The Journal of Bone and Joint Surgery (American) 86:1337-1346 (2004)
© 2004 The Journal of Bone and Joint Surgery, Inc.
What's New in Pediatric Orthopaedics
Mininder S. Kocher, MD, MPH1 and
John F. Sarwark, MD2
1 Department of Orthopaedic Surgery, Children's Hospital, 300 Longwood Avenue,
Boston, MA 02115. E-mail address:
mininder.kocher{at}childrens.harvard.edu
2 The Children's Memorial Hospital, 2300 Children's Plaza, Chicago, IL 60614.
E-mail address:
j-sarwark{at}northwestern.edu
Specialty Update has been developed in collaboration with the Council of
Musculoskeletal Specialty Societies (COMSS) of the American Academy of
Orthopaedic Surgeons.
The authors did not receive grants or outside funding in support of their
research or preparation of this manuscript. They 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
authors are affiliated or associated.
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Introduction
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The purpose of this fourth 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) (Amelia Island, Florida, May
2003), the American Academy of Orthopaedic Surgeons (AAOS) (New Orleans,
Louisiana, February 2003), the Scoliosis Research Society (SRS) (Quebec City,
Quebec, September 2003), the American Academy of Pediatrics (AAP) (New
Orleans, Louisiana, November 2003), and selected references. Orthopaedic
surgeons, residents, and fellows are encouraged to attend educational programs
on topics in pediatric orthopaedics presented at the 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.
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Pediatric Orthopaedic Conditions and Management
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Shoulder
Brachial Plexus Palsy
The management of children who have brachial plexus palsy continues to be
an area of active research interest. In preparation of a POSNA-sponsored
prospective, multicenter study of brachial plexus palsy, Bae et al. studied
eighty children who had this condition and found that the modified Mallet
Classification, the Toronto Test Score, and the Hospital for Sick Children
Active Movement Scale had acceptable interobserver and intraobserver
reliability for use in outcomes
assessment1. Pearl
et al. compared magnetic resonance imaging and arthrographic findings with
arthroscopic findings in a study of eightyfour children with brachial plexus
palsy who were treated for internal rotation contracture of the
shoulder2. They
found that 61% of the patients had substantial glenoid deformity, that the
severity of contracture was associated with the type of deformity, and that
magnetic resonance imaging showed greater detail than arthrography did. Hui
and Torode prospectively studied twenty-three patients who required open
glenohumeral reduction with tendon-lengthening and found that the angle of
glenoid retroversion decreased with time after open reduction as measured with
computerized
tomography3.
Elbow
Congenital Radial Head Dislocation
Horii et al. emphasized the importance of ulnar osteotomy in the surgical
correction of congenital radial head
dislocation4. In a
study of twenty-two patients who were treated with a variety of procedures
that included combinations of open reduction of the radial head, radial
osteotomy, ulnar osteotomy, and reconstruction of the anular ligament, the
nine patients who underwent elongation and angulation of the ulna demonstrated
the best results, with maintenance of reduction and range of motion being
observed in seven of these patients.
Elbow Contracture
Flexion contracture is a recognized sequela after elbow injury in children
and can be difficult to manage. Stans et
al.5 performed an
open capsular release in thirty-seven young patients who were between ten and
twenty years old and found that the total arc of motion improved from 66°
to 94°. However, the results were not uniformly good, with only 46% of
patients achieving a functional arc from 30° to 130° and two patients
losing motion after surgery. Gaur et al., in a study of nine elbows in
children who had major burn injuries and heterotopic ossification resulting in
a total arc of motion of <50°, found an average improvement of 57°
after excision of the heterotopic bone, without
recurrence6.
Forearm
Hereditary Multiple Osteocartilaginous Exostoses
Noonan et al. described the function of the forearm in thirtynine untreated
adults with multiple hereditary
osteochondromatosis7.
Overall, the patients had definite decreases in hand and wrist function;
however, they had little disability and had relatively low rates of vocational
impairment (13%) and pain (12%). These data will provide an untreated
comparison group for studies evaluating the results of surgical treatment of
this disorder in patients with involvement of the forearm.
Hand
Trigger Thumb
McAdams et al. evaluated the mean 15.1-year results for twenty-one patients
(thirty thumbs) who had undergone a release procedure for the treatment of
trigger thumb8.
Although there was no recurrence of triggering or functional deficits, 23% of
the patients had loss of interphalangeal motion and 18% had
metacarpophalangeal hyperextension. These data can help physicians to counsel
parents with regard to the long-term results of trigger thumb release.
Hip
Perthes Disease
The etiology, classification, and management of Perthes disease remain
controversial. Hresko et al. reexamined the association between thrombophilia
and Perthes disease in a random series of consecutive patients and found no
relationship with protein-C, protein-S, antithrombin-III deficiency, or factor
V Leiden
mutation9.
Herring et al. provided an update on a prospective, multicenter trial of
Perthes disease, started in 1984, in which the results of no treatment,
range-of-motion therapy, bracing, femoral osteotomy, and Salter osteotomy were
compared in a group of patients who were more than six years old at the time
of diagnosis. The Stulberg system was used to classify 352 hips in 343
patients who were studied at skeletal maturity. Surgical treatment resulted in
better outcomes for Herring type-B and type-B/C hips in patients who were more
than eight years old at the onset of the disease. No treatment was necessary
for younger patients and patients with Herring type-A hips. There was no
treatment effect for Herring type-C hips. In another study in which patients
with Perthes disease were followed to skeletal maturity, Grzegorzewski et al.
reported on 197 patients who had been treated with traction or bed rest,
Petrie casting, abduction bracing, or pelvic or femoral
osteotomy10.
Overall, 63% of the patients had a satisfactory result according to the
criteria of Mose and 74% had a satisfactory result according to the criteria
of Stulberg. Herring type-C hips had worse outcomes, and no significant
treatment effect was noted.
The lateral pillar classification described by Herring remains the most
widely used system for the evaluation of patients with Perthes disease. Lappin
et al. questioned the predictability of the initial Herring classification on
the basis of their finding that upgrading was required for ninety-two of 275
hips11. They
suggested that after seven months of symptoms, upgrading was less likely to be
needed.
Joseph et al. sought to identify the optimal timing for containment surgery
in a study of ninety-seven children who had been treated with femoral
osteotomy12. They
found that the chance of retaining a spherical femoral head was higher for
children in whom surgery was performed before the development of
advanced-stage fragmentation of the femoral head.
Developmental Dysplasia of the Hip
Selective ultrasonographic screening of infants for hip dysplasia was
questioned in two studies from the United Kingdom. Bache et al. performed
routine ultrasonographic screening in 48,000
infants13. Of the
ninety-two infants who had persistent ultrasonographic abnormality at six
weeks, only 20% had displayed evidence of clinical instability at the original
examination. Female infants without the risk factors of breech delivery or
family history accounted for 75% of the treated cases. Paton et al., in a
study of 1806 infants (comprising 6.3% of 28,676 live births) who underwent an
ultrasound examination because of instability or risk factors, reported no
overall reduction in the rate of surgery compared with that associated with
conventional clinical screening
programs14.
