Session 9: Pediatrics

14. November
14:30 - 16:00
Lokale: Sal C
Chair: Peter Buxbom & Julie L. Erichsen

74. Development of a data-based prediction model for residual dysplasia of the hip using ultrasound screening parameters: A population-based study of 7174 children using natural language processing on radiology reports
Martin Gottliebsen1, Michel Bach Hellfritzsch2, Aida Hejlskov Poulsen3, Anders El-Galaly4, Mathias Hauge Bünger1
1. Department of Orthopaedics, Aarhus University Hospital 2. Department of Radiology, Aarhus University Hospital 3. Data Science Lab, BI office, Central Denmark Region 4. Department of Orthopaedics, Copenhagen University Hospital

Background: Ultrasound screening of the hip in newborns aims to identify those requiring treatment for dysplasia. Residual acetabular dysplasia (RAD) is detected on later radiographs and may exist even after appropriate treatment of neonatal hip dysplasia. It is speculated that RAD can also be a delayed finding in children not identified in the current screening programme. We investigated RAD after ultrasound screening and its association with initial screening parameters.
Aim: To compare the risk for RAD with initial hip ultrasound screening parameters.
Materials and Methods: This is a population-based study on 7174 children using data from their ultrasound screening of the hip in the period 2012 to 2022 at a single center. Utilizing natural language processing (NLP) on radiology reports, we extracted quantitative parameters (alfa-angles, femoral head coverage, pubo-femoral distance) from ultrasounds. Logistic regression models calculated odds ratios for RAD based on these parameters.
Results: Among 7174 children screened, 444 underwent hip radiographs at 11–18 months, with 174 (39%) showing RAD (this was assessed using text-mining on radiology reports). RAD odds ratios were 17.4 for upper pubo-femoral distance quintile, 14.2 for lower alfa-angle quintile, and 11.5 for lower femoral head coverage quintile.
Interpretation / Conclusion: Our findings suggest strong associations between specific ultrasound parameters and RAD, affirming the validity of NLP-based analysis of radiology reports. Further research should explore how general data- based analysis can enhance RAD prediction.

75. A novel plate design for rotational guided growth. An experimental study in immature porcine femurs.
Ahmed Halloum1, Ole Rahbek1, Shima Gholinezhad1,2, Søren Kold1, John Rasmussen2, Jan D. Rölfing, Maria Trta1, Ahmed A. Abood1,3
1. Interdisciplinary Orthopaedics, Aalborg University Hospital; 2. Department of Materials and Production, Aalborg University; 3. Department of Orthopaedics, Aarhus University Hospital.

Background: Current treatment of rotational deformities of long bones in children is osteotomies and fixation. In recent years the use of guided growth for correction of rotational deformities has been reported in several pre-clinical and clinical studies. Various techniques have been used and different adverse effects, like growth retardation and articular deformities have been reported.
Aim: The aim of this study was to test a novel plate concept (RotOs Plate TM) intended for correction of rotational deformities of long bones by guided growth, with sliding screw holes to allow for longitudinal growth, in a porcine model.
Materials and Methods: Twelve, 12-week-old female porcines were included in the study. Mean weight at insertion of the plates was 42 kg (38-45), mean duration of intervention was 88 days (83-98). Surgery was performed in the left femur while the right femur was used as control. Plates were placed on the lateral and medial side of the distal femur, spanning the growth plate, to induce external rotation, as longitudinal growth occurred. CT-scans were performed at plate insertion and removal. 3D-models of the left and right femur were made and used for measuring the achieved rotation.
Results: The plates rotated as intended in all 12 porcines. One porcine was excluded due to congenital deformity of the proximal part of the femurs. Two porcines had cut-out of the proximal screw on the lateral side, observed at the end of the intervention. These two porcines were included in the results. We observed a ?rotation of 5.7° ± 2° in external direction (CI: 3.7°- 7.7°). ?Femur length was -0.4 cm [-0.7 cm – 0 cm] equal to 1.5% shortening of the operated femur. No significant difference was observed in coronal or sagittal plane.
Interpretation / Conclusion: The plate worked as intended and significant external rotation was achieved. While the use of guided growth for correction of rotational deformities is already being used clinically, it is still to be considered an experimental procedure with sparse evidence. This study shows promising results for the feasibility of the method in a large animal model and is an important first step in validating the technique and detecting possible adverse effects, before future clinical studies.

