Session 3: Pediatrics

15. November
09:00 - 10:30
Lokale: 202-205
Chair: Bjarne M Madsen and Louise Klingenberg

21. Age-related trends in unintentional injuries among children and adolescents in an urban Danish population 1980-2021. A study of 292,737 cases.
Frederik Haller1,2, Jens Martin Lauritsen1,2, Christian Færgemann1,2
1. Department of Orthopaedic Surgery and Traumatology, Odense University Hospital. 2. Orthopaedic Research Unit, University of Southern Denmark.

Background: Pediatric unintentional injuries remain a common cause of morbidity. However, no larger study has described the age and gender stratified epidemiology of unintentional injuries among children and adolescents.
Aim: The study aimed to describe the age and gender stratified epidemiology of unintentional injuries in children and adolescents in an urban Danish population from 1980-2021.
Materials and Methods: A retrospective study of all children and adolescents aged 0-17 years treated for lesions due to unintentional injuries at Odense University Hospital 1980-2021. We extracted information about age, gender, place of injury, time of injury, and diagnoses from the emergency department register. We estimated gender specific annual incidence rates (IRs) in different age groups (0-4, 5-9, 10-14, and 15-17 years) per 1000 population/years. The severity was measured using a diagnose-based tool, which transformed diagnoses into mild or severe injuries.
Results: Overall, 292,737 unintentionally injured children and adolescents were included. The median age was 10 years for both gender and 57.4% were boys. The overall IR was 241.2 (CI: 240.2-242.2) for boys and 187.5. (CI: 186.5-188.4) for girls. The highest IR was in the age group 15-17 years for boys and 10-14 years for girls, respectively 275.6 (CI: 273.1-278.1) and 231.6 (CI: 229.6- 233.5). The overall IR for severe injuries was 26.9 (CI: 26.6-27.3) for boys and 20.4 (CI: 20.0-20.8). The highest IR for severe injuries was in the age group 10-14 years in both gender. The IRs for severe injuries decreased significantly in the 10-14 and 15- 17 years age groups for both genders and the 5-9 years age group for boys. The upper limbs were the most frequently injured. Bone fractures accounted for 14.5% of all lesions. Injury time, injury place, and diagnoses varied significantly between age groups.
Interpretation / Conclusion: The IRs varied significantly between the different age groups throughout the study. The study provides information about the injury frequency, mechanism, location, and type of injury, which are useful when coordinating the resources at emergency departments and planning preventive campaigns targeting different age groups.

22. Birthweight correlates to pubo-femoral distances and alpha angles in hip ultrasound of newborns at six weeks of age.
Maria Tirta1, Michel Bach Hellfritzsch2,3, Rikke Damkjær Maimburg2,5,6,7, Mads Henriksenb2,3, Natallia Lapitskaya2,3, Søren Kold1,2, Bjarne Møller Madsen2,4, Ole Rahbek1,2, Hans-Christen Husum1,2
1. Interdisciplinary Orthopaedics, Aalborg University Hospital, Denmark 2. Danish Paedatric Orthopaedic Research, Denmark 3. Department of Radiology, Aarhus University Hospital, Denmark 4. Department of Children’s Orthopaedics, Aarhus University Hospital, Denmark 5. Department of Midwifery, University College of Northern Denmark, Aalborg 6. Department of Clinical Medicine, Aarhus University, Denmark 7. Department of Occupational Medicine, Danish Ramazzini Centre, Aarhus University Hospital, Denmark

