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© 2002 The Journal of Bone and Joint Surgery, Inc.
What's New in Pediatric Orthopaedics
The purpose of this second annual Specialty Update on Pediatric Orthopaedics is to serve as a primary source and a 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 and skills in the subspecialty. The material is not intended to represent the only, or necessarily the best, method or procedure appropriate for the medical situations discussed. Sources for this article were presentations at meetings of the Pediatric Orthopaedic Society of North America (POSNA) (Cancun, Mexico, May 1 through 5, 2001) and the Scoliosis Research Society (SRS) (Cleveland, Ohio, September 19 through 22, 2001) and selected references. Orthopaedic surgeons, residents, and fellows are encouraged to attend educational programs on topics in pediatric orthopaedics presented at the American Academy of Orthopaedic Surgeons (AAOS) conferences and courses, Specialty Day at the AAOS, and the POSNA annual meeting. Upcoming educational events are listed at the end of this update. Background Evidence-based medicine and outcomes research continue to advance the quality and impact of health care in the United States and elsewhere. The number of instruments for the assessment of musculoskeletal conditions has increased greatly, such that the AAOS has recently published an inventory of these instruments online as part of the Bone and Joint Decade Monitor Project (www.aaos.org/wordhtml/research/outcomes/bjdecad.htm). The site includes an overview Instrument Inventory Form, which identifies the instrument, its bibliographic citation, the population for which it was designed (e.g., pediatric or general population), the disease conditions that it assesses, reliability data, validity data, the type of indicators (e.g., generic, specific, or economic), the areas measured (e.g., quality of life or resource utilization), the language, and who it is "administered by" (e.g., self or parent). A number of instruments that are appropriate in pediatrics are inventoried on this site, and the reader is encouraged to refer to it. It should be noted that this site is not comprehensive for pediatric outcomes instruments. Knowledge of pediatric diseases and the approaches to them have continued to improve. Better strategies and techniques in musculoskeletal trauma care are resulting in increased quality of results, reduced morbidity, and increased consensus among orthopaedic surgeons. Finally, advances in surgical technique have improved clinical outcomes and the satisfaction of the patient and family. These advances continue to result in shorter hospital stays and reduced morbidity as well. Patient safety: Patient safety is and will continue to be an important health-care issue as has been highlighted by the Institute of Medicine report "To Err is Human." 1 The AAOS has been proactive with many of its programs, including setting up its Medical Errors Oversight Panel, which was charged with developing comprehensive practice-based and educational programs aimed at keeping the hospital a safe house. Hensinger has encouraged pediatric orthopaedic surgeons to approach error reduction through a systems approach and by developing patient-safety initiatives 2 . This type of professional activity represents the highest level of ethics 2,3 . Health-care access and graduate medical education: Among the current and future challenges for pediatrics is health-care access and financing graduate education to meet pediatric workforce needs. The American Academy of Pediatrics (AAP) stated that it is necessary to develop reimbursement methods that cover all of the health-care needs of children 4 . Additionally, the AAP takes the position that there should be no financial barriers to access to pediatric specialty care 5 . Culturally competent care; training in care of children with physical disabilities: When training pediatricians and pediatric subspecialists, it is imperative to place emphasis on enhancing the racial and ethnic diversity of providers 6 . It is also imperative that pediatric orthopaedic surgeons remain involved in providing pediatricians with musculoskeletal training that includes care of children with special health-care needs and physical disabilities 7 . Human embryo research: U.S. News & World Report announced the first successful cloning of a human embryo in its November 25, 2001, issue. The National Institutes of Health and the United States Congress have deliberated recently on the issue of human embryo research. At the time of this writing, the House of Representatives has voted to ban human embryo research, although such a ban has not been enacted into law. At the same time, the National Academy of Sciences has supported therapeutic cloning (although not reproductive cloning, with the Academy noting that at this time there are too many safety and ethical issues remaining). Research in this area in order to "accelerate the pace of research on health issues with important implications for children" is supported by the AAP 8 . Evidence-Based Medicine and Outcomes Studies