76. A systematic review of staples, tension-band plates and percutaneous epiphysiodesis screws for leg-length discrepancy (LLD) treatment.
Maria Tirta1, Mette Holm Hjorth2, Jette Frost Jepsen3, Søren Kold1, Ole Rahbek1
1. Interdisciplinary Orthopaedics, Aalborg University Hospital 2. Department of Orthopaedics Surgery, Aarhus University Hospital 3. Medical Library, Aalborg University Hospital

Background: Epiphysiodesis, defined as the process of closing the growth plate (physis), have been used for several years as a treatment option of cases where the predicted leg-length discrepancy (LLD) falls between 2 to 5 cm.
Aim: The aim of this study was to systematically review the existing literature on the effectiveness of three different epiphysiodesis techniques with implant usage for the treatment of leg-length discrepancy in the pediatric population. The secondary aim was to address the reported complications of staples, tension-band plates (TBP) and percutaneous epiphysiodesis screws (PETS).
Materials and Methods: This systematic review was performed according to PRISMA guidelines. We searched MEDLINE (PubMed), Embase, Cochrane Library, Web of Science and Scopus for studies on skeletally immature patients with LLD treated with epiphysiodesis with an implant. The extracted outcome categories were effectiveness of epiphysiodesis (LLD measurements pre/post-operatively, successful/unsuccessful) and complications that were graded on severity.
Results: Forty-four studies (2184 patients) were included, from whom 578 underwent TBP, 455 PETS and 1048 staples. From pooled analysis of the studies reporting success rate, 64% (150/234) successful TBP surgeries (10 studies), 78% (222/284) successful PETS (9 studies) and 52% (212/407) successful Blount staples (8 studies). Severe complications rate was 7% for PETS, 17% for TBP and 16% for Blount staples. TBP had 43 cases of angular deformity (10%), Blount staples 184 (17%) while PETS only 18 cases (4%).
Interpretation / Conclusion: Our results highlighted that PETS seems to be the most successful type of epiphysiodesis surgery with an implant, with higher success rate and lower severe complications than TBP or Blount staples.

77. Declining numbers of femoral fractures in children: a Danish nationwide register study of 8885 fractures between 1999 and 2018
Martin Gottliebsen1, Per Hviid Gundtoft1, Topi Laaksonen2, Yrjänä Nietosvaara3, Bjarke Viberg4
1. Department of Orthopaedics, Aarhus University Hospital, Denmark 2. University of Helsinki, Finland 3. University of Eastern Finland, Finland 4. Department of Orthopedic Surgery and Traumatology, Odense University Hospital, Denmark

Background: Femoral fractures in children are often the result of high energy injuries. In younger children associated non-accidental injury needs to be considered. Injury prevention for children has been imposed in our society and general safeguarding for children could be affecting the number of these severe injuries in children. Optimal orthopaedic treatment is based on age and weight of the injured child. Little is known of incidence and age distribution of femoral fractures in children in Denmark.
Aim: To investigate incidence and age patterns for femoral fractures in children aged 0 - 15 year in Denmark.
Materials and Methods: This is a population-based register study with data from 1999 to 2018 retrieved from the Danish National Patient Registry using ICD10 codes (S72*). The primary outcome was incidence and age distribution for femoral fractures in children aged 0 - 15 year.
Results: We identified 8885 femoral fractures, yielding a mean incidence of 0.42 fractures per 1000 children / year. The incidence of fractures decreased from 0.50 in 1999 to 0.36 in 2018. Peak numbers of fractures are observed in children aged 2 (1000 fractures) in comparison to children aged 8 with lowest numbers of injuries (406 fractures).
Interpretation / Conclusion: Femoral fractures in children are relatively rare injuries with a declining incidence. The lesions are more common among the youngest children. These individuals often require non-operative treatment and a possible investigation by child protective service. Our findings should lead to a discussion on planning of optimal treatment of femoral fractures in children in Denmark.

