The Journal of Bone and Joint Surgery (American) 85:976-981 (2003)
© 2003 The Journal of Bone and Joint Surgery, Inc.
What's New in Pediatric Orthopaedics
John F. Sarwark, MD
The purpose of this third 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 topics that have been selected have value for the practicing orthopaedist as well as for the pediatric orthopaedic specialist 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 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) (Salt Lake City, Utah, May 2 through 4, 2002), the Scoliosis Research Society (SRS) (Seattle, Washington, September 19 through 21, 2002), the American Academy of Pediatrics (AAP) (Boston, Massachusetts, October 18 through 23, 2002), 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 annual meeting, and the POSNA annual meeting. Upcoming educational events are listed at the end of this update.
Health Policy/Postgraduate Medical Education and Training
Surgical Referral Guidelines
Guidelines for the referral of patients to pediatric surgical specialists were published in Pediatrics in July 2002
1 . The Surgical Advisory Panel of the American Academy of Pediatrics (AAP), in response to a recommendation from the AAP Subspecialty Work Group, created these referral guidelines, which are intended to serve as "voluntary practice parameters to assist general pediatricians in determining when and where to refer their patients to pediatric surgical specialists," including orthopaedic surgeons. It also should be noted that many complex pediatric problems are more optimally managed by a medical-surgical team rather than by an individual surgical specialist. Conditions recommended for treatment by pediatric surgical specialists include major congenital anomalies, malignancies, major trauma, and chronic illnesses in infants and children. As stated in the guidelines, "the optimal management of the child with complex problems, chronic illness, or disabilities requires coordination, communication, and cooperation of the pediatric surgical specialist with the child's primary care pediatrician or physician." Centers dedicated to children may provide special expertise in such areas as imaging, pediatric medical subspecialty consultation, pediatric anesthesia, and pediatric intensive care
1 . These guidelines may be viewed online at www.aap.org.
ACGME (The Accreditation Council for Graduate Medical Education) Core Competencies for Residency Programs
The ACGME is moving to process evaluations of training programs (evaluations of how an educational program does on a day-to-day basis) under the leadership of Dr. David Leach. Each residency program must ensure that its trainees achieve competency in six areas
2 . These competencies are listed below.
1. Patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health.
2. Medical knowledge about established and evolving biomedical, clinical, and cognate sciences and the application of this knowledge to patient care.
3. Practice-based learning and improvement that involves investigation and evaluation of one's own patient care as well as appraisal and assimilation of scientific evidence and improvements in patient care.
4. Interpersonal and communication skills that result in effective exchange of information and teaming with patients, their families, and other health professionals.
5. Professionalism as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population.
6. Systems-based practice as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value.
Outcomes Research
Quality of Life of Individuals with Idiopathic Scoliosis
Grimard et al. compared the results of operative and nonoperative treatment of idiopathic scoliosis in a study of age-matched patients who had a Cobb angle of >35° and more than twenty years of follow-up. No differences were observed between the groups with regard to sexual activity, life status, education, work, alcoholism, smoking habits, chronic illness, or reproductive health. In addition, no differences in quality of life were observed with use of the Oswestry, SF-36, Roland, Quebec Back Pain Disability Scale, SRS, and Euro-Qol-5D instruments.
Problems with the Measurement of Orthopaedic and Neurosurgical Outcomes in Patients with Cerebral Palsy
Damiano et al. noted that the sensitive and specific measurement of changes in the function and health status of children undergoing surgery for cerebral palsy remains a challenge, despite the development of new outcome evaluation instruments. Gross motor function scores and the Pediatric Orthopaedic Society Outcomes Scale score identified no significant changes after surgical intervention, suggesting ceiling and/or basement effects. The study also suggested that more responsive measures may need to be developed to quantify the effects of intervention in children with chronic disorders.
