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BACKGROUND/AIM In the last few decades, treatment strategies for acute lymphoblastic leukemia (ALL) have been associated not only with improvement of prognosis, but also with an increasing rate of late complication as osteonecrosis (ON). Herein, the cumulative incidence, risk factors, new conservative therapeutic strategies as hyperbaric oxygen therapy (HBO), and outcome of symptomatic ON were studied in pediatric patients with ALL. PATIENTS AND METHODS Between 2000 and 2017, 495 children and young adolescents with a diagnosis of ALL were evaluated. All the symptomatic patients underwent magnetic resonance imaging (MRI) to detect bone vascularization and structure. RESULTS Twenty-three out of 495 patients presented ON (4.6%). ON was associated with an older age (p

Objectives To collect and analyze current diagnosis and treatment options of symptomatic flexible flatfoot (FFF), as well as to identify treatment expectations, among the members of the Italian Pediatric Orthopedics Society (SITOP). Methods Diagnosis and treatment preferences were recorded according to a web-based survey. The survey was divided into six main sections: (1) general clinical parameters; (2) foot aspects; (3) X-ray angles (or lines); (4) expectations; (5) standard clinical assessment; (6) treatment options. Results One hundred and ten out of 248 SITOP members answered to the questionnaire. Age (85.5%), pain at the level of the plantar arch or fascia (61.8%), fatigue (59.1%) were the clinical parameters of crucial importance. Heel valgus (85.4%), flexibility (61.8%) and forefoot supination (47.3%) were identified as the most important foot aspects. Ninety-two responders (83.6%) identified the 'improved ability to walk longer without symptoms or discomfort' as the principal treatment expectation. Pain evaluated through the visual analog scale (VAS) was considered crucial in 31.8% of cases. All respondents confirmed they also treat patients with FFF surgically; in particular, 97.3% of SITOP affiliates declare to perform arthroereisis followed by lateral column lengthening (29.1%) and medializing calcaneal osteotomy (9.1%). Conclusions Although in this survey heterogeneous findings for diagnosis and treatment of patients with symptomatic FFF within SITOP members were found, a large preference for age, heel valgus, flexibility as clinical aspects and parameters, as well as nonoperative treatment and arthroereisis, was reported.

Background: We aimed to investigate the variation of medical and surgical activities in pediatric orthopedics in Italy, during the year of the COVID-19 pandemic, in comparison with data from the previous two years. The differences among the first wave, phase 2 and second wave were also analyzed. Methods: We conducted a retrospective multicenter study regarding the clinical and surgical activities in pediatric orthopedics during the pandemic and pre-pandemic period. The hospital databases of seven tertiary referral centers for pediatric orthopedics and traumatology were queried for events regarding pediatric orthopedic patients from 1 March 2018 to 28 February 2021. Surgical procedures were classified according to the “SITOP Priority Panel”. An additional classification in “high-priority” and “low-priority” surgery was also applied. Results: Overall, in 2020, we observed a significant drop in surgical volumes compared to the previous two years. The decrease was different across the different classes of priority, with “high-priority” surgery being less influenced. The decrease in emergency department visits was almost three-fold greater than the decrease in trauma surgery. During the second wave, a lower decline in surgical interventions and a noticeable resumption of “low-priority” surgery and outpatient visits were observed. Conclusion: Our study represents the first nationwide survey quantifying the impact of the COVID-19 pandemic on pediatric orthopedics and traumatology during the first and second wave.

The rapid spread of the COVID-19 outbreak in Italy has dramatically impacted the National Healthcare System, causing the sudden congestion of hospitals, especially in Northern Italy, thus imposing drastic restriction of almost all routine medical care. This exceptional adaptation of the Italian National Healthcare System has also been felt by non-frontline settings such as Pediatric Orthopaedic Units, where the limitation or temporary suspension of most routine care activities met with a need to maintain continuity of care and avoid secondary issues due to the delay or suspension of the routine clinical practice. The Italian Society of Pediatric Orthopaedics and Traumatology formulated general and specific recommendations to face the COVID-19 outbreak, aiming to provide essential care for children needing orthopaedic treatments during the pandemic and early post-peak period, ensure safety of children, caregivers and healthcare providers and limit the spread of contagion.