There are conflicting data regarding the importance of radiographic
evidence of the ossific nucleus in decreasing the risk of postreduction
osteonecrosis. In a study of forty-eight hips that had been treated with
closed reduction for developmental dysplasia of the hip, Carney et al.
observed fifteen cases of osteonecrosis. A lower risk of osteonecrosis was
associated with adductor tenotomy and the presence of the ossific nucleus.
Luhmann et al., in a study of 153 hips in 124 children who had been less than
two years old at the time of reduction for the treatment of developmental
dysplasia, reported a two-fold increase in the rate of secondary
reconstructive procedures when patients who had been at least six months old
at the time of the index procedure were compared with those who had been less
than six months old (35% compared with
17%)15. Thus,
delaying the reduction of a dislocated hip until the appearance of the ossific
nucleus may slightly decrease the rate of osteonecrosis; however, the delay
may result in less remodeling potential in older infants, thereby increasing
the need for secondary procedures.
Pelvic osteotomies are often necessary for the surgical treatment of
developmental dysplasia of the hip. Bohm and Brzuske described the long-term
results of the Salter innominate osteotomy in seventy-three hips after a mean
duration of follow-up of 30.9
years16. The mean
age of the patients at the time of the procedure was 4.1 years. A poor outcome
was reported for 21% of the hips, and seven hips underwent revision. The grade
of dislocation at the time of the initial examination, osteonecrosis of the
femoral head, and the adequacy of surgical correction were important
prognostic factors that had an effect on the clinical result. The
periacetabular osteotomy has gained popularity for the treatment of acetabular
dysplasia in skeletally mature adolescents and in adults. Ko et al. and Hsieh
et al. reported on the clinical and radiographic results for patients in whom
this procedure was performed through a transtrochanteric
approach17,18.
They noted that the anterior center-edge angle increased by 14° and
32°, that the lateral center-edge angle increased by 29° and 32°,
and that the femoral head coverage improved by 25% and 39%, respectively.
Slipped Capital Femoral Epiphysis
The treatment of the contralateral hip in patients with slipped capital
femoral epiphysis is controversial, with some investigators advocating
prophylactic pinning and others advocating watchful waiting. Using
expected-value decision analysis with probabilities of contralateral slip
determined from the literature and utility values for the different outcomes
obtained from the Iowa-hip-rating-system scores from a previously published
long-term follow-up study, Shultz et al. recommended prophylactic pinning.
However, Kocher et al. studied the same question with use of decision analysis
with utility values for the different outcomes obtained from the preferences
of patients and concluded that watchful waiting was the preferred
strategy.
Osteonecrosis is a dreaded sequela of slipped capital femoral epiphysis,
particularly in cases of unstable slips. Tokmakova et al. reported that
osteonecrosis developed in twenty-one of 240 patients in whom slipped capital
femoral epiphysis had been treated with various
methods19. All
twenty-one cases of osteonecrosis occurred in patients with unstable slips,
and the risk of osteonecrosis increased with the severity of the slip and with
reduction of the slip. Gordon et al. reported that osteonecrosis developed in
two of sixteen patients who had been managed with reduction and pinning of an
unstable slipped capital femoral
epiphysis20. They
recommended early reduction with arthrotomy and pinning with use of two
cannulated screws.
Carney et al., in a study of forty-six stable slips, evaluated slip
progression after in situ fixation with a single cannulated
screw21. The
authors recommended screw advancement until five threads engage the epiphysis,
as all nine slips that demonstrated progression of >10° had engagement
of fewer than five threads.
Knee
Anterior Cruciate Ligament Injury
The treatment of anterior cruciate ligament injuries in skeletally immature
patients is an area of much interest in the pediatric orthopaedic and sports
medicine communities. Controversy exists regarding the surgical technique for
anterior cruciate ligament reconstruction given the risk of injury to the
physes. Kocher et al. reported on fifteen cases of growth disturbance in
skeletally immature patients who had had anterior cruciate ligament
reconstruction, including eight cases of distal femoral valgus deformity with
arrest of the lateral distal femoral physis, three cases of tibial recurvatum
with arrest of the tibial tubercle apophysis, two cases of genu valgum without
arrest, and two cases of leg-length
discrepancy22.
Anderson, in a study of twelve skeletally immature patients, described a
physeal-sparing technique for anterior cruciate ligament reconstruction that
involved the placement of a quadruple hamstring tendon graft through
epiphyseal femoral and tibial
tunnels23. With
this technically challenging method, overall function was excellent and there
were no cases of growth disturbance.
Blount Disease
Chotigavanichaya et al., in a review of the results of seventyfour tibial
osteotomies that had been performed for the treatment of Blount disease,
confirmed the concept that surgery before the age of four years and
overcorrection into slight valgus may decrease the risk of recurrent varus
deformity24. At the
time of the six-year follow-up, varus deformity had recurred in 46% of
patients who had been four years old or younger at the time of the procedure
and in 88% of patients who had been more than four years old at the time of
the procedure.
Leg
Tibial Pseudarthrosis
Johnston compared three different variations of intramedullary fixation for
the treatment of congenital pseudarthrosis of the tibia in a study of
twenty-three consecutive patients who were reviewed after four to fourteen
years of
follow-up25. Eleven
patients had union with full unrestricted weight-bearing function and no
additional surgery, whereas three patients had persistent nonunion or
refracture requiring full-time external support. Patients who underwent
pseudarthrosis resection, tibial bone-grafting, and fibular resection or
osteotomy fared better than did those who did not have any fibular surgery.
Outcome was not associated with the initial radiographic appearance,
transfixation of the ankle, or age at the time of initial surgery. Similarly,
Joseph et al. found that an early age (less than three years) at the time of
initial surgery did not affect the union rate in a case series of twenty-six
consecutive patients with severe, atrophic (Crawford type-IV) tibial
pseudarthrosis who were managed with resection, intramedullary rodding, and
bone-grafting.
Fibular Hemimelia
Stanitski and Stanitski suggested a new classification system for fibular
hemimelia that was based on fibular and ankle morphology, hindfoot coalition,
and foot ray
deficits26. The
authors emphasized the unpredictable relationships among the fibula, ankle,
and foot in patients with this disorder. Paley et al., in a study of
seventy-eight patients with ninety-four lengthenings, reported that the
results were excellent after forty-six procedures, good after thirty, and fair
after eighteen. There were twenty recurrent foot deformities. Functional
results were not correlated with the number of rays in the foot.