Background: There is inconsistency in the literature as to the relationship between increased birthweight and risk of developmental dysplasia of the hip (DDH).
Aim: The aim of this study was to investigate the correlation of birthweight to pubo-femoral distances (PFD) values in DDH ultrasound, as well as if increased birthweight is negatively correlated to Graf a angles in newborns undergoing hip ultrasound at five- six weeks of age as well as correlation with gender.
Materials and Methods: Newborns’ data and ultrasound measurements were collected during a one- year study period from October 2021 to October 2022. Information recorded included birthweight, gestational week, gender, age at examination, and at ultrasound measurements. We excluded multiple births since newborns from multiple births are usually lighter, as well as born more premature, newborns born at 37 gestational week or less, and newborns with incomplete information. Simple and multiple linear regression analysis were performed to evaluate the association of birthweight and PFD, and secondly that of birthweight and a angle.
Results: 670 newborns (1340 hips) were included in this study with equal distribution of males and females. Birthweight was statistically significant higher for male newborns 3712 ± 450 grams vs 3555 ± 428 grams (p<0.001). Increased birthweight was positively correlated to PFD values (crude coefficient = 0.245 (95% CI: 0.127; 0.363)) the correlation was still present after adjusting for gender, family history, and breech presentation (adjusted coefficient 0.253 (95% CI: 0.132; 0.373). The stratified model for males was statistically insignificant for both the crude coefficient (p=0.163) and the adjusted (p=0.06). The effect of birthweight on a measurement for the females was statistically significant (crude coefficient -0.939 (95% CI: -1.828; -0.050); adjusted coefficient -0.926 (95% CI: -1.029; -0.035)).
Interpretation / Conclusion: This study indicated that increases in birthweight is positively correlated to PFD measurements for both females and male newborns, and negatively correlated to a angle measurements in female newborns screened for DDH at six weeks of age.

23. Point-of-care ultrasound in hip dysplasia screening increases detection rates by 60%.
Hans-Christen Husum1,2, Michel Bach Hellfritzsch2,3, Rikke Damkjær Maimburg2,5, Bjarne Møller-Madsen2,4, Mads Henriksen2,3, Natallia Lapitskaya2,3, Søren Kold1,2, Ole Rahbek1,2
1 Interdisciplinary Orthopaedics, Aalborg University Hospital, Denmark; 2. Danish Paedatric Orthopaedic Research, Aarhus University Hospital, Denmark; 3. Department of Radiology, Aarhus University Hospital, Denmark; 4. Department of Children’s Orthopaedics, Aarhus University Hospital, Denmark; 5. Department of Midwifery, University College of Northern Denmark, Aalborg

Background: Screening programmes for hip dysplasia (DDH) can be divided into selective referral of at-risk newborns for hip ultrasound (US) or universal referral of all newborns regardless of risk of DDH. While selective screening is the predominant approach worldwide, it fails to reduce the rate of late diagnoses of DDH. Conversely, universal screening increases detection rates, but the need for examiners trained in the complex gold standard US examination method, makes it challenging to implement.
Aim: The present study investigates the effectiveness of a selective screening program using a point-of-care (POC) US examination method as a referral criterion for follow-up (FU) hip US and compares it to the traditional selective screening criteria of clinical examination and risk factor identification.
Materials and Methods: We prospectively included all newborns consented to receive a POC pubo-femoral distance (PFD) US screening in addition to the traditional screening for DDH at our institution. The PFD criterion was compared to traditional referral criteria in terms of sensitivity and specificity in detecting US abnormal hips as well as detection- and referral rates.
Results: We included 2,735 newborns of which 616 received a FU hip US. After exclusion 561 newborns were included for analysis. 317 newborns (11.6%) were referred by traditional screening criteria and 303 newborns (10.8%) were referred by the PFD criterion. Sensitivities/specificities for detecting =Graf type IIa hips were: 17.4%/94.2% for clinical examination, 27.9%/47.5% for risk factors, 40.7%/51% for clinical examination and risk factors combined and 65.1%/72% for PFD examination using a cut-off of 5.8 mm. Differences in sensitivities and specificities between traditional referral criteria and the PFD criterion were statistically significant (p<0.01). PFD US increased the detection rate of immature hips (Graf IIa) by 72% and dysplastic hips (= Graf IIc) by 60% with similar referral rates
Interpretation / Conclusion: Early POC PFD US screening was significantly more effective in detecting abnormal hips than traditional selective screening. As PFD US is an accessible examination method, PFD screening may be a viable alternative to current selective screening for DDH.