Orthopaedic Diseases and Management
Fetal Diagnosis-Fetal Surgery
The fetus as a potential therapeutic target is becoming a clinical reality. Fetal diagnosis, mass genetic screening, and even fetal phenotype correction appear to be on the horizon. This new and unique area of surgical science and clinical knowledge has been advanced in large part by our colleagues in pediatric surgery, particularly Dr. Alan Flake of the University of Pennsylvania and Dr. Michael Harrison of the University of California at San Francisco. The phases of development of fetal interventions have gone from fetal surgery (used for the treatment of some forms of pulmonary neoplasia, congenital diaphragmatic hernia, and myelomeningocele defects) to fetoscopic diagnosis and intervention. Fetal cellular intervention and fetal gene therapy/stem-cell therapy for phenotype correction are on the horizon. Early screening and diagnosis is an essential requirement for this type of approach. One can imagine the panoply of possibilities associated with the future use of fetal magnetic resonance imaging, which allows for a virtual "fly-through" assessment of the fetus. Balancing fetal benefit with acceptable maternal risk will be a requirement in the ethical evaluation and the clinical applicability of these tools and techniques
3 .
Prenatal Ultrasonography
The prevalence of congenital abnormalities associated with all pregnancies is 2%, and the prevalence of musculoskeletal anomalies is further estimated to be 0.4% to 0.6%. Prenatal or perinatal death reduces the prevalence of congenital musculoskeletal anomalies in the general population to 0.024%. Orthopaedic conditions that are currently recognizable with fetal ultrasound were well summarized recently by Foster et al.
4 . These conditions include talipes equinovarus, humeral hypoplasia, radial or ulnar ray aplasia, proximal focal femoral dysplasia and fibular hemimelia, myelomeningocele (readily identifiable 95% of the time), anencephaly, diastematomyelia, hemivertebra, scoliosis, sacral agenesis, and bone dysplasias.
Growth and Development of the Pediatric Cervical Spine
Readers are encouraged to review and to refer to the study by Wang et al.
5 on the development of the pediatric cervical spine as documented on the basis of the radiographic resources of the Cleveland Study of Normal Growth and Development (Bolton-Brush Collection, Cleveland, Ohio). Highlights of the article included the finding that the anterior arch of the first cervical vertebra had ossified in 81% of the patients by the age of one year and that closure of the posterior synchondroses was completed in all children by the age of three years.
A New Classification of Adolescent Idiopathic Scoliosis
Orthopaedic surgeons are encouraged to become familiar with a newly developed and increasingly used system for the classification of adolescent idiopathic scoliosis
6 . The new classification system takes into account three major components of curve evaluation: (1) curve type (types 1 through 6), (2) a lumbar spine modifier (A, B, or C) that takes into account the degree of apical lumbar coronal malalignment, and (3) a sagittal thoracic modifier (-, N, or +) that takes into account the sagittal profile of the thoracic apical vertebra. The initial interobserver and intraobserver reliability of the system (with the exception of the interobserver reliability of curve-type assessment) was shown to be acceptable. This new system may allow for improved long-term assessment of patients with varying but specific curve types and may allow for more precise surgical planning.
Thoracic Vertebrae and Pedicle Morphology in Vertebrae from Scoliotic Spines
Parent et al. identified marked abnormalities in thoracic pedicle morphology in vertebrae from scoliotic spines. In particular, pedicles located on the concave side of a typical right thoracic curve were significantly smaller than those in matched normal individuals. Liljenqvist and coworkers also noted distinct vertebral asymmetry in the apical region of thoracic curves, with significantly thinner pedicles on the concave side as demonstrated with magnetic resonance imaging
7 . Both groups of investigators further stated that this information is of critical importance for surgeons who perform corrective surgery for patients with adolescent idiopathic scoliosis. Caution is recommended in the use of pedicle screws in the thoracic spine, especially on the concave side, given the small size of the epidural safe zone (<1.0 mm) and the extreme proximity of the thoracic spinal cord, the segmental nerve roots, and the vital structures (the aorta, esophagus, and lung parenchyma).
