The Journal of Bone and Joint Surgery (American). 2005;87:1171-1179.
doi:10.2106/JBJS.E.00169
© 2005 The Journal of Bone and Joint Surgery, Inc.
What's New in Pediatric Orthopaedics
Mininder S. Kocher, MD, MPH1 and
Peter O. Newton, 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 Children's Hospital and Health Center, University of California San Diego,
3030 Children's Way, San Diego, CA 92123
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. One or more of the authors
received payments or other benefits or a commitment or agreement to provide
such benefits from a commercial entity (DePuy Spine). In addition, a
commercial entity (DePuy Spine) paid or directed, or agreed to pay or direct,
benefits to a 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 fifth 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) (St. Louis, Missouri, April
2004), the American Academy of Orthopaedic Surgeons (AAOS) (San Francisco,
California, March 2004), the Scoliosis Research Society (SRS) (Buenos Aires,
Argentina, September 2004), the American Academy of Pediatrics (AAP) (San
Francisco, California, October 2004), 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. The absence of biceps muscle function at
the age of three months has been used as an indication for early brachial
plexus microsurgery. Smith et al. evaluated the long-term outcome for
twenty-eight patients who had absent biceps muscle function at the age of
three months1. The
mean duration of follow-up was 11.1 years. Twenty-two patients did not have
surgery on the brachial plexus, but nine of those patients had subsequent
orthopaedic procedures. Patients who regained biceps muscle function between
three and six months of age and patients with a C5-C6 lesion had better
functional outcomes.
Moukoko et al. found that posterior shoulder dislocation can occur earlier
and more rapidly in infants with neonatal brachial plexus palsy than has been
appreciated
previously2. In that
study, eleven (8%) of 134 consecutive infants had posterior shoulder
dislocation. The mean age at the time of diagnosis was six months. There was
no correlation between the occurrence of dislocation and the type of initial
neurological deficit, and a rapid loss of passive external rotation between
monthly examinations indicated dislocation. Waters et al., in a study of
twenty-five patients with a mean age of forty-two months who underwent
latissimus dorsi and teres major transfers to the rotator cuff and
extra-articular musculotendinous lengthening for the treatment of brachial
plexus birth palsy, reported improved shoulder function but only modest
changes in remodeling of glenoid retroversion.
Pearl et al. reported the minimum two-year results of twenty-six
arthroscopic internal rotation contracture releases in children who were 0.8
to twelve years old. The mean increase in external rotation was 55° for
younger children undergoing release alone and 86° for older children
undergoing release with latissimus dorsi transfer. Improvements in elevation
were only modest. James, in a study of the longer-term results of external
rotation tendon transfer, found that longer-term improvement in external
rotation may not be as good as the short-term results. At one year
postoperatively, the average external rotation had improved from 19° to
61°. However, at the time of the latest follow-up, at a mean of 3.3 years
postoperatively, the average external rotation had decreased to 48°.
Elbow
Wang et al. performed open radial head reduction, ulnar osteotomy, and
annular ligament reconstruction in thirteen patients at an average of 5.9
months after radial head dislocation. Most patients had excellent elbow and
forearm motion, and there were no instances of redislocation.
Forearm and Hand
Many children with unilateral congenital below-elbow deficiency abandon the
use of their prostheses. James et al., in a study of 152 such patients,
evaluated the function associated with various prostheses with use of the
Unilateral Below Elbow Test. Prosthetic wear did not improve function.
James et al. evaluated the relationship between congenital longitudinal
deficiencies of the radius and thumb in a study of 227 affected upper
extremities in 139
patients3. They
found that the severity of the thumb deficiency was directly proportional to
the severity of the radial deficiency, supporting the concept that components
of radial longitudinal deficiency represent a progressive spectrum of upper
extremity abnormalities and a distal progression of severity, with distal
structures likely to be more involved than proximal structures.
Hip
Perthes Disease
Both the etiology and the treatment of Perthes disease remain
controversial. There is conflicting evidence regarding the relationship
between Perthes disease and thrombophilia. Balasa et al., in a case-control
study in which seventy-two patients with Perthes disease were compared with
197 healthy controls, found two thrombophilic risk factors: the factor-V
Leiden mutation and anticardiolipin
antibodies4. Aksoy
et al., in a case-control study in which forty-three patients with Perthes
disease were compared with thirty-eight healthy controls, found higher levels
of tissue factor pathway inhibitor (an anticoagulant that modulates the tissue
factor-dependent pathway) in the patients with Perthes disease.
