The Journal of Bone and Joint Surgery (American) 83:959-966 (2001)
© 2001 The Journal of Bone and Joint Surgery, Inc.
What’s New in Pediatric Orthopaedics
John F. Sarwark, MD
John F. Sarwark, MD
Children’s Memorial Hospital, 2300 Children’s Plaza,
Chicago, IL 60614. E-mail address: j-sarwark{at}northwestern.edu
The author did not receive grants or outside funding in support
of his research or preparation of this manuscript. He did not receive
payments or other benefits or a commitment or agreement to provide such
benefits from a commercial entity. No commercial entity paid or
directed, or agreed to pay or direct, any benefits to any research
fund, foundation, educational institution, or other charitable or nonprofit
organization with which the author is affiliated or associated.
Specialty Update has been developed in collaboration with the
Council of Musculoskeletal Specialty
Societies (COMSS) of the American Academy of Orthopaedic Surgeons.
The purpose of this Specialty Update is to serve
as a primary source and review for the general orthopaedic surgeon
who wishes to stay up-to-date in pediatric orthopaedics. The selected
topics have value for the practicing orthopaedist and are important
in their own right for the advancement of knowledge in the specialty.
The material is not intended to represent the only, or necessarily the
best, methods or procedures for the treatment of the medical conditions
that are discussed.
The sources for this article were presentations at the annual
meetings of the Pediatric Orthopaedic Society of North America in
Orlando, Florida, May 1999, and in Vancouver, British Columbia,
Canada, May 2000; presentations at the annual meeting of the Scoliosis
Research Society in Cairns, Australia, October 2000; and selected
references. Orthopaedic surgeons, residents, and fellows are encouraged
to attend educational programs on topics related to pediatric orthopaedics;
such programs are presented at conferences and courses sponsored
by the American Academy of Orthopaedic Surgeons, including Specialty
Day, and at the annual meeting of the Pediatric Orthopaedic Society
of North America. Upcoming educational events are listed at the
end of this update.
Introduction
Advances in pediatric orthopaedic surgery follow many of the
advances in medicine as a whole. Within the last year, substantive
advances have been made in the areas of genetics, genomics, and gene
therapy. The era of genetic approaches to medicine is upon us1, and it will have an impact as great
as (if not far greater than) the introduction of antibiotics did upon
the treatment of infectious diseases. Within the next decade, researchers
will find most of the estimated 30,000 or more genes in the human genome.
These discoveries will have a direct impact on reducing the burden
of disease, both overall and within the pediatric population.
Since the orthopaedic treatments of serious genetic and metabolic
diseases are often treatments of their sequelae, primary treatments,
including gene therapy, enzyme-replacement therapy, and bone-marrow
transplantation, hold the promise of eliminating or reducing the
rates of these sequelae and the need for many traditional orthopaedic
interventions and surgery. However, the orthopaedic surgeon will
still have the important role of recognizing and diagnosing these
serious diseases early in their course2,3.
Evidence-based medicine and outcomes research are continuing
to increase the quality and impact of health care in the United
States. Progress has been made in the understanding of pediatric
diseases and the approaches to them. Treatments for musculoskeletal
trauma have improved substantially in the last several years. Finally,
advances in surgical technique have led to better clinical results
and to increased levels of satisfaction on the part of patients
and their families. In many cases, these advances have resulted
in shorter hospital stays and reduced morbidity. The challenge
for pediatrics is in how society will balance the medical needs
of children with the growing demands of a large aging population4. Decisions about resource allocation
will most likely favor the elderly population on the basis of its numbers
and political influence. Advocacy for the needs of children, a vulnerable
population, will become increasingly important.
Evidence-Based Medicine and Outcomes Studies
Pediatric Orthopaedic Outcomes Instruments
A reliable, valid, and sensitive pediatric musculoskeletal functional
health questionnaire became available in 19985.
The tool’s effectiveness was shown in two recent reports.
Haynes et al. confirmed the validity of this instrument for the
assessment of health status in healthy children and adolescents.
In another study, Haynes et al. confirmed the instrument’s
validity and usefulness with respect to the assessment of children
with several chronic conditions, including cerebral palsy and myelomeningocele.
A summary of several useful, important, and validated functional
health questionnaires was also published recently6.
