Whats New in Pediatric Orthopaedics

Noonan, Kenneth J. MD; Zaltz, Ira MD; Wenger, Dennis MD

Journal of Bone & Joint Surgery - American Volume:
doi: 10.2106/JBJS.J.01693
Specialty Update
Author Information

1University of Wisconsin School of Medicine and Public Health, Health Sciences Learning Center, 750 Highland Avenue, Madison, WI 53705. E-mail address for K.J. Noonan: noonan@orthorehab.wisc.edu

2Pediatric Orthopedic and Scoliosis Center, 3030 Children’s Way, Suite 410, San Diego, CA 92123. E-mail address: orthoedu@rchsd.org

Article Outline
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Pediatric Hip

Developmental Dysplasia of the Hip

A prospective randomized trial evaluating immediate treatment compared with active sonographic surveillance for infants with dysplastic, nondislocatable hips demonstrated that surveillance halved the need for treatment without having an effect on the radiographic appearance of the hip at the age of one year1. In a study in which twenty-nine patients with bilateral dislocation of the hip were compared with thirty-eight patients with unilateral dislocation, there was no significant difference between the two groups with regard to the failure of Pavlik treatment2. Two studies analyzed factors associated with unsuccessful Pavlik harness treatment of dislocated hips3,4. In one series of 221 hips, successful reduction was obtained in 81.9% of the hips, with development of osteonecrosis in 8.8%3. Adduction contracture and decreased distance from the proximal medial femoral metaphysis (indicated by the “a” line) were identified as risk factors that were predictive of failure. Another study of eighty-five patients demonstrated a rate of Pavlik harness failure of 37%4. Sonographic findings associated with unsuccessful Pavlik harness treatment included an increased beta angle, superior femoral head migration relative to the labrum, and total femoral head displacement less than −30°4. In a retrospective review of late-presenting patients (age range, six to twenty-four months) who were managed with Pavlik harness reduction, 60% of Graf type-3 hips were reduced with no associated osteonecrosis, whereas no Graf type-4 hips were reduced5.

A single-institution review of operative reduction of dislocated hips in late-presenting children demonstrated that femoral shortening osteotomy was more common in children with an age of more than thirty-six months or with femoral displacement of >30% of the pelvic height, with an overall prevalence of 35%6. In the study by Spence et al., open reduction combined with varus derotational proximal femoral osteotomy (thirty-eight patients) was compared with open reduction combined with Salter innominate osteotomy (thirty-three patients) with regard to the effect on developing acetabular morphology7. The authors reported significantly better acetabular improvement in the Salter osteotomy group at the time of the four-year follow-up. Kitoh et al., in a study of eighty-six who were patients managed with Salter osteotomy for the treatment of acetabular dysplasia, evaluated geometric acetabular changes and reported an average improvement of 19° in the center-edge angle and of 13° in the acetabular index8. That study provided valuable guidelines for surgeons performing the Salter osteotomy as acetabular morphologic improvement correlated with intended alterations in lateral rotation, displacement, and reduction in obturator foramen height. Osteonecrosis of the femoral epiphysis remains a serious complication in the treatment of developmental dysplasia of the hip, although it can be difficult to detect on early post-reduction radiographs. A review of forty-seven patients who underwent closed reduction suggested that a femoral epiphyseal height:width ratio of <0.357 as measured on radiographs made twelve to eighteen months after reduction suggests the development of a nonspherical femoral head as a consequence of osteonecrosis9.

In the study by Sankar et al., the average femoral anteversion in thirty children (average age, thirty-three months) who presented for open reduction for the treatment of developmental dysplasia of the hip was 50° (range, 0° to 95°)10. Kobayashi et al., in an effort to determine when patients begin to show radiographic signs of dysplasia, analyzed acetabular development on radiographs of the contralateral hip for eighty-eight patients who were followed for unilateral acetabular dysplasia11. The authors concluded that morphologic differences between normal and dysplastic acetabula are evident after the age of six years that and there are significant changes from the age of six to twelve years. No hip with a center-edge angle of <15° developed a normal acetabulum.

