Ammar K. Alomran

Introduction Determining the optimal timing and type of surgical interventions for children with cerebral palsy (CP) remains challenging. This systematic review and meta-analysis aimed to investigate and evaluate the effects of early surgical interventions on functional mobility, independence, developmental trajectories, and deformity prevention in pediatric CP. Methods Following PRISMA 2020 guidelines, we searched multiple literature databases from inception up to May 18, 2025. Randomized and non-randomized studies evaluating surgical interventions (selective dorsal rhizotomy, single-event multilevel surgery, hip reconstruction, spinal fusion, intrathecal baclofen) in children with CP were included. Primary outcomes were changes in gross motor function, gait parameters, functional mobility, and independence measures. Results Thirty-two studies met our defined inclusion criteria. Children undergoing Selective Dorsal Rhizotomy (SDR) between ages four to seven-years showed sustained improvements in GMFM-66 scores (+9.5 points at five-years). Single-Event Multilevel Surgery (SEMLS) demonstrated optimal outcomes when performed at ages ten to 12-years, with Gross Motor Function Classification System (GMFCS) III patients being "benchmark responders" (Gait Deviation Index [GDI] improvement +12.1 points at one-year, maintained at +10.3 points after ten-years). Risk-benefit profiles varied significantly by GMFCS level, with interventions for GMFCS IV-V patients showing higher complication rates (20.5% for spinal fusion) but still providing good improvements in comfort and care. Conclusions Surgical interventions show age-specific and GMFCS-specific effectiveness. SDR demonstrates greatest benefit when performed earlier at four to seven-year old, while SEMLS shows optimal results in the ten to 12-year old range, especially for GMFCS III patients. Strategic timing of interventions based on functional classification can maximize developmental outcomes and deformity prevention.

Avulsion fractures at the femoral origin of the medial head of the gastrocnemius are exceptionally rare, particularly in skeletally immature patients, and may be overlooked when evaluating acute posterior knee pain. A previously healthy 13-year-old boy developed acute posteromedial left knee pain and felt a sudden pop while running. He could bear weight with difficulty and held the knee in slight flexion because terminal extension was painful. Examination showed focal posteromedial tenderness, preserved motion with pain at full extension, and an intact distal neurovascular status. Plain radiographs demonstrated a small osseous fragment posterior to the distal femur. Magnetic resonance imaging (MRI) identified a 1.2 × 0.5 cm minimally displaced, partially corticated fragment arising from the femoral origin of the medial head of the gastrocnemius, with no associated ligamentous, meniscal, or musculotendinous injury. The patient was managed with a long-leg cast at 30° of knee flexion for six weeks, followed by six weeks of supervised range-of-motion, stretching, and strengthening exercises. He regained painless full range of motion, normal strength on clinical examination, and a stable knee, and subsequently returned to sports without reported pain or functional limitation. At two-year clinical follow-up, he remained asymptomatic without instability or treatment-related complications. This case adds to the limited pediatric literature on this uncommon injury and highlights the role of MRI in characterizing the lesion and excluding associated injuries. Because no follow-up imaging was obtained, the outcome represents clinical recovery rather than radiographically confirmed osseous union.

Background: Radiation Personal Protective Equipment (RPPE) is crucial for shielding against radiation exposure in medical settings, particularly in orthopedics. Typically stored on open racks outside operating rooms, these items are shared among users without designated ownership. Objective: This study aims to evaluate contamination rates and levels in lead aprons used in orthopedic surgery, as well as assess the efficacy of cleaning procedures in reducing microbial growth. Methods: A cross-sectional study was conducted at major tertiary hospital in Eastern Saudi Arabia. Twenty aprons out of thirty in the hospital’s orthopedic operating rooms were sampled over two months, both before and after cleaning. Microbiological analysis was performed at Imam Abdulrahman bin Faisal University’s microbiology laboratory. Results: Out of 120 swabs, 62 tested positive for microorganisms including micrococcus, Coagulase-negative staphylococci, Methicillin-sensitive Staphylococcus aureus, Pseudomonas Stutzeri, yeast, Haemophilus spp, Corynebacterium diphtheriae, and Klebsiella. Pre-cleaning contamination was significantly reduced from 37% to 25% post-cleaning (P = 0.023). Highest contamination levels were found inside the aprons (P < 0.001). Conclusion: While cleaning processes reduced contamination levels, detection of concerning organisms post-cleaning highlights the need for enhanced cleaning protocols in orthopedic surgery settings to mitigate contamination risks effectively.