Herring et al., in a large, multicenter, prospective study of 345 hips in
patients with Perthes disease, more clearly defined the lateral pillar
classification by adding a new intermediate group termed the B/C border
group5. The
interobserver and intraobserver reliability of the lateral pillar
classification were acceptable. Herring et al. then evaluated the effect of
treatment and other risk factors on outcome in a study of 451 affected hips in
438 patients6. They
found that the lateral pillar classification and age at the time of onset of
the disease were strongly correlated with outcome in patients with Perthes
disease. Patients who were more than 8.0 years of age at the time of onset and
who had a hip in the lateral pillar B or B/C border group at the time of
treatment had a better outcome in association with surgical treatment than
they did in association with nonoperative treatment. Children who were 8.0
years of age or less at the time of onset and who had group-B hips at the time
of treatment had very favorable outcomes regardless of the type of treatment,
whereas children of all ages who had group-C hips at the time of treatment
frequently had poor outcomes regardless of the type of treatment.
Developmental Dysplasia of the Hip
Kim et al. utilized contrast-enhanced magnetic resonance imaging after
closed reduction in infants with twenty-eight idiopathic hip dislocations.
Decreased enhancement on magnetic resonance imaging was associated with the
radiographic development of osteonecrosis, suggesting that magnetic resonance
imaging may be useful for assessing both the adequacy of reduction and the
risk of osteonecrosis after closed reduction of a dislocated hip in an
infant.
Anderson et al. performed a limited open medial approach as an adjunct to
closed reduction in a study of twenty-two children (average age, 15.6 months)
with twenty-four reducible hips that remained relatively unstable, with a
narrow safe zone. Patients who were less than twelve months old had stable
hips with remodeling and a normal radiographic appearance. Patients who were
more than twelve months of age had a predictable lack of remodeling,
necessitating secondary procedures. Mosely et al. evaluated the value of the
Salter pelvic osteotomy as an adjunct to open reduction in a study of
sixty-two dislocated hips in patients who were more than 1.5 years old.
Patients who had an adjunctive Salter osteotomy had improved femoral head
roundness, improved acetabular coverage, and fewer subsequent procedures
compared with patients who had open reduction alone, suggesting the value of a
concurrent pelvic osteotomy at the time of open reduction.
The Bernese periacetabular osteotomy is being used increasingly for older
adolescents and adults with acetabular dysplasia. Kim et al. prospectively
studied a cohort of twenty-six hips and reported six failures. Preexisting
arthritis and evidence of arthritis on magnetic resonance imaging were
associated with progression of arthritis after osteotomy.
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. Kocher et al., in
a study involving expected-value decision analysis in which the probabilities
of a contralateral slip were determined from the literature and utility values
were obtained from a questionnaire on patient preferences, concluded that
watchful waiting was the preferred strategy if the risk of a contralateral
slip was <27%7.
Bhatia et al., in a study that was performed to identify patients with slipped
capital femoral epiphysis who are at risk for contralateral involvement, found
that a high body mass index (>35) was associated with an increased risk of
a contralateral slip.
Armstrong et al. used finite-element analysis to study potential etiologic
forces associated with slipped capital femoral epiphysis. The authors found
increased femoral head coverage in patients with slipped capital femoral
epiphysis, which increased forces on the proximal femoral physis.
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. Ganley et al. performed survivorship analysis on
247 patients who were thirteen to eighteen years old and had undergone
anterior cruciate ligament reconstruction with an Achilles tendon allograft.
There was a 7.8% failure rate, with most failures occurring within three years
after surgery. Kocher et al. reported on the prevalence of meniscal and
chondral injuries associated with anterior cruciate ligament tears in a study
of 102 skeletally immature patients. Meniscal tears were common (prevalence,
45%) and occurred more frequently in patients with chronic anterior cruciate
ligament insufficiency.
Blount Disease
Abraham et al. found that the Taylor spatial frame was an effective and
reliable fixator for the correction of adolescent tibia vara. In their study
of twenty-seven limbs in twenty-five patients, the average measurements after
correction were 7° valgus, 12° procurvatum, and 15° external
rotation foot progression angle. Complications included delayed union (three
limbs), overcorrection (two), undercorrection (two), transient peroneal nerve
palsy (two), and pin-track infection (one).
Epiphyseodesis
Sanders et al., in a study of forty-four patients with limb-length
discrepancy and/or angular deformity, investigated the efficacy of a technique
for epiphyseodesis about the knee with use of cannulated 7.3-mm screws in lieu
of physeal staples. There were two complications associated with screw
malposition, and, in all three patients with desired temporary epiphyseodesis,
growth resumed after screw removal.