Scoliosis Research Society Outcomes Instrument
The outcomes instrument of the Scoliosis Research Society was
recently used to evaluate a prospective series of 737 patients who
were treated for adolescent idiopathic scoliosis. Patients who were
treated surgically had substantial relief of pain and improvement
in self-image, general functioning, and satisfaction. There
were no differences between those treated with an anterior approach
and those treated with a posterior approach. Patient satisfaction
was independent of the magnitude of curve correction. These findings
underscore the importance of balancing risks and benefits when highly aggressive
methods to gain correction are considered.
Pediatric Orthopaedic Diseases and Management
Molecular Etiologies
A mutation in a parathyroid-hormone-related protein pathway (IHH-PTHrP),
resulting in a loss of normal regulation, was recently described.
This disruption of regulation of the IHH-PTHrP pathway
is possibly related to abnormal cartilage-cell growth as seen in
enchondromatosis. Chemotherapeutic approaches that are able to block
this pathway may reduce the cartilage proliferation seen in enchondromatosis,
according to Hopyan et al.
Several types or genetic variations of hereditary multiple exostosis
have been identified recently. Abnormalities within chromosomes
8, 11, and 19 have been found. The phenotypic identification of each
of these three subtypes was described by Carroll and is more clearly
delineated and understood now.
Birth Defects and Their Prevention
According to Oakley, "one of the most exciting medical
findings of the last part of the 20th century is that folic acid,
a simple, widely available, water-soluble vitamin can prevent
spina bifida and anencephaly (SBA). Not since rubella vaccine became
available 30 years ago have we had a comparable opportunity for
primary prevention of such common and serious birth defects." The
proof that folic acid will prevent 85% of spina bifida
is an extraordinary finding7.
The prevalence of neural tube defects (myelomeningocele) in the
United States has been decreasing within the last several years.
The decline in the prevalence of this common major birth defect
is likely due both to the increased consumption of folic acid by
mothers before conception and to more aggressive screening. However,
epidemiological confirmation is pending, as this trend is too recent
to allow a definitive assessment of prevalence.
Osteomyelitis and Septic Arthritis
The epidemiology of osteomyelitis and septic arthritis has changed
recently as a result of immunization. Howard et al. noted that vaccination
with Haemophilus influenzae type B has succeeded
in virtually eliminating hematogenous septic arthritis and osteomyelitis caused
by this organism in developed nations. These diseases are no longer
seen in appropriately vaccinated children. Current empiric antibiotic therapy
now dictates coverage only for gram-positive organisms in vaccinated
infants and children.
Differentiating between septic arthritis and transient synovitis
of the hip continues to be challenging to both the pediatrician
and the orthopaedist in the acute-care setting. Kasser et al. noted
that the presence of four factors—a history of fever, an inability
to bear weight, an erythrocyte sedimentation rate of at least 40
mm/hr, and a white blood-cell count of more than
12,000 cells/mm3—enhances
the physician’s ability to make the correct diagnosis.
Brachial Plexus Palsy of Infancy
Gilbert and Tassin observed, and Waters confirmed, that complete
neurological recovery is rare in infants with brachial plexus palsy
who have recovery of biceps function after the age of three months. Function
is worse for infants who have recovery of biceps function in the
fourth, fifth, or sixth month of life than it is for those who have
recovery in the first three months. The function of six infants
who had microsurgical repair six months after birth was significantly
better than that of infants who had recovery of biceps function
in the fifth month of life and were not operated upon. Later surgery
consisting of humeral derotation osteotomy with or without latissimus
dorsi/teres major tendon transfers leads to improved function
in older infants and children.
Congenital Scoliosis, Kyphosis, and Kyphoscoliosis
Loder et al. observed a dose-response relationship between carbon
monoxide exposure and vertebral anomalies in an animal model.
Congenital kyphotic deformities are uncommon pediatric spinal
deformities with great potential for progression and neurological
deficit. McMaster and Singh, in a series of 112 consecutive patients
from Edinburgh, reported that the apex of the deformity was seen
at all levels but that it was most frequently noted at the thoracolumbar
junction between the tenth thoracic and the first lumbar vertebra
(the region of the conus medullaris and the cauda equina). No relationship
was noted between the location in the spine and the severity of
the kyphosis. Progression was most rapid in children with kyphosis
due to anterior failure of vertebral-body formation and an anterior
bar. Spontaneous neurological deterioration was uncommon and occurred at
a mean age of thirteen years and eight months8.
