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The Journal of Bone and Joint Surgery (American). 2008;90:1401-1411. doi:10.2106/JBJS.H.00236 © 2008 The Journal of Bone and Joint Surgery, Inc. What's New in Pediatric Orthopaedics
1 Texas Scottish Rite Hospital, 2222 Welborn Street, Dallas, TX 75219. E-mail address: dan.sucato{at}tsrh.org
Specialty Update has been developed in collaboration with the Council of Musculoskeletal Specialty Societies (COMSS) of the American Academy of Orthopaedic Surgeons.
Femoroacetabular Impingement Hip impingement as a mechanism of hip pain and osteoarthritis continues to be an active area of investigation. Previously, theoretical analysis of slipped capital femoral epiphysis deformity demonstrated that with increasing proximal femoral deformity (i.e., increasing severity of the slipped capital femoral epiphysis), the proximal head-neck junction will start to impinge against the acetabulum with less hip flexion. Abraham et al.1 compared the cartilage degeneration pattern in sixteen hips with osteoarthritis due to slipped capital femoral epiphysis with that in eighty-four hips with primary osteoarthritis in a study of patients undergoing hip arthroplasty. The patients in the slipped capital femoral epiphysis group were collected over a ten-year period and were identified on the basis of a history of hip surgery in adolescence for a diagnosis consistent with slipped capital femoral epiphysis. The patients in the primary osteoarthritis group were identified from an arthroplasty practice after the exclusion of other causes of osteoarthritis such as hip dysplasia or trauma. The patients in the slipped capital femoral epiphysis group underwent arthroplasty at a mean age of forty-six years, which was eleven years younger than the mean age of the patients in the primary osteoarthritis group at the time of surgery. As expected, the patients in the slipped capital femoral epiphysis group had loss of the anterior head-neck offset, causing femoroacetabular impingement, whereas most of those in the primary osteoarthritis group had a preserved anterior head-neck offset. The cartilage degeneration patterns in these two groups were characteristically different. The patients in the slipped capital femoral epiphysis group had superior peripheral acetabular cartilage damage, consistent with the area of impingement, whereas those in the primary osteoarthritis group had more central acetabular cartilage damage and preservation of the superior peripheral cartilage. The patterns of cartilage loss suggested that the mechanism of cartilage damage in these two groups is different. The coincident location of the area of impingement with the loss of cartilage in the slipped capital femoral epiphysis group is highly suggestive that the abnormal mechanics in patients with slipped capital femoral epiphysis are responsible for the development of osteoarthritis in this group. Idiopathic decreased head-neck offset is an entity that also causes femoroacetabular impingement in a manner similar to slipped capital femoral epiphysis. Some investigators have postulated that this condition may be a mild form of slipped capital femoral epiphysis, but its exact cause is unknown. Nevertheless, it can result in premature osteoarthritis and is a common cause of hip pain and disability in young males. Beaulé et al.2 evaluated the results of surgical treatment of this condition by means of safe surgical dislocation and femoral head-neck junction osteochondroplasty. The average age of the patients was approximately forty years. After a mean duration of follow-up of approximately three years, there was significant improvement in terms of pain, disability, and activity level. The pattern of acetabular cartilage damage appears to have been similar to that described by Abraham et al.1, and presumably the mechanism of cartilage damage was the same. The surgical treatment of femoroacetabular impingement is based on removal of the underlying cause of impingement and, in uncontrolled studies, the treatment has appeared to be effective. Many questions remain regarding femoroacetabular impingement as a cause of hip pain and osteoarthritis, including the prevalence and natural history of pain and dysfunction as well as the development of osteoarthritis. Impingement in hips with slipped capital femoral epiphysis is most often caused by the metaphyseal prominence at the head-neck junction. However, an improperly placed screw also can cause impingement and can be a source of joint damage and pain. Goodwin et al.3, in a biomechanical study, demonstrated that, for moderate and severe slipped capital femoral epiphysis, in situ pinning at the ideal position of the femoral head (i.e., a central position with the axis of the screw perpendicular to the physis) probably will cause impingement of the screw against the acetabulum. As an alternative technique in cases of moderate and severe slipped capital femoral epiphysis, they recommended that the screw head should rest lateral to the intertrochanteric line on the anteroposterior radiograph in order to avoid screw head impingement. With any in situ pinning technique, it is still imperative that joint penetration by the screw tip be avoided. Van Valin and Wenger4, in a case report, demonstrated that the false-profile projection can be more easy to use than a frog-leg lateral view for the detection of posterior penetration of the femoral head by a posteriorly placed pin. Whether caused by osseous deformity or surgically placed hardware, hip impingement continues to be an active area of investigation as a cause of hip pain and arthritis.