Ehrlich et al. evaluated the efficacy of percutaneous radiofrequency
epiphyseodesis in a rabbit model. Radio-frequency ablation was found to be
effective for the reduction of growth in this experimental model.
Leg
Tibial Pseudarthrosis
The treatment of congenital pseudarthrosis of the tibia remains difficult
and controversial. Dobbs et al., in a study of twenty-one consecutive
patients, evaluated the long-term results of a technique consisting of
excision of the pseudarthrosis, autologous bone-grafting, and insertion of a
Williams intramedullary rod into the tibia. The mean duration of follow-up was
14.2 years. Initial consolidation occurred in eighteen of the twenty-one
patients, refracture occurred in twelve, and amputation was eventually
required in five. Overall, the authors concluded that this technique should be
considered for the treatment of congenital pseudarthrosis of the tibia.
Fibular Hemimelia
Paley et al. reported their experience with seventy-eight patients
(ninety-four limbs) who were managed with leg-lengthening. Overall, there were
forty-six excellent results, twenty-eight good results, and eighteen fair
results; the remaining two limbs were lost to follow-up. There were twenty
recurrent foot deformities. Functional results were not correlated with the
number of rays in the foot. However, excellent long-term functional results
have been reported following conventional treatment with amputation for more
severe forms of fibular hemimelia.
Foot and Ankle
Clubfoot
Ponseti's technique of manipulation and casting continues to be an area of
great interest and inquiry. In a review of 374 idiopathic clubfeet that were
treated with the Ponseti method, Morcuende reported successful correction in
all but four feet. Percutaneous heel-cord tenotomy was performed in 81% of
these clubfeet. There was a 10% rate of deformity relapse. However, only
thirteen patients (5%) required surgery. Morcuende et al. also reported on the
effective use of the Ponseti method for the treatment of thirty-two
arthrogrypotic clubfeet.
Dobbs et al.8,
Scher et al., and Morcuende et al. all emphasized the importance of compliance
with the prolonged use of the foot abduction orthosis after casting with use
of the Ponseti method, with higher deformity recurrence rates being noted
among noncompliant patients. Herzenberg described performing the percutaneous
heel-cord tenotomy with the patient under general anesthesia instead of local
anesthesia and reported no anesthetic complications and less stress for the
family and surgeon.
Richards et al., in a nonrandomized trial of sixty-one feet, reported
similar early results in association with the Ponseti method and the French
physical therapy and taping method.
It is apparent that current trends in the treatment of clubfoot support
nonoperative care with casting or manipulation. The results of the Ponseti and
French methods are improved compared with those of older methods of
nonoperative treatment.
In contrast, Dobbs et al. reported sobering long-term results following the
use of extensive surgical release for the treatment of thirty-four idiopathic
clubfeet. After a minimum of twenty-five years of follow-up, there were no
excellent results and only one good result according to the Laaveg and Ponseti
functional scale. In general, the patients had poor functional results as
adults despite the fact that many of them had functioned well throughout
childhood and adolescence.
The utility of radiographs for the evaluation and outcomes assessment of
patients with clubfoot has been questioned. However, in a study of forty-five
clubfeet in twenty-nine patients who were evaluated with radiographs, the
Child Health Questionnaire, and a condition-specific outcome instrument,
Aronsson et al. found that radiographic parameters did correlate with patient
function.
Flatfoot
Calcaneal lengthening osteotomy has gained popularity for the treatment of
painful idiopathic pes planovalgus in patients with tight heel cords.
Puigdevall et al. reported the results of calcaneal lengthening osteotomy for
the treatment of twenty-six feet in patients with planovalgus associated with
cerebral palsy or myelomeningocele. A satisfactory clinical result was
obtained in 83% of the feet.
Spine
Etiology of Adolescent Idiopathic Scoliosis
The etiology of adolescent idiopathic scoliosis remains a mystery, although
several presentations this year continued to suggest a genetic link.
Conflicting results regarding the role of melatonin in adolescent idiopathic
scoliosis continue to be reported. Cheung et al. reported a lack of
development of scoliosis in pinealectomized monkeys (as compared with previous
reports describing the development of scoliosis in chickens), whereas Moreau
et al. presented data suggesting a melatonin signaling dysfunction in
osteoblasts of patients with adolescent idiopathic
scoliosis9. A study
by Ogilvie et al. involving 100 families in Utah suggested that at least one
gene is involved in the development of adolescent idiopathic scoliosis.
Interestingly, two candidate genes, aggrecan and type-I collagen alpha 2, were
reported this year by Merola et al. and Cheng et al., respectively. Lowe et
al. noted that patients with sustained high levels of serum platelet
calmodulin are more likely to have progressive scoliosis.