Scoliosis Associated with Marfan Syndrome
Sponseller reported that bracing was less effective for the treatment
of scoliosis associated with Marfan syndrome than it was for the
treatment of idiopathic scoliosis. In most skeletally immature patients
with scoliosis associated with Marfan syndrome, the deformity eventually
reaches a level requiring surgery.
Idiopathic Scoliosis
Progression
It is widely understood that curve progression is related to
growth in idiopathic scoliosis. Little et al. analyzed the precise
interaction between curve progression and growth in terms of the
relationship between peak height velocity and other maturity indicators.
These investigators noted that height velocities obtained from vertical
height measurements documented the growth peak and reliably predicted
the cessation of growth. Growth had ceased in 90% of girls
by 3.6 years after the attainment of peak height velocity. In addition,
most girls with curves of 30º or more at peak height velocity had
progressive curves. Knowing the timing of the peak growth is useful
in clinical decision-making9.
Evaluation
The use of routine magnetic resonance imaging to screen for atypical
idiopathic scoliosis was not supported by Weinstein et al. in a
recent Pediatric Orthopaedic Society of North America study comprising
1206 patients. Magnetic resonance imaging for patients with idiopathic
scoliosis is recommended if there are objective risk factors, such
as abnormal neurological findings, very severe curves, and immaturity.
Spondylolysis
Stress injury to the low back is common in children and teenagers.
Anderson et al. recently reported that evaluation of symptomatic
spondylolysis should include bone-scanning with single-photon-emission
computed tomography (SPECT). Bracing with a lumbosacral orthosis
for a minimum of two months has been shown to be highly effective
for reducing or eliminating back pain in symptomatic patients, especially
when such treatment is instituted promptly.
Scheuermann Kyphosis
In an evaluation of the long-term morbidity of Scheuermann kyphosis,
sixty-seven patients were compared with age-matched controls with
use of a questionnaire, physical examination, radiography, pulmonary
function testing, and testing of the strength of the trunk muscles10. No significant differences were
found with regard to level of education, days absent from work due
to low-back pain, interference with activities of daily living,
presence of numbness in the lower extremities, self-consciousness,
self-esteem, social limitations, use of medication for
back pain, or level of participation in recreational activities.
Patients with Scheuermann kyphosis had more severe back pain and
held jobs that had a lower requirement for activity. Restrictive
lung disease was not seen in patients who had kyphosis of less than
100, but it was noted in those who had kyphosis of greater than
100 in the thoracic region10.
Developmental Dysplasia of the Hip
An array of anatomic and radiographic abnormalities may be associated
with formation of the hip. Since many of these abnormalities may
not be present at birth, the term developmental more
accurately describes these features than does the term congenital. The
term developmental dysplasia of the hip was recognized
recently as the preferred term to describe the variety of conditions
in which the femoral head has an abnormal relationship to the acetabulum11.
Risk factors for treatable developmental dysplasia of the hip
in infants have been developed as a result of a literature decision
analysis and epidemiological standard. To assist the primary-care
provider, Goldberg et al. identified risk groups among healthy newborns
and children up to eighteen months of age, excluding those with
neuromuscular disorders, myelodysplasia, and arthrogryposis. The data
support performing more than a screening physical examination for
infant girls presenting with a history of breech delivery. Additional
imaging studies are recommended for this group of patients, even
those who have an unremarkable physical examination.
Slipped Capital Femoral Epiphysis
Slipped capital femoral epiphysis is a disorder of puberty that
results from both biomechanical and biochemical factors. The majority
of children with this condition are obese, with at least 50% of
the children having a weight exceeding the ninety-fifth percentile
according to age. Other mechanical factors include increased femoral
retroversion and increased physeal obliquity. In a minority of cases, slipped
capital femoral epiphysis is secondary to associated endocrine dysfunction12; unfortunately, this diagnosis may
be overlooked. Loder et al. proposed an age-weight test
as a simple method of determining the necessity for further endocrinological
evaluation12. According to this
method, children who are less than ten or more than sixteen years
of age are 4.2 times more likely to have an endocrinological etiology
of the slipped capital femoral epiphysis. Children whose body weight
is less than the fiftieth percentile are 8.4 times more likely to
have an atypical form of slipped capital femoral epiphysis. Short
stature, interestingly, was also identified as a risk factor for
atypical slipped capital femoral epiphysis, by Burrow et al. It
has been suggested that children who are at or below the tenth percentile
for height at the time of presentation should be evaluated for an
endocrinopathy.
