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.