Pediatric Orthopaedic Outcomes Instruments Comparison of three outcomes instruments: The scores of three instrumentsæthe Activities Scales for Kids (ASK), the Child Health Questionnaire Parent Form (CHQ-PF-28), and the PODCI-were recently compared 11 . The scores for the ASK and the PODCI correlated highly with one another and discriminated better than the CHQ-PF-28 did. It was noted that the questionnaires measured different factors. Reliability of SRS-22 Questionnaire: Asher et al. noted that the Scoliosis Research Society (SRS)-22 Questionnaire is reliable and valid in comparison with the Short Form-36 (SF-36) 12 . A question being raised is the need for disease-specific questionnaires, such as the SRS-22 for scoliosis, when other instruments such as the SF-36 have substantial normative databases. Health-related quality of life after bracing or surgery for idiopathic scoliosis: Danielsson et al. reported on a consecutive series of patients who had been followed for at least twenty years after treatment of idiopathic scoliosis with bracing or fusion surgery 13 . There were no differences with respect to sociodemographic data between the surgically treated and brace-treated patients. After treatment, the patients were found to have approximately the same health-related quality of life as age and sex-matched controls in the general population. Physical disability in children with spina bifida and scoliosis: Wai et al. developed and analyzed a specific questionnaire to assess physical disability related to the spine in children with spina bifida. The questionnaire was found to be valid and reliable. The authors stated that this type of assessment will be useful to define the need for interventions as well as outcomes after interventions. Outcomes after clubfoot surgery: According to Roye et al., a pediatric functional status scale (FSIIr) showed that the functional status of children at an average of forty-five months after surgical repair of clubfoot did not differ from that of age-matched normal controls. Management of Pediatric Orthopaedic Diseases Axonal regeneration in spinal cord injury: Use of genetically modified fibroblasts secreting neurotrophic factors (neurotrophin-3 [NT-3] and brain-derived neurotrophic factor [BDNF]) in a study by Antonocci et al. and treatment with recombinant adenovirus using Bcl-2 in a study by Yukawa et al. resulted in regeneration of neural tissue in animal models. A transection model was utilized in the former study, and weight- drop injury was used in the latter. These studies indicated improved cell and tissue recovery. In addition, temporal factors were found to be important. Treatment of clubfoot with growth-factor blockade: Li et al. noted expression of transforming growth factor-ß (TGF-ß) and platelet-derived growth factor (PDGF) in the contracted tissues in the clubfeet of infants. Blockade of these factors led to decreased collagen expression, proliferation, and chemotaxis. Growth-factor blockade may improve treatment outcomes. Manual stretching for congenital muscular torticollis in infants: Controlled manual stretching is safe and effective when performed in infants before the age of one year. Surgical release of the sternocleidomastoid muscle is recommended only when the infant has undergone at least six months of controlled manual stretching and has deficits of passive rotation and lateral bending of the neck of >15° and a tight muscular band 14 . Clinical value of routine preoperative magnetic resonance imaging in idiopathic scoliosis: Do et al. prospectively evaluated 327 consecutive patients with idiopathic scoliosis prior to arthrodesis and instrumentation of the spine 15 . No patient required neurosurgical intervention or additional work-up as a result of the findings on magnetic resonance imaging. The authors concluded that magnetic resonance imaging is not indicated in the routine preoperative assessment of patients with idiopathic scoliosis and normal findings on neurological examination. Magnetic resonance imaging in infantile scoliosis: Dobbs et al. noted neural axis abnormalities in 20% (eleven) of fifty-six infants and children with an age of three years or younger, scoliosis of >20°, no neurological abnormalities, no diagnosis of a syndrome, and no congenital abnormalities. The authors recommended magnetic resonance imaging of the total spine when infants present with scoliosis of >20°. They did not state whether their series was prospective or consecutive. Magnetic resonance imaging of congenital spine abnormalities: Suh et al. noted a 31% prevalence of major intraspinal anomalies in forty-one nonrandomized children with congenital spinal deformities who had been referred for magnetic resonance imaging. Some of these patients had normal neurological findings. A case was made for including magnetic resonance imaging as part of the initial evaluation of children with congenital scoliosis and spinal abnormalities. Accuracy of measurement of congenital scoliosis: According to Facanha-Filho et al., skilled observers were able to measure scoliotic curves on radiographs with a high level of accuracy (3°, 95% of the time). Bracing for idiopathic scoliosis in males: The success rate of bracing for idiopathic scoliosis in males is different from that in females, as noted by Karol at the Texas Scottish Rite Hospital 16 . Males are generally treated with bracing at an older age than are their female counterparts, and it is often difficult to ensure compliance with treatment. Skeletal immaturity and thoracic curves were risk factors in males, as they are in females with idiopathic scoliosis. Etiology of idiopathic scoliosis: I encourage readers to refer to The Journal of Bone and Joint Surgery's Current Concepts Review on this topic 