Classifications of slipped capital femoral epiphysis are useful
when they have prognostic value. While the traditional classification
of the condition as either acute or chronic has not been helpful,
the classification as stable or unstable, described by Loder et
al., has prognostic value. Unstable slipped capital femoral epiphysis
is defined as simply an inability to bear weight, with or without
crutches. Stable slipped capital femoral epiphysis is defined as
an ability to bear weight on the symptomatic side. Unstable slipped
capital femoral epiphysis is associated with a much higher prevalence
of avascular necrosis on follow-up than is stable slipped capital
femoral epiphysis. The higher rates of complications associated
with unstable slips are most likely due to vascular injuries at
the time of the initial displacement.
Clubfoot
Nonoperative care, including gentle manipulation and use of serial
casts, has been found to be effective as a definitive intervention
for infants with intrinsic clubfoot. Protocols involving the Iowa method
of cast treatment and early percutaneous Achilles-tendon lengthening,
and those involving the French method of early physiotherapy, also have
been found to be effective. The successful results obtained with
these methods suggest that the great majority of infants with intrinsic
clubfoot will go on to have a satisfactory outcome without additional
extensive surgery. When surgery has been required to treat resistant
clubfoot, poor outcomes, as reported by Templeton et al., have been
related to a young age (less than eight months) at the time of surgery
and to failure to release the tibiofibular ligament.
Gait-Analysis Data for Children with Cerebral Palsy
Subjectivity in physicians’ interpretations of gait-analysis
data and its impact on treatment recommendations were recently described
by Skaggs et al. The most consistent recommendations were those
for soft-tissue surgery, and the least consistent were those for
bone surgery, including derotation osteotomy.
What is the effect of muscle-tendon surgery on gait in
children with spastic cerebral palsy? Granata et al. recently analyzed
the gait patterns of these children before and nine months after
muscle-tendon lengthening and compared them with those
of age-matched subjects with normal development. Interestingly,
the joint angular velocity could be used to discriminate between
the patients with cerebral palsy and the normal subjects, both before
and after surgery. Also, the correcting effect of the muscle-tendon
surgery was identified as improvement in the biomechanical alignment
of the lower extremity in the sagittal plane and improvement in knee
extension in the stance phase of gait, with less knee flexion. The
joint angular velocity was not significantly improved, and the underlying
neural input and abnormality remained largely unchanged. However,
the activation pattern of the gastrocnemius-soleus complex
in response to stretch was improved13.
Koman et al. noted that an intramuscular injection of botulinum
toxin type A is effective for improving the gait of patients with
cerebral palsy. Functional-performance measures were not utilized
in that study, so definitive conclusions regarding improved function
cannot be made. The consensus appears to be that this is a useful
interim therapy for young children with lower-extremity spasticity. Repeated
administration of botulinum toxin may be less effective because
of axonal sprouting. When this treatment is combined with nonsurgical
intervention (physical therapy and orthotics), it allows muscle-tendon
surgery to be done at a later age. Surgery performed at a later
age is associated with much less risk of repeat surgery than is
surgery done at an age of less than ten to twelve years.
Fibular Hemimelia
McCarthy et al. noted that children who undergo early amputation
because of fibular hemimelia are more active and more satisfied
with the result than are those who undergo lengthening procedures. Children
in the early-amputation group had less pain, fewer complications,
and fewer operative procedures, and their families incurred less
cost.
Long-Term Follow-up of Pediatric Orthopaedic Conditions
Weinstein recently summarized the current knowledge regarding
the natural history of several important pediatric conditions, including
slipped capital femoral epiphysis, Legg-Calvé-Perthes
disease, congenital hip dysplasia and dislocation, clubfoot, metatarsus
adductus, adolescent idiopathic scoliosis, Scheuermann kyphosis,
and spondylolisthesis10. The reader
is encouraged to review that classic reference.