Physeal fractures, which represent almost 25% of all the fractures in children, are generally classified according to the Salter Harris (S-H) classification, which is accepted worldwide thanks to its simplicity and reproducibility. However, during the last two decades several reports have questioned its prognostic value. In this review, the main prognostic factors of lower limb physeal injuries were identified on the basis of our personal experience and of the most recent literature. Although a bad prognosis may be still recognised as S-H type III and type IV, particularly when anatomic reduction of the articular fracture is not obtained, type I and type II lesions may also have a poor outcome especially in case of high-energy trauma.

Introduction Oxygen has positive benefits and potentially damaging properties in biological systems. It is a highly reactive molecule, which participates in a high-energy electron transfer and through oxidative phosphorylation thereby supports generation of adenosine-5-triphosphate (ATP)

A total of 70 clubfeet were treated by a posterior above-knee cast (pressure points on the talus and on the first metatarsal) according to Ponseti method. At diagnosis, average Pirani score was 4.44, and mean time of treatment was 50.32 days. Overall, 27 (38.6%) clubfeet had only conservative treatment (5.29 casts) and 43 (61.4%) also had Achilles tenotomy (6.38 casts). At the end 61/70 feet (87.14%) had Pirani score 0; 10/70 feet (5.71%) had Pirani score 0.5. The Pirani score gain/cast was β=-0.432 (P

It is controversial as to whether osteotomy, by restoring a more normal pelvic anatomy, might improve the final outcome of bladder exstrophy (BE) repairs. We compared the functional orthopaedic and urological outcomes in BE patients treated with and without osteotomy. Orthopaedic and urological outcomes were compared in eight BE patients treated with osteotomy and six BE patients treated without osteotomy. Orthopaedic evaluation included an assessment of pubic bones dissymmetry, bending of the spine, presence of Trendelenburg or Thomas sign, and presence of out-toeing. Pubic diastasis was ruled out on a plain X-ray of the pelvis. A Pediatric Orthopedic Society of North America (POSNA) questionnaire was administered to every child or his/her caregiver to assess functional outcome. Urological evaluation included an assessment of required continence surgeries and of contemporary continence status. All patients presented a pubic diastasis. This was in median 49 (24-66) mm in patients treated without osteotomy and 42 (25-101) mm in those treated with osteotomy (p = 0.3). There was no difference either in the orthopaedic outcome or in any features of the POSNA questionnaire between groups. Neither was there a difference in the final continence rate nor in the number of additional continence procedures required. Although osteotomy is an essential step in the treatment of many BE patients in order to achieve a tension-free closure of the abdominal wall and bladder, our preliminary results suggest that it does not improve the eventual orthopaedic or urological outcomes of BE.

Fifty-six patients with 72 duplicated toes were analysed. Postaxial duplication accounted for 79%, and the most common anatomical pattern was duplication of the proximal phalanx with a wide metatarsal head. Forty-two patients with 55 duplications were clinically and radiographically evaluated at long-term follow-up (mean 22.5 years). Results were satisfactory in 91% of the patients. Poor results were often associated with preaxial polydactyly because of persistent hallux varus. Surgical treatment is usually straightforward but must be individualized, and some anatomical and surgical details should be considered to obtain a better result.

Purpose This study was performed to develop a standardized methodology for the sonographic assessment of clubfoot at birth and at the end of both conservative treatment and surgical correction. Methods Forty-two congenital clubfeet and 42 normal feet were examined sonographically in the position of spontaneous alignment and during passive manual correction. Scans along 4 planes provided information relevant to the assessment: sagittal posterior, sagittal anterior, coronal lateral, and transverse. Results Sagittal posterior sonograms demonstrated the progressive gain of dorsiflexion ability during the different steps of treatment for clubfoot. Sagittal anterior sonograms could not demonstrate the normal alignment of the navicular in clubfeet because of the bone's medial displacement. On transverse sonograms, the talar head and the medially displaced navicular may lie on the same plane, depending on the severity of the deformity. Coronal lateral sonograms provided for estimation of the relationships between the calcaneus and cuboid, which were described by the calcaneal-cuboid angle. Conclusions Sonography is a promising technique for assessment and monitoring of clubfoot during treatment. The method described here yields accurate and reproducible information about the anatomy of the nonossified clubfoot, helping the orthopedic team decide on appropriate treatment steps. © 2004 Wiley Periodicals, Inc. J Clin Ultrasound 32:235–242, 2004; Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jcu.20022