Foot and Ankle
Clubfoot
Ponseti's technique of manipulation and casting has received renewed
interest. Heilig et al. reported that the results of a survey of 416 POSNA
members confirmed widespread adoption of the Ponseti
technique27.
Herzenberg et al. compared the results for the first thirty-four feet that
they treated with the Ponseti technique with the results for thirty-four feet
that were not treated with the Ponseti technique and found a marked decrease
in the need for posteromedial release in the first year of life (3% compared
with 94%)28. In
that study, percutaneous heel-cord tenotomy at the age of two to three months
was performed in 91% of the feet that were treated with the Ponseti technique.
Compliance with the prolonged use of a foot abduction orthosis after casting
was emphasized by both Thacker et al. and Dobbs et al., who found diminished
functional rating scores and greater recurrence of deformity in patients from
noncompliant families.
Macrodactyly
Chang et al., in a series of seventeen feet in fifteen patients with
macrodactyly, reported that ray resection resulted in a better cosmetic and
functional outcome than did toe amputation in cases of lesser toe
involvement29. The
results were only fair in cases of great toe involvement, with repeat
soft-tissue debulking often being necessary.
Spine
Aggrecan Gene Polymorphism
Aggrecan is the shortened name of the large aggregating
chondroitin sulphate proteoglycan, and it represents up to 10% of the dry
weight of cartilage. Many individual monomers of aggrecan bind to hyaluronic
acid to form an aggregate; it is the monomer that is termed aggrecan.
Although the aggrecan gene has been studied extensively and has been linked
with osteoarthritis, more recent studies have linked aggrecan gene
abnormalities with spinal deformity. At the 2003 meeting of the SRS, Merola
and associates reported that individuals under the age of twenty-one years
with differences in exon 12 of the aggrecan gene had an increased risk for the
development of idiopathic scoliosis compared with a control group.
Natural History/Adolescent Idiopathic Scoliosis and 30° to 50° Curves
Mehbod et al., from the Twin Cities Spine Center in Minneapolis, reported
on forty-six patients with major curves between 30° and 50° who were
followed for at least ten years. All patients were braced and then were left
untreated after skeletal maturity. At the time of the last follow-up, 30% of
the curves had not increased, 33% had increased between 6° and 10°,
and 34% had increased between 11° and 20°. Neither the location of the
curve nor the magnitude of the curve at the time of maturity influenced the
risk of progression.
Normal Lung Development
Smith et al., in a study from the University of Utah, analyzed 940
computerized tomographic scans of the normal chest to establish the normal
size of the lungs as a function of age. This study led to the construction of
an age-based normative data model for lung development in children. This
clinical tool will add to the evaluation of respiratory status in children
with simple and complex spinal deformities at all ages.
Range of Motion of the Trunk Following Anterior or Posterior Spinal Fusion
Lenke et al., in a study from Washington University in St. Louis, found
that the range of motion of the trunk in patients with idiopathic scoliosis
was decreased after spinal fusion through either an anterior or a posterior
approach, although the results favored the anterior approach. With use of
reflective markers and a six-camera motion-analysis system, the investigators
also noted no differences in gait between the two groups.
Anterior Reconstruction for Idiopathic Thoracolumbar Scoliosis
Kaneda and coworkers from Japan, in a study that was presented at the SRS
meeting in 2003, demonstrated excellent correction and solid fusion in
patients with thoracolumbar scoliosis who had been treated with a dual-rod
anterior system. After a mean duration of follow-up of five years and seven
months, 90% deformity correction had been achieved over the instrumented
levels.
Posterior Spinal Fusion/Isola Instrumentation
Asher and colleagues, in a study that was presented at the SRS meeting in
2003, evaluated the effectiveness of posterior Isola instrumentation for the
treatment of idiopathic scoliosis. After an average duration of follow-up of
4.9 years, the authors concluded that the integrated wire, hook, and
pedicle-screw system can be used safely and effectively for the treatment of
idiopathic scoliosis.
Experimental Endoscopic Hemiepiphyseodesis
Wall and coworkers, in an animal study from Cincinnati Children's Hospital
that was presented at the SRS meeting in 2003, found that spinal
hemiepiphyseodesis repeatedly induced spine curvature, thereby demonstrating
the ability of a vertebral staple to modulate growth. This study bears the
clinical promise of surgical treatment of scoliosis without fusion.
Outcomes of Major Perioperative Neurologic Complications in Pediatric Spinal Deformity
Moroz et al., in a study from Children's Hospital in Boston that was
presented at the SRS meeting in 2003, noted neurological deficits in
association with fourteen of 4317 cases of spinal deformity in children, with
six of the fourteen cases being identified intraoperatively and eight being
identified at an average of 32.9 hours postoperatively. Two of the fourteen
patients had full return of neurological function, and ten had notable
recovery of motor function but were left with some residual motor deficit and
"almost always a bladder function problem."
Spinal Instrumentation in Congenital Spine Deformities
Hedequist et al., in a study from Children's Hospital in Boston that was
presented at the SRS meeting in 2003, found spinal instrumentation to be safe
and effective for the treatment of congenital spinal abnormalities in
children. Little information demonstrating this effectiveness has been
published previously. No neurological deficits were reported in this
series.
Spino-Pelvic Balance and Spondylolisthesis
Labelle et al., in a study that was presented at the SRS meeting in 2003,
found that pelvic morphology and pelvic balance do not change following
lumbosacral reduction and posterior instrumentation and fusion. Spinal shape
and spinal balance cephalad to the fusion and instrumented areas are changed
and improved. The issues of pelvic morphology and its relationship to spinal
balance in the sagittal plane in patients with developmental spondylolisthesis
continue to be investigated.
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Fractures in Children
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General Considerations
Fagelman et al. assessed the performance of the Mangled Extremity Severity
Score (MESS), which was originally designed for adults, in a study of
thirty-six children with grade-IIIB and IIIC open lower extremity
fractures30. The
MESS prediction was accurate for 93% of the twenty-eight limbs that were
treated with salvage and for 63% of the limbs that were treated with
amputation. The authors suggested that use of the MESS should be considered
when managing a child who has severe lower extremity trauma.
Flynn et al., in a series of twenty-seven children, emphasized the
importance of early recognition and treatment of acute traumatic compartment
syndrome of the leg. Good end results without sequelae were observed in 89% of
patients. The three patients with sequelae all had late fasciotomies
(performed more than thirty-six hours after the injury).
Supracondylar Humeral Fracture
Studies of type-3 supracondylar humeral fractures have confirmed previous
findings indicating that there is no relationsip between delayed reduction and
an unfavorable result. Leet et al., in a study of 158 such fractures, found
that the time between injury and surgical treatment (mean, 21.3 hours) had no
association with longer operative times, the need for open reduction, or
complications31.
Gupta et al., in a study of 150 fractures, reported no differences in the
rates of open reduction or complications between fractures that had been
treated within twelve hours after the injury and those that had been treated
twelve hours or more after the injury.