Analysis of the Position of the Aorta in Patients with Right Thoracic Idiopathic Scoliosis
Few studies have documented the relationship of the aorta to the thoracic vertebral bodies in patients with idiopathic scoliosis. Despite increasing interest among scoliosis surgeons in the surgical placement of anterior instrumentation in the thoracic vertebral bodies, the anatomic relationship of the aorta and vital organs to the vertebral bodies has not been well studied in patients with common conditions such as idiopathic scoliosis. Sucato and Duchene assessed axial magnetic resonance images of the spine (from T4 to L3) for scoliotic and normal individuals and noted that the aorta is positioned more lateral to the vertebral bodies at T5 through T11 in patients with scoliosis. In contrast, the aorta is positioned more anteriorly in individuals without scoliosis. The more lateral position of the aorta makes it particularly susceptible to injury from right-to-left vertebral screw placement, regardless of whether the placement is performed through a thoracotomy or a thoracoscopic approach. Preoperative magnetic resonance imaging may be helpful in planning such surgery when anterior thoracic approaches are being considered.
Growth Pattern in Patients with Idiopathic Scoliosis
A comprehensive physical morphology study of 582 girls with idiopathic scoliosis demonstrated that these adolescents were shorter than age-matched controls before puberty and taller than age-matched controls after puberty. Cheung, Lee, and coworkers assessed detailed anthropometric measurements that included body weight, height (corrected for scoliosis with use of the Bjure formula), body-mass index, arm span, sitting height, and leg length. Pubertal growth was graded with Tanner's staging system. That study identified abnormal peripubertal anthropometric measurements that were associated with a delay in menarche. While the precise etiology and mechanisms for the development of idiopathic scoliosis remain to be determined, the authors' findings are an important contribution to our knowledge about the etiology of idiopathic scoliosis, particularly with regard to the aspects pertaining to growth.
Ventilatory Functional Restriction in Adolescents with Mild or Moderate Idiopathic Scoliosis
Barrios and coworkers recently demonstrated, for the first time, that patients with mild and moderate idiopathic scoliosis have impairment of cardiopulmonary function. Those investigators noted a worse tolerance to maximal exercise testing, lower ventilatory efficiency at maximal exercise, an earlier anaerobic threshold, and a lower normalized maximal aerobic capacity in subjects with scoliosis than in matched nonscoliotic controls. That important study received the Hibbs Award for clinical research at the annual meeting of the Scoliosis Research Society in 2002. The study established that there is impairment of cardiopulmonary function even in patients with mild and moderate scoliosis, necessitating a reassessment of our understanding of and approach to mild and moderate scoliosis as a benign condition. Individuals with idiopathic scoliosis had a significantly lower tolerance to maximal and submaximal exercise but did not exhibit significant cardiopulmonary restrictions.
Treatment of Idiopathic Scoliosis with the SpineCor Brace
Rivard and coworkers recently reported on their experience with the new SpineCor brace (a unique, soft, strap-like device) for the treatment of idiopathic scoliosis. Using a survival-analysis method, the authors noted that stabilization and/or correction was maintained with this device throughout four years of follow-up. These results compare favorably with those associated with traditional "hard" braces such as the Boston, Wilmington, and Milwaukee-style braces. The advantages of the SpineCor brace to the patient are its low profile and its flexibility.
Limb-Length Discrepancy and Health-Related Quality of Life
Traditionally, orthopaedic surgeons utilize a 2-cm limb-length discrepancy as a cutoff value for determining the need for treatment. Interestingly, this guideline is based on little scientific information. As a method of determining what constitutes a clinically important discrepancy in children, Vitale et al. studied quality-of-life and scanographic data and concluded that a discrepancy of >2 cm has adverse effects on the quality of life. Those authors supported treatment for discrepancies of >2 cm.
Trauma
Treatment of Polytrauma in Children
Trauma remains the leading cause of mortality in children who are more than one year old. There remains a bimodal pattern of injury, with peaks in the toddler and adolescent years. The prevalence of injury is far more common in boys than in girls, with a ratio of 2:1. The majority of pediatric polytrauma is blunt trauma resulting from pedestrian injuries, falls from heights, and child abuse. Arguments have been made both in support of and against the management of injured children in specialized pediatric centers
8-10 . In either case, successful outcomes are closely related to expert treatment of head injuries, nonoperative care of liver and spleen injuries, and appropriate triage. The roles of the orthopaedist include identifying cervical spine injuries with use of computerized tomographic scans (most injuries in children are at C1-C2 and are not subaxial as is the case in adults), surveying for thoracolumbar spine injuries (assessing for back pain and using computerized tomography to define injuries), surveying for open fractures, checking for compartment syndrome, documenting peripheral nerve status, and splinting all fractures in the context of the global management of the patient.