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Slipped Capital Femoral Epiphysis

The increasing incidence of slipped capital femoral epiphysis, possibly resulting from increased obesity, was reported in a nationwide Korean study by Song et al.12. In a review of hospital discharge databases from 1989 until 2003, the authors demonstrated an incremental increase in the incidence of slipped capital femoral epiphysis, with a relative increase in body mass in affected patients. The treatment of unstable slipped capital femoral epiphysis continues to pose a therapeutic challenge. Palocaren et al.13 demonstrated that twenty-seven of 280 patients who were managed between 1995 and 2006 had unstable slips. After a mean duration of follow-up three years, osteonecrosis was reported in six (22.2%) of twenty-seven patients. Chen et al., in a review of twenty-eight consecutive patients with an unstable slipped capital femoral epiphysis who were managed with urgent reduction with or without percutaneous arthrotomy (thirteen patients) or capsulotomy (five patients), reported that four patients (14%) developed osteonecrosis and one developed a progressive slip14.

Castañeda et al.15, in a retrospective review of 105 patients (129 hips) with severe stable slipped capital epiphysis who were managed with in situ fixation and were followed for a mean of sixty-six months, reported an average Iowa hip rating score of 84. The results trended better in patients who were less than twelve years of age. Poorer results were present in patients with complications, primarily associated with inadequate pin placement. Sink et al. reported the prevalence and type of chondrolabral damage that was noted at the time of surgical hip dislocation for patients who had been managed in the past for slipped capital femoral epiphysis16. There were eight mild, twenty moderate, and eleven severe slips, with labral damage present in thirty-four of thirty-nine patients and cartilage damage present in thirty-three of thirty-nine patients. Dodds et al., in a study that was performed to determine the frequency of symptomatic femoroacetabular impingement in patients managed for slipped capital femoral epiphysis, found that the Southwick grade of the slip was not predictive of femoroacetabular impingement17. In thirty-six of forty-nine hips that were followed for a mean of 6.1 years, the prevalence of symptomatic femoroacetabular impingement was 31% and was found to be correlated most closely with the alpha angle.

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Sports Medicine

Cohen et al., in a retrospective analysis of twenty-six skeletally immature athletes following anterior cruciate ligament (ACL) reconstruction with use of quadrupled hamstring autograft, found that 65% of the patients had associated meniscal pathology18. After a mean duration of follow-up of forty-five months, no patient developed a clinically important limb-length discrepancy or angular deformity. Shea et al., in a study evaluating the volumetric injury to the physis with use of three-dimensional models made from reconstructed adolescent magnetic resonance imaging (MRI) scans, found that transphyseal drill holes ranging from 6 to 9 mm produced volume reduction of <7% in the tibia and <9% in the femur19, a possible explanation for the low reported prevalence of growth disturbances. Lawrence et al., in a case series of patients managed with an all-intraepiphyseal technique of ACL reconstruction, demonstrated the capability of restoring stability and returning even younger patients to full activities20. Although rare, posterior cruciate ligament (PCL) injuries can produce instability in children. Similar to ACL reconstruction, surgical treatment can risk injury to the physis. Two recent case reports describing the use of intraepiphyseal femoral tunnels and either a tibial inlay technique or the use of a small transphyseal tunnel suggested that PCL repair is technically achievable in symptomatic children21,22.