Pediatric Orthopaedic Trauma
Trauma Management
Potoka et al. demonstrated improved survival rates for children
treated at pediatric trauma centers compared with those treated
at adult trauma centers14. The
rate of survival was especially higher for children who had sustained
head, spleen, and liver injuries. That study underscores the importance
of having appropriate standards of care that are designed for the
special needs of children, as the standards for that population
are, by definition, different from those for adults. To receive
accreditation as a pediatric trauma center, a hospital must provide
comprehensive pediatric medical services that include full-time
availability of pediatric surgeons, anesthesiologists, neurosurgeons,
orthopaedic surgeons, and other specialists.
Sedation
Ketamine is safe and efficacious for sedation prior to reduction
of fractures in children in the emergency-room setting. McCarthy
et al. recently recommended its use and emphasized the importance of
an emergency-room environment in which monitoring is available and
physicians capable of airway management are continuously involved
in the care of the child.
Femoral Fractures
Epidemiology
The understanding of the epidemiology of acute fractures of the
femoral shaft in patients in the United States who are less than
eighteen years old has improved. Past knowledge has been based on Scandinavian
studies from the 1970s and 1980s. Hinton et al., at The Johns Hopkins
Medical Institutions, analyzed demographic data on 1485 cases from
the state of Maryland for the years 1990 through 1996. They reported
the annual rate of acute femoral shaft fractures to be 19.15 per 100,000,
with a bimodal distribution with peaks at two and seventeen years
of age. Boys had higher rates of fracture than did girls at all
ages, and blacks had higher rates than did whites. The mechanisms of
injury were age-dependent and included falls in children less than
six years of age, motor vehicle-pedestrian accidents in children
six to nine years old, and motor-vehicle accidents in teenagers. Adverse
socioeconomic conditions were significantly associated with higher
rates of fracture. As a result of these important data, improved
prevention strategies are now possible.
Child Abuse as the Mechanism of Injury
Schwend noted that a toddler or child who is older than walking
age but less than the age of four years is very unlikely to have
sustained a femoral fracture as a result of child abuse. A very
low prevalence of child abuse (7%) was found in this age-group, whereas
a higher prevalence (29%) was found among children who
were not yet walking. Conservation of medical resources when evaluating
toddlers with femoral shaft fractures is recommended.
Changing Approaches to Treatment
An algorithmic approach to pediatric femoral fractures is gaining
a greater degree of acceptance among orthopaedists. This developing
consensus is mostly based on age, as reported recently by Sanders.
As a general guideline, children who are less than five years old
are satisfactorily managed with an early hip-spica cast, provided
that the shortening of the femur is not excessive. In children between five
and twelve years of age, flexible intramedullary nailing is effective,
even for so-called difficult fractures associated with
comminution or long spiral components. It is important to note,
however, that many orthopaedic surgeons still use an early spica
cast or traction and a spica cast in the five-to-twelve-year age-group.
In children older than twelve years, the preferred surgical intervention
is flexible or rigid intramedullary nailing. In patients with multiple
trauma or in those with a proximal and severely comminuted femoral
fracture, other approaches, such as the use of external fixators, may
have greater efficacy. The recently developed technique of subcutaneous
bridge-plating, which is currently under investigation
by a study group of the Orthopaedic Trauma Association, also holds promise
for the treatment of femoral fractures in children.
Supracondylar Fractures of the Humerus
The timing of urgent treatment of displaced supracondylar fractures
of the humerus is controversial and has led to emotional debates.
In a report in which 198 patients who had urgent treatment were compared
with a cohort of patients who were treated more than eight hours
(average, twenty-three hours) after the injury, Mehlman found no substantial
differences with respect to conversion from a closed to an open
reduction, infection, or iatrogenic nerve injury. There were no
compartment syndromes in either group. The hand must be warm, have
capillary refill, and be viable in order to permit this delayed
approach. Mehlman concluded that operative reduction and percutaneous
stabilization may be safely delayed if deemed appropriate by the
surgeon.
Diagnosis of Anterior Interosseous Nerve Injury
Diagnosis of an anterior interosseous nerve injury in children
may be difficult. Typically, the child is asked to place the thumb
and index finger together to form a circle. Canale et al. recently
reported on the use of a passive flexion sign as an indication of anterior
interosseous nerve injury. When asked to flex the interphalangeal
joint of the thumb or the distal interphalangeal joint of the index
finger, the child with an anterior interosseous nerve injury may
passively flex the joint with use of the contralateral hand. When
present, this sign appears to be a simple and useful screening tool
to test for neurological injury. A positive finding may indicate the
need for further neurovascular evaluation.