Forearm Fracture
The optimal position of immobilization was studied by Boyer et al. in a
randomized clinical trial of ninety-nine distal-third forearm
fractures32.
Residual fracture angulation at the time of union was not significantly
affected by forearm position (pronation, supination, or neutral) during cast
immobilization.
Scaphoid Fracture
Henderson and Letts, in a study of scaphoid waist fracture nonunions in
adolescents, reported that union was achieved in all patients after operative
treatment involving internal fixation and/or bone-grafting, with good overall
functional
results33. Waters
and Stewart, in a report on three adolescents with proximal scaphoid nonunion
and avascular necrosis, reported that union was achieved after treatment with
vascularized bone graft from the distal part of the
radius34.
Femoral Fracture
Wright et al. described the results of a randomized, multicenter clinical
trial in which early spica casting was compared with external fixation for the
treatment of femoral fractures in 101 children who were between four and
eleven years of age. The rate of nonunion (defined as a leg-length difference
of  2 cm, flexion-extension angulation of 15°, or varus-valgus
angulation of 10°) was higher in the external fixation group than in
the spica casting group (45% compared with 16%). However, there was no
difference in functional outcome or parent/child satisfaction between the two
groups.
The treatment of pediatric femoral fractures with titanium elastic nails
has become widespread. Snibbe et al., in a series of seventeen children who
were four to thirteen years old, suggested that these nails can be used for
subtrochanteric fractures. Luhmann et al., in a study of complications
associated with titanium elastic nails, reported twenty-one complications
after the treatment of forty-three femoral shaft
fractures35. The
complications included septic arthritis after nail removal (one patient),
hypertrophic nonunion (one), pain over the nails (fourteen), nail erosion
through the skin (four), and delayed union (one). The authors recommended
leaving <2.5 cm of the nail out of the femur and using the largest nail
sizes possible.
The use of limited open bridge-plating of pediatric femoral fractures also
has received interest. Agus et al. reported good functional results in a study
of fourteen children (mean age, 11.3 years) in whom closed comminuted femoral
shaft fractures were treated with bridge-plating through two small
incisions36.
Tibial Spine Fracture
Operative treatment of displaced (type-3) or hinged (type-2) tibial spine
fractures may allow for removal of an entrapped meniscus. The prevalence of
meniscal entrapment has been studied recently. Lowe et al. reported no
instances of entrapment in a study of twelve patients with a type-3 fracture,
emphasizing that the anterior horn of the lateral meniscus remains attached to
the tibial eminence
fragment37.
However, Kocher et al., in a report on eighty patients with nonreducible
type-2 and 3 fractures, found meniscal entrapment in association with 26% of
the type-2 fractures and 65% of the type-3 fractures. The structures that were
entrapped most commonly were the anterior horn of the medial meniscus and the
intermeniscal ligament.
Distal Tibial Fracture
Barmada et al. studied the incidence and predictors of premature physeal
closure after distal tibial fracture in a series of ninety-two
children38. After a
minimum duration of followup of one year, physeal arrest was observed in
association with twenty-five fractures (27%). Salter-Harris type-III and IV
fractures were associated with the highest risk of physeal arrest (38%). More
anatomic reductions resulted in decreased rates of physeal arrest. In patients
with Salter-Harris type-I and II fractures, a residual physeal gap of >3 mm
following reduction increased the risk of physeal arrest from 17% to 60%.
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Other Musculoskeletal Conditions
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Tumors
The prognostic importance of pathologic fractures in patients with
osteosarcoma was investigated by Scully et al. in a study of fifty-two
patients who had such a fracture and fifty-two patients who did
not39. Patients who
had a pathologic fracture had an increased risk of local recurrence and a
decreased overall rate of survival.
Rougraff and Kling, in a study of twenty-three patients, reported that the
percutaneous injection of demineralized bone matrix and bone marrow was
effective for the treatment of unicameral bone
cysts40. Five
patients required a second injection to achieve healing of the cyst. Seven
patients demonstrated incomplete healing.
Ghanem et al. investigated the effectiveness of percutaneous radiofrequency
ablation for the treatment of osteoid osteoma in a study of twenty-three
children and
adolescents41. Pain
disappeared immediately after surgery in twenty-one patients and resolved
after an average of 3.5 years of follow-up in the remaining two.
Cerebral Palsy
The use of formal gait analysis for decision-making in the treatment of
cerebral palsy is common. Cook et al. assessed the value of gait analysis in a
study of 102 patients with cerebral palsy who were able to
walk42. The authors
noted that gait analysis altered the treatment decision that had been based on
clinical analysis 40% of the time, particularly for patients undergoing
soft-tissue operations. Noonan et al., however, questioned the reliability of
gait analysis43.
Eleven patients with cerebral palsy who were able to walk were evaluated with
instrumented gait analysis at four different centers. There was wide
variability in the raw gait analysis data and in treatment
recommendations.
Knapp and Cortes investigated the natural history of hip dislocation in
adults with cerebral
palsy44. The
authors identified thirty-eight dislocated hips in twenty-nine patients who
had a mean age of thirty-four years. Seven hips were definitely painful, and
four were intermittently painful. The authors questioned the aggressive
surgical treatment of established nonpainful hip dislocations in severely
involved spastic quadriplegic patients.
Murray-Weir et al. investigated the effect of proximal femoral varus
derotational osteotomy on gait in a consecutive series of thirty-seven
patients45. The
procedure resulted in increased hip external rotation, increased hip
extension, decreased anterior pelvic tilt, and increased knee extension
strength.
Saw et al. studied the effectiveness of rectus femoris transfer for the
treatment of a stiff-knee gait in a series of twenty-four children
(thirty-eight limbs) with cerebral
palsy46. Gait
analysis revealed improvements in maximum swing-phase knee flexion and total
knee motion along with a small loss of knee extension in stance phase, a
condition that may necessitate hamstring lengthening in some cases. Baddar et
al. investigated the effect of gastrocnemius recession on knee flexion in a
series of thirty-four subjects with an equinus
gait47. Knee
extension did increase at foot contact; however, excessive midstance knee
flexion persisted and likely was due to concomitant contracture of the
hamstrings.
Piazzi et al. studied the mechanics of split transfers of the tibialis
anterior and posterior tendons for hindfoot varus deformities in cadaveric
specimens. Split transfer of the tibialis posterior tendon produced the
desired effect of an eversion moment when the foot was inverted and an
inversion moment when the foot was everted, whereas split transfer of the
tibialis anterior tendon resulted in an eversion moment regardless of the
position of the hindfoot. Ackman et al. reported the results of a randomized
clinical trial investigating the use of Botox (botulinum toxin) and casting,
placebo and casting, and Botox alone for the treatment of dynamic equinus in
children with cerebral palsy who were able to walk. Interestingly, the
investigators found significant improvement both in the group treated with
Botox and casting and in the group treated with placebo and casting, with no
significant difference between the groups.