Surgical Outcomes
Third-generation segmental posterior spinal instrumentation systems have
led to increasing correction of scoliosis. Asher et al., in a study of 179
patients managed with Isola instrumentation, reported an average 63%
correction in the thoracic Cobb angle two to twelve years after
surgery10. There
were no instances of spinal cord injury or acute infection, and the prevalence
of confirmed pseudarthrosis was low (2%). In a second study, the authors
presented data supporting lasting transverse plane correction as well
(average,
40%)11.
Pulmonary Function
The effect of scoliosis on pulmonary function was clarified by Faro et al.
in a presentation on 515 patients with adolescent idiopathic scoliosis.
Thoracic scoliosis of >60° was associated with an increasing frequency
of pulmonary dysfunction, as was thoracic hypokyphosis of <10° and
thoracic hyperkyphosis of >60°. Gollogly et al. reported that
three-dimensional chest-wall distortion as measured with computed tomographic
scanning was a better predictor of diminished pulmonary function than Cobb
angle measurements
were12.
Nonfusion Instrumentation Systems
The treatment of severe scoliosis in the young child who is less than eight
years of age remains a substantial challenge. Several methods for addressing
the spinal and chest deformities associated with severe scoliosis are under
intense investigation. The vertical expandable prosthetic titanium rib
received Food and Drug Administration approval with a humanitarian device
exemption in 2004. The device was approved for use in the treatment of
thoracic insufficiency syndrome, and Campbell et al. reported on the early
outcomes associated with the use of this device for the treatment of several
conditions, including congenital
scoliosis13. In
another study, Campbell et al. reported that application of the vertical
expandable prosthetic titanium rib in combination with the performance of an
opening-wedge thoracostomy at an early age (less than five years) may improve
ultimate lung growth and aid in limiting the progression of
scoliosis14. Smith
et al. confirmed an increase in lung volume as measured with computed
tomography, but data regarding actual pulmonary function are as yet
lacking.
Posterior spinal "growing rod" constructs were evaluated by
Akbarnia and Thompson. Patients who were managed with a dual-rod system in
whom lengthening was routinely performed every six months were compared with
patients who were managed with a single-rod construct in whom relengthening of
the rods was done only when curve progression was noted. In this relatively
limited analysis of twenty-eight patients, the patients in the dual-rod group
fared better, with greater overall gain in length (mean, 1.5 cm/yr) and fewer
complications.
Experimental anterior solutions also are being investigated. Braun reported
the ability to modify spinal growth with use of various anterior vertebral
tethering methods in an experimental scoliosis model, as did Newton et al. in
a non-scoliosis model. Mechanically limiting vertebral growth asymmetrically
in patients with progressive scoliosis in order to effect a reduction in
spinal curvature was the ultimate goal of these studies. Betz et al. presented
limited clinical results following vertebral body stapling across disc spaces,
suggesting a potential benefit, although a comparison with observation alone
and bracing has not been completed.
Innovative Surgical Methods
Two relatively new methods for surgical correction of scoliosis, the use of
thoracic pedicle screws and minimally invasive approaches, remain
controversial, with studies supporting and criticizing both techniques. Parent
et al. clarified the regional variation in the anatomic dimensions of thoracic
pedicles, a necessity for safe screw
insertion15. Arlet
et al.16 reported
that the use of thoracic pedicle screws reduced the need for anterior release
in patients with curves of between 70° and 90°, and Lenke et al.
reported that the use of thoracic pedicle screws increased the percentage of
thoracic curve correction (74% for screws compared with 52% for hooks).
However, Cheng et al. found apical sublaminar wires to be equally as effective
as screws for reducing the Cobb angle. This finding was supported by a study
by Rohmiller et al. in which segmental fixation—that is, increasing the
number of bone anchors—was the factor that had the greatest correlation
with curve correction. One of the remaining claims for thoracic pedicle screws
is in the area of rib hump correction. Kuklo et al. analyzed the difference
between monoaxial and polyaxial thoracic pedicle screws in this regard. The
use of segmental monoaxial thoracic pedicle screw fixation allowed greater
transverse-plane correction of the rib hump than the use of polyaxial screws
did (68% compared with 33%). The biomechanics of applying such a derotational
force were evaluated by King et al., who demonstrated greater failure loads in
the convex sided screws. Interestingly, more than one-half of the screws bent
before failing, giving some idea of the forces tolerated by the spine. Safety
remains a concern in association with the use of thoracic pedicle screws, both
from the standpoint of canal intrusion (neurologic injury) as well as from the
standpoint of major vessel (aorta) impingement anteriorly.