Angiodysplastic lesions of the extremities are very often of great interest for the orthopedist, involving not only bones with length discrepancy, but also joints with hemarthrosis and synovial hypertrophy.We describe 4 patients with cutaneous hemangiomatosis in the lower limb and a concomitant knee arthropathy. Like in other arthropathies, the articular damage is rapidly invasive and leads to progressive damage in the joint if not adequately diagnosed and treated. We treated the 4 patients at different ages, corresponding to different stages of intra-articular involvement. The preoperative management included MRI and diagnostic arthroscopy. All patients underwent an open synovectomy. All our patients were reviewed at a clinical and radiographic follow-up after 10 years.In all patients, the range of motion was improved or at least not worsened after surgery, in spite of a larger extent of cutaneous lesions. X-ray and MRI confirmed clinical data showing no recurrence of the lesion inside the joint and no progression of the articular damage.The clinical outcomes were very good or good in the patients treated early, poorer in the patient operated on at an adult age. The importance of an early and precise diagnosis and of an accurate preoperative planning must be underlined.

BACKGROUND Focal Myositis is a rare pseudotumor of unknown aetiology that is often difficult to diagnose and treat. Typically afflicting people in adulthood, it has occasionally been reported also among children. PURPOSE the aim of this study is to review the literature of Focal Myositis in paediatric age in order to compare the clinical manifestation and the various treatment suggested by different authors. METHODS this article describes a 6-year-old boy with focal myositis in gracilis muscle successfully treated by conservative methods, including nocturnal leg traction, intensive physiokinesi therapy and articulated knee orthosis guided to progressive extension. Furthermore a systematic review of literature concerning focal myositis in paediatric age is reported. CONCLUSION our case and the review of literature suggests that conservative methods should be the first-choice treatment for FM in paediatric age and that surgery should be strictly reserved for selected cases where non-invasive methods have previously failed.

Because survival of pediatric acute lymphoblastic leukaemia (ALL) has improved in the last years, adverse effects acquire increasing importance. Avascular osteonecrosis (ON) is a long term complication of ALL treatment affecting the patients' quality of life. Its pathogenesis recognizes multiple factors (age, race, genetics, chemotherapies and steroids). The different roles of dexamethasone (DXM) versus prednisone (PDN) is still under discussion, as dosages and rate of administration. The prevalence of ON varies in different series (0.43-17.6%). It affects mostly the weight-bearing epiphyseal bone, usually knee and hip. Multiple joint involvement is common. ON treatment is not established: efficacious drugs are not available; surgery is strongly invasive for pediatric patients (pts); among physical treatments, the use of hyperbaric oxygen therapy (HBO) is uncommon. We report our experience in children treated consecutively from 2000 to 2015 for ALL at the Pediatric Hematology Clinic of Padua, who developed ON. HBO was used in some pts with variable efficacy, suggesting its possible role in early stages. Materials and methods Prevalence ofON was assessed retrospectively in 469 pts with ALL enrolled in AIEOP 2000 Protocol (P 2000, 327 pts) and AIEOP BFM ALL 2009 Protocol (P 2009, 142 pts); median age was 5 years (yrs, range 1-17). Girls were 53% and boys 47% (Table 1). ON was defined as persistent pain in one or more major joints (hip, knee, elbow, shoulder, ankle) and peculiar radiological findings (plain XR or MRI). Severity was graded radiologically by the ARCO (Association of Research Circulation Osseous) staging system; clinically by the CTCAE v3.0. Statistical analysis was done using z- and t-tests. Results 19/469 pts (4%) developed ON of CTCAE grade 2-4. Age at leukaemia diagnosis was over 10 yrs in 17/19 pts. ON always presented during maintenance or off therapy. Median follow up after ON development in P 2000 was 54 months (range 21-170) and 28.5 months (8-48) in P 2009. The most frequent sites were knee, hip and ankle. Multiple joint involvement was frequent (11/19, 58%); 14/19 (74%) had also functional limitation at diagnosis (grade 3-4). Nine ON pts (3 in P 2000, 6 in P 2009) were at high risk, receiving higher steroid dosages than low risk (p As for ON treatment, 14/19 (74%) pts were treated conservatively; 5/19 (26%) pts underwent joint replacement; 7/19 (37%) pts received HBO (25-40 sessions, 2.5 ATA). Four children showed complete recovery or only limited disturbances; 14 pts had more severe impairment (grade 3-4, 5 joint replacements). One patient developed osteosarcoma as secondary malignancy after first line chemotherapy, TCSE and HBO. HBO results: pain improvement was not obtained in any patient. The 5 pts with ON ARCO grade II-III showed lesion stability without joint collapse at control MRI. The 2 pts with very advanced ON (grade IV) placed implants. Comparing the two consecutive Protocols (P 2000 vs P 2009), we found different prevalence of ON (0,3 % vs 8,4% respectively, p Conclusion In our experience the prevalence of symptomatic ON in pts treated with two consecutive and similar ALL protocols was 4% (19/469) as reported by literature. No asymptomatic cases were reported, probably due to lack of screening. Boys were affected similarly than girls; age was significantly higher in patients with ON (p 0.001). A marked different prevalence between the two groups (0.3% vs 8.4%) was found, without apparent role of age, gender or steroid dosages. However, a possible underdiagnosis in P 2000 can be considered, due to higher attention given recently to this problem. High risk pts developed ON more frequently (p HBO seems to stabilize the progression of early stage of ON, but it is not efficacious in advanced ON. Screening MRI could be useful for early diagnosis and to understand the utility of HBO in these cases. Disclosures No relevant conflicts of interest to declare.