Posterior Fat-Pad Sign and Occult Fracture
of the Elbow
Skaggs reported that the radiographic presence of a posterior
fat-pad sign indicated an occult fracture about the elbow in 76% of
children who had a history of elbow trauma, as demonstrated by new-bone formation
on follow-up radiographs. Children with this finding and
a history of trauma should be managed as if they have an undisplaced
fracture about the elbow.
Posttraumatic Tibia Valga
Growing children who sustain a fracture of the proximal tibial
metaphysis are at risk for a valgus deformity of the tibia during
the twelve months after healing. Tuten et al. noted that most children with
this posttraumatic deformity have spontaneous improvement, with
a well-aligned, asymptomatic limb. Children who have sustained this
injury should be followed until skeletal maturity. Operative correction
is recommended only for patients who have symptoms due to malalignment,
such as pain in the lateral aspect of the knee.
Surgical Techniques
Scoliosis
Mazda reported that thoracoscopic approaches for anterior spinal
release and discectomy/fusion demonstrated efficacy in
the treatment of scoliosis, even in very young children. The morbidity
associated with thoracoscopic approaches is lower than that associated
with open techniques. These approaches require an expert skill level
and knowledge of alternative techniques. The use of thoracoscopic approaches
for instrumentation and correction remains under investigation;
to date, these approaches have not led to results that are clearly superior
compared with those of posterior instrumentation.
Wall et al. recently reported on the use of a spinal hemiepiphysiodesis
for the modification of spinal growth in an animal model. This very
interesting concept advances a technique that failed in the past. The
new procedure utilizes a more developed and more anatomically precise
vertebral staple. If successful, it would allow the highly desirable
outcome of modulation and perhaps correction without the need for
spinal arthrodesis.
Spinal Fusion with Use of Gene Therapy
Riew et al. recently demonstrated intradiscal spinal fusion in
an animal model. Marrow-derived mesenchymal cells were transduced
with an adenovirus carrying the gene for BMP-2 (Adv-BMP2),
and the cells were then implanted into the disc space. Anterior
spinal fusion was demonstrated by radiographic and histologic examination.
In an earlier study, Boden et al. reported that osteoinductive protein
promoted fusion in a transverse-process intervertebral spinal-fusion
model in animals. These methods may substantially reduce the need
to obtain autologous graft for spinal arthrodesis procedures in
the future.
Intraoperative Spinal-Cord Monitoring
Padberg et al. recently recommended the use of warning criteria
as an indicator of significant change in intraoperative somatosensory-evoked-potentials.
On the basis of their series of 3783 monitored cases, an amplitude
decrease of 60% or greater in these potentials is currently
recommended as the accepted standard of a "significant change." Those
authors stated that this criterion will allow fewer wake-up
tests to be performed without increasing the risk of failing to
identify a neurologic deficit.
Neuromuscular Spinal Deformities
Scoliosis averaging 70° has been managed efficaciously with posterior
spinal arthrodesis with instrumentation alone. The Galveston technique
of pelvic fixation is effective for the correction of pelvic obliquity
and the maintenance of such correction, as noted by Asher et al.
The posterior implant system integrates hooks, wires and cables,
screws, and post anchors for the pelvis.
Spinal Deformity in Association with Myelomeningocele
The indications for corrective surgery or stabilization of spinal
deformity in children with myelomeningocele have been controversial,
as studies have not always assessed function according to objective criteria.
Wai et al. described a questionnaire for the assessment of functional
status in children with complex neuromuscular spinal deformities.
Analysis of the results of this questionnaire will help to clarify
which children are helped by the surgery and which children do not
need it.
Sarwark et al. recently described the subtraction-vertebrectomy
technique combined with posterior instrumentation at the level of
the sacrum and the pelvis for kyphectomy in children with myelomeningocele.
The technique produced satisfactory results, with reduced perioperative
morbidity.