Developmental Dysplasia of the Hip At the present time, the recommended screening method varies by country. In North America, the standard primary screening method is the physical examination, with a focus on the Ortolani sign, which is considered to be positive when the dislocated hip reduces with hip abduction. Lipton et al.7 evaluated the value and validity of the Ortolani test as compared with ultrasound findings in infants with a positive Ortolani sign and in infants with a negative Ortolani sign but a positive ultrasound finding of a dislocated hip. They found that all hips with a positive Ortolani sign had an abnormal ultrasound study, with the majority of the hips being dislocated. The average age of the patients in whom the hip was dislocated on ultrasound but who had a negative Ortolani sign was approximately ninety days. In both groups, the hips that were irreducible when evaluated with ultrasound were mostly in these older patients who had a negative Ortolani sign. That study confirms that a positive Ortolani sign, when present, is a clear sign of hip instability. As the child gets older, the value of the Ortolani sign decreases and other physical findings or ultrasound must be used to detect a dislocated hip. The need for continued screening by means of physical examination until walking age was illustrated in a report on five cases of late dislocation involving hips that previously had been radiographically normal8. In all five cases, the physical examination and radiographs had both revealed normal findings before the age of three months. None of the infants were screened with ultrasound, and it remains to be seen if these cases represented instances of true late dislocation of normal hips or subtle abnormalities that may have been detected with ultrasound. That study points out the need for continued monitoring until walking age, especially if physical examination is the primary method of screening. When dislocation of the hip is discovered late, surgical treatment often is the only available option. The primary goal of surgical treatment is to provide a pain-free, functioning hip at least into middle age. Hence, true long-term follow-up is necessary to assess the final clinical outcome, but such long term-studies are in reality difficult to achieve. Thomas et al.9 recently completed a forty-three-year follow-up study of dislocated hips that had been treated with open reduction and innominate (Salter) pelvic osteotomy. The patients were an average of forty-six years old at the time of the latest follow-up, by which time approximately 31% of the hips had been converted to an arthroplasty. The overall complication rate for the entire group was 25%, with a higher complication rate in the group undergoing early arthroplasty. Such long-term preservation of a functioning joint is certainly an enviable result and a goal for which we all should strive; however, that study points out that, even in the best of hands, surgical treatment of a dislocated hip, even when performed in a patient who is 1.5 years of age, appears to have a different natural history than early reduction of the hip with use of a brace.
Osteonecrosis Hernigou et al.10 studied the natural history of asymptomatic osteonecrosis in adult patients with sickle-cell disease. These lesions were identified during magnetic resonance imaging for the evaluation of osteonecrosis in the contralateral hip. The authors found that, unlike hips with osteonecrosis due to other etiologies, 91% of asymptomatic hips with osteonecrosis in patients with sickle-cell disease eventually became painful and 77% collapsed. In contrast, among hips with osteonecrosis due to causes such as steroid use or alcohol abuse or an idiopathic etiology, only 33% of previously asymptomatic lesions that were detected with magnetic resonance imaging progressed to symptoms. In a condition with such a dismal natural history, any clinical improvement after therapy is interpreted to be evidence of the effectiveness of the intervention, even when studied without a control group or studied in a nonrandomized fashion. Core decompression for the treatment of osteonecrosis appears to be such an intervention in the case of sickle-cell disease. Neumayr et al.11 reported the results of a prospective randomized study in which the clinical and radiographic results of core decompression combined with physical therapy were compared with those of physical therapy alone in patients with osteonecrosis due to sickle-cell disease. The investigators found that both groups had improvement in clinical findings and that the difference between the groups was not significant. In addition, the rates of hip survival were similar. That study points out the value of a prospective randomized clinical trial for clarifying the efficacy of an intervention for a complex disease such as osteonecrosis in patients with sickle-cell disease. Osteonecrosis due to unstable slipped capital femoral epiphysis, femoral neck fracture, or traumatic hip dislocation is another condition that has a poor prognosis. Studies involving animal models of osteonecrosis have suggested that bisphosphonate therapy may shift the balance between osteoclastic and osteoblastic activity during the revascularization that occurs after the onset of osteonecrosis. On the basis of this hypothesis, Ramachandran et al.12 reported on seventeen patients with traumatic osteonecrosis of the femoral head who were managed with bisphosphonate therapy. The study was an uncontrolled prospective case series. Nine hips were Stulberg class I or II, six were class III, and two were class IV. The investigators found that fourteen of seventeen hips were pain-free. That observational study suggests that bisphosphonate therapy may preserve bone structure in patients with osteonecrosis. It was only the first, albeit necessary, step in laying the groundwork for a prospective randomized trial to demonstrate the efficacy of bisphosphonate therapy in patients with osteonecrosis.