24. National rates of pediatric fractures over a 20–year timespan in Denmark. A population-based cohort study
Anja Rønnov Lund1, Christian Færgemann1, Per Gundtoft2,3, Bjarke Viberg1,2
1. Department of Orthopaedic Surgery and Traumatology, Odense University Hospital 2. Department of Orthopaedic Surgery and Traumatology, Hospital Lillebaelt Kolding 3. Department of Orthopaedic, Aarhus University Hospital

Background: Previous reports on incidences of Scandinavian pediatric extremity fractures have varied, as they are often anatomically specific and based on institution specific findings. In order to gain knowledge of current and future burden on the health care system, a national cohort assessment is necessary.
Aim: To assess incidence, proportion and distribution of pediatric extremity fractures in Denmark in relation to age, sex, and anatomical areas.
Materials and Methods: A population-based cohort study with data retrieved from the Danish National Patient Registry between 1999-2018. All fractures were registered following the 10th revision of the International Classification of Diseases. Age was categorized into four groups while anatomical region was categorized into six groups. Incidence rate was calculated based on national population counts.
Results: We found a total of 668,595 pediatric extremity fractures. The overall incidences rates of extremity fractures were 3,164 (CI 3,156-3,171) per 100,000 person years for all children. The incidence rate increased from 3,078 (CI 3,044–3,111) in 1999 to 3,402 (CI 3,367– 3,437) in 2018. The distribution between sex (57% boys) and age groups (11% 0-3 years, 21% 4-7 years, 33% 8-11 years, 36% 12-15 years) did not change during the study period. The distribution was different from girls to boys in the age groups, for girls 29% was in the 8-11 years old and 41% in 12-15 years old in comparison to 38% and 29% for the boys. The distribution between the anatomical areas did not change markedly and there were 111,212 upper arm fractures (15%), 293,786 (39%) lower arm, 181,599 (24%) hand, 10,070 (1%) upper leg, 83,916 (11%) lower leg and 80,914 (11%) foot fractures. There were different distribution rates between the age groups. The first and second most frequent fracture areas were lower arm (32% and 46%) and upper arm (27% and 23%) for 0-3 and 4-7 year old, lower arm (44%) and hand (24%) for 8-11 year old, and hand (34%) and lower arm (32%) for 12-15 year old.
Interpretation / Conclusion: The IR increased during the study period thereby yielding a greater burden to the health care system. There were different distribution rates of fracture in relation to sex, age and anatomical area.

25. Five-day accelerated Ponseti protocol is efficient and safe in the treatment of clubfoot
Vilhelm Engell1,2, Søren Ege Qwist1,2
1. Department of Orthopaedics, Aarhus University Hospital 2. Danish Pediatric Orthopaedic Research (DPOR)

Background: The management of clubfoot is non-operative with repeated manipulation and casting as described by Ponseti. Later accelerated versions of the Ponseti method have been published. Studies suggest the deforming forces are resolved within hours of the manipulations. Recently, a method with daily manipulation and casting have been described.
Aim: We have used a five-day accelerated Ponseti method with daily manipulations and castings, in order to accommodate parental needs for faster and more convenient treatment since 2020.
Materials and Methods: In our accelerated one-week protocol we added an ultrasound evaluation of the clubfeet at three months to asses any deformation or damage to the cartilage/bones and/or swelling of the soft tissues. Otherwise, management was according to the Ponseti method.
Results: This prospective consecutive series included all clubfeet, where the parents chose the five-day accelerated Ponseti protocol. All patients completed the treatment with full clinical correction. 21 clubfeet in 14 patients were included. Pirani score at inclusion was median 6 (4-6) and at control at 3 months median 0 (0-0,5). Median 5 (4-5) casts to obtain correction before Achilles tenotomy, which was performed in all cases. Ultrasound evaluation at three months; no signs of deformation or damage to the cartilage/bones or soft tissue swelling was observed. There were no early recurrences at 1year follow-up. Pirani score at follow-up was median 0 (0- ½).
Interpretation / Conclusion: Morcuende et al. reported results of an accelerated Ponseti protocol for clubfoot. Edema of the feet was a concern. Hence, they recommended 5-day casting interval. However, others have found accelerated Ponseti techniques to be effective and safe. The fact that no feet had signs of deformation or damage to the cartilage/bones or soft tissue swelling at ultrasound evaluation at three months, indicates that the five – day accelerated Ponseti protocol is safe. A longer follow-up time may tell relapse frequency. Overall acceleration of the Ponseti method seems efficient and safe.