Severe Spondylolisthesis
Hresko et al. reported that partial reduction, instrumentation,
and arthrodesis is a safe and effective method for the treatment
of severe spondylolisthesis. Complete reduction in the transverse
plane is associated with higher rates of permanent neurological
injury and is not always advisable. It appears that partial reduction
in the transverse plane, combined with instrumentation and arthrodesis,
leads to satisfactory results. Complete or nearly complete correction
of the sagittal kyphotic deformity is recommended.
Endoscopic Techniques for Pelvic Osteotomy
Open pelvic osteotomy is an invasive procedure that is associated
with muscle-stripping and potential functional loss, increased blood
loss, and prolonged recovery. Mini-open endoscopic techniques for
rotational acetabuloplasty have been described and evaluated by
Millis et al. and by Wall et al. The results, although preliminary,
are encouraging. Satisfactory reconstruction of the pelvis and/or
the acetabulum can be achieved with these techniques, with reduced
morbidity.
Septic Arthritis of the Hip
Percutaneous lavage of the hip joint with use of cannulae placed
medially and anteriorly, with continuous flushing performed under
fluoroscopic control, was recently described by Chambers et al.
for the treatment of septic arthritis of the hip. The benefits are
similar to those of open irrigation and drainage in children who
are more than two years old, but the percutaneous technique requires smaller
incisions and results in less surgical morbidity.
Flexible Nailing of Femoral Shaft Fractures
Flexible intramedullary nailing has been demonstrated to be effective
for the treatment of femoral fractures in children and adolescents15. Flexible pins are placed from the
distal femoral metaphysis in a retrograde manner. Generally, two pins
of the same diameter are placed, one medially and the other laterally.
Their combined diameter should fill approximately 80% of
the canal width. This approach has resulted in shorter hospital
stays and less need for the alternative of longer-term skeletal
traction followed by application of a spica cast. This may represent
a major trend in the management of trauma in children, leading to
improved outcomes and reduced morbidity. It is advisable to offer
immobilization in a spica cast to many of these patients in the
early postoperative period.
Intramedullary Pinning of Unstable Forearm
Fractures
Gerardi reported that intramedullary pinning is also a simple
and effective technique for the treatment of unstable forearm fractures
in children. One or both of the forearm bones may be selected for
fixation, depending on the specific fracture pattern. The radial
pin is placed from the level of the Lister tubercle, and the ulnar
pin is placed from the posterior surface of the olecranon.
Reconstruction of the Anterior Cruciate Ligament in
Patients with Open Physes
Aronowitz et al. reported satisfactory results after anterior
cruciate ligament reconstruction in teenagers nearing skeletal maturity.
Those authors found that a femoral or tibial bone tunnel placed
centrally across the physis did not lead to premature closure of
either physis. A recent report described a premature distal femoral
physeal closure that resulted in a valgus deformity in a sixteen-year-old
boy two years after anterior cruciate ligament reconstruction. A
cannulated transfixing screw was placed across the lateral aspect
of the distal femoral physis. While use of bone tunnels alone has
been demonstrated to be safe and does not lead to premature physeal
closure, fixation that is permanent and crosses the physis is hazardous
and is not recommended.
Osteochondritis Dissecans
Extra-articular drilling of osteochondritis dissecans lesions
following arthroscopic confirmation results in satisfactory healing,
with very low morbidity. Bruffey et al. noted that this is particularly
true when the technique is compared with transchondral intra-articular
drilling. Other approaches that are currently under investigation
include bioabsorbable fixation and osteochondral articular transplantation.
Congenital Pseudarthrosis of the Tibia
Schoenecker et al., in a recent review of a twenty-year experience
with the surgical treatment of this challenging problem, found that
use of an intramedullary rod that crosses the ankle joint, combined
with open autogenous bone-grafting, led to generally successful
results. Typically, functional range of movement was regained once
the rod had been removed from the ankle joint. Knowledge of alternative
methods, such as segmental bone transport, is important in order
to achieve union and satisfactory outcomes in difficult cases.
Upcoming Educational Events in Pediatric Orthopaedics
The American Academy of Orthopaedic Surgeons (AAOS) will sponsor
a course on Current Perspectives and Techniques in Pediatric Orthopaedics (Course #3375),
to be held on October 5-7, 2001, at the Westin Grand Hotel,
Washington, DC. Additional information is available at the AAOS
web site, www.aaos.org. The Annual Meeting of the Pediatric Orthopaedic
Society of North America (POSNA) will be held on May 1-5, 2002,
at The Grand America Hotel, Salt Lake City, Utah. Additional information
is available at the POSNA web site, www.posna.org. The American
Academy of Orthopaedic Surgeons will sponsor a course on Surgical
Techniques for Managing Pediatric Orthopaedic Trauma, to be held
on October 4-6, 2002, at the Orthopaedic Learning Center,
Rosemont, Illinois. Additional information is available at the AAOS
web site, www.aaos.org.