The minimally invasive thoracoscopic approach is gaining acceptance as an
alternative to open thoracotomy for anterior
release17;
thoracoscopic instrumentation remains controversial. Both Newton et al. and
Lonner et al. found thoracoscopic instrumentation to be reasonably safe and
effective for the correction of scoliosis. The mean thoracic curve correction
in those studies was reported to be 54% and 55%, respectively. These findings
are in contrast to those of the study by Policy et al., in which one-half of
the patients had curve progression, one-third had implant failure, and
one-quarter required revision surgery. Wong et al. compared a group of
patients who were managed with thoracoscopic instrumentation with a matched
group of patients who were managed with posterior
instrumentation18.
The radiographic outcomes were similar in both groups, but the operative times
were longer in the thoracoscopic group. Challenges clearly remain in the area
of minimally invasive scoliosis correction. In a recent report, Sucato et al.
pointed out the proximity of anterior thoracic vertebral screws to the
aorta19. The same
group also offered some hope that biological solutions may lead to a faster
anterior arthrodesis; specifically, they reported that rh-BMP-2 enhanced
fusion following thoracoscopic instrumentation in a pig model.
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Fractures in Children
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General
Vitale et al. categorized pediatric orthopaedic injuries with use of the
Healthcare Cost and Utilization Project Kids' Inpatient Database. In 1997,
more than 84,000 children were admitted for the treatment of orthopaedic
trauma in the United States, accruing an estimated 932.8 million dollars in
hospital charges. Femoral fracture was the most common injury in this
inpatient population.
Loder reviewed 256 traumatic amputations in 235 children who had been
managed at one center from 1980 to
200020. Amputations
were caused most frequently by lawn-mower injuries, farm machinery, and
motor-vehicle accidents. Common patterns of traumatic amputations in children
were elucidated on the basis of the mechanism of injury, the season, and the
age of the child.
Flynn et al. emphasized the importance of early recognition and treatment
of acute traumatic compartment syndrome of the leg in a series of twenty-nine
children. Good end results without sequelae were observed in 93% of the
patients. The two patients with sequelae both had had a late fasciotomy (more
than eighty hours) after presentation.
Smith et al. advocated using mini C-arm fluoroscopy in the emergency room
rather than radiographs for pediatric fracture reduction. In their study of
296 fracture reductions, use of the mini C-arm resulted in more efficient
patient encounters, less radiation exposure, and fewer re-reductions.
Supracondylar Humeral Fractures
Skaggs et al. promoted the use of lateral entry pinning for the treatment
of displaced supracondylar humeral
fractures21. In
their series of 124 consecutively treated type-2 and 3 supracondylar
fractures, there were no instances of loss of reduction, malalignment, or loss
of motion. The authors emphasized the technical aspects of lateral-entry
pinning, including maximizing separation of the pins at the fracture site,
engaging the medial and lateral columns proximal to the fracture, engaging
sufficient bone in both the proximal segment and the distal fragment, and
maintaining a low threshold for use of a third lateral-entry pin if there is
concern about fracture stability or the location of the first two pins.
Forearm Fractures
Galpin et al. compared short-arm cast immobilization with long-arm cast
immobilization in a randomized clinical trial of seventy-eight patients with
displaced distal-third pediatric forearm fractures. There was no difference
between the groups in terms of loss of fracture reductions; however, short-arm
casts caused less interference with daily activities.
Femoral Fractures
Vitale et al. reviewed the treatment of pediatric femoral fractures in
children six to ten years of age with use of the Kid's Inpatient Database in
1997 and again in 2000. They found that children in this age-group were
increasingly managed with internal fixation. In addition, care at a
non-children's hospital was associated with a higher rate of spica casting,
higher charges, and longer length of stay.
Elastic nailing has become a widespread technique for the treatment of
pediatric femoral fractures. In the study by Flynn et al., thirty-five
children who were managed with traction and spica casting were compared with
forty-eight children who were managed with titanium elastic
nails22.
Unsatisfactory results and complications were more common in association with
traction and casting. Compared with the children who were managed with
traction and casting, those who were managed with titanium elastic nails had a
shorter period of hospitalization, walked with support sooner, walked
independently sooner, and returned to school earlier. Frick et al. and Mehlman
et al. evaluated complications associated with the use of elastic nailing for
the treatment of pediatric femoral fractures, finding an increased risk of
malunion in older children (more than eleven or twelve years old) and heavier
children (>45 kg). Finally, submuscular plating has been advocated for the
treatment of some pediatric femoral fractures. Sink et al. reported good
results in a series of ten patients.