Lower Extremity Deformity Lower extremity deformities such as limb-length discrepancy and Blount disease are relatively common. Methods of assessment and treatment continue to evolve. In the study by Sabharwal et al.13, the accuracy of limb-length measurements on a standing anteroposterior radiograph was compared with the accuracy of measurements on a scanogram. The authors found an average magnification of 4.6% in association with the measurement of lower extremity length with use of a full-length standing radiograph, with excellent agreement between the measurements made on scanograms and those made on standing anteroposterior radiographs (correlation coefficient, 0.96). They believed that the standing anteroposterior radiograph of the lower extremity had sufficient accuracy as well as the added benefit of being able to depict the lower extremity deformity to justify its use as the primary imaging technique for the assessment of length discrepancy. Currently, there are many options for the gradual correction of limb deformity. Percutaneous epiphysiodesis remains a standard technique to achieve a permanent physeal arrest. In contrast with the single-portal technique, the double-portal approach does not cross the physis and is associated with a fourfold lower complication rate. Temporary epiphysiodesis with either percutaneous screw insertion or an extraperiosteal two-hole plate technique appears to be safe and effective and relatively noninvasive. Lee et al. noted that when stromal cell-derived factor-1 (SDF-1) was infused into the proximal tibial growth plate of rabbits, there was significant growth inhibition compared with the sham control side. Improved understanding of the factors that regulate physeal growth may help us to develop biologic therapies in the future. Blount disease is a relatively rare condition, but it is associated with various risk factors, including obesity. Sabharwal et al.14 reported on forty-five patients with sixty-five limbs that were affected by either early-onset or late-onset Blount disease. Eighty-eight percent of the children with early-onset disease were overweight, compared with 93% of those with late-onset disease. There was a direct correlation between body mass index and increased varus malalignment and tibial procurvatum in the early-onset group, but not in the late-onset group. The strongest correlation with these radiographic deformities was seen in the patients who were extremely obese. The stabilization of long bones in children with osteogenesis imperfecta continues to be a technical challenge. Cho et al.15 described a new telescopic rod system that is a modification of the telescopic rod with a T-piece. In this modification, distal fixation is obtained by means of an interlocking pin placed through a hole in the telescoping rod. This may have the advantage of providing better fixation in the distal part of the femur as well as allowing easier insertion of the rod. The Ponseti method for the treatment of idiopathic clubfoot has become the preferred method among most pediatric orthopaedists today. As part of this method, percutaneous Achilles tendon lengthening is performed to correct the equinus contracture. Although it is assumed that correction is achieved at the ankle joint primarily, this has not been previously studied. Radler et al.16 performed a retrospective review of radiographs that had been made before and after treatment with percutaneous Achilles tendon lengthening as part of the Ponseti method. Lateral radiographs of eighty-seven feet demonstrated a 17° improvement in the lateral tibiocalcaneal angle following tenotomy, which closely correlated with the clinical measurement of 15° of dorsiflexion. The lateral tibiocalcaneal angle and dorsiflexion were the only measurements that significantly changed after the Achilles tenotomy, and the authors concluded that the dorsiflexion obtained with the tenotomy came primarily from the ankle joint. The Ponseti method has largely been quite effective for the treatment for idiopathic clubfoot; however, it has not been universally successful. Haft et al.17 reviewed their experience with this technique in the New Zealand population to analyze characteristics that predict recurrence. The authors reported a 41% rate of recurrence overall, with a 23% rate of major recurrences and a 17% rate of minor recurrences. Only 11% of the children whose parents were compliant with the abduction bracing protocol had a recurrence, whereas the children whose parents were not compliant had a five times greater likelihood of having a recurrence. Other factors, such as the severity of presentation, the number of casts, ethnicity, and a family history of clubfoot, did not correlate with recurrence, and the authors concluded that compliance with the use of the brace after casting is critical for a successful outcome.