Myelodysplasia
Sun et al. evaluated peripheral circulation in forty-one patients who had
myelodysplasia and forty-one age-matched controls with use of an
ankle-brachial index and transcutaneous measurements of the partial pressure
of oxygen48.
Patients with myelodysplasia had lower ankle-brachial indices but similar
transcutaneous measurements of the partial pressure of oxygen. Impaired
circulation may contribute not only to neurologic deficits but also to the
increased propensity for wound dehiscence and ulcer formation among patients
with myelodysplasia.
Muscular Dystrophy
Aparicio et al. reported that osteoporosis was documented with use of
dual-energy x-ray absorptiometry in ten children (mean age, eight years) with
Duchenne muscular dystrophy who were able to
walk49. Scher and
Mubarak recommended posterior tibial tendon transfer and Achilles tendon
lengthening as a way to maintain a plantigrade foot in patients with Duchenne
muscular dystrophy after reviewing the results of this procedure in
forty-eight feet (twenty-four
patients)50.
Limb-Lengthening
Complications associated with limb-lengthening, including nerve injury and
fracture, were reported by Nogueria et al. and O'Carrigan et al. In the study
by Nogueria et al., neurologic complications were noted in association with
9.3% of 814 limb-lengthening procedures. Patients undergoing double-level
tibial lengthening and those with skeletal dysplasia were at higher risk for
nerve injuries (77% and 48%, respectively). Early decompression was strongly
recommended for those nerve injuries. In the study by O'Carrigan et al.,
fractures occurred in association with 8.1% of 986 limb-lengthening
procedures. Fractures occurred most frequently outside of the frame through
regenerated bone. Patients with congenital and dysplastic limb abnormalities
with fractures had higher rates of residual deformity.
Additional surgical techniques for limb-lengthening also have been
reported. Gordon et al. described a technique of femoral lengthening over a
humeral intramedullary nail placed through the greater trochanter in a study
of nine preadolescent children without proximal femoral growth
disturbance51.
Guichet et al. described their experience with femoral lengthening with use of
a ratcheting intramedullary nail (the Albizzia nail) in a study of forty-one
femora in thirty-one
patients52.
Infection
The timely diagnosis of septic arthritis in children is essential. Levine
et al. compared the test characteristics of C-reactive protein with those of
the erythrocyte sedimentation rate in a study of 133 patients who were being
evaluated for septic
arthritis53.
C-reactive protein was found to be a better predictor of septic arthritis than
the erythrocyte sedimentation rate was. Willis et al. pointed out the
considerable overlap between the initial clinical and laboratory presentations
of acute septic arthritis and Lyme arthritis in
children54.
Morrissy et al. evaluated the value of the polymerase chain reaction test in
the diagnosis of septic arthritis and found that the test had a good positive
predictive value but an unreliable negative predictive value. Kocher et al.
developed a clinical practice guideline for the management of children who
have septic arthritis and found that it reduced hospital stay, optimized
antibiotic management, and decreased variation in a case-control study of such
patients55.
Health Services and Outcomes
The use of the Internet as a source of medical information is common among
parents of children visiting the pediatric orthopaedist. Bealls et al., in a
survey of 212 families, found the lowest rates of usage for fractures (18.2%)
and the highest rate of usage for scoliosis (53.5%). Discrepancies in access
to timely orthopaedic care for Medicaid patients was reported by Skaggs et al.
in a study of children with forearm fractures and by Kocher et al. in a study
of children with slipped capital femoral epiphysis.
Outcomes assessment in patients with cerebral palsy is challenging. Abel et
al. evaluated the relationships among clinical impairment measures with use of
standardized assessments of function and disability (gait analysis, the Gross
Motor Function Measure, and the Pediatric Outcomes Data Collection Instrument)
in a study of 129 children with cerebral palsy who were able to
walk56. They found
that isolated impairment measures of motion and spasticity had only weak
correlations with motor function. Haynes et al., in a study of fifty-three
patients with cerebral palsy who were able to walk, found that the Pediatric
Outcomes Data Collection Instrument was related to technical measures of gait
analysis and energy consumption. Sanders et al., in a study of 470 patients
with cerebral palsy who were seen at ten Shriners hospitals, found that the
Pediatric Outcomes Data Collection Instrument was correlated with the severity
of neurologic involvement; however, it was not responsive to interventions and
demonstrated ceiling effects for mobility. Graham et al., on the other hand,
found that the Pediatric Outcomes Data Collection Instrument and the Child
Health Questionnaire were responsive in a study of thirty-five spastic
diplegic patients.
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Health Policy
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Surgical Referral Guidelines
Guidelines for referral to pediatric surgical specialists were published in
the journal Pediatrics in July 2002. 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 with the
intention that they would 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. The 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." Many complex pediatric problems are more
optimally managed by a medical-surgical team rather than by an individual
surgical specialist. Centers dedicated to children may provide special
expertise in areas such as imaging, pediatric medical subspecialty
consultation, pediatric anesthesia, and pediatric intensive care. The
guidelines may be viewed online at
www.aap.org/policy/pprgtoc.cfm.
Certificate of Special Qualification in Spine Deformity Surgery
POSNA leaders have recently responded critically to a proposal for a
Certificate of Special Qualification in Spine Deformity Surgery. The proposal,
which was made to the American Board of Orthopedic Surgery (ABOS) in the fall
of 2003, was sponsored by the leadership of the Scoliosis Research Society
(SRS).
Adolescents and Anabolic Steroids
According to pediatric specialists, most pediatric athletes will find a way
to meet their sports goals without using anabolic steroids. These athletes
should be reminded that the health, fitness, and social benefits of sports
participation can be met readily without use of performance-enhancing
substances. According to the American Academy of Pediatrics, current clinical
experience and scientific evidence support an approach to the anabolic steroid
issue that minimizes preconceptions about the users, recognizes the potential
benefits as well as risks of use, and maximizes informed, balanced, and open
interaction with patients
(www.aap.org/policy/pprgtoc.cfm).
Atlantoaxial Instability in Down Syndrome
According to the American Academy of Pediatrics, lateral plain radiographs
of the cervical spine are of potential, but unproven, value for identifying
patients with Down syndrome who are at risk for the development of spinal cord
injury during participation in sports. Radiographic evaluation is emphasized
for patients with neurologic symptoms. Recognition of symptomatic patients
requires frequent interval histories and physical examinations, including
evaluations before participation in sports, preferably by physicians who have
cared for these patients longitudinally. Parents must be taught the signs and
symptoms of antlantoaxial instability that indicate the need to seek immediate
medical care.