26. Knee-related Quality of Life, Symptoms, Pain, and Function in Sport and Recreational activities in adults with a history of adolescent Sinding-Larsen Johansson disease: A registry-based cohort study
Kasper Krommes1, Kristian Thorborg1,2, Jørgensen Amalie Bjerre1,3, Mathias Fabricius Nielsen1, Lasse Christensen4, Per Hölmich1,2
1. Sports Orthopedic Research Center – Copenhagen (SORC-C), Department of Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre, Denmark; 2. Department of Clinical Medicine, University of Copenhagen, Denmark; 3. Faculty of Physiotherapy, Center of Nutrition and Rehabilitation, University College Absalon, Roskilde, Denmark; 4. Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark

Background: Sinding-Larsen Johansson Disease (SLJD) is a common growth-related condition in adolescence that causes knee pain and decreased sports-participation. However, little is known about its long-term consequences into adulthood.
Aim: To investigate the long-term consequences of SLJD based on self-reported knee health of adults diagnosed with SLJD during adolescence compared to normative data.
Materials and Methods: All adults aged 18-55 years, diagnosed in Danish secondary care with SLJD during 1977-2020, were invited to complete a survey on SLJD-history and current knee- related health. Knee-related health was assessed with the Knee Injury and Osteoarthritis Outcome Score (KOOS) on subscales Quality of Life (QoL), Symptoms, Pain, and Sport/Rec. A priori we planned to subgroup participants according to sex and age (female/male; 18-25, 26-35, 36-45, 46- 55 years), and compare these to matched subgroups from a healthy cohort (Williamson et al. 2015, n=1000).
Results: 76 adults completed the survey (age 36.9±13 years, 45% male). Due to few observations in the SLJD-subgroups, all participants were compared to weighted means from the entire healthy cohort across KOOS subscales, showing clinically relevant differences (QoL: -28 points, p<0.0001; Symptoms: -14 points, p<0.0001; Pain: -15 points, p<0.0001; Sport/Rec subscale -32 points, p<0.0001). Adults reporting “a lot of pain” vs. “little pain” during SLJD in adolescence had decreased KOOS- Symptom score (77 vs. 92 points, p<0.05). Adults reporting being “some”/“very” limited in their sports-participation during SLJD in adolescence, had increased risk of having “some”/“severe” symptoms from their SLJD as adults (OR >1.30, p<0.05).
Interpretation / Conclusion: Adults diagnosed with SLJD in adolescence seems to have decreased self-reported knee health as adults when compared to healthy populations. The degree of pain, and limitations in sport and physical activity during SLJD in adolescence is associated to knee-related symptoms as adults. As it seems SLJD can lead to reduced knee- health in adulthood, and certain severity- characteristics can result in a worse prognosis, the information given during clinical consultations with adolescents with SLJD should reflect this.

27. Outcome of Pavlik Harness treatment for unstable hip dysplasia in infants
Mathias Hauge Bünger1, Line Holm Jensen1, Martin Gottliebsen1
1. Department of paediatric orthopaedics, Aarhus University Hospital