17 for an update on the current knowledge of the etiology of idiopathic scoliosis. In short, the true etiology of idiopathic scoliosis remains unknown. The etiology is probably multifactorial, and a single-gene disorder with variable penetrance has been suggested. A possible defect in processing by the central nervous system affecting the growing spine may have a role as well. Repeat surgical interventions for idiopathic scoliosis: Reoperations after spinal instrumentation and arthrodesis are perhaps more common than was thought. Richards noted a 14% reoperation rate, often because of hardware prominence or shifting, or because of deep infection16. This possibility of a reoperation should be communicated to the family in the preoperative period. Spinal deformity in familial dysautonomia: Axelrod et al., in a large center known to provide comprehensive care to patients with familial dysautonomia, recently noted that spinal deformity developed in 83% of patients who lived for at least twenty years. By the age of ten years, 52% had scoliosis and 21% had kyphosis with or without scoliosis. Curves progressed in 89% of the patients, despite bracing, and 37% of the patients had undergone spinal arthrodesis. Progressive spinal deformity and pulmonary function in Duchenne muscular dystrophy: In Sapporo, Japan, Yamashita et al. noted a relationship between severe progression of spinal deformity and vital capacity of <1900 mL and an age of less than fourteen years. Vital capacity can thus be used as an indicator of the severity of spinal deformity in Duchenne muscular dystrophy. Cervical spine problems in adults with Down syndrome: Older individuals with Down syndrome continue to have problems with the cervical spine, including atlantoaxial instability and precocious degenerative changes in the subaxial cervical spine, with or without cervical myelopathy. Pathological findings should be expected in individuals over the age of thirty years 16 . Reliability of the Stulberg system for evaluation of Legg-Calvé-Perthes disease: The classification of Legg-Calvé-Perthes disease that was described by Stulberg et al. has been used since 1981 to guide treatment decisions because of its proposed utility as a predictor of long-term outcome. This predictive value has recently been called into question as a result of a study of interrater and intrarater reliability by Neyt et al. Those authors noted variability between the classifications assigned by the raters and only marginally acceptable interrater reliability. These findings challenge the validity of treatment decisions and studies based on this classification system. Herring lateral pillar classification of Legg-Calvé-Perthes disease: Podeszwa et al. found good intraobserver and interobserver reliability for the classification of radiographs with use of the lateral pillar classification of Legg-Calvé-Perthes disease. The method was reproducible and independent of the amount of experience that the observers had in pediatric orthopaedics. Slipped capital femoral epiphysis: Slipped capital femoral epiphysis is a disorder of puberty that results from both biomechanical and biochemical factors. It may be secondary to an associated endocrine dysfunction in a minority of cases. Loder proposed an age-weight test as a simple method of determining the necessity for further medical-endocrine evaluation. The principle behind this test is that children who are less than ten years old or more than sixteen years old are 4.2 times more likely to have an endocrine etiology for slipped capital femoral epiphysis, whereas children with a body weight below the fiftieth percentile are 8.4 times more likely to have an atypical form of slipped capital femoral epiphysis. Vascular supply of slipped capital femoral epiphysis: In a study by Maeda et al., twelve hips, seven with stable slipped capital femoral epiphysis and five with unstable slipped capital femoral epiphysis, underwent selective angiography prior to reduction. The authors concluded that the vascular insult occurs at the time of injury. This conclusion was based on observed filling of the superior retinacular artery with contrast medium in all hips with a stable slip and no filling in three of the hips with an unstable slip. The authors also concluded that reduction of slipped capital femoral epiphysis does not necessarily contribute to the risk of avascular necrosis. Botox for infant clubfoot: In a study by Delgado et al., infants with clubfoot who had reached a treatment plateau with physical therapy, stretching, taping, and splinting (French method) had additional substantial improvement in foot dorsiflexion and flexibility after injections of botulinum toxin type A. The authors recommended the use of such injections as an adjunct to conservative care of patients with resistant clubfoot. Pathomechanics and modeling of spastic hip dislocation in cerebral palsy: According to Miller et al., computerized modeling of the hip in spastic cerebral palsy demonstrated hip-force magnitudes that were three times that of a child with a normal hip in a normal physiologic position. According to this model, the muscles to be released for best normalization of forces are the psoas or iliacus, gracilis, adductor brevis, and adductor longus. Decreasing femoral anteversion had little additional effect on the direction or magnitude of the hip forces. Diagnosis and treatment of juvenile rheumatoid arthritis: Ten years