Background. Pyle's disease is a rare skeletal dysplasia involving the metaphyses of long bones. To date, spinal involvement has been only rarely described in the literature.¶Objective. To show that spinal changes, which are an expression of the same growth defect of the long bones, are an important and constant sign of the disease in the families studied.¶Materials and methods. The radiographic skeletal changes in five patients have been observed.¶Results. The pathognomonic metaphyseal widening of tubular bones (known as the ’Erlenmeyer flask sign') was associated with the spinal changes in all cases. Radiographic findings in the spine varied from moderate platyspondyly to the bodies having the appearance of a biconcave lens. This may be attributed to two main causes: (1) a defect in the modelling process of the vertebrae (comparable to that observed in the metaphyses) and (2) chronic pathological fractures secondary to osteoporosis (a typical feature of Pyle's disease).¶Conclusions. The finding of platyspondyly of varying severity widens the spectrum of radiographic findings in this disease and can assist in diagnosis.

Background: In children, acute leukemia (AL) at presentation can mimic several orthopaedic pathologies, so that a variable delay of the correct diagnosis is often reported. Methods: To define more clearly the clinical and radiological musculoskeletal manifestations of leukemia in children, 122 affected children referred from 1984 to 1999 to our Pediatric Onco-Hematologic Clinic were retrospectively reviewed. Average age at diagnosis was 6.6 years (from 7 months to 17 years). Seventy-three (60%) were boys and adolescent boys, 49 (40%) were girls and adolescent girls. One hundred two (83.6%) had acute lymphoblastic leukemia, 20 (16.4%) had acute myeloid leukemia. The mean follow-up was 8.2 years for the 104 survivors and 2.5 years for the 18 nonsurvivors. The x 2 test was used to perform the statistical analyses. Results: At presentation, complaints related to the musculoskeletal system were frequent (38.3%), including pain (34.4%), functional impairment (22.9%), limping (12.3%), swelling (10.6%), and joint effusion (5.7%). At presentation, 40.2% of children had at least 1 radiographic abnormality. In order, they were osteolysis (13.1%), metaphyseal bands (9.8%), osteopenia (9%), osteosclerosis (7.4%), permeative pattern (5.7%), pathological fractures (5.7%), periosteal reactions (4.1%), and mixed lysis-sclerosis lesions (2.5%). Different from previous reports, late radiographic lesions were uncommon (5.7%), probably because of milder newer medication protocols. They included avascular necrosis (3.3%), vertebral collapses (1.6%), and osteolysis (0.8%). Conclusions: Both clinical and radiological changes had various and no uniform localization. Poor correlation was found between symptoms and radiological lesions. Survival rates in children with AL were 95.8% at 1 year, 89.6% at 3 years, 85.8% at 5 years, and 83.4% at 10 and at 13 years. Radiographic abnormalities (P = 0.400), type of leukemia (P = 0.291), sex (P = 0.245), and white blood cell count at presentation (P = 0.877) were not prognostic factors. The presence of multiple bone lesions did not affect the survival rate (P = 0.632). As early diagnosis significantly decreases morbidity and mortality of AL, the orthopaedist should suspect AL in any child with unexplained persistent skeletal pain or radiographic alterations. Accurate history, general physical examination, and complete blood cell count tests should address the suspicion, which is confirmed by a peripheral and/or iliac crest bone marrow biopsy.

