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The Journal of Bone and Joint Surgery (American). 2006;88:1412-1421. doi:10.2106/JBJS.F.00442 © 2006 The Journal of Bone and Joint Surgery, Inc. What's New in Pediatric Orthopaedics
1 Department of Orthopaedic Surgery, Children's Hospital, 30 Longwood Avenue,
Boston, MA 02115. E-mail address:
mininder.kocher{at}childrens.harvard.edu
Specialty Update has been developed in collaboration with the Council of
Musculoskeletal Specialty Societies (COMSS) of the American Academy of
Orthopaedic Surgeons.
The purpose of this specialty update is to serve as a primary source and review for the general orthopaedic surgeon who wishes to stay up-to-date in pediatric orthopaedics. The topics that have been selected have value for the practicing orthopaedist as well as for the pediatric orthopaedic specialist. The material is not intended to represent the only, or necessarily the best, method or procedure appropriate for the medical situations discussed. Sources for this article were presentations at meetings of the Pediatric Orthopaedic Society of North America (POSNA) (Ottawa, Ontario, Canada, May 13, 14, and 15, 2005), the American Academy of Orthopaedic Surgeons (AAOS) (Washington, DC, February 23 through 27, 2005), the Scoliosis Research Society (SRS) (Miami, Florida, October 27 through 30, 2005), and the American Academy of Pediatrics (AAP) (Washington, DC, October 8 through 11, 2005), 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.
Shoulder Brachial Plexus Birth Palsy The timing of early microsurgical intervention in brachial plexus birth palsy is controversial. Waters and Brauer created an economic model to compare the costs of microsurgical treatment at three months compared with the costs of the surgery at six months in patients with brachial plexus birth palsy who had absent biceps function at three months. For surgery at three months to be as cost-effective as surgery at six months, with the assumption that 40% of patients will have a spontaneous return of biceps function between three and six months, the success rate of early surgery would have to be nine times higher than that of surgery at six months. If there is an 80% return of biceps function between three and six months, then early surgery could not be more cost-effective. This model supports waiting for six months before performing microsurgery in most cases. Kambhampati et al. prospectively studied 183 cases of posterior subluxation or dislocation of the shoulder associated with brachial plexus birth palsy. After performing shortening of the coracoid, elongation of the subscapularis, and correction of humeral retroversion, the authors found, on the average, improvement in the Mallet score from 9.4 to 13.0 points, an increase in lateral rotation of 58°, and an increase in forearm supination of 51°. They also found that the extent of secondary deformity and the result after treatment were determined by the severity of the nerve injury and the duration of the dislocation. Waters and Bae reviewed the results of derotational humeral osteotomy in forty-three children with brachial plexus birth palsy and found a mean 68° improvement in external rotation and a mean improvement in the Mallet score from 13 to 19 points.
Forearm and Hand
Hip
Developmental Dysplasia of the Hip The Bernese periacetabular osteotomy has become an established procedure for the correction of acetabular dysplasia in older adolescents and young adults. Clohisy et al. reported the early results of this osteotomy in sixteen hips in thirteen patients after 4.2 years of follow-up1. There was a mean improvement of 44.6° in the lateral center-edge angle, 51.0° in the anterior center-edge angle, and 25.9° in the acetabular roof obliquity. The average Harris hip score improved from 73.4 points preoperatively to 91.3 points at the time of the latest follow-up. Millis et al. presented the results in their large series of 154 periacetabular osteotomies at a minimum of five years postoperatively. Failure was based on pain scores or conversion to a total hip replacement. Multivariate analysis identified three predictors of failure: a labral tear, older age, and joint incongruity. These findings suggest that the intermediate-term results of a periacetabular osteotomy are best if the procedure is performed on congruous hips prior to the development of a labral tear or arthrosis.
Slipped Capital Femoral Epiphysis Hormonal disorders may predispose children to the development of slipped capital femoral epiphysis. Papavasiliou et al. performed a comprehensive endocrinological work-up for fourteen patients with slipped capital femoral epiphysis. Fourteen of 168 hormonal determinations revealed abnormal values, including those for luteinizing hormone, parathyroid hormone, follicle stimulating hormone, and testosterone, although no cases of true endocrinopathy were found. The authors suggested that a temporary hormonal disorder during the early years of adolescence, and not necessarily a true endocrinopathy, may play a role in the development of slipped capital femoral epiphysis. The risk of a contralateral slipped capital femoral epiphysis is estimated to be 25% to 40%, and some surgeons routinely perform prophylactic contralateral pinning at the time of pinning of a unilateral slipped capital femoral epiphysis. Stratification of the risk of contralateral slipped capital femoral epiphysis would identify patients who are at greatest risk for a contralateral slip and may be candidates for prophylactic pinning. In a study of 260 patients followed through maturity, Karol et al. found that the modified Oxford bone age was a useful predictor of a contralateral slipped capital femoral epiphysis.