after diagnosis, 50% of children with polyarticular and systemic juvenile rheumatoid arthritis and 40% of children with pauciarticular juvenile rheumatoid arthritis will have active arthritis. Three major therapeutic interventions have substantially improved the quality of life of children with juvenile rheumatoid arthritis. These are intra-articular injections of triamcinolone hexacetonide, weekly administration of methotrexate, and twice-weekly subcutaneous administration of etanercept. Etanercept is a biologic agent that blocks tumor necrosis factor (TNF). There is a notable risk of serious infection with etanercept treatment since it blocks the inflammatory response. An intravenous preparationæinfliximab, a monoclonal anti-TNF agentæis also available 18 . Scleroderma of childhood: Patients with scleroderma benefit from early diagnosis, supportive care, and physical therapy combined with early orthopaedic surgical intervention for release of muscle-tendon and joint contractures. Scleroderma remains a diagnostic and therapeutic challenge, as noted by Bottani et al. Pediatric Orthopaedic Trauma Effects of trauma on the child and family: Thompson et al. noted that some children and families experience adverse effects during the first year after a serious fracture 16 . Their study indicated that operative stabilization, particularly of femoral fractures, may be advantageous to the child and family. Interviews were conducted with the National Health Interview Survey and the Child Health Status Scales (Vineland Adaptive Behavior Scale and Behavior Checklist). Polytrauma scoring systems and prognosis: Yian et al. noted that the Trauma Score was useful if it was employed together with a survival statistic early in the management of a child with traumatic injury. If a prolonged stay in an intensive-care unit is predicted, operative fracture management was recommended. Effect of delayed fracture treatment: Skaggs et al. noted that operative irrigation and débridement of open fractures can be delayed more than six hours without increasing the risk of infection if children are given early parenteral antibiotics. Conclusions could not be made about patients with a grade-III open fracture and a delay in treatment of more than twenty-four hours. School sports accidents: In a study conducted in Germany, Kelm et al. reported that about 5% of all schoolchildren sustained a serious injury during physical education each year. Most of the injured students were older, with an average age of thirteen years. The most common injuries were sprains, contusions, and fractures, which involved the upper extremity more often than the lower extremity. The most common sports in which children were injured were soccer and basketball. The authors emphasized the need to outline individualized programs and to reintegrate injured children into physical education once they have recovered. Magnetic resonance imaging of pediatric thoracolumbar spine injuries: Thoracolumbar spine injuries are uncommon in children under the age of twelve years. When such injuries are seen, magnetic resonance imaging is the imaging modality of choice according to Sledge et al. Magnetic resonance imaging enables classification of injuries to bone, ligaments, and the spinal cord. The patterns of cord injury have predictive value. Intramedullary pinning of unstable forearm fractures and compartment syndromes: Mubarak et al. suggested that the risk of compartment syndrome of the forearm is increased when a fracture is treated with intramedullary pinning with Kirschner wires or elastic pins rather than with a cast alone 16 . This risk may be due to greater initial trauma, additional manipulation, and/or repeated passage of the Kirschner wires. Classification of pediatric pelvic fractures and associated injuries: Silber et al. classified pelvic fractures and recorded associated injuries in a large group of children and noted multisystem injuries in 60% and additional skeletal injuries in 50%. The death rate was 3.6%. The leading causes of death were head and/or visceral injury. Life-threatening hemorrhage was not seen, and urethral injury was less common than in adults. Computed tomography classification and management of pelvic fractures: Computed tomography scanning of pediatric pelvic fractures is less useful than that of adult pelvic fractures. Silber et al. noted that plain radiographs alone predicted the need for and type of operative intervention, with less of a need for computed tomography imaging than in adults. The average age above which the addition of computed tomography scans assisted in a change of classification or management was 11.2 years. The average age below which the addition of computed tomography scans failed to provide additional useful information was 7.4 years. Approaches to femoral shaft fractures: An algorithmic approach to the treatment of pediatric femoral fractures is gaining a greater degree of acceptance among orthopaedists. This developing consensus is based mostly on the age of the patient, as reported recently by Sanders et al. 19 . According to their 1998 Pediatric Orthopaedic Society of North America (POSNA) survey, operative treatment was increasingly preferred over nonoperative treatment as patient age increased. Prevention of infant walker injuries: In 1999, an estimated 8800 children younger than 1.5 months were treated in hospital emergency rooms in the United States for injuries associated