BACKGROUND. Treatment of initially unresectable nonrhabdo suft tissue sarcomas (NRSTS) in pediatric age is debated, due to their different chemosensitivity. The authors objective was to evaluate clinical features and treatment results observed in a series of Italian patients over a 24-year period. METHODS. Fifty-two patients age 8-18 years (median 8 years) were observed (1979-2002). Primary sites were on the lower limbs in 41 and on the upper limbs in 11 cases. Clinical TNM and surgical Intergroup Rhabdomyosarcoma Staging systems were adopted. Therapeutic guidelines recommended an initial biopsy plus neoadjuvant chemotherapy. Aggressive delayed surgery of residual disease, including compartmental resections, was recommended. Radiotherapy was suggested only for patients age > 3 years when surgery was incomplete or not feasible. RESULTS. The evaluation was performed dividing the patients into two categories according to their chemosensitivity. Chemosensitive (CTs) sarcomas, 21: synovial sarcoma, 11; extraosseous Ewing sarcomas, 5; primitive peripheral neurocctodermic tumors, 5. Nonchemosensitivc (CTns) sarcomas, 31: fibrosarcoma, 11; malignant peripheral nerve sheet tumors, 10; liposarcoma, 2; hemangiopericitoma adult type, 2; epithelioid sarcoma, 2; and alveolar soft part sarcoma, leiomyosarcoma, clear cell sarcoma, and sarcoma NOS, each 1. Nineteen of 21 patients with CTs-NRSTS were alive without disease: the 5-year overall survival (OS) and progression-free survival (PFS) were 94.4% and 79.3%, respectively; 23 of 31 patients with CTns-NRSTS were alive without disease: 5-year OS and PFS were 75.3% and 68.3%, respectively. Response to neoadjuvant chemotherapy was complete or partial in 10 of 20 evaluable CTs and in 8 of 26 evaluable CTns tumors. The achievement of complete delayed resection was particularly important for CTns-NRSTS. Tumor size < 5 cm, distal site, and tumor grading for CTns sarcomas were often linked to a favorable outcome; no conclusive results were detected concerning age of the patients or T status of the tumor. CONCLUSIONS. Multidisciplinary treatment without mutilating procedures allowed the cure of most patients with CTs and CTns-NRSTS. Relapses were cured in several cases of CTs tumors, whereas almost all patients with relapsed CTns tumors died due to the high rate of metastatic spread.

To compare the prognostic value of the Catterall and Herring classification, 32 patients, treated without surgery for unilateral Perthes diseases, were reviewed and classified at skeletal maturity according to Stulberg. The Catterall classification had no significant prognostic correlation with the final outcome. Only some head at-risk signs, such as lateral epiphyseal calcification and epiphyseal subluxation >4 mm, were prognostic. The Herring lateral pillar was not predictive when it was considered alone, but it became prognostic when related to age at onset. Moreover, in group C of the Herring classification (lateral pillar

We describe a case of synovitis, acne, pustulosis, hyperostosis, osteitis (SAPHO syndrome) in an 8-year-old boy with an unusual presentation of acute transitory hemiparesis. SAPHO syndrome has been reported in association with inflammatory bowel diseases, chest complications, and pulmonary involvement. No patient with both SAPHO syndrome and neurologic complaints has been previously described. Further observations are needed to confirm if SAPHO syndrome and hemiparesis represent a coincidence or a new association.

In 20% of the cases Juvenile Chronic Arthritis (JCA) has a monoarticular onset. Usually the inflammatory process spreads out to other joints with pauciarticular or polyarticular course. Very rarely the disease persists in one joint only and this is in about 70% of the cases, the knee. We describe a case of Monoarticular JCA with isolate and persistent involvement of the shoulder never reported in the literature. The clinical, pathologic features and different diagnoses are discussed.

Massive osteolysis of the humerus occurred in a 19-year-old male. The lesion was successfully treated with an autogenous fibular shaft transplant. During the 20-year follow-up period, humerus function was restored. Roentgenograms showed incorporation of the graft without any recurrence of the disease. This experience and reports in the literature show that only predominantly cortical autogeneic bone grafting has been successful. This could be due to the intrinsic characteristic of cortical bone. In fact, it seems that cortical bone shows greater resistance to erosion than cancellous bone to the lymphangiomatous osteolytic tissue. Therefore, autogenous bone grafting could be considered as a reasonable alternative to radiotherapy, particularly in young people with monostotic disease localized in bones that are easily operable and have no soft-tissue involvement.