The Special Olympics does not plan at this time to remove its requirement
for all athletes with Down syndrome to be evaluated with radiographs of the
cervical spine. Pediatricians and orthopaedic specialists will continue to be
called on to order these tests. Better research is needed to determine which
symptoms, signs, and findings from imaging studies best identify individuals
with Down syndrome who are at increased risk for a catastrophic spinal cord
injury during participation in sports
(www.aap.org/policy/pprgtoc.cfm).
Managed Care and Children with Special Health-Care Needs
Dialogue opportunities exist for improving some aspects of care for
children with chronic illnesses and disabilities who are patients in
managed-care systems. The AAP has suggested the following guidelines for
discussion
(www.aap.org/policy/pprgtoc.cfm).
(1) Create an understanding of major differences between adult and childhood
disability and the resulting need for managed-care models to be sufficiently
flexible to serve children with special needs and their families. (2)
Establish fair reimbursement to compensate for the increased time and
complexity associated with providing and coordinating care for children and
families of children with special health-care needs. This translates into risk
adjustment for capitated systems. (3) Ensure access to and appropriate use of
pediatric subspecialists with defined roles, and open lines of communication
between secondary and tertiary care and the medical home. (4) Create viable
systems of monitoring care that are capable of producing process and outcomes
data from which appropriate adjustments can be made to refine care for the
benefit of children and their families.
Use of a Knee Brace by the Young Athlete
The AAP has recommended that physicians establish an accurate diagnosis of
the injury and understand the classifications, benefits, limitations,
indications, and cost of any knee brace that is prescribed
(www.aap.org/policy/pprgtoc.cfm).
There is insufficient scientific evidence to recommend the use of
prophylactic knee braces for the pediatric athlete. In fact, available studies
have not supported the prescription of most knee braces. The use of knee
sleeves, functional braces, and postoperative braces has been accepted
clinically on the basis of physician assessment. When used, knee braces should
complement, rather than replace, rehabilitative therapy and surgery.
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Evidence-Based Orthopaedics
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During 2002, the editorial staff of The Journal reviewed a large
number of research studies related to pediatric orthopaedics that received a
Level of Evidence grade of I. Over forty medical journals were reviewed to
identify these articles, which all have high-quality study design. In addition
to articles published previously in this journal or cited already in this
Update, six level-I articles were identified that were relevant to pediatric
orthopaedics. A list of those titles is appended to this review after the
standard bibliography. We have provided a brief commentary about each of the
articles to help to guide your further reading, in an evidence-based fashion,
in this subspecialty area.
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Upcoming Educational Events
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AAOS (American Academy of Orthopaedic Surgeons) Surgical Techniques for
Managing Pediatric Orthopaedic Trauma Orthopedic Learning Center Rosemont,
Illinois October 22-24, 2004 Web site:
www.aaos.org
POSNA (Pediatric Orthopaedic Society of North America) Annual Meeting
Ottawa, Ontario, Canada May 13-15, 2005 Web site:
www.posna.org
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Evidence-Based Articles Related to Pediatric Orthopaedics
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Morris S, Cassidy N, Stephens M, McCormack D, McManus F.
Birth-associated femoral fractures: incidence and outcome. J Pediatr
Orthop. 2002; 22:27-30.
Eight femoral fractures in seven patients occurred in association with a
total of 55,296 live births in Ireland. Twin pregnancies, breech
presentations, prematurity, and disuse osteoporosis were associated with the
occurrence of fracture. All patients had a good clinical outcome after
treatment with a variety of modalities. The findings of this study will help
the physician to estimate the incidence of and risk factors for
birth-associated femoral fractures.
McLaughlin J, Bjornson K, Temkin N, Steinbok P, Wright V, Reiner A,
Roberts T, Drake J, O'Donnell M, Rosenbaum P, Barber J, Ferrel A.
Selective dorsal rhizotomy: meta-analysis of three randomized controlled
trials. Dev Med Child Neurol. 2002;44:17-25.
The authors performed a meta-analysis of three randomized clinical trials
of children with spastic diplegia who had had either selective dorsal
rhizotomy with physical therapy or physical therapy only. Common outcome
measures were used to assess spasticity (Ashworth scale) and function (Gross
Motor Function Measure), and the baseline and nine to twelve-month data from
the three studies were pooled. There was a greater reduction in spasticity and
greater functional improvement in children who had been treated with selective
dorsal rhizotomy with physical therapy. There was a direct multivariate
relationship between the percentage of dorsal root tissue transected and
functional improvement.
Pommer A, Muhr G, David A. Hydroxyapatite-coated Schanz pins in
external fixators used for distraction osteogenesis. J Bone Joint Surg
Am. 2002;84:1162-6.
Forty-six consecutive patients undergoing segmental transport or
lengthening of the tibia with external fixation were randomized to treatment
with either standard titanium Schanz pins or hydroxyapatite-coated
stainless-steel pins. Lower rates of loosening and infection were found in
association with the hydroxyapatite-coated pins, suggesting that their use is
appropriate in clinical situations requiring prolonged external fixation.
Mladenov K, Dora C, Wicart P, Seringe R. Natural history of hips
with borderline acetabular index and acetabular dysplasia in infants. J
Pediatr Orthop. 2002;22:607-12.
Sixty-eight clinically stable hips with an age-related increase in the
acetabular index were followed without treatment for a mean of 9.5 years.
Forty-four hips demonstrated normalization, twenty hips had minor deviations
from normal values, and four hips showed no improvement. Displacement of the
femoral head was not observed in any of the hips that showed improvement,
whereas displacement was present in all four of the hips that showed no
improvement. Longer-term follow-up is essential to determine the fate of the
hips with minor deviations.
Holen KJ, Tegnander A, Bredland T, Johansen OJ, Saether OD, Eik-Nes SH,
Terjesen T. Universal or selective screening of the neonatal hip using
ultrasound? A prospective, randomised trial of 15,529 newborn infants. J
Bone Joint Surg Br. 2002;84:886-90.
In this Norwegian study, a large number of newborn infants were randomized
to clinical examination and routine ultrasound examination of all hips or
clinical examination and selective ultrasound examination of only hips in
patients with risk factors (abnormal findings on examination, family history,
breech position, and foot deformity). After six to eleven years of follow-up,
one late-detected case of hip dysplasia was seen in the universal group
compared with five in the selective group; however, this difference was not
significant. The authors concluded that universal ultrasound screening of hips
has only marginal benefit in preventing the development of late cases of hip
dysplasia.
Kermond S, Fink M, Graham K, Carlin JB, Barnett P. A randomized
clinical trial: should the child with transient synovitis of the hip be
treated with nonsteroidal anti-inflammatory drugs? Ann Emerg Med.
2002;40:294-9.