Background: There is general consensus that unstable hips in infants require treatment if spontaneous improvement doesn’t occur in patients with hip dysplasia (DDH). Many different braces and splints exist. In Denmark, abduction bracing using the Dennis-Brown rigid splint has traditionally been used. However, globally the Pavlik Harness (PHT) which is allowing hip motion in abduction is most commonly used. We report data of our experience with PHT of infants with DDH.
Aim: The aim of the study was to describe efficiency of PHT in our cohort of infant babies of unstable DDH.
Materials and Methods: The cohort includes 61 infants (5 boys/56 girls) PH treated for 23/24h in the hip clinic at AUH from 2020 to 2023. Decision of treatment was based on a combination of dynamic ultrasound (US) using a modified Graf method showing hip instability and clinical examination. In case of treatment, patients were seen at a one week follow-up to adjust the PH and do US to document the femoralhead centered in the acetabulum. At the one week mark parents were asked about problems using the PH. After this, hips were reviewed clinically and with dynamic US every 4th week until normalization (a- angle >60°, Cov>50% and stable) when PH treatment was stopped.
Results: The mean age of the infants at PHT beginning was 7.3 weeks (range 1-19), while mean treatment duration was 8.1 week (range 4-14). Of the 61 infants initiating PHT, hip normalized in 51 pt (84%). PHT was abandoned for a rigid DB splint in 6 patients (10%) and for closed reduction and hips spica casting in 3 patients (5%). 6 of 51 patients (12%) successfully PHT had an acetabular index >30° at the radiographs age 6 months. In 52% (32/61) of the infants, parents reported that their child appeared unaffected. 4 of 61 (7%) reported problems with breastfeeding, 23/61 (38%) had sleeping problems and irritability the first days. No parents terminated treatment by the self.
Interpretation / Conclusion: The data show that a most unstable hips can be successfully treated with the Pavlik Harness. In a few patients the PH failed, typically in very unstable hips in which the PH didn’t provide enough abduction to keep the hips reduced or in irreducible hips. The PH was well tolerated by infants and parents.

28. Is Simple Talectomy a Beneficial Procedure for Severe Foot Deformity?
Marianne Frydendal Nielsen1,2, Jan Rölfing1,2, Line Kjeldgaard Pedersen1,2, Michael Davidsen1,2, Bjarne Møller-Madsen1,2
1. Department of Children's Orthopaedics, Aarhus University Hospital 2. Danish Paediatric Orthopaedic Research,

Background: Talectomy is rarely performed. Non-invasive techniques are the gold standard to redress Severe Neuromuscular Foot Deformity (SNFD). Yet, talectomy may be considered for rigid, painful, or neglected SNFD to obtain a stable, plantigrade and pain-free foot. We present a 10-year follow-up accessing radiological correction, functional outcomes, complications, and patient satisfaction.
Aim: The aim of the study was to investigate whether simple talectomy is a beneficial procedure.
Materials and Methods: This single centre retrospective case series evaluated talectomies in 2012-2022. Simple talectomy was combined with Steinman pin fixation of calcaneus to tibia for approximately six weeks. Main diagnoses included arthrogryposis multiplex congenita and cerebral palsy. The primary outcome was radiological correction rates. Tibiotalar angle (TiTa) and tibiocalcaneal angle (TiCa) were measured on mediolateral projections. Talectomy indications were pain, wounds, pressure marks, problems wearing shoes/orthoses and residual/recurrent deformity after former interventions. Secondary outcomes were functional outcomes graded as good/fair/poor based on degree of deformity and pain. Validated patient-reported outcome measures, i.e., EQ-5D-5L and two items from the Scoliosis Research Society-30 Questionnaire assessed health-related quality of life and patient satisfaction.
Results: 19 talectomies in 11 patients were analysed. Mean follow-up was 62 months (range 9-112 months). Mean TiTa prior talectomy was 137±17°. TiCa improved significantly with a mean difference of -24°(95%CI=[-44;-5])(p˜0.02). All 19 feet became plantigrade and pain-free with no skin sores. Functional outcomes were graded as 9/19(47%) good, 10/19(53%) fair and 0/19(0%) poor. 9/11(82%) patients could stand with support versus 6/11(55%) before talectomy. Four patients walked supported by aids prior surgery (all bilateral cases). In-house walking distance improved in three cases. Parents/primary caregivers ranked their satisfaction level between neutral and very satisfied. Perceived health was rated with a mean visual analogue scale score of 54±27 out of 100, emphasizing complex medical conditions.
Interpretation / Conclusion: Simple talectomy is a beneficial procedure for SNFD.