Upper Extremity Deformity
Acute hematogenous osteoarticular infections are relatively common in the pediatric population. With early diagnosis and effective surgical and medical therapies, the end result can be complete resolution of the infection without long-term consequences. Most hematogenous infections are caused by Staphylococcus aureus and, when the results of culture are unavailable, the initial management often may be antibiotic treatment targeted to methicillin-sensitive Staphylococcus aureus. In some communities, an increase in the incidence of methicillin-resistant Staphylococcus aureus infections even in populations without a risk factor for such infections was noted. Arnold et al.19 presented epidemiologic data on acute hematogenous osteoarticular infections that had been treated at the Le Bonheur Children's Medical Center in Memphis, Tennessee, from 2000 to 2004. They noted a constant rate of septic arthritis during this period but observed a significant increase in the rates of both osteomyelitis and combined osteomyelitis and septic arthritis. The main pathogen remained Staphylococcus aureus; however, the increased incidence of osteoarticular infections during this period was mainly due to an increased number of methicillin-resistant Staphylococcus aureus and culture-negative cases. The patients with methicillin-resistant Staphylococcus aureus infections had a more complicated and prolonged hospital course. The patients with methicillin-resistant Staphylococcus aureus infections were more likely to have subperiosteal abscesses, and there was a trend toward more episodes of septic thrombophlebitis, septic emboli, and large muscle abscesses. Additionally, the patients with methicillin-resistant Staphylococcus aureus infections required more frequent surgical intervention. In light of these findings, we believe that the local rate of methicillin-resistant Staphylococcus aureus infections should be monitored and that medical and surgical interventions should be adjusted accordingly. Osteomyelitis of the pelvis can be difficult to diagnose. When a patient presents with acute nontraumatic hip pain, septic arthritis of the hip should be the first item in the differential diagnosis when the pain is accompanied by signs of infection. The diagnosis of septic arthritis of the hip can be made readily with use of ultrasound, but in the setting of a negative clinical suspicion of an infection of the hip and/or a negative hip ultrasound study, the next diagnostic imaging test is unclear. Karmazyn et al. and McPhee et al. evaluated the diagnostic value of plain radiographs, computed tomography, and magnetic resonance imaging in making the proper diagnosis when a patient presents with acute nontraumatic hip pain. Both groups of investigators concluded that the initial study should be a plain radiograph as it is easily made; however, the diagnostic value of a pelvic radiograph is low for pelvic osteomyelitis, and hence, if the clinical suspicion is high, additional studies should be performed. The optimal imaging study to diagnose pelvic infection was found to be a magnetic resonance imaging scan because both the soft tissue and osseous structures can be imaged, and it should be the preferred test after plain radiographs or an ultrasound study of the hip have been made.
Surgical Treatment of Spinal Deformity Preoperative traction is a technique that is used to improve curve flexibility and pulmonary function in patients with severe spinal curves; however, it requires a long hospital stay, risks complications, and is generally contraindicated when cervical instability is present. The concept of applying traction intraoperatively with temporary distraction instrumentation involving posterior implants was reported by Buchowski et al.20. The authors reviewed the records of ten patients with large curves who had had a staged procedure in which the distraction had been performed with a single posterior rod followed by the definitive posterior instrumentation and fusion. The authors demonstrated a 53% average curve correction after the distraction phase and a final 80% coronal curve correction following the definitive instrumentation and fusion. There were no neurologic deficits in any patient. Six of the ten patients had an anterior release at the time of the initial placement of the distraction instrumentation to improve curve flexibility. The surgical approach to spinal deformity has changed in association with the greater use of multiple anchor points for the spinal instrumentation to gain control of the spine, and this approach has generally improved the degree of deformity correction. Herrera-Soto et al., in a review of sixty-seven patients who had undergone surgical treatment of adolescent idiopathic scoliosis with use of collar-button (Wisconsin or Drummond) wires and hooks over multiple segments of the spine, reported a 72.2% mean correction of thoracic curves and a 63.2% mean correction of lumbar curves. Minimal loss of correction occurred over time. The authors concluded that the employment of multiple fixation points with use of concave collar-button wires is an excellent method for achieving coronal plane correction, and it is extremely safe for these curves. Di Silvestre et al.21 analyzed the risk of complications associated with the use of transpedicular thoracic screws in a study of 115 patients with scoliosis. A mini-laminotomy technique was used to assess the position of the medial pedicle wall prior to placement of the screw. Of the 1035 screws placed, only eighteen (1.7%) were misplaced in thirteen patients (11.3%). Screw malposition resulted in a pleural effusion and fever in one patient and was asymptomatic in the remaining twelve patients. Intraoperative pedicle fractures occurred in fifteen patients, and dural tears without neurologic sequelae occurred in fourteen patients. Misplaced screws were removed in three additional patients, despite the absence of symptoms, because of the intrathoracic position of the screws as noted on a postoperative computed tomographic scan. The authors concluded that the mini-laminotomy approach for the placement of transthoracic screws was safe, and they recommended it as an excellent technique to avoid complications related to thoracic pedicle screws. Rajasekaran et al. compared the safety and accuracy of