Background and Objectives: Developmental dysplasia of the hip (DDH) in children can result in long-term skeletal complications, including a reduced bone mineral density (BMD) and an increased risk of osteoporosis. This study aimed to evaluate BMD in children with DDH and to identify clinical, functional, and nutritional factors associated with reduced BMD. Materials and Methods: A cross-sectional study was conducted on 25 children aged 5–10 years with confirmed DDH. Bone mineral density was measured at the total body, subtotal, and lumbar spine using dual-energy X-ray absorptiometry (DXA), and Z-scores were calculated. Functional assessments included isometric muscle strength, weight-bearing symmetry, and physical activity measured via accelerometry. Demographic data and daily calcium intake were recorded. Correlation and multiple linear regression analyses were performed to determine predictors of BMD. Results: Most participants exhibited normal growth and mobility, with mild asymmetries in limb strength and length. The mean total BMD was within normative ranges, whereas the lumbar spine Z-score (−1.41 ± 1.72) was mildly reduced. BMD positively correlated with age, anthropometric measures, weight-bearing capacity, and calcium intake, and negatively correlated with a family history of osteoporosis. Multiple regression analysis identified the muscle strength symmetry index as the strongest independent predictor of BMD across all sites (subtotal Z-score: β = 1.000, p < 0.001; total Z-score: β = 0.425, p = 0.023; lumbar Z-score: β = 0.499, p = 0.014). Physical activity levels showed no significant associations with BMD. Conclusions: Children with DDH generally demonstrate preserved overall BMD; however, mild lumbar spine deficits may occur. Muscle strength symmetry appears to be the most influential modifiable factor for optimizing bone health in this population, highlighting the importance of targeted physiotherapy interventions.

BACKGROUND In pediatric age group patients (< 18 years old) treated operatively for distal radius/both bone fractures extending imaging beyond the initial postoperative period -particularly in uncomplicated cases - appears to provide limited additional benefit. AIM To determine the necessary number of follow-up X-rays to use resources efficiently. METHODS Participants included in this study are pediatric age group patients who were treated operatively for distal radius/both bone fractures and were identified from a prospected collected data from the operating room database between the years 2009 and 2017. The data in the study included patients who had distal radius fractures and underwent fixation surgery (n = 88). RESULTS When assessing the difference in the odds of conducting 1 or less X-ray compared to 2 or more X-rays in regard to the type of fixation, the only significant difference is the closed reduction fixation method. Patients who underwent closed reduction method procedure have significantly lower odds of having 2 more X-rays compared to those who didn’t have closed reduction method. Open reduction, internal fixation, and other fixation methods (close reduction and internal fixation, debridement, or epiphysiodesis) have higher odds of having two or more X-rays compared to patients who did not receive these methods; however, these odds are not statistically significant. CONCLUSION The findings of this study reveal notable absence of a statistically significant association between the frequency of postoperative X-rays and the outcome of children with distal radius fractures.

BACKGROUND Artificial intelligence (AI) is a branch of computer science that allows machines to analyze large datasets, learn from patterns, and perform tasks that would otherwise require human intelligence and supervision. It is an emerging tool in pediatric orthopedic surgery, with various promising applications. An evaluation of the current awareness and perceptions among pediatric orthopedic surgeons is necessary to facilitate AI utilization and highlight possible areas of concern. AIM To assess the awareness and perceptions of AI among pediatric orthopedic surgeons. METHODS This cross-sectional observational study was conducted using a structured questionnaire designed using QuestionPro online survey software to collect quantitative and qualitative data. One hundred and twenty-eight pediatric orthopedic surgeons affiliated with two groups: Pediatric Orthopedic Chapter of Saudi Orthopedics Association and Middle East Pediatric Orthopedic Society in Gulf Cooperation Council Countries were surveyed. RESULTS The pediatric orthopedic surgeons surveyed had a low level of familiarity with AI, with more than 60% of respondents rating themselves as being slightly familiar or not at all familiar. The most positively rated aspect of AI applications for pediatric orthopedic surgery was their ability to save time and enhance productivity, with 61.97% agreeing or strongly agreeing, and only 4.23% disagreeing or strongly disagreeing. Our participants also placed a high priority on patient privacy and data security, with over 90% rating them as quite important or highly important. Additional bivariate analyses suggested that physicians with a higher awareness of AI also have a more positive perception. CONCLUSION Our study highlights a lack of familiarity among pediatric orthopedic surgeons towards AI, and suggests a need for enhanced education and regulatory frameworks to ensure the safe adoption of AI.