29. Scoping review of rotational guided growth in the growing bone
Ahmed Halloum1, Søren Kold1, Jan D. Rölfing2, Ahmed A. Abood1,3, Ole Rahbek1
1. Interdisciplinary Orthopaedics, Aalborg University Hospital; 2. Children’s Orthopaedics and Reconstruction, Aarhus University Hospital; 3. Orthopaedic Oncology and Reconstruction, Aarhus University Hospital

Background: Guided growth is routinely used to correct angular deformities in long bones in children. It has also been proven to be a viable method to correct rotational deformities, but the concept is not yet fully examined.
Aim: The aim of this scoping review is to understand the extent and type of evidence in relation to the use of guided growth for correcting rotational deformities of long bones
Materials and Methods: Databases searched include Medline, Embase, Cochrane Library, Web of Science and Google Scholar. All published and unpublished studies were included. All identified citations were collated and uploaded into and screened by at least two reviewers. Data from included studies were extracted using a predesigned extraction tool.
Results: The search resulted in 3569 hits. 14 studies were included: 1 review, 3 clinical trials and 10 pre-clinical trials. The review covers guided growth for treating angular deformities of lower limbs but includes a paragraph about rotational deformities. Clinical trials: a total of 21 children (32 femurs and 5 tibiae) were included. Surgical methods were 2 canulated screws connected by cable, PediPlates obliquely oriented, and separated Hinge Plates connected by FiberTape. Rotation was achieved in all but 1 child. Adverse effects reported include limb length discrepancy (LLD), knee stiffness and rebound of rotation after removal of tethers. 2 pre-clinical studies were ex-vivo studies, 1 using 8-plates on Sawbones and 1 using novel z-shaped plates on human cadaver femurs. There were 5 lapine studies (2 using femoral plates, 2 using tibial plates and 1 using an external device on tibia), 1 ovine (external device on tibia), 1 bovine (canulated screws and cable on metacarp) and a case-report on a dog that had an external device spanning from femur to tibia. Rotation was achieved in all studies. Adverse effects reported include implant extrusions, LLD, articular deformities (including menisci), joint stiffness and rebound of rotation.
Interpretation / Conclusion: All included studies conclude that guided growth is a viable treatment for rotational deformities of long bones, but there is great variation in models and surgical methods used, and in reported adverse effects.

30. Measurement of anterior knee laxity with the Rolimeter® changes with flexion angle but not when a shortened Rolimeter® for smaller children is used
Maria Østergaard Madsen1, Susan Warming2, Robert Bennike Herzog2, Michael Rindom Krogsgaard1
1. Section for Sports Traumatology M51, Copenhagen University Hospital Bispebjerg- Frederiksberg, Copenhagen, Denmark 2. Department of Physical and Occupational Therapy Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark

Background: The most widely used instrument to measure anterior tibial translation in the evaluation of anterior cruciate ligament (ACL) sufficiency is the Rolimeter®. Little is known about how knee flexion in the interval 10-40 degrees affects laxity measures. For smaller children the standard Rolimeter® is too long to fit onto tibia, so to be able to measure these children we have modified the Rolimeter®, reducing the length by 1/3 - but whether this modification influences the measurement of anterior tibial translation is unknown.
Aim: To investigate if anterior tibial translation measured by the Rolimeter® varies with knee flexion in the interval 10-40 degrees, and when a standard or a shortened (“pediatric”) Rolimeter® is used.
Materials and Methods: Fourty-eight children and adults with an isolated ACL-rupture were measured with a standard Rolimeter® and the “pediatric” Rolimeter® with 1/3 reduced length. All patients were measured in 10°, 20°, 30° and 40° degrees of flexion by two independent observers.
Results: The weighted kappa showed that measurements made with the standard Rolimeter® and the ”pediatric” version had moderate agreement. T-test demonstrated that anterior tibial laxity was significantly affected by the degree of knee flexion showing higher values with increasing flexion in the range 10°-40°. However, laxity of the injured and the non-injured knee changed to the same extent with knee flexion.
Interpretation / Conclusion: It is important that repeated measurements of anterior tibial translation are made with the same degree of knee flexion. The variance in laxity dependent on flexion can be compensated for by comparison with the non-injured side. The shortened, “pediatric” Rolimeter® can be used in the daily clinic to supply valid instrumented measurements of ACL stability in smaller children.