Thirty-six patients with transient synovitis of the hip were randomized to
treatment with either ibuprofen or placebo, and the time to symptom resolution
was recorded in diaries. Only patients with a low index of suspicion for more
serious pathology were included, and concurrent use of acetaminophen was not
controlled. Patients who received ibuprofen had a shorter duration of symptoms
(2.0 compared with 4.5 days), thereby encouraging the use of ibuprofen for
patients with transient synovitis. However, the use of ibuprofen should be
restricted to those with a low index of suspicion for septic arthritis in
order to avoid masking symptoms that are associated with this serious medical
condition.
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Acknowledgments
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NOTE: The authors thank the POSNA Board of Directors for their
editorial review of this manuscript—Drs. Charles Price, Scott Mubarak,
David Aronsson, Laura Lowe Tosi, John Dormans, Anthony Ashworth, James Roach,
George Thompson, John Sarwark, William Warner, Kenneth Noonan, James Kasser,
James Beaty, Dale Blasier, Richard Haynes, Lori Karol, and Ben Alman. They
also thank POSNA staff Sharon Goldberg and Teri Stech.
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References
|
|---|
- Bae DS, Waters PM, Zurakowski D.
Reliability of three classification systems measuring active motion in
brachial plexus birth palsy. J Bone Joint Surg Am.2003; 85:1733
-8.[Abstract/Free Full Text]
- Pearl ML, Edgerton BW, Kon DS,
Darakjian AB, Kosco AE, Kazimiroff PB, Burchette RJ. Comparison of
arthroscopic findings with magnetic resonance imaging and arthrography in
children with glenohumeral deformities secondary to brachial plexus birth
palsy. J Bone Joint Surg Am.2003; 85:890
-8.[Abstract/Free Full Text]
- Hui JH, Torode IP. Changing
glenoid version after open reduction of shoulders in children with obstetric
brachial plexus palsy. J Pediatr Orthop.2003; 23:109
-13.[Medline]
- Horii E, Nakamura R, Koh S, Inagaki
H, Yajima H, Nakao E. Surgical treatment for chronic radial head
dislocation. J Bone Joint Surg Am.2002; 84:1183
-8.[Abstract/Free Full Text]
- Stans AA, Maritz NG, O'Driscoll SW,
Morrey BF. Operative treatment of elbow contracture in patients twenty-one
years of age or younger. J Bone Joint Surg Am.2002; 84:382
-7.[Abstract/Free Full Text]
- Gaur A, Sinclair M, Caruso E, Peretti
G, Zaleske D. Heterotopic ossification around the elbow following burns in
children: results after excision. J Bone Joint Surg
Am. 2003;85:1538
-43.[Abstract/Free Full Text]
- Noonan KJ, Levenda A, Snead J,
Feinberg JR, Mih A. Evaluation of the forearm in untreated adult subjects
with multiple hereditary osteochondromatosis. J Bone Joint Surg
Am. 2002;84:397
-403.[Abstract/Free Full Text]
- McAdams TR, Moneim MS, Omer GE
Jr. Long-term follow-up of surgical release of the A(1) pulley in
childhood trigger thumb. J Pediatr Orthop.2002; 22:41
-3.[Medline]
- Hresko MT, McDougall PA, Gorlin JB,
Vamvakas EC, Kasser JR, Neufeld EJ. Prospective reevaluation of the
association between thrombotic diathesis and Legg-Perthes disease.
J Bone Joint Surg Am.2002; 84:1613
-8.[Abstract/Free Full Text]
- Grzegorzewski A, Bowen JR, Guille JT,
Glutting J. Treatment of the collapsed femoral head by containment in
Legg-Calve-Perthes disease. J Pediatr Orthop.2003; 23:15
-9.[Medline]
- Lappin K, Kealey D, Cosgrove A.
Herring classification: how useful is the initial radiograph? J
Pediatr Orthop. 2002;22:479
-82.[Medline]
- Joseph B, Nair NS, Narasimha Rao KL,
Mulpuri K, Varghese G. Optimal timing for containment surgery for Perthes
disease. J Pediatr Orthop.2003; 23:601
-6.[Medline]
- Bache CE, Clegg J, Herron M. Risk
factors for developmental dysplasia of the hip: ultrasonographic findings in
the neonatal period. J Pediatr Orthop B.2002; 11:212
-8.[Medline]
- Paton RW, Hossain S, Eccles K.
Eight-year prospective targeted ultrasound screening program for instability
and at-risk hip joints in developmental dysplasia of the hip. J
Pediatr Orthop. 2002;22:338
-41.[Medline]
- Luhmann SJ, Bassett GS, Gordon JE,
Schootman M, Schoenecker PL. Reduction of a dislocation of the hip due to
developmental dysplasia. Implications for the need for future surgery.
J Bone Joint Surg Am.2003; 85:239
-43.[Abstract/Free Full Text]
- Bohm P, Brzuske A. Salter
innominate osteotomy for the treatment of developmental dysplasia of the hip
in children: results of seventy-three consecutive osteotomies after twenty-six
to thirty-five years of follow-up. J Bone Joint Surg
Am. 2002;84:178
-86.[Abstract/Free Full Text]
- Ko JY, Wang CJ, Lin CF, Shih CH.
Periacetabular osteotomy through a modified Ollier transtrochanteric approach
for treatment of painful dysplastic hips. J Bone Joint Surg
Am. 2002;84:1594
-604.[Abstract/Free Full Text]
- Hsieh PH, Shih CH, Lee PC, Yang WE,
Lee ZL. A modified periacetabular osteotomy with use of the
transtrochanteric exposure. J Bone Joint Surg Am.2003; 85:244
-50.[Abstract/Free Full Text]
- Tokmakova KP, Stanton RP, Mason
DE. Factors influencing the development of osteonecrosis in patients
treated for slipped capital femoral epiphysis. JBone Joint Surg
Am. 2003;85:798
-801.[Abstract/Free Full Text]
- Gordon JE, Abrahams MS, Dobbs MB,
Luhmann SJ, Schoenecker PL. Early reduction, arthrotomy, and cannulated
screw fixation in unstable slipped capital femoral epiphysis treatment.
J Pediatr Orthop.2002; 22:352
-8.[Medline]
- Carney BT, Birnbaum P, Minter C.
Slip progression after in situ single screw fixation for stable slipped
capital femoral epiphysis. J Pediatr Orthop.2003; 23:584
-9.[Medline]
- Kocher MS, Saxon HS, Hovis WD,
Hawkins RJ. Management and complications of anterior cruciate ligament
injuries in skeletally immature patients: survey of the Herodicus Society and
The ACL Study Group. J Pediatr Orthop.2002; 22:452
-7.[Medline]
- Anderson AF. Transepiphyseal
replacement of the anterior cruciate ligament in skeletally immature patients.