Tibial Fractures
Scher et al. compared the results of elastic nailing with those of external
fixation in a study of thirty-one patients with high-energy tibial fractures
who had a mean age of eleven years. Patients managed with elastic
intramedullary nailing had a decreased time to union, reduced fracture
complications, and improved outcome.
Mubarak et al. compared the results of operative and nonoperative treatment
in a study of 147 Salter-Harris type-I and II distal tibial fractures.
Premature physeal closure was noted in association with 32% of the fractures
that were treated nonoperatively and 23.5% of those that were treated
operatively. Older patients were more likely to have premature physeal
closure.
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Other Musculoskeletal Conditions
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Tumors
Dormans et al. described a percutaneous technique for the treatment of
nonossifying fibromas with use of percutaneous curettage, intramedullary
decompression, and grafting with calcium sulfate pellets. Compared with
traditional open treatment, the percutaneous technique was associated with
faster resolution of pain, return to activities, and signs of healing.
Alman et al. found RNA markers of vascular progenitors in cyst-lining cells
from six patients with simple bone cysts, suggesting a vascular etiology, and
cited the potential for anti-angiogenic treatment.
Cerebral Palsy
Botulinum toxin has become a common treatment for contractures in patients
with cerebral palsy. Kay et al. performed a randomized trial in which serial
casting only was compared with serial casting combined with botulinum toxin-A
injection for the treatment of ankle equinus contractures in twenty-three
children with cerebral
palsy23.
Unexpectedly, the investigators found that the addition of botulinum toxin A
to a serial casting regimen led to earlier recurrence of spasticity,
contracture, and equinus during gait. Koman et al. performed a randomized
clinical trial in which botulinum toxin-A injections were compared with
placebo injections for the treatment of upper extremity spasticity in
pediatric patients with cerebral palsy. The investigators found improved
function in patients who received botulinum toxin.
Dietz et al. reported discouraging results in association with Achilles
tendon lengthening for the treatment of spastic equinus of the ankle. In a
series of seventy-nine patients with diplegia and quadriplegia, the authors
found an unacceptably high prevalence of overweakening, with a crouched gait
and the need for anterior floor-reaction braces.
Treatment of the dislocated hip in patients with cerebral palsy remains
controversial. Noonan et al. studied seventy-seven adults with severe cerebral
palsy who had hip subluxation or dislocation. Neither hip displacement nor
osteoarthritis was found to be associated with hip pain or diminished
function. Because the prevalence of hip pain was low and was not associated
with hip displacement or osteoarthritis, they suggested that surgical
treatment of the hip in severely affected patients should be based on the
presence of pain or contractures and not on radiographic signs of hip
displacement or osteoarthritis.
Johnson et al. evaluated the relationship between Pediatric Outcomes Data
Collection Instrument scores and technical measures of gait in a study of
fifty-three children with cerebral palsy who had bilateral lower extremity
involvement and were able to walk. Technical measures of gait were found to
correlate in expected directions with the Pediatric Outcomes Data Collection
Instrument scores related to lower extremity function. Oxygen cost was most
strongly correlated with Pediatric Outcomes Data Collection Instrument
scores.
Myelodysplasia
Patients with myelodysplasia often experience wound dehiscence and ulcer
formation. Yen et al. evaluated peripheral circulation with use of ankle
brachial index and transcutaneous pO2 (TcO2) measurements in a study of
forty-one patients with myelodysplasia and forty-one age-matched controls.
Patients with myelodysplasia had lower ankle brachial indices but similar TcO2
values.
Muscular Dystrophy
Previous studies have shown that corticosteroid treatment slows the decline
in muscle strength and stabilizes muscle strength in patients with Duchenne
muscular dystrophy. Alman et al. studied fifty-four patients with Duchenne
muscular dystrophy and found that steroid treatment appeared to slow the
progression of scoliosis as
well24.
Osteogenesis Imperfecta
Treatment of osteogenesis imperfecta has been directed toward increasing
bone density; however, the effect of bone density on function in these
patients has not been established. Huang et al. evaluated the correlation
between dual energy x-ray absorptiometry findings and Pediatric Outcomes Data
Collection Instrument functional scores in a study of twenty-four patients
with osteogenesis imperfecta. Significant correlations between bone density
and function were found.
Fibrous Dysplasia
Lesions of fibrous dysplasia involving the spine and causing scoliosis are
thought to be uncommon entities in patients with polyostotic fibrous dysplasia
and McCune-Albright syndrome. Leet et al. evaluated sixty-two patients who had
polyostotic fibrous dysplasia with regard to the prevalence of lesions of the
spine and
scoliosis25. Spinal
lesions were observed in 63% of the patients and scoliosis was observed in
40%, indicating that both findings may be more common than previously thought
in patients with polyostotic fibrous dysplasia.