Knee
Osteochondritis Dissecans
Blount Disease The efficacy of staple hemiepiphysiodesis for the treatment of late-onset tibia vara was studied by Park et al.3. Thirty-three extremities in twenty-six patients were treated with lateral stapling of the proximal part of the tibia. Additional distal femoral lateral stapling was performed in fourteen patients. At the time of follow-up, twenty extremities were in normal alignment, four were in mild varus, seven were in moderate varus, and two were in valgus. The authors recommended this procedure for patients with mild-to-moderate deformity who are younger and have sufficient growth remaining.
Leg Children with fibular deficiency may be managed with amputation or limb reconstruction. There are scant data comparing health-related quality of life and function between these two treatments. Walker et al. used multiple outcome instruments to compare thirty-two patients treated with an amputation and twenty-five patients treated with limb lengthening and found no difference between the results with regard to almost all quality-of-life measures. Compared with controls, both groups of patients were functioning with an average or above-average health-related quality of life.
Foot and Ankle
Cavovarus Foot
Spine A prospective analysis of 324 girls with adolescent idiopathic scoliosis determined that a risk factor for scoliotic curve progression was osteopenia in the femoral neck on the side of the concavity5. Sanders et al. correlated the maturation of the hand phalanges with peak height velocity and found that an uncapped phalangeal epiphysis indicated pre-peak height velocity.
Bracing
Etiology of Adolescent Idiopathic Scoliosis
Congenital Scoliosis
Early-Onset Scoliosis and Thoracic Insufficiency
Pulmonary Function
Thoracic Pedicle Screws in Scoliosis
Neuromuscular Disorders
Spondylolisthesis
Back Pain
Spinal Cord Monitoring
Outcomes and Complications
General Playground accidents can result in fractures in children. In a study of data from the Canadian Hospitals Injury Reporting and Prevention Program database, Howard et al. identified 1092 children with fractures resulting from playground accidents and found that falls from equipment were much more likely to cause severe fractures than were falls from the child's height (odds ratio, 5.03). These data support further efforts to improve playground equipment design, height, and surfaces. Urgent débridement and fixation is commonly advocated for open fractures in children. In a retrospective multicenter study of 554 open fractures in 536 consecutive patients who were eighteen years old or younger, Skaggs et al. found no difference in the infection rate between fractures treated within six hours after the injury (twelve of 344) and those treated after six hours (four of 210)12. They advocated early antibiotic treatment with surgical débridement within twenty-four hours after the injury.
Supracondylar Humeral Fractures
Lateral Condylar Fractures
Femoral Shaft Fractures Flexible intramedullary nails are usually routinely removed. In a study of thirty-five children followed for a mean of three years after flexible nailing and for whom nail removal was not routinely planned, Hoffinger et al. reported that the nail had to be removed from seven patients because of lateral knee pain. However, the remaining children had no symptoms and retained the nail. Wall et al. compared titanium nails with stainless-steel nails in ninety-two children with a femoral shaft fracture and found no difference in terms of complications, nonunions, or malunions. This suggests that stainless-steel flexible nails are as effective as titanium flexible nails. Immediate application of a spica cast is the standard treatment for femoral shaft fractures in children who are six years old or younger. However, spica cast treatment has potential drawbacks. Willis et al. compared the results of the use of a spica cast (seventeen patients) with those of flexible nailing (fifteen patients) in a study of children with a femoral shaft fracture who were between the ages of three and six years. They found a faster time to full weight-bearing, full motion, and no limp in the group that had undergone the flexible nailing. In addition, they found that those children missed fewer days of school or daycare and had a lower rate of malunion. Mubarak et al. drew attention to the potential disastrous complication of compartment syndrome with the immediate use of a 90/90 spica cast for seven children. Application of a short leg cast with a large amount of traction followed by completion of the spica cast should be avoided. The management of femoral shaft fractures in obese children is challenging. Leet et al. studied the results of the treatment of 103 femoral fractures with external fixation or a flexible intramedullary rod in children14. Complication rates after both treatment techniques were higher in the obese and very heavy children.
Ankle Fractures
Tumors Unicameral bone cyst is a common benign bone lesion in children that may lead to pathologic fracture. Yandow et al. reported the results from a multicenter bone cyst randomized clinical trial carried out through the Pediatric Orthopaedic Society of North America (POSNA) clinical trials network. In a group of forty-eight patients who had been followed for two years, there was no significant difference in healing rates between those treated with methylprednisolone injection (22%; five of twenty-three) and those treated with bone-marrow injection (12%; three of twenty-five). Dormans et al. reviewed their experience with the treatment of fourteen children who had osteoblastoma. The mean age at the time of diagnosis was nine years, and the lesions were most frequently seen in the lower extremities (43%) or the spine (36%). The patients were treated with open incisional biopsy and intralesional curettage, and those with a spinal lesion were also treated with spinal fusion and instrumentation. The local recurrence rate was 28%, and all recurrences were in young children who were less than six years of age.
Cerebral Palsy Botulinum toxin is often used as an adjunct to application of serial casts for the management of contractures in children with cerebral palsy. In a randomized clinical trial, Kay et al. compared the results of serial casts alone with those of serial casts as well as botulinum toxin injections in twenty-three children with cerebral palsy and fixed equinus contractures15. On the basis of motion, spasticity, and gait parameters, the authors found that botulinum toxin offered no additional benefit in the management of these patients. The optimal technique for lengthening of the Achilles tendon in patients with cerebral palsy is controversial. Yen et al. performed a randomized clinical trial of three different procedures (z-lengthening of the Achilles tendon, Vulpius gastrocnemius recession, and percutaneous [Hoke] lengthening of the Achilles tendon) in nineteen patients with spastic diplegia. They found that all three procedures improved functional gait, but z-lengthening of the Achilles tendon was the most effective in terms of maintenance of the initial correction. Hip flexion contracture is common in children with cerebral palsy who are able to walk. Iliopsoas lengthening, in the context of multilevel lower-extremity surgery, has been proposed to decrease this deformity and improve function. Pirpiris et al. performed a randomized clinical trial comparing iliopsoas lengthening with no lengthening in seventy-nine children with cerebral palsy who were undergoing multilevel surgery. They found that iliopsoas lengthening decreased static hip flexion contractures but did not significantly alter the functional and health-related quality-of-life outcome measures. Hip subluxation and dislocation are common in spastic cerebral palsy. Presedo et al. studied the results in sixty-five children with cerebral palsy who had undergone open adductor tenotomy and psoas muscle recession or iliopsoas tenotomy at a mean age of 4.4 years16. The mean hip migration index changed from 34% preoperatively to 18% at a mean of 10.8 years postoperatively. Nineteen patients required subsequent osseous reconstructive procedures, and eleven required repeat soft-tissue releases. The migration percentage at one year postoperatively was the best predictor of the final outcome, and patients who had been able to walk preoperatively had a better long-term outcome.
Rickets
Osteogenesis Imperfecta Improving bone mineral density is a primary goal of the medical management of these patients. Guarniero et al. randomized fifty-five patients with osteogenesis imperfecta into three groups—no medication, treatment with pamidronate, and treatment with alendronate—and measured bone mineral density initially and at one year. Pamidronate, the newer bisphosphonate, resulted in the greatest improvement in bone mineral density (19.7%). While treatment of osteogenesis imperfecta has been directed at improving bone mineral density, the effect of such an improvement on functional outcome has not been elucidated. Huang et al. correlated bone mineral density to functional outcome, as measured with the Pediatric Outcomes Data Collection Instrument, in twenty-four consecutive children with osteogenesis imperfecta. They found a significant (p = 0.025) positive relationship between bone mineral density and physical function, including upper-extremity function, transfers, sports, and global function.
Linden et al. performed a controlled intervention study of the effect of exercise, for three years, on bone mineral density in healthy children. Seventy-six boys and forty-eight girls who performed forty minutes of physical activity every school day were compared with ninety-nine age and sexmatched children who performed the standard physical activity regimen for sixty to ninety minutes per week. At three years after the start of the intervention, the boys had greater spine bone mineral density and the girls had greater spine, total body, femoral neck, and leg bone mineral density than did the controls. This suggests that increased time spent in physical activity during childhood can result in lasting improvements in bone mineral density, which may help avoid the development of osteoporosis. Bone density decreases in children who cannot walk. Snyder et al. found increased calcaneal bone mineral density in twelve nonambulatory children who had been treated with a program that involved standing for two hours per day, five days per week; however, the improvements diminished with noncompliance with the program.
The Heuter-Volkmann principle of physeal growth states that longitudinal growth is retarded by increased compressive forces. Ballock et al. investigated the basic science of this principle in growth-plate chondrocytes loaded in a static compression chamber. They found that compression of growth-plate chondrocytes inhibited differentiation into hypertrophic cells by suppressing the expression and activity of bone morphogenetic proteins in the growth plate.
Hahn et al. compared the results of femoral and tibial lengthening by means of the Ilizarov technique (twenty-eight cases) and those of the use of an elongating intramedullary nail (twenty-three cases) in young adults. Following treatment with the Ilizarov technique, there were seventeen excellent, eight good, and three fair results. Following use of the elongating intramedullary nail, there were nineteen excellent and four good results. The authors concluded that the elongating nail was effective and had advantages in terms of maintaining the range of motion, avoiding pin-track infection, and improving patient convenience.
In a prospective study of fifty-three children who had undergone aspiration because of an irritable hip, Caird et al. found that fever, an elevated C-reactive protein level, an elevated erythrocyte sedimentation rate, non-weight-bearing, and an elevated serum white blood-cell count were predictors of septic arthritis17. The probability of septic arthritis was estimated to be 98% when five predictors were present, 93% when four predictors were present, and 83% when three predictors were present. The recent emergence of community-acquired methicillin-resistant Staphylococcus aureus as a cause of bone and joint infections in children is alarming. Over a four-year period from 2000 through 2003 at the Campbell Clinic in Memphis, Tennessee, Warner et al. found that twenty-seven (26%) of 104 cases of acute hematogenous osteomyelitis or septic arthritis involved methicillin-resistant Staphylococcus aureus, with 41% of the cases in the last year of the study involving that organism. Methicillin-resistant Staphylococcus aureus infections were much more difficult to treat, with higher rates of subperiosteal abscesses, multiple surgical procedures, longer hospital stays, and prolonged periods for which blood cultures tested positive. The emergence of musculoskeletal infections with methicillin-resistant Staphylococcus aureus in children has major implications in terms of management: (1) initial antibiotic management may need to be changed to clindamycin or vancomycin if the local prevalence of methicillin-resistant Staphylococcus aureus is relatively high, (2) aspiration of the bone or joint is imperative prior to the initiation of treatment to identify methicillin-resistant Staphylococcus aureus, and (3) patients with infection due to methicillin-resistant Staphylococcus aureus likely need multiple surgical procedures and prolonged intravenous antibiotics.
Awards At the 2005 POSNA annual meeting, the Distinguished Achievement Award was given to Dr. Robert Hensinger, the Arthur H. Huene Memorial Award for excellence and promise was given to Dr. Paul Sponseller, the Angela S.M. Kuo Young Investigator Memorial Award for recognition of an outstanding young investigator and to promote a long-term research career was given to Dr. Jeffrey Shilt, and the St. Giles Young Investigator Award for educational or research endeavors was given to Dr. James McCarthy.
The AAOS and POSNA collaborated to produce a public service announcement promoting pediatric orthopaedics (Fig. 1).
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, 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.
American Academy of Pediatrics: Section on Orthopaedics October 7 through 10, 2006 Atlanta, Georgia. Third International POSNA/AAOS Pediatric Orthopaedic Symposium November 29 through December 3, 2006 Orlando, Florida. POSNA Specialty Day Meeting February 17, 2007 San Diego, California. POSNA One Day Course: Upper Extremity May 22, 2007 Hollywood, Florida. POSNA Annual Meeting May 23 through 26, 2007 Hollywood, Florida. Information at www.posna.org.
Lanou AJ, Berkow SE, Barnard ND. Calcium, dairy products, and bone health in children and young adults: a reevaluation of the evidence. Pediatrics. 2005;115:736-43. These authors performed a quantitative synthesis of the literature regarding dairy products and total dietary calcium and bone integrity in children and young adults to assess whether there is evidence to support the current recommended calcium intake levels and the suggestion that dairy products are better for promoting bone integrity than other calcium-containing food sources or supplements. The authors concluded that, in clinical, longitudinal, retrospective, and cross-sectional studies, neither increased consumption of dairy products specifically nor total dietary calcium consumption has shown even a modestly consistent benefit for bone health in children or young adults. Thus, there is scant evidence to support nutrition guidelines focused specifically on increasing milk or other dairy product intake for promoting bone health in children and adolescents. West S, Andrews J, Bebbington A, Ennis O, Alderman P. Buckle fractures of the distal radius are safely treated in a soft bandage: a randomized prospective trial of bandage versus plaster cast. J Pediatr Orthop. 2005;25:322-5. Thirty-nine children with a buckle fracture of the distal part of the radius were randomized to be treated with a plaster cast for four weeks or with a soft bandage. There were no adverse events or skin problems in either group. The soft bandage was removed by 83% of the patients in the first week and by 100% by the second week. Care was simpler when the bandage was used. The authors suggested that use of a conventional cast for buckle fractures may be overtreatment and that a soft bandage may be appropriate. Keppler P, Salem K, Schwarting B, Kinzl L. The effectiveness of physiotherapy after operative treatment of supracondylar humeral fractures in children. J Pediatr Orthop. 2005;25:314-6. Forty-three children treated with open reduction and pinning of a supracondylar humeral fracture were randomized to receive physical therapy or no therapy after pin removal at four weeks. At twelve and eighteen weeks post-operatively, the range of motion was greater in the physical therapy group, but there was no difference in the range of motion at one year. The results of this study are not generalizable to patients treated with closed reduction and percutaneous pinning, as that method was not studied. Closed reduction and pinning is the most common method of treatment for these fractures, and physical therapy is usually not utilized after the pins and cast are removed at three to four weeks. The results of this study suggest that physical therapy may not be necessary after open reduction and pinning of supracondylar humeral fractures. However, physical therapy may be of some benefit for patients who had the limb immobilized for longer than four weeks or for older patients. Florentino-Pineda I, Thompson GH, Poe-Kochert C, Huang RP, Haber LL, Blakemore LC. The effect of Amicar on perioperative blood loss in idiopathic scoliosis: the results of a prospective, randomized double-blind study. Spine. 2004;29:233-8. Thirty-six patients with adolescent idiopathic scoliosis who underwent posterior spinal fusion with instrumentation and autogenous iliac crest bone graft were randomized to receive Amicar (aminocaproic acid) or saline solution. Amicar inhibits activation of plasminogen to plasmin. Patients in the Amicar group demonstrated a significant decrease in the perioperative estimated blood-volume loss (41% compared with 47% in the control group) and the need for autologous blood transfusion (1.0 compared with 1.7 autologous units given). The decrease in blood loss was predominantly in the postoperative suction drainage. The patients who took Amicar had no intraoperative or postoperative thromboembolic complications. The results of this study support the use of Amicar to decrease blood loss and the need for transfusion after posterior spinal surgery in patients with adolescent idiopathic scoliosis. Caulton JM, Ward KA, Alsop CW, Dunn G, Adams JE, Mughal MZ. A randomized controlled trial of standing programme on bone mineral density in non-ambulant children with cerebral palsy. Arch Dis Child. 2004;89:131-5. Twenty-six nonambulatory patients with cerebral palsy were randomized to be treated with a program that involved increased standing, compared with baseline, in an upright or semiprone standing frame for nine months or were randomized to a control group, and bone mineral density was measured with quantitative computerized tomography. After the treatment period, the median standing duration was 80.5% and 140.6% of baseline in the control and intervention groups, respectively. There was a significant (p = 0.040) (6%) increase in vertebral bone mineral density in the intervention group. There was no significant increase in proximal tibial bone mineral density. The results of this study suggest that increasing the time that nonambulatory patients with cerebral palsy stand may increase bone density, which may reduce fracture risk. Piza G, Caja VL, Gonzalez-Viejo MA, Navarro A. Hydroxyapatite-coated external-fixation pins. The effect on pin loosening and pin-track infection in leg lengthening for short stature. J Bone Joint Surg Br. 2004;86:892-7. Twenty-three patients underwent a total of twenty-eight bilateral lower-extremity lengthening procedures with external fixators, and a total of 322 pins, because of short stature. The patients were randomized, by side, to be treated with either hydroxyapatite-coated pins or non-hydroxyapatite-coated pins. The mean implantation time was 530 days, and the mean lengthening achieved was 78% of the initial bone length. The mean extraction torque was 7611.6 Nmm/deg for the hydroxyapatite-coated pins and 85.4 Nmm/deg for the non-hydroxyapatite-coated pins. The rate of loosening was lower for the hydroxyapatite-coated pins (4% compared with 80%). There was no significant difference in the prevalence of pin-track infections. The results of this study support the use of hydroxyapatite-coated pins during limblengthening with external fixation.
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Introduction
Pediatric Orthopaedic Conditions...
14° or an angle of 