placing thoracic pedicle screws for the treatment of spinal deformity before and after the use of a commercially available navigation system. Pedicle screw breaches were found in association with 23% of the screws that had been placed without surgical navigation and only 2% of those that had been placed with use of the navigation system. The time that it took to place the screws was also significantly less when the navigation system was used. The authors concluded that the navigation system provides surgeons with the ability to improve their accuracy to place pedicle screws while reducing surgical time and perhaps exposure to radiation. Surgical treatment for adolescent idiopathic scoliosis is generally considered to be a one-time procedure that is associated with a low rate of revision surgery in these young patients. Richards et al.22 performed a retrospective review of the fifteen-year experience, at a single institution, with the treatment of adolescent idiopathic scoliosis with anterior or posterior instrumentation and fusion, which was considered to be the "definitive" procedure. Repeat surgical treatment was required for 12.9% of 1046 patients, with a higher rate of reoperation for patients who initially had posterior surgery than for those who initially had anterior surgery (14.0% compared with 9.3%). The posterior fusion group had a higher rate of reoperation for the treatment of infection and symptomatic implants as compared with the anterior fusion group; however, the rate of pseudarthrosis was the same for both groups. The authors concluded that instrumentation and fusion is not necessarily a definitive procedure for the treatment of adolescent idiopathic scoliosis and that repeat surgical procedures may be necessary for as many as 14% of patients. The results of that study can be used by surgeons when discussing surgical treatment for adolescent idiopathic scoliosis with patients and families. High-grade spondylolisthesis at L5-S1, defined as a translational slip of >50%, is relatively rare, and the optimal surgical treatment for this condition has yet to be firmly established. Lamberg et al.23 reported on sixty-nine patients who underwent in situ fusion, without instrumentation, for the treatment of high-grade isthmic spondylolisthesis. The mean duration of follow-up was seventeen years. There were three treatment groups (posterolateral fusion, anterior fusion alone, and circumferential anterior and posterior fusion). The authors demonstrated that the circumferential in situ fusion group had better long-term results on patient-based outcome instruments than did either of the other two groups, although the differences were relatively small. The mean Oswestry disability index at the time of follow-up was 9.7 for the posterolateral fusion group, 8.9 for the anterior fusion group, and 3.0 for the circumferential fusion group. These results seem to indicate that a solid fusion is important, leads to a good functional outcome, and can be better accomplished with a combined anterior and posterior arthrodesis. Although instrumentation was not utilized in any patient in that series, the improvement in sagittal plane deformity seen in association with greater use of three-column fixation allowing for safe vertebral reduction may provide added benefit when treating this difficult condition. The challenge of treating severe spinal deformity may require the utilization of osteotomies of the spine or resection of vertebrae to maximize deformity correction; however, these techniques carry substantial neurologic risk. Lenke reported on a series of vertebral column resections in forty-three patients (including thirty children) with severe spinal deformity and demonstrated between 50% and 72% correction without any permanent neurologic deficits. During closure of the osteotomy site, the neurogenic motor evoked potentials disappeared in 18% of the patients; however, a return to baseline occurred in all patients following prompt surgical intervention. This technique provided outstanding correction of severe spinal deformities but is technically demanding and requires a skilled surgeon and an experienced team to be effective and safe.
Cervical Spine
Growth Predictors
Neuromuscular Scoliosis Mercado et al.27, in a literature review of 198 studies published between 1980 and 2006, analyzed the quality of life of patients with neuromuscular scoliosis and concluded that spinal fusion improved the quality of life of patients with cerebral palsy and muscular dystrophy but did not improve the quality of life of patients with spina bifida. Karol and Elerson28 reviewed the medical records of 298 patients who had Charcot-Marie-Tooth disease and identified forty-five patients with scoliosis. The average age of these forty-five patients at the time of presentation was 12.9 years, and the average curve was 28°. Thirty percent of the curves were left thoracic, and 49% were associated with increased thoracic kyphosis. The majority of the curves progressed over time; however, bracing was ineffective in 80% of the patients for whom it was prescribed. Posterior spinal fusion and instrumentation was performed in fourteen of the forty-five patients; however, baseline intraoperative neuromonitoring was performed for only a quarter of the fourteen patients. The authors concluded that scoliosis in patients with Charcot-Marie-Tooth disease is different from idiopathic scoliosis because of increased thoracic kyphosis and unsuccessful brace treatment. They noted that surgeons should expect challenges in obtaining baseline intraoperative monitoring when instrumentation and fusion is performed in these patients.
Spinal Cord Monitoring
Functional Status and Quality of Life Sponseller et al.31 performed an analysis of the literature pertaining to spine and chest wall deformity and its treatment in the context of evidence-based medicine. The authors found that most studies were case-controlled series and case series as these conditions are rare and are very heterogeneous. These limitations hopefully will be overcome with advances in imaging and other measures to allow for greater comparison of similar patient groups. Data on the natural history of most types of spine and chest wall deformities are currently limited, and considerable opportunity for evidence-based research exists in these areas.