BACKGROUND Clubfoot, or congenital talipes equinovarus, is a widely recognized cause of disability and congenital deformity worldwide, which significantly impacts the quality of life. Effective management of clubfoot requires long-term, multidisciplinary intervention. It is important to understand how common this condition is in order to assess its impact on the population. Unfortunately, few studies have investigated the prevalence of clubfoot in Saudi Arabia. AIM To determine the prevalence of clubfoot in Saudi Arabia via the patient population at King Fahad University Hospital (KFUH). METHODS This was a retrospective study conducted at one of the largest hospitals in the country and located in one of the most densely populated of the administrative regions. RESULTS Of the 7792 births between 2015 to 2023 that were included in the analysis, 42 patients were diagnosed with clubfoot, resulting in a prevalence of 5.3 per 1000 live births at KFUH. CONCLUSION The observed prevalence of clubfoot was significantly higher than both global and local estimates, indicating a substantial burden in the study population.

Objective: Supracondylar humeral fractures are among the most common pediatric fractures that require surgical intervention when displaced. Recent attention has been directed towards the utilization of serial radiographs in the post-operative period and their effect on decision-making. This study aimed to determine the usefulness of postoperative radiographs early post-operatively, with the goal of determining the optimal frequency for these radiographs. Methods: Pediatric patients who sustained a supracondylar humeral fracture and underwent operative intervention over a 15-year period were included in this study. Data were collected, including the baseline characteristics of the patients, fractures, and operative interventions. In addition, the time until healing, the total number of X-rays before K-wire removal, and postoperative function were evaluated. Results: A total of 122 pediatric patients were included, with a mean age of 5.33 +/- 2.93 years. Most fractures were Gartland Type III (74.6%). Most fractures healed at 4 (36.1%) and 3 weeks (35.2%) after surgery. Of the cohort, 94.3% underwent four different x-rays before wire removal, with 4.9% requiring revision surgery. All revision cases were Gartland type 3, and for all cases, the decision to revise was made within three weeks of surgery. Conclusion: Routine post-fixation radiography should not be performed for surgically treated supracondylar humeral fractures before healing. An exception is the Gartland type 3 fracture, for which earlier imaging may be indicated.

Background: Developmental dysplasia of the hip (DDH) is one of the most common hip pathologies in pediatric age group and late diagnosis remains a major concern in Saudi Arabia. Objective: The aim of this study is to examine the ability of Saudi Arabian pediatricians and family physicians to conduct clinical screening for (DDH) by estimating their clinical knowledge and skills and analyzing the gaps therein to determine whether there is potential to launch a national screening protocol for DDH in Saudi Arabia. Methods: This is a multicenter cross-sectional study from three major regions in Saudi Arabia (Central, Eastern and Western provinces). The assessed aspects are risk factors, age of screening, incidence in Saudi Arabia, physical signs and diagnostic markers, and treatment, along with their ‘clinical knowledge and skills’ score. Results: Half of the participants were pediatricians, while the rest were family physicians. More than a third of the participants were considered to have adequate knowledge, ie, above the mean score. Dimensions with the most significant knowledge gaps included the incidence of DDH in Saudi Arabia, adverse effects of swaddling, and the management of a high-risk infants presenting with a negative physical examination. Additionally, there were relatively low rates of awareness regarding positive risk factors as well as a generally poor ability to identify physical signs. Clinical knowledge and skill levels were significantly lower among family physicians. Conclusion: Pediatricians and family physicians in Saudi Arabia still need further training to improve their clinical skills for DDH screening. The proper administration of training programs could eventually enable the gradual implementation of a national systematic screening program.

Background: Hip spica tables are widely used among pediatric orthopedic surgeons to maintain the hip position during cast application and drying processes for a better outcome. Locally customized spica tables can be a significant concern if their limitations significantly interfere with the quality of care. Objective: This study aims to explore the current practice of pediatric hip spica table application among hospitals in the GCC countries and report comprehensive data that help surgeons enhance their practice. Methods: This is a cross-sectional study on pediatric orthopedic surgeons using a self-administered Online Questionnaire. The respondents were grouped as those using locally customized tables, where further information about the material and characteristics were collected, and those using company manufactured tables. Both groups answered analytical questions related to their current practice of hip spica tables. Results: Sixty-three surgeons completed the survey. More than half the physicians in this study are using locally customized spica tables (n= 41, 65%). Compared to company-manufactured tables, locally customized tables were associated with a higher rate of difficulties when taking an X-ray, when the patient weighs more than 50.0 kg, and with anesthesia, although not statistically significant. Conclusion: Obtaining a good quality spica table at a suitable price is a primary obstacle pediatric orthopedic surgeons face. This study shows no statistically significant difference between locally customized and company-manufactured tables regarding the outcomes and that spica tables have room for development to optimize their utilization.