Injury Rates for Children Involved in Community Sports
In order for physicians and health-care workers to formulate appropriate strategies for the prevention of sports injuries, surveillance is required to establish injury patterns. Radelet and coworkers reported on 1659 children, ranging in age from seven to thirteen years, who were participating in community-based baseball, softball, soccer, and football programs in an urban area
11 . Across all of these sports, contusions were the most frequent injury. The injury rate, calculated per 100 athlete exposures, was 1.7 for baseball, 1.0 for softball, 2.1 for soccer, and 1.5 for football. Serious injuries (fractures, dislocations, concussions) constituted 3% of all baseball injuries, 1% of all soccer injuries, and 14% of all football injuries. The frequency of injury per team per season, an estimation of injury risk, was 3 for baseball, 2 for softball, and 14 for football. The authors of that study recommend that coaches have first-aid training; that clear, enforceable return-to-play guidelines be established for concussions, neck and back injuries, fractures, and dislocations; and that faceguards be added to batting helmets used in baseball and softball.
The Epidemiology of Elbow Fractures in Children
Elbow fractures are common in children, but which are the most common and which are the least common? A consecutive, regional series of 547 elbow fractures was recently described by Hennrikus et al. at a meeting of the American Academy of Pediatrics. A prevalence of eighteen cases per 10,000 was noted. The five most common fractures were supracondylar extension (Type-1 or undisplaced) fractures, lateral condyle fractures, radial head/neck fractures, supracondylar extension (Type-3) fractures, and supracondylar extension (Type-2) fractures. Common mechanisms of injury included falls from furniture, falls from playground equipment, and falls on level ground. Child abuse is not a common cause of elbow fractures.
Effect of Delay of Surgical Treatment for Supracondylar Humeral Fractures in Children
Skaggs et al. further confirmed the findings of previous reports suggesting that the risk of complications is not increased in children with displaced supracondylar humeral fractures who are treated more than twelve hours after the injury. As this approach requires that a perfused and viable extremity be present, individualized patient assessment continues to be recommended
1 .
Submuscular Bridge-Plating of Pediatric Femoral Fractures
Operative approaches continue to be widely accepted for the treatment of femoral fractures in skeletally immature patients, especially six to twelve-year-old children, in whom retrograde titanium elastic nails are primarily used. Patients nearing skeletal maturity may be treated with locked trochanteric antegrade nails. Difficult femoral fractures with comminution, long spiral components, or a subtrochanteric or distal metaphyseal location may not be amenable to nailing. In these cases, another surgical alternative is biologic osteosynthesis with submuscular bridge-plating. This approach was demonstrated to be effective by Agus and colleagues and also by an Orthopaedic Trauma Association (OTA) pediatric femoral fracture study group that included Kanlic and colleagues.
Surgical Techniques
Antegrade Drilling for Treatment of Osteochondritis Dissecans of the Knee
Most skeletally immature children with osteochondritis dissecans of the femoral condyle are treated successfully with conservative (nonoperative) approaches. However, if nonoperative treatment fails, antegrade drilling may be effective. Ganley et al. reported that antegrade drilling was effective but was not uniformly successful in adolescent patients who had had a failure of nonoperative treatment. Factors associated with inadequate healing despite drilling included lesions in unusual locations, multiple lesions, and medical comorbidities.
Allografts for Pediatric Acetabuloplasty
Donor-site morbidity and graft failure are known to occur during acetabuloplasty in children. If the risk of these complications could be reduced or even eliminated, surgical outcomes would be enhanced. Stevens and coworkers reported on a series of twenty-six Pemberton acetabuloplasties that were performed with use of allograft bone wedges
12 . All of the osteotomy sites united radiographically within three months. The grafts provided acceptable correction and immediate stability. This stability often was sufficient to obviate the need for postoperative spica casting.