Limb-Length Discrepancy
Muscle stiffness frequently occurs during limb-lengthening. Birch et al.
evaluated muscle fiber and sarcomere length changes during tibial lengthening
in a goat model and found insufficient sarcomere production in the posterior
muscles, which may contribute to equinus deformity. Shilt et al. found that
muscle function was diminished and normal neuromuscular junction morphology
was lost following 30% diaphyseal lengthening in a rabbit model.
Hamdy et al., in a rabbit tibial lengthening model, found accelerated bone
formation during distraction osteogenesis with use of bone morphogenetic
protein-7.
Kocaoglu et al. reported on complications encountered during lengthening
over an intramedullary rod in a study of forty-two segments in thirty-five
patients26. The
mean amount of lengthening was 6.3 cm. The complication rate was 38%.
Complications were more likely to occur in association with lengthenings of
>6 cm or 21.5% of the original bone length.
Infection
The timely and accurate diagnosis of septic arthritis of the hip is
essential. Luhmann et
al.27 tested
Kocher's clinical prediction rule for differentiating septic arthritis from
transient synovitis of the hip in children and found decreased diagnostic
performance. In their population, the best predictive model was based on a
history of fever, a serum total white blood-cell count of
>12,000/mm3, and
a previous health-care visit. Kocher et al., however, found diminished, but
still very good, performance of the prediction rule in a new patient
population at the original
institution28.
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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 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. The conditions recommended
for treatment by pediatric surgical specialists include major congenital
anomalies, malignant lesions, major trauma, and chronic illnesses in infants
and children. The report stated that "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 treated 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.
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 Patients with Down Syndrome
According to the American Academy of Pediatrics, lateral plain radiographs
of the cervical spine are of potential, but unproven, value for detecting
which patients with Down syndrome are at risk for the development of spinal
cord injury during sports participation. 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 atlantoaxial 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 in order to
determine what symptoms, signs, and findings from imaging studies best
identify which individuals with Down syndrome are at increased risk of a
catastrophic spinal cord injury during sports participation
(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 illness and disabilities in managedcare systems. The AAP
has suggested several guidelines for discussion
(www.aap.org/policy/pprgtoc.cfm)
regarding the need to (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 (which
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, and (4) create viable systems of monitoring care capable of producing
process and outcome data from which appropriate adjustments are made to refine
care to benefit children and families.
Knee Brace Use in the Young Athlete
The AAP recommends that when prescribing the use of knee braces, physicians
should establish an accurate diagnosis of the injury and understand the
classifications, benefits, limitations, indications, and cost of any brace
prescribed
(www.aap.org/policy/pprgtoc.cfm).
Insufficient scientific evidence exists to recommend the use of
prophylactic knee braces for the pediatric athlete. In fact, available studies
do not support the prescription of most knee braces. The use of knee sleeves,
functional braces, and postoperative braces has been accepted clinically on
the basis of the physician's 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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The editorial staff of The Journal reviewed a large number of
recently published research studies related to the musculoskeletal system that
received a Level of Evidence grade of I. Over 100 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, two 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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POSNA Tutorials: Growing Rod Technique for Progressive Early Onset
Scoliosis July 22, 2005 San Diego, California
POSNA Tutorials: Cerebral Palsy Treatment: Current Concepts Update November
9-11, 2005 Wilmington, Delaware
2nd International POSNA/AAOS Pediatric Orthopaedic Symposium November
30–December 4, 2005 Orlando, Florida
POSNA Specialty Day March 11, 2006 New Orleans, Louisiana
POSNA Annual Meeting May 3-6, 2006 San Diego, California
Information regarding all events can be found at
www.posna.org
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Evidence-Based Articles Related to Pediatric Orthopaedics
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Bisinella GL, Birch R. Obstetric brachial plexus lesions: a study of
74 children registered with the British Paediatric Surveillance Unit (March
1998-March 1999). J Hand Surg [Br]. 2003;28:40-5.
Seventy-four children with obstetric brachial plexus palsy who were
registered with the British Paediatric Surveillance Unit were prospectively
followed for a minimum of two years. Thirty-nine patients (52.7%) had
spontaneous recovery to normal or nearly normal levels and another twenty-nine
(39.2%) regained good function in the upper limb. The most important secondary
deformity involved the glenohumeral joint, and twenty patients (27%) needed
surgical correction. The brachial plexus was explored in nine patients (12.2%)
and was repaired in seven. This study provides information regarding
spontaneous neurologic recovery and glenohumeral deformity in patients with
obstetric brachial plexus palsy.