A preliminary report. J Bone Joint Surg Am.2003; 85:1255
-63.[Abstract/Free Full Text]
- Chotigavanichaya C, Salinas G, Green
T, Moseley CF, Otsuka NY. Recurrence of varus deformity after proximal
tibial osteotomy in Blount disease: long-term follow-up. J Pediatr
Orthop. 2002;22:638
-41.[Medline]
- Johnston CE 2nd. Congenital
pseudarthrosis of the tibia: results of technical variations in the
Charnley-Williams procedure. J Bone Joint Surg Am.2002; 84:1799
-810.[Abstract/Free Full Text]
- Stanitski DF, Stanitski CL.
Fibular hemimelia: a new classification system. JPediatr
Orthop. 2003;23:30
-4.
- Heilig MR, Matern RV, Rosenzweig SD,
Bennett JT. Current management of idiopathic clubfoot questionnaire: a
multicentric study. J Pediatr Orthop.2003; 23:780
-7.[Medline]
- Herzenberg JE, Radler C, Bor N.
Ponseti versus traditional methods of casting for idiopathic clubfoot.
J Pediatr Orthop.2002; 22:517
-21.[Medline]
- Chang CH, Kumar SJ, Riddle EC,
Glutting J. Macrodactyly of the foot. J Bone Joint Surg
Am. 2002;84:1189
-94.[Abstract/Free Full Text]
- Fagelman MF, Epps HR, Rang M.
Mangled extremity severity score in children. J Pediatr
Orthop. 2002;22:182
-4.[Medline]
- Leet AI, Frisancho J, Ebramzadeh
E. Delayed treatment of type 3 supracondylar humerus fractures in
children. J Pediatr Orthop.2002; 22:203
-7.[Medline]
- Boyer BA, Overton B, Schrader W,
Riley P, Fleissner P. Position of immobilization for pediatric forearm
fractures. J Pediatr Orthop.2002; 22:185
-7.[Medline]
- Henderson B, Letts M. Operative
management of pediatric scaphoid fracture nonunion. J Pediatr
Orthop. 2003;23:402
-6.[Medline]
- Waters PM, Stewart SL. Surgical
treatment of nonunion and avascular necrosis of the proximal part of the
scaphoid in adolescents. J Bone Joint Surg Am.2002; 84:915
-20.[Abstract/Free Full Text]
- Luhmann SJ, Schootman M, Schoenecker
PL, Dobbs MB, Gordon JE. Complications of titanium elastic nails for
pediatric femoral shaft fractures. J Pediatr Orthop.2003; 23:443
-7.[Medline]
- Agus H, Kalenderer O, Eryanilmaz G,
Omeroglu H. Biological internal fixation of comminuted femur shaft
fractures by bridge plating in children. J Pediatr
Orthop. 2003;23:184
-9.[Medline]
- Lowe J, Chaimsky G, Freedman A, Zion
I, Howard C. The anatomy of tibial eminence fractures: arthroscopic
observations following failed closed reduction. J Bone Joint Surg
Am. 2002;84:1933
-8.[Abstract/Free Full Text]
- Barmada A, Gaynor T, Mubarak SJ.
Premature physeal closure following distal tibia physeal fractures: a new
radiographic predictor. J Pediatr Orthop.2003; 23:733
-9.[Medline]
- Scully SP, Ghert MA, Zurakowski D,
Thompson RC, Gebhardt MC. Pathologic fracture in osteosarcoma: prognostic
importance and treatment implications. J Bone Joint Surg
Am. 2002;84:49
-57. Erratum in: J Bone Joint Surg Am.
2002;84:622.[Abstract/Free Full Text]
- Rougraff BT, Kling TJ. Treatment
of active unicameral bone cysts with percutaneous injection of demineralized
bone matrix and autogenous bone marrow. J Bone Joint Surg
Am. 2002;84:921
-9.[Abstract/Free Full Text]
- Ghanem I, Collet LM, Kharrat K,
Samaha E, Deramon H, Mertl P, Dagher F. Percutaneous radiofrequency
coagulation of osteoid osteoma in children and adolescents. J
Pediatr Orthop B. 2003;12:244
-52.[Medline]
- Cook RE, Schneider I, Hazlewood ME,
Hillman SJ, Robb JE. Gait analysis alters decision-making in cerebral
palsy. J Pediatr Orthop.2003; 23:292
-5.[Medline]
- Noonan KJ, Halliday S, Browne R,
O'Brien S, Kayes K, Feinberg J. Interobserver variability of gait analysis
in patients with cerebral palsy. J Pediatr Orthop.2003; 23:279
-91.[Medline]
- Knapp DR Jr, Cortes H. Untreated
hip dislocation in cerebral palsy. J Pediatr Orthop.2002; 22:668
-71.[Medline]
- Murray-Weir M, Root L, Peterson M,
Lenhoff M, Daly L, Wagner C, Marcus P. Proximal femoral varus rotation
osteotomy in cerebral palsy: a prospective gait study. J Pediatr
Orthop. 2003;23:321
-9. Erratum in: J Pediatr Orthop.
2003;23:563.[Medline]
- Saw A, Smith PA, Sirirungruangsarn Y,
Chen S, Hassani S, Harris G, Kuo KN. Rectus femoris transfer for children
with cerebral palsy: long-term outcome. J Pediatr
Orthop. 2003;23:672
-8.[Medline]
- Baddar A, Granata K, Damiano DL,
Carmines DV, Blanco JS, Abel MF. Ankle and knee coupling in patients with
spastic diplegia: effects of gastrocnemiussoleus lengthening. J
Bone Joint Surg Am. 2002;84:736
-44.[Abstract/Free Full Text]
- Sun EC, Yen YM, Ip T, Otsuka NY.
Peripheral circulation in patients with myelodysplasia. J Pediatr
Orthop. 2003;23:714
-7.[Medline]
- Aparicio LF, Jurkovic M, DeLullo
J. Decreased bone density in ambulatory patients with Duchenne muscular
dystrophy. J Pediatr Orthop.2002; 22:179
-81.[Medline]
- Scher DM, Mubarak SJ. Surgical
prevention of foot deformity in patients with Duchenne muscular dystrophy.
J Pediatr Orthop.2002; 22:384
-91.[Medline]
- Gordon JE, Goldfarb CA, Luhmann SJ,
Lyons D, Schoenecker PL. Femoral lengthening over a humeral intramedullary
nail in preadolescent children. JBone Joint Surg Am.2002; 84:930
-7.[Abstract/Free Full Text]
- Guichet JM, Deromedis B, Donnan LT,
Peretti G, Lascombes P, Bado F. Gradual femoral lengthening with the
Albizzia intramedullary nail. J Bone Joint Surg Am.2003; 85:838
-48.[Abstract/Free Full Text]
- Levine MJ, McGuire KJ, McGowan KL,
Flynn JM. Assessment of the test characteristics of C-reactive protein for
septic arthritis in children. J Pediatr Orthop.2003; 23:373
-7.[Medline]
- Willis AA, Widmann RF, Flynn JM,
Green DW, Onel KB.
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Top
Introduction
Pediatric Orthopaedic Conditions...