78. Risk factors for developmental dysplasia of the hip at 3 months of age – A systematic review and meta-analysis.
Maria Tirta1, Ole Rahbek1, Søren Kold1, Hans-Christen Husum1
1. Interdisciplinary Orthopaedics, Aalborg University Hospital

Background: Selective screening of children at risk for developmental dysplasia of the hip (DDH) is based on clinical examination and risk factor identification. The current use of risk factors in DDH screening is largely reflected by two meta-analyses published in 2012, which found breech presentation, family history of DDH, female sex and primiparity to increase the risk of DDH. However, the definition of DDH, reference tests and age of the examined children vary considerably both between these meta-analyses and for the studies that were included, complicating the translation of those findings to current screening guidelines.
Aim: The aim of the present meta-analysis was to evaluate the association of previously proposed risk factors to the risk of sonographically verified DDH.
Materials and Methods: We searched PubMed, EMBASE and the Cochrane library to identify cohort, RCTs, case-control and cross-sectional studies from 1980 to January 2023 in English language. Eligible studies included participants under 3 months of age, where the diagnosis of DDH was made by hip ultrasound using the gold standard Graf method and reported information on one or more of the proposed risk factors and final diagnosis was available.
Results: Of 5363 studies screened, 20 studies (n=64543 children) were included. Breech presentation (OR: 4.2, 95%CI 2.6-6.6), family history of DDH (3.8, 95%CI 2.1-7.2), female sex (2.5, 95%CI 1.7-3.6), oligohydramnios (3.8, 95%CI 1.7-8.5) and high birthweight (2.0, 95%CI 1.6-2.5) significantly increased the risk of DDH. C-section, primiparity, multiple births, low birthweight and prematurity were not found to increase the risk for DDH, and there was only one study about clubfoot as a risk factor. Heterogeneity was high (I2 >75%) in all the tested factors except high birthweight (I2 =0%). Subgroup analysis was performed to investigate these heterogeneities
Interpretation / Conclusion: Family history of DDH and breech presentation are associated with a significant increase of the risk of sonographic DDH in children aged 3 months. A similar risk increase was detected for oligohydramnios, which was not detected in previous meta-analyses. Additionally, the DDH risk increase of female sex was found to be lower than previously reported.

79. Incidences and trends in management of paediatric distal forearm fractures 1999-2018. A population-based registry study.
Katrine Rønn Abildgaard1, Per Hviid Gundtoft2,3, Stig Brorson1, Bjarke Viberg2,4
1. Centre for Evidence-Based Orthopaedics, Department for Orthopaedic Surgery, Zealand University Hospital, Køge, Denmark 2. Department of Orthopaedic Surgery and Traumatology, Hospital Lillebaelt Kolding- University Hospital of Southern Denmark 3. Department of Orthopaedic Surgery and Traumatology, Aarhus University Hospital 4. Department of Orthopaedic Surgery and Traumatology, Odense University Hospital

Background: Indications for surgery and treatment choice of paediatric forearm shaft fractures has changed during a 20-year period. Our hypothesis was that the same has occurred for distal forearm fractures.
Aim: To report the incidence rate of paediatric distal forearm fractures in Denmark over a 20-year period and report differences in treatment choices stratified by age group.
Materials and Methods: Population-based register study of 0-15 years old children with distal forearm fractures registered in the Danish National Patient Registry (S525+6) from 1999-2018. The primary outcome was the incidence rate of non-surgical (cast) or surgical treatment (surgical procedure code within 1 week from injury). Surgical procedure codes included closed reduction (KNCJ0*), open reduction (KNCJ1*), K-wires (KNCJ4*), or other type of fixation such as external fixation, nail, plate or screws (KNCJ3*,5*-7*).
Results: There were 136,257 fractures yielding an overall incidence rate of 646 per 105 persons/year. Peak incidences for girls and boys were 1236 per 105 persons/year (11 years) and 1341 per 105 persons/year (13 years), respectively. There was a slight increase in incidence due to an increase among 8-15 year old boys. The primary treatment option in all age groups was non- surgical treatment decreasing from 95% in 1999 to 92% in 2018. Closed reduction was the primary surgical treatment, but decreased from 5% to 1.5% during the 20-year period. This decrease corresponded with an increase in K- wire fixation from 0.5% to 6%. When stratified by age groups, the preferred treatment changed in the period 2006-2010 in all age groups (except 0-3 years) from closed reduction to K-wire fixation.
Interpretation / Conclusion: There was a slight increase in overall incidence, predominantly because of an increased incidence among the 8-15 year old boys. Interestingly, while the use of K-wires increased over the investigated period, we saw a decrease in non-surgical treatment and closed reduction. Our study design does not allow for causal explanations, but this knowledge should lead to reflection concerning why there has been a change in treatment.