Cole JW, Murray DJ, Snider RJ, Bassett GS, Bridwell KH, Lenke LG.
Aprotinin reduces blood loss during spinal surgery in children.
Spine. 2003;28:2482-5.
This prospective, blinded, randomized, controlled study compared the effect
of a perioperative infusion of aprotinin with the infusion of a placebo during
long-segment spinal fusions (fusions involving seven or more segments) in
forty-four children. There was a significant reduction in estimated blood loss
(545 mL in the aprotinin group, compared with 930 mL in the placebo group) and
transfusion requirements (1.1 U in the aprotinin group, compared with 2.2 U in
the placebo group). The duration of intensive-care unit admission was similar
in the two groups, as was the time until discharge. This study suggests that
aprotinin can significantly decrease blood loss and transfusion requirements
in pediatric and adolescent scoliosis patients undergoing spinal fusion.
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Acknowledgments
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NOTE: The authors are grateful to the POSNA Board of Directors
(Drs. Scott Mubarak, David Aronsson, Perry Schoenecker, John Dormans, James
Roach, Chad Price, William Warner, Steven Albanese, Daniel Sucato, Dale
Blasier, James Kasser, George Thompson, John Sarwark, Richard Haynes, Baxter
Willis, Ben Alman, and Lori Karol) for their editorial review of this
manuscript.
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References
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Carter PR. Neonatal brachial plexus palsy. Outcome of absent biceps function
at three months of age. J Bone Joint Surg Am.2004; 86:2163
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- Moukoko D, Ezaki M, Wilkes D, Carter P.
Posterior shoulder dislocation in infants with neonatal brachial plexus palsy.J Bone Joint Surg Am
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- James MA, Green HD, McCarroll HR Jr,
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- Campbell RM Jr, Smith MD, Hell-Vocke AK.
Expansion thoracoplasty: the surgical technique of opening-wedge thoracostomy.
Surgical technique. J Bone Joint Surg Am.2004; 86 Suppl 1:51
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- Campbell RM Jr, Smith MD, Mayes TC,
Mangos JA, Willey-Courand DB, Kose N, Pinero RF, Alder ME, Duong HL, Surber
JL. The effect of opening wedge thoracostomy on thoracic insufficiency
syndrome associated with fused ribs and congenital scoliosis. J Bone
Joint Surg Am. 2004;86:1659
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- Parent S, Labelle H, Skalli W, de Guise
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- Arlet V, Jiang L, Ouellet J. Is there a
need for anterior release for 70-90 masculine thoracic curves in adolescent
scoliosis? Eur Spine J.2004; 13:740
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- Al-Sayyad MJ, Crawford AH, Wolf RK.
Early experiences with video-assisted thoracoscopic surgery: our first 70
cases. Spine. 2004;29:1945
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JM, Kay RM. Lateral-entry pin fixation in the management of supracondylar
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- Flynn JM, Luedtke LM, Ganley TJ, Dawson
J, Davidson RS, Dormans JP, Ecker ML, Gregg JR, Horn BD, Drummond DS.
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femoral fractures in children. J Bone Joint Surg Am.2004; 86:770
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- Kay RM, Rethlefsen SA, Fern-Buneo A,
Wren TA, Skaggs DL. Botulinum toxin as an adjunct to serial casting treatment
in children with cerebral palsy. J Bone Joint Surg Am.2004; 86:2377
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- Alman BA, Raza SN, Biggar WD. Steroid
treatment and the development of scoliosis in males with duchenne muscular
dystrophy. J Bone Joint Surg Am.2004; 86:519
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- Leet AI, Magur E, Lee JS, Wientroub S,
Robey PG, Collins MT. Fibrous dysplasia in the spine: prevalence of lesions
and association with scoliosis. J Bone Joint Surg Am.2004; 86:531
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- Kocaoglu M, Eralp L, Kilicoglu O, Burc
H, Cakmak M. Complications encountered during lengthening over an
intramedullary nail. J Bone Joint Surg Am.2004; 86:2406
-11.[Abstract/Free Full Text]
- Luhmann SJ, Jones A, Schootman M, Gordon
JE, Schoenecker PL, Luhmann JD. Differentiation between septic arthritis and
transient synovitis of the hip in children with clinical prediction
algorithms. J Bone Joint Surg Am.2004; 86:956
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Barnewolt C, Kasser JR. Validation of a clinical prediction rule for the
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Introduction
Pediatric Orthopaedic Conditions...