Pulmonary Function
Pain management in the acute setting following a pediatric injury is an important element of care. Many modalities have been utilized to achieve adequate pain control, and these modalities are, in part, specific to each institution. The next five studies to be discussed focused on pain management during the visit to the pediatric emergency room for the treatment of acute injuries. Borland et al.34 performed a randomized, prospective, double-blind, placebo-controlled clinical trial in a tertiary pediatric emergency room setting. A sample of children ranging from seven to fifteen years of age who had closed displaced long-bone fractures were randomized to receive either intravenous morphine and intranasal placebo or intranasal fentanyl and intravenous placebo during fracture reduction. A 100-mm visual analog scale was used to measure pain at five-minute intervals for thirty minutes. Sixty-seven patients were enrolled in the study, thirty-four of whom received intravenous morphine and thirty-three of whom received the intranasal fentanyl. There were no significant differences in the pain scores between the two treatment groups at any time period. There were reductions in pain scores at the five, ten, and twenty-minute periods for both groups. The authors concluded that intranasal fentanyl is an effective analgesic in an emergency room setting. In the study by Clark et al.35, patients presenting with musculoskeletal injury involving the extremities, neck, or back were randomized into three pain-management modalities (acetaminophen, ibuprofen, and codeine) within forty-eight hours after presentation to the emergency department. The measured outcome was the change in the pain level from the baseline value obtained prior to the administration of pain medication. Three hundred patients were randomly assigned to each group. The results demonstrated that the ibuprofen group had greater improvement in pain scores in comparison with the other two groups at sixty minutes and that more patients in the ibuprofen group had adequate analgesia in comparison with the other two groups. The authors concluded that ibuprofen is a better analgesic than acetaminophen or codeine following acute musculoskeletal trauma in pediatric patients. The results of that study are very encouraging; however, it should be remembered that only 10% of the patients in that study presented with a fracture requiring reduction whereas the remaining patients had more benign conditions that did not require manipulation. In the study by Roback et al.36, 225 pediatric patients with orthopaedic injuries were randomized to one of two methods of sedation. Two hundred and eight patients completed the study, of whom 109 received intravenous ketamine and ninety-nine received intramuscular ketamine. Although vomiting was more common in the intramuscular group, the patients in that group had less pain and lower distress during the procedure; however, the duration of sedation was longer. When the parents and physicians were asked about satisfaction with sedation, there seemed to be no difference between the two groups. The study was stopped, however, because the nursing staff believed that the sedation period in the intramuscular ketamine group was too long. The authors concluded that intramuscular ketamine at a dose of 4 mg/kg was more effective than intravenous ketamine at a dose of 1 mg/kg. Kriwanek et al.37 performed a prospective randomized controlled trial in which axillary block regional anesthesia was compared with deep sedation with ketamine and midazolam for patients undergoing closed reduction of a forearm fracture. The primary outcome was distress during manipulation as measured with the Children's Hospital of Eastern Ontario Pain Scale. The Children's Hospital of Eastern Ontario Pain Scale score was no different between the axillary block group (6.4) and the deep sedation group (7.5), and there were no adverse effects in association with either treatment. Luhmann et al.38 performed a prospective randomized study in which children between the ages of five and seventeen years undergoing reduction of a forearm fracture were randomly assigned to receive either intravenous ketamine with midazolam or nitrous oxide and a hematoma block. Videotapes were made before, during, and after reduction of the fracture, and a procedure behavioral checklist was completed by an observer who was blinded to the purpose of the study. The primary outcome measure was change in the procedure behavioral checklist before and during the procedure. One hundred and two children were randomly assigned to the ketamine/midazolam group (fifty-five subjects) or the nitrous oxide/hematoma block group (forty-seven subjects). The mean change in the checklist was small in both groups. However, it was smaller in the nitrous oxide/hematoma block group, and recovery times were significantly shorter in that group. In addition, parents and patients reported less pain during the fracture reduction in association with use of the nitrous oxide/hematoma block method. Adverse effects occurred in both groups but were less common in the ketamine/midazolam group during and after the visit. The authors concluded that children who received nitrous oxide and a hematoma block had minimal increases in distress and fewer adverse effects, with significantly less recovery time.