Note: The author thanks John Grayhack, MD, and Erik King, MD,
for their editorial review, and Tony Rinella, MD, for his assistance
with the bibliography search.
References
-
Collins FS, and McKusick VA: Implications of the human genome project for medical science. JAMA, 2001.285: 540-4, [Abstract/Free Full Text]
-
Dietz FR, and Mathews KD: Update on the genetic bases of disorders with orthopaedic
manifestations. J Bone Joint Surg Am, 1996.78: 1583-98, [Free Full Text]
-
Baitner AC; Maurer SG; Gruen MB; and Di Cesare PE: The genetic basis of the osteochondrodysplasias. J Pediatr Orthop, 2000.20: 594-605, [Medline]
-
Guyer B; Freedman MA; Strobino DM; and Sondik EJ: Annual summary of vital statistics: trends in the health
of Americans during the 20th century. Pediatrics, 2000.106: 1307-17, [Abstract/Free Full Text]
-
Daltroy LH; Liang MH; Fossel AH; and Goldberg MJ: The POSNA pediatric musculoskeletal functional health
questionnaire: report on reliability, validity, and sensitivity
to change. Pediatric Outcomes Instrument Development Group. Pediatric
Orthopaedic Society of North America. J Pediatr Orthop, 1998.18: 561-71, [Medline]
-
Young NL, and Wright JG: Measuring pediatric physical function. J Pediatr Orthop, 1995.15: 244-53, [Medline]
-
Berry RJ; Li Z; Erickson JD; Li S; Moore CA; Wang H; Mulinare J; Zhao P; Wong LY; Gindler J; Hong SX; and Correa A: Prevention of neural-tube defects with folic
acid in China. China-U.S. Collaborative Project for Neural Tube
Defect Prevention [corrected; erratum to be published]. N Engl J Med, 1999.341: 1485-90, [Abstract/Free Full Text]
-
McMaster MJ, and Singh H: Natural history of congenital kyphosis and kyphoscoliosis.
A study of one hundred and twelve patients. J Bone Joint Surg Am, 1999.81: 1367-83, [Abstract/Free Full Text]
-
Little DG; Song KM; Katz D; and Herring JA: Relationship of peak height velocity to other maturity
indicators in idiopathic scoliosis in girls. J Bone Joint Surg Am, 2000.82: 685-93, [Abstract/Free Full Text]
-
Weinstein SL: Long-term follow-up of pediatric orthopaedic
conditions. Natural history and outcomes of treatment. J Bone Joint Surg Am, 2000.82: 980-90, [Free Full Text]
-
American Academy of Pediatrics
Committee on Quality Improvement, and Subcommittee on Developmental Dysplasia of the Hip: Clinical practice guideline: early detection of developmental
dysplasia of the hip. Pediatrics, 2000.105: 896-905, [Abstract/Free Full Text]
-
Loder RT; Aronsson DD; Dobbs MR; and Weinstein SL: Slipped capital femoral epiphysis. J Bone Joint Surg Am, 2000.82: 1170-88, [Free Full Text]
-
Granata KP; Abel MF; and Damiano DL: Joint angular velocity in spastic gait and the influence
of muscle-tendon lengthening. J Bone Joint Surg Am, 2000.82: 174-86, [Abstract/Free Full Text]
-
Potoka DA; Schall LC; Gardner MJ; Stafford PW; Peitzman AB; and Ford HR: Impact of pediatric trauma centers on mortality in a statewide
system. J Trauma, 2000.49: 237-45, [Medline]
-
Flynn JM; Hresko T; Reynolds RA; Blasier RD; Davidson R; and Kasser J: Titanium elastic nails for pediatric femur fractures: a
multicenter study of early results with analysis of complications. J Pediatr Orthop, 2001.21: 4-8, [Medline]
 CiteULike  Connotea  Del.icio.us  Technorati What's this?
|