Surgical Management of Snapping Iliopsoas Tendon in Adolescents
Persistent, symptomatic snapping of the iliopsoas tendon may not resolve without surgery. Schoenecker and colleagues recently reported that fractional lengthening of the iliopsoas at the musculotendinous junction via a modified iliofemoral approach was effective for the treatment of snapping of the iliopsoas tendon in adolescents
13 . The reader is encouraged to refer to that study for its detailed and useful description of the surgical technique. In that series, all patients were able to return to the preoperative level of activity, without subjective weakness, at an average duration of follow-up of four years. All patients stated that they would have the operation again under similar circumstances. Two patients had a transient sensory loss in the anterior aspect of the thigh.
Surgery for Early-Onset Idiopathic Scoliosis
Progressive early-onset idiopathic scoliosis remains a challenging and largely unsolved problem in the field of pediatric orthopaedics. Two recent reports, however, have added to our knowledge in this area and have demonstrated encouraging results. Sengupta et al. noted acceptable surgical results in association with the use of a short segmental anterior fusion combined with a posterior so-called growing-rod construct. Ten of their thirty patients demonstrated maintenance of correction until skeletal maturity without definitive fusion, and only three patients demonstrated regression. Definitive fusion, when needed, was performed at an average age of 14.5 years. Mineiro and Weinstein recently reported on their experience with the use of subcutaneous rods for the treatment of progressive early-onset scoliosis
14 . They noted that this procedure, combined with consecutive distraction over time, allowed for the correction of curves that had failed to respond to nonoperative treatment and thereby preserved individual growth potential. The authors noted, however, that the limited amount of growth that was achieved and the number of procedures that were required raised the question of whether such patients might be better served by a limited anterior-posterior fusion with instrumentation at a younger age.
Allograft Cancellous Bone for Posterior Spinal Fusion in Idiopathic Scoliosis
Satisfactory surgical outcomes have been reported in association with the use of freeze-dried cancellous allograft for posterior spinal fusion in the treatment of idiopathic scoliosis. In one study, the fusion rate was 93% after an average duration of follow-up of thirty-nine months and minimal loss of curve correction was observed
15 .
Use of Modified Marrow Cells as a Technique to Enhance Spine Fusion
Goshi, Boachie-Adjei, and coworkers investigated a genetically modified marrow cell-allograft spine fusion model in animals. Allogenic bone graft combined with bone marrow that had been genetically modified with an adenovirus encoding bone morphogenetic protein-7 (BMP-7) enhanced fusion in the bilateral single-level model. This innovative method of combining laboratory and surgical approaches may hold promise for clinical application in the very near future.
Prone Positioning for Thoracoscopic Anterior Release and Fusion for Pediatric Spinal Deformity
As recently reported by Sucato and Elerson at a meeting of the Scoliosis Research Society, prone positioning for anterior thoracoscopic approaches may have advantages over lateral (decubitus) positioning. Use of the prone position appears to save time in the operating room because of reduced transition times between the stages of surgery and also appears to reduce serious complications related to single-lung ventilation.
Note: The author thanks John Grayhack, MD, and Erik King, MD, for their editorial review; Denise Ibrahim, DO, for her assistance with the bibliography search; and Jennifer Sutton for her editorial assistance.
Upcoming Educational Events
POSNA (Pediatric Orthopaedic Society of North America) Annual Meeting, Amelia Island Plantation, Amelia Island, Florida, May 1-4, 2003, Web site: www.posna.org
POSNA (Pediatric Orthopaedic Society of North America), Annual Meeting, Adam's Mark Hotel, St. Louis, Missouri, April 29-May 2, 2004, Web site: www.posna.org
AAOS Pediatric Orthopaedics: Current Perspectives and Techniques, October 17-19, 2003, Scottsdale, Arizona, The Marriott Mountain Shadows Resort and Golf Club, Web site: www.aaos.org
References
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- Kessler JI, Stevens PM, Smith JT, Carroll KL. Use of allografts in Pemberton osteotomies. J Pediatr Orthop, 2001;21: 468-73. [Medline]
- Dobbs MB, Gordon JE, Luhmann SJ, Szymanski DA, Schoenecker PL. Surgical correction of the snapping iliopsoas tendon in adolescents. J Bone Joint Surg Am, 2002;84: 420-4. [Abstract/Free Full Text]
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