80. Understanding What Matters to Patients Undergoing Cosmetic Stature Lengthening: A Systematic Scoping Review to Examine Outcome Measures Reported in the Literature to Assess How Well They Reflect Real Patient Experiences
Ali Yalcinkaya1,2, Maria Tirta1,2, Michael Skovdal Rathleff3,4, Christopher Iobst5, Ole Rahbek1,2, Søren Kold1,2
1. Interdisciplinary Orthopaedics, Aalborg University Hospital, Aalborg, Denmark; 2. Department of Orthopaedic Surgery, Aalborg University Hospital, Aalborg, Denmark; 3. Center for General Practice at Aalborg University, Aalborg, Denmark; 4. Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark; 5. Center for Limb Lengthening and Reconstruction, Nationwide Children’s Hospital, Columbus, Ohio, USA.

Background: The literature on cosmetic limb lengthening surgery has many limitations. Studies often provide a low level of evidence, with varying techniques and outcome reporting, with some studies missing important outcomes and others using unvalidated outcome scores. This makes it difficult to compare functional outcomes between the lengthening techniques used.
Aim: The aim of this review was to identify the areas that may play an important role in the treatment process of patients undergoing cosmetic lengthening, but may have been neglected in the current literature.
Materials and Methods: A systematic literature search was performed. All outcome measures reported in the included studies of cosmetic lengthening were extracted and simultaneously mapped to the overarching domains that bundled similar outcome measures. These domains were then further categorized according to the taxonomy developed by Dodd et al.
Results: 24 studies were included in the review. All reported outcome measures were extracted and then grouped into a total of 62 overarching domains. The average number of domains reported in each article was 17. The most common domain covered by the articles was lengthening (82%), followed by deformity correction and complications. Only 21% of all domains covered the impact of treatment on patients' lives, such as physical, social, role, and emotional functioning, quality of life, and patient satisfaction.
Interpretation / Conclusion: The current literature shows the dominance of clinical outcome measures, and we are not sure that the outcome measures used in these studies address what patients who choose to undergo this surgery consider important. The outcome measures studied are mostly limited to the broad domain of "musculoskeletal outcomes", which suggests that the domains of social and physical health and emotional health, which may be more important to patients than to clinicians, are neglected. These limitations in the domains covered by the current literature run the risk of not being relevant to patients. In addition, heterogeneity in the reporting of outcomes may lead to the use of ineffective or even harmful interventions and waste of already limited health care and research resources.

81. Can pin site inflammation be detected with thermographic imaging? A cross-sectional multicenter study of patients treated with external fixators
Marie Fridberg1, Ole Rahbek1, Hans-Christen Husum1, Anirejuoritse Bafor2, Kirsten Duch1, Christopher A Iobst2, Søren Kold1
1. Interdisciplinary Orthopedics, Aalborg university hospital, Denmark (Aalborg UH) 2. Nationwide Children’s Hospital, Columbus, Ohio, US (NCH)

Background: Patients with external fixators are at risk of pin site infection. A more objective assessment of possible pin site infection is warranted, particularly for future home-based monitoring of pin sites.
Aim: The aim was to determine if thermography can detect signs of inflammation around pin sites by 1) Establishing a maximum temperature cut-off value 2) Investigating the correlation between local temperature and visual signs of inflammation 3) Adjust for anatomical location and ambient room temperature.
Materials and Methods: This was a cross-sectional international multi- center study following STROBE guidelines. All patients with external ring-fixators scheduled for a visit in the out-patient clinic were eligible. Visual signs of inflammation were categorized using the Modified Gordon classification System (MGS, simplified sMGS). Thermographic imaging was done with an infrared camera (FLIR T540) and the maximum temperature within the ROI (MaxTp) was the primary outcome measure. Sample size and reliability were estimated. Cohen-Kappa, ROC-curve/AUC and Poisson regression were used for statistical analysis.
Results: Data from 1970 pin sites were included. Inter-rater reliability of MGS was Kappa=0.79 and for MaxTp ICC=0.99 (95%CI: 0.99;0.99). Overall, a tendency of rising temperature with increasing sMGS was seen. The difference between sMGS=0 and sMGS>0 was significant. The performance of MaxTp as a screening tool to detect inflammation was reasonable with an AUC of 0.71 (95% CI: 0.65- 0.76). The empirically optimal cut-off value was 34.1?C (Sensitivity=65%, Specificity=72%, Positive predictive value=23%, Negative Predictive value=94%). A 1?C increase in MaxTp increased the RR of visual signs of inflammation by a factor 1.5 (95% CI: 1.3; 1.7).
Interpretation / Conclusion: We found a clinical positive association between the temperature at the pin site measured with thermography and visual signs of inflammation. The empirically optimal temperature cut-off value for inflammation screening was 34.1?C. Thermography may be a promising tool for a for a future point of care technology.