Bone Tumors Osteogenesis imperfecta can be difficult to diagnose when children are young and have the milder forms of the condition. Kocher et al. reviewed the Children's Hospital Boston experience with families in which osteogenesis imperfecta had been misdiagnosed as child abuse. The study included thirty-three children who had presented at an average age of 7.1 months. Symptoms included pain, swelling, decreased limb movement, or unusual limb position. All patients had radiographic evaluation of the injury, and nearly all patients had additional imaging studies. Multiple fractures were found in twenty-eight of the thirty-three children, with an average of seven fractures per patient. Forty-two percent of the patients had some physical or radiographic finding that was consistent with the diagnosis of osteogenesis imperfecta, yet 70% of the children and 62% of their siblings were removed from the family to protect them from suspected abuse. The diagnosis of osteogenesis imperfecta was then made at an average age of 10.5 months, with 94% of the patients having type-I osteogenesis imperfecta and 52% having a family history of the condition. A mean of $42,000 was spent by the families on legal fees. The authors concluded that the consequences of misdiagnosis of osteogenesis imperfecta as child abuse are very significant and that the diagnosis of osteogenesis imperfecta should be considered in all cases of suspected child abuse. They recommended genetic testing for any child with clinical, radiographic, or family history features of the condition. Elke et al., in a review of the European Paediatric Orthopaedic Society experience with all four types of dysplasia epiphysealis hemimelica, or Trevor disease, identified fifty-one cases in thirteen cities in eight countries. Six patients were observed with progressive disappearance of the lesions and had a good functional outcome. The remaining patients underwent surgical treatment, especially if the lesion was causing pain or deformity or was interfering with function. An average of 1.4 operations per patient were performed, including excision and correction of deformity and arthrodesis for nonfunctional painful joints. The authors concluded that excision is preferred for symptomatic juxta-articular lesions and loose bodies and that it generally leads to good results. Excision of intra-articular lesions is necessary to improve a painful joint; however, the intra-articular surgery needed to remove these lesions may lead to articular damage and permanent joint stiffness in the future. The treatment of congenital pseudoarthrosis of the tibia continues to be challenging, and a good understanding of the pathophysiology of the lesion is lacking. Cho et al. histologically reviewed the fibrous hematoma that had been removed from the central part of the tibia in a series of patients who had this condition. The authors reported increased osteoclastogenesis and decreased osteogenicity of the cells. Exposure of the cells to exogenous bone morphogenic protein did not result in osteoblastic differentiation. The authors concluded that complete excision of the fibrous hematoma should be an essential part of the surgical treatment and that additional research is necessary to understand the molecular pathways in this condition. Hosalkar et al. reviewed seventy children who had primary musculoskeletal Langerhans cell histiocytosis. Twenty-six of the children had primary spine involvement, whereas forty-six had extraspinal involvement. The mean age of the group with spine lesions was 8.2 years, and the most common presenting symptom was pain followed by neurologic symptoms. Of the children with spine lesions, ten were managed with chemotherapy, four were managed with radiation therapy, two were managed with both, and the remaining patients were observed. Of the forty-six patients with extraspinal lesions, thirty-two had involvement of one bone, four had involvement of two bones, and ten had involvement of three bones or more. Systemic involvement occurred in 24% of the patients. Seventeen patients were managed with curettage, one was managed with radiation, and fifteen were managed with a combination of chemotherapy and radiation. The authors concluded that there is variability in the presentation of this disease and that primary treatment should always be observation as most of the lesions heal, although curettage and grafting may be needed when observation fails. Multisystem disease is best treated with chemotherapy. Ippolito et al. reviewed the surgical treatment of lower extremity polyostotic fibrous dysplasia. Twenty-one patients were reviewed, sixteen of whom also had an endocrinopathy (McCune-Albright syndrome). The mean age at the time of surgery was 12.8 years, and the mean duration of follow-up was three years. A variety of implants were utilized, including plates and intramedullary nails, depending on the age of the patient and the severity of deformity. The authors reported overall good outcomes and concluded that plate fixation was very useful as a temporary method for the correction of severe epiphyseal deformities in smaller patients and could later be converted to intramedullary fixation. Titanium elastic nails were useful for smaller children; however, locked intramedullary nails were optimal for older patients.