with infant walkers, according to the American Academy of Pediatrics (AAP), Committee on Injury and Poison Prevention. Walkers do not help a child to walk and can delay motor development. Since their use has no clear benefit, the AAP recommends a ban on the manufacture and sale of mobile infant walkers. In-line skating injuries: Nguyen and Letts noted 331 injuries associated with in-line skating in children over a nine-year period. Fractures represented 38% of all injuries, 61% of the injuries were in boys, and the average overall patient age was twelve years. The upper extremity was more commonly injured; 16% of the injuries involved the head and neck. Inexperience, lack of instruction, and failure to use protective equipment were mentioned as factors. Surgical Techniques Severe spinal deformities and perioperative halo-gravity traction in scoliosis: Sink et al. reported on the utility of perioperative halo-gravity traction for treatment of severe scoliosis of varying etiologies in nineteen children seen at the Texas Scottish Rite Hospital. Most of the patients required an interim spinal osteotomy. The traction was used for six to twenty-one weeks, and all patients had improvement after definitive spinal fusion and instrumentation. Trunk balance was improved in both the frontal and the sagittal planes, and the surgical outcome was improved and the surgery was facilitated by use of this approach. Severe congenital spinal deformities and expansion thoracoplasty: Campbell developed an approach for treatment of severe congenital spine anomalies, particularly those associated with growth inhibition and associated restrictive lung disease 16 . The untreated spine and pulmonary problems can, in many cases, be progressive and insidious. Expansion thoracoplasty allows both the concave and the convex side of the spine to grow, enabling the thoracic spine to grow in length. A pulmonary benefit can also be expected. The procedure involves use of an innovative rib implant. Occipitocervical fixation with the inside-outside technique: Occipitocervical fusion is a challenging task in children. McCarthy et al. reported a new technique for the procedure, involving an inside-outside occipital implant (bolt) 16 . They evaluated the results of the procedure in seventeen patients and reported that all had a successful fusion except one with Down syndrome, who required a reoperation and a supplemental bone graft. Halo immobilization was used for two patients. Early surgery for congenital pseudarthrosis of the clavicle: Molto et al. recommended early surgical repair of congenital pseudarthrosis of the clavicle on the basis of their experience with five patients between the ages of eighteen months and four years. Bone graft and internal fixation with a Kirschner wire were used successfully, resulting in healing in all patients by six to eight weeks. Anterior innominate osteotomy for bladder exstrophy: Anterior innominate osteotomy performed contemporaneously with bladder reconstruction is an effective way to treat bladder exstrophy. The osteotomy reduces tension and allows adequate bladder closure, and gait is normalized. With this technique, bilateral posterior iliac osteotomy is unnecessary 20 . Flexible nailing of femoral shaft fractures: Flexible intramedullary nailing of femoral fractures has been demonstrated to be effective in children and adolescents 21 . 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 one laterally. Their combined diameter should fill approximately 80% of the canal width. An analysis of the results of this approach showed a shorter hospital stay and less need for the alternative of long-term skeletal traction followed by application of a spica cast. However, immobilization in a spica cast is often advisable in the early postoperative period. Supracondylar fractures of the humerus and consequences of pin placement: Skaggs et al. noted that fixation of displaced (Gartland types-2 and 3) supracondylar fractures of the humerus with only lateral pins is safe and effective 22 . This approach prevents iatrogenic injury to the ulnar nerve. The routine use of crossed pins is not recommended. If a medial pin is used, hyperflexion of the elbow should be avoided during insertion. Pin fixation of lateral condylar fractures for no more than three weeks: A recent report by Thomas et al. noted successful rates of union after open reduction of lateral condylar fractures with three weeks of smooth-pin fixation and immobilization. Longer periods of immobilization and pinning were unnecessary. Surgery for chronic posttraumatic dislocation of the radial head: Peterson and Seel reported an innovative technique for successful repair of delayed or chronic posttraumatic dislocation of the radial head. The interval between the injury and the operation in their patients averaged thirty months. The new procedure involves use of two drill-holes in the proximal part of the ulna for the original attachments of the annular ligament and enables the ligament or other tissue to be secured in its normal position. The procedure allows for contemporaneous osteotomy of any associated deformity of the radius or ulna. A prerequisite for surgery is a normal concave proximal radial articular surface. All patients were active and had no elbow pain on follow-up. Open surgical treatment of elbow contracture: In a study of thirty-nine patients treated with open surgical release of an elbow contracture 16 , only seventeen (44%) obtained a functional arc of motion of 30° to 130°. The procedure was not without complications, which included deep infection, transient radial nerve palsy, and hematoma formation. The presence and excision of loose bodies was associated with a favorable outcome. Arthrodesis of the hip in adolescents: Karol et al. reported on gait and function of individuals who had had arthrodesis of the hip during adolescence 23 . Motion analysis revealed excessive motion at the level of the lumbar spine and at the level of the ipsilateral knee. Pain was associated with the abnormal motion and was directly related to the duration of follow-up. The authors recommended an intraoperative position of the hip of neutral abduction-adduction, 20° to 25° of flexion, and neutral rotation. Long-term follow-up after Colonna arthroplasty: Using innovative follow-up strategies, Boardman and Moseley contacted sixteen of nineteen patients known to be alive forty years after a Colonna arthroplasty. The authors noted that only four of the sixteen had not undergone total hip arthroplasty. They concluded that the revival of this procedure is not justified. Physeal stapling for idiopathic genu valgum: Stevens et al. reported on 152 knees (seventy-six patients) who had undergone hemiphyseal stapling, as an alternative to osteotomy, for the treatment of adolescent idiopathic genu valgum and who were followed to maturity. An improvement in gait, a decrease in clinical symptoms, and an improvement in radiographic parameters were reported. The procedure was noted to be safe and effective, and no premature physeal closure was observed. Arcuate osteotomy for adolescent tibia vara: An inverted arcuate osteotomy of the proximal part of the tibia (without osteotomy of the fibula) with avoidance of the physis was recently described by Miller et al. The procedure requires the use of an external fixator. Angulation and rotation are corrected through the osteotomy, with interim adjustments in the amount of correction possible in the early postoperative period. The authors reported on fifteen patients who had generally satisfactory results. Calcaneal lengthening for valgus deformities of the foot: In 1995, Mosca reintroduced the concept of lengthening of the neck of the calcaneus with a structural graft for the treatment of valgus deformities of the foot and confirmed the usefulness of this method with clinical follow-up. Recently, Davitt et al. further confirmed the effectiveness of the procedure by using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot scoring system, plantar pressure measurements, and measurement of radiographic parameters at both preoperative and postoperative evaluations. Those authors noted improvement in all parameters, including weight-shifting as demonstrated by plantar pressure measurements, the talocalcaneal coverage angle, and the talo-first metatarsal angle on the lateral radiograph. The average AOFAS score was 90 points. Clubfoot: Nonoperative care, including gentle manipulation and serial casts, of infants with intrinsic clubfoot has been demonstrated to be effective as a definitive intervention. Protocols using the Ponseti (Iowa) method of cast immobilization and early percutaneous Achilles tendon lengthening and protocols using the Demiglio (French) method of early physiotherapy have been demonstrated to reduce the number of severe clubfoot deformities requiring surgery. Williams et al. reported that the procedure was expensive and time-consuming 16 . The successful results of these methods suggest that the great majority of babies with intrinsic clubfoot will have a satisfactory outcome without the need for extensive surgery. Foot deformity in Duchenne muscular dystrophy: Surgery, consisting primarily of posterior tibial tendon transfer with or without Achilles tendon lengthening corrects and maintains foot position and can prolong the patient's ability to walk, as noted by Sher et al. Not all patients need surgery to prolong their capacity to walk, however. Regardless of the desire to continue to walk, all patients should have this surgery after appropriate discussion with their physician, family, and other caregivers 16 . Transplantation of allografts for physeal problems: Stevens et al. studied the feasibility of microvascular transplantation of epiphyseal plate allografts in animals of different ages 24 . Successful transplantation was confirmed. Interestingly, the growth rate was found to depend on the age of the donor of the epiphyseal plate and was independent of the age of the recipient. Use of tourniquets in extremity surgery in children: Use of a well-fitting tourniquet with a corresponding limb-protection sleeve, specifically designed for children, was advised by Tredwell et al. to prevent skin pinches and wrinkles on the skin surface postoperatively. Upcoming Educational Events AAOS Surgical Techniques for Managing Pediatric Orthopaedic Trauma, Orthopaedic Learning Center, Rosemont, Illinois. October 4, 5, and 6, 2002. Web site: www.aaos.org
POSNA (Pediatric Orthopaedic Society of North America), Annual Meeting, Amelia Island Plantation, Amelia Island, Florida. May 1 through 4, 2003. Web site: www.posna.org
Note: The author is grateful to John Grayhack, MD, and Erik King, MD, for their editorial review and to Laura Powers Lemke, MD, for her assistance with the bibliography search.
References
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