82. Extramedullary internal motorized lengthening for reduction defects in children with open growth plates – early experience.
Jan Duedal Rölfing1, Mathias Bünger1, Martin Gottliebsen1
Children's Orthopaedics and Reconstruction, Aarhus University Hospital

Background: Extramedullary internal motorized lengthening nails (EM-IMLN) for femoral lengthening in children with open growth plates have only been reported in 3 scientific papers, and 13+11+5 = 29 patients in total. The results seem favorable compared with external fixation and thus worthwhile to implement and monitor in clinical practice.
Aim: To provide an early report of our first 3 cases of EM-IMLN and its complications in a cross- sectional study
Materials and Methods: One girl and two boys, age at operation: 5,6; 6,9 and 7.7 years with a body weight of 18, 18, 24 kg underwent EM-IMLN and concomitantly titanium elastic nailing (TEN) (Ø3.0-3.5) of the femur suffering from reduction deficiencies. We report our initial experience in terms of length of hospitalization, distraction phase, complications, and lessons learned.
Results: The first patient was discharged after 5 days, while the subsequent two patients were discharged after 2 days. Distraction phase with 1.0 mm daily was initiated on day 6. One patient stopped lengthening due to a knee flexion contracture of 15 degrees after 35 mm lengthening. The contracture resolved and full weight bearing was allowed 3 months after the initial surgery, and the implants were removed after 5.3 months. One patient had the TEN removed on postop day 28 as it started to migrate proximal into the bone. Distraction phase was completed with 48 mm within 48 days. The third patient completed distraction phase without any complications and achieved 38 mm. All patients tolerated the submuscular lateral femoral EM-IMLN implant rather well. No hardware failure was noticed.
Interpretation / Conclusion: EM-IMLN implementation needs to be introduced in a protocolized fashion and monitored closely, but our initial experience is in line with international case series making it worthwhile to pursue in terms of safety and patient comfort. Longer follow-up and larger cohorts need to be reported.

83. A scoping review to inform core outcome set development: What outcomes have been reported in literature on patients undergoing lower-limb lengthening surgery, and how have they been measured?
Ali Yalcinkaya1,2, Maria Tirta1,2, Michael Skovdal Rathleff3,4, Christopher Iobst5, Ole Rahbek1,2, Søren Kold1,2
1 Interdisciplinary Orthopaedics, Aalborg University Hospital, Aalborg, Denmark 2 Department of Orthopaedic Surgery, Aalborg University Hospital, Aalborg, Denmark 3 Center for General Practice at Aalborg University, Aalborg, Denmark 4 Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark 5 Center for Limb Lengthening and Reconstruction, Nationwide Children’s Hospital, Columbus, Ohio, USA

Background: The heterogeneity of outcomes used in the field of lower limb lengthening surgery (LLLS) affects our ability to synthesize evidence. This hampers robust systematic reviews and treatment recommendations for clinical practice. Ultimately this reduces the impact of research for both patients and healthcare professionals.
Aim: This scoping review aimed to describe the outcomes and outcome measurement instruments (OMIs) used within the field of LLLS.
Materials and Methods: A systematic literature search of WOS, Scopus, Embase, MEDLINE, and the Cochrane Library identified all studies reporting outcomes in children and adults after LLLS. All outcomes and OMIs were extracted verbatim. An iterative process was used to group outcome terms under standardized outcome headings categorized using the COMET Taxonomy of Outcomes.
Results: Data saturation was achieved in 2020. A total of 142 studies were included between 2024-2020, reporting 2964 verbatim outcomes with 663 standardized outcome terms collapsed into 119 outcome headings (subdomains). A total of 29 patient-reported and 26 clinician-reported outcome instruments were identified. The most commonly reported outcome was “Lengthening amount”, reported in over 72% of the included studies, while “health-related quality of life” was measured in 16% and all life impact outcomes were reported in 19% of the included studies.
Interpretation / Conclusion: A large number of peer-reviewed publications are available, demonstrating that significant resources are being devoted to research on LLLS. However, reported outcomes for people with LLLS are heterogeneous, subject to reporting bias, and vary widely in the definitions and measurement tools used to collect them. Outcomes likely to be important to patients, such as quality of life and measures of physical function, have been neglected. This scoping review identifies a need to standardize outcomes and outcome measures reported on patients recovering from lower limb lengthening surgery; this can be addressed by creating a core set of outcomes.