Establishing a prognosis for osteochondritis dissecans healing is difficult. Ramirez et al., in a recent review of eighty-five children and adolescents, demonstrated that the presence of a sclerotic rim around the lesion and older age correlated with a lower rate of spontaneous healing23. Fixation techniques used for stabilization of unstable juvenile osteochondritis dissecans lesions vary. In the review by Tabaddor et al., twenty-two of twenty-four patients had either full or partial healing after a mean duration of follow-up of thirty-nine months following fixation with use of poly-lactide bioabsorbable pins24. Gudas et al., in a randomized prospective study in which the efficacy of mosaic-type autologous osteoarticular transfer was compared with microfracture for the treatment of osteochondritis dissecans defects, found that both techniques produced similar improvement in terms of function and pain after one year25. The results of microfracture, however, deteriorated over time, with a 41% rate of failure four years after treatment. Other areas of interest affecting the knee have been reported. Wilfinger et al., in a retrospective review of thirty-eight patients with tibial spine avulsions that were treated with knee aspiration and closed reduction in extension followed by immobilization, found that all knees were stable and pain-free at a mean of 3.5 years of follow-up26. Pihlajamäki et al., in a long-term follow-up study of military recruits who underwent surgery for the treatment of unresolved Osgood-Schlatter disease, reported that that 87% had no restrictions in daily activity and 75% returned to the preoperative activity level27.

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Basic Science

Oetgen and Richards, in a recent retrospective review of eighty-one immature patients in whom rhBMP-2 (recombinant human bone morphogenetic protein-2) was used to heal a nonunion or to obtain fusion, reported that the complication rate related to BMP use was low and that the product appears to be safe in the pediatric population28.

The understanding of skeletal growth and the development and modulation of postnatal growth is an area of intensive study. The mechanical effects on molecular events, orderly growth of the skeleton, and the consequences of medication with respect to skeletal growth are examples of clinical applications of recent advances in basic-science knowledge. Ciprofloxacin has the potential to adversely affect musculoskeletal growth in children. Tsai et al., in a recent study of adults, showed that ciprofloxacin can upregulate the expression of matrix metalloproteinase-2 and that there is associated degradation of type-I collagen29. Isaksson et al., in a study investigating the development of the collagen network and mineralization pattern of rabbit cortical bone, demonstrated that substantial postnatal changes occur, with the collagen network maturing prior to complete matrix mineralization30. Cairns et al. reported that muscle cells positively affected chondrocyte expression of type-II and IX cartilage, suggesting that muscle tissue, in proximity to developing cartilage, is important for normal gene expression31. In the study by Donnelly et al., the role of primary cilia in the response of musculoskeletal tissue to externally applied loads was extended with the demonstration of organized cilia in tenocytes, further illustrating the importance of this mechanosensory structure32.

Mansbach et al.33, in a study investigating vitamin-D levels in a nationally representative sample of children between the ages of one and eleven years, found that non-Hispanic black and Hispanic patients were most at risk for hypovitaminosis D. Millions of children were estimated to be at risk for relative vitamin-D deficiency. In the study by Dong et al., low vitamin-D levels in children and adolescents living in warm climates were associated with increasing obesity, decreasing participation in athletics, poorer cardiovascular fitness, and African descent34. Cole et al. reported that low vitamin-D levels are more prevalent in lower-income black and Hispanic children35. Overall, 22% of the subjects in that study were vitamin-D3-deficient and 73% had less-than-optimal levels.

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Deformity Correction and Limb Lengthening

Funk et al. reported that distraction osteogenesis has a catabolic effect on remote cortical bone mineralization and bone formation that persists through the consolidation phase36. Investigations into growth factors that are required for regenerate formation and possible applications to enhance bone formation substantiate the importance of endogenous BMPs. In the study by Alam et al., heterozygous mice producing lesser amounts of various BMPs showed decreased number of trabeculae and increased spaces between trabeculae with mechanically weaker regenerate37. In the study by Moore et al., the injection of recombinant human platelet-derived growth factor-BB in a rat model of diaphyseal distraction suggested a significantly increased healing rate and enhancement of bone formation38. Kitoh et al, in a study investigating the clinical efficacy of culture-expanded bone marrow cell and platelet-rich plasma injected into patients undergoing tibial and femoral lengthening, demonstrated a decreased healing index, dependent on osteoblastