neonate presented with right lower extremity ischemia at birth because of sponta... more CASE A full-term neonate presented with right lower extremity ischemia at birth because of spontaneous thrombosis of the right common iliac artery. He was initially managed with supportive treatment, anticoagulation, and dressings; however, advanced gangrenous changes precluded salvage of the ischemic limb. A guillotine amputation was performed at day 15 of life, and the stump went on to heal well by secondary intention. CONCLUSION Thromboembolic events occurring in infancy are well-recognized phenomena; however, it is far rarer to encounter a neonate born with "congenital gangrene". We discuss the etiology, approach to diagnosis, and treatment of this rare but devastating condition.
Purpose In India and other Global South countries, developmental dysplasia of the hip (DDH) is of... more Purpose In India and other Global South countries, developmental dysplasia of the hip (DDH) is often diagnosed after walking age, leading to more invasive surgeries and long-term disability. DDH care pathways aim to enhance early detection and must be tailored to meet a country’s needs and diverse practice settings. We describe a multi-phase methodology for context-specific DDH care pathway development, demonstrating its use in India. Methods In Phase I, Orthopaedic surgeons, Pediatricians/Neonatologists, and Radiologists in India were surveyed regarding DDH screening. Seven relevant Indian organizations partnered together and assembled a multidisciplinary working group, which then met fortnightly to establish an evidence base and prepare for the subsequent consensus-building phase. During Phase II, panelists participated in a modified Delphi process to reach consensus on a list of DDH screening statements. Phase III applied the statements to develop the care pathway. Results The De...
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