Fractures Blanco et al. reviewed their experience with lateral pin and cross-pin fixation for the treatment of type-3 supracondylar humeral fractures. The investigators studied 104 consecutive patients who had been managed with either lateral pins (fifty-seven) or cross-pin fixation (forty-seven patients). The change in the Baumann angle and the difference in the humeral-capitellar angle between the two groups was the same. There were two temporary ulnar neuropathies in the cross-pin group; however, both recovered completely. The authors concluded that there is no significant difference in radiographic outcomes between the lateral pin and cross-pin fixation techniques for these fractures. Sankar et al.40 evaluated the causes of loss of pin fixation following the treatment of displaced supracondylar humeral fractures in a study of 279 patients. Eight fractures (2.9%), all of which were type-3 fractures, lost fixation postoperatively. Seven of the eight fractures had been treated with two lateral pins, and the remaining fracture had been treated with cross-pins. The fractures that had been treated with three pins, whether they had been placed laterally or in a cross-pin configuration (two lateral and one medial), were more stable and had no loss of fixation. The authors identified technical errors in the pin configurations, including failure to engage both fragments with two or more pins, failure to achieve cortical fixation with two or more pins, and failure to achieve pin separation by >2 mm at the fracture site. Flynn et al. demonstrated an increasing frequency of surgical treatment of both-bone forearm fractures in children over the past decade. One hundred and five consecutive patients who had had surgical treatment of 110 diaphyseal forearm fractures were reviewed. These fractures represented 6.1% of all forearm fractures that had been treated at their institution over a period of ten years. During that period, there had been a sevenfold increase in the operative treatment of these fractures. Of the 110 fractures, 63.6% had intramedullary fixation and 34.5% underwent plate fixation. The most common surgical indication was unacceptable alignment after closed reduction. There was a significantly higher prevalence of forearm compartment syndrome in patients who had been managed with intramedullary fixation on the day of the injury as compared with those who had delayed treatment. Podeszwa et al. retrospectively compared children who had had bioabsorbable screw fixation with those who had had metallic screw fixation for the treatment of distal tibial epiphyseal ankle fractures. Radiographically, there were no nonunions in either group. One of the twenty-four patients in the bioabsorbable screw group and three of the twenty-six patients in the metallic screw group had distal tibial joint irregularity. Fourteen of the twenty-six patients in the metallic screw group underwent planned screw removal. The authors concluded that bioabsorbable screw fixation can be used effectively for the treatment of distal tibial epiphyseal fractures, eliminating the need for screw removal later. Calcaneal fractures in children are relatively uncommon, and it is exceptionally rare for them to require operative treatment. Kocher et al. reviewed fourteen fractures (in thirteen patients) that had been treated with open reduction and internal fixation. The mean Bohler angle improved from 11.8° preoperatively to 23.4° postoperatively. The mean American Foot and Ankle Society hindfoot score was 64 of a possible 68 points at an average of sixty-seven months postoperatively. Four minor complications occurred in three patients. The authors concluded that most patients with displaced intra-articular calcaneal fractures that are treated with open reduction and internal fixation have good clinical outcomes with few complications. Gordon et al. retrospectively reviewed thirteen children who had had flexible titanium intramedullary nail fixation of nonpathological humeral shaft fractures at an average age of twelve years. All fractures united within three months without any perioperative complications. However, nine of the thirteen patients required nail removal because of discomfort near the elbow. One patient who had an open fracture due to a gunshot wound had mild restriction of elbow motion following treatment. The operative treatment of femoral shaft fractures continues to improve, and the investigation into improved fixation techniques is ongoing. Hedequist et al. reviewed thirty-two patients with an average age of eleven years who had had locking plate fixation for the treatment of a femoral shaft fracture. The indication for locking plate fixation was comminution in thirteen patients, pathologic fracture in nine, fracture location in seven, and osteopenia in three. No patient had a loss of reduction, the overall quality of the reductions was outstanding, and the rate of complications was very low. The authors concluded that locking plates are a useful and effective method for treating challenging femoral fractures as they provide rigid fixation until union is achieved. In the study by Wall et al.41, titanium elastic nails (fifty-six children) were compared with stainless steel elastic nails (forty-eight children) for the treatment of femoral fractures. There were fewer complications in the stainless steel nail group, and the nonunion rate was significantly lower (6.3% compared with 23.2%). The overall conclusion was that the higher flexibility of titanium is responsible for the higher nonunion rate in comparison with stainless steel elastic nails, and the authors recommended stainless steel fixation.
Neuromuscular Conditions Graham et al. performed a randomized controlled trial in which repeated injections of Botox (Allergan, Irvine, California) combined with abduction bracing were compared with observation for the treatment of hip subluxation in patients with cerebral palsy. There was a 3.1% reduction in the hip migration index in the Botox and bracing group as compared with the control group. Twenty of the twenty-seven children in the Botox and bracing group required an adductor release and eight required proximal femoral osteotomy, whereas fifteen of the twenty-five children in the control group required an adductor release and four required a femoral osteotomy. The risk of requiring adductor release was 1.2 times higher in the treatment group as compared with the control group, whereas proximal varus derotational osteotomies were 1.9 times more frequent in the treatment group than in the control group. The authors concluded that serial injections of Botox together with abduction bracing reduced the rate of increase in the migration index; however, longer follow-up demonstrated that these patients were more likely to need surgery, and it was hypothesized that this was due to a delay in achieving a concentric reduction of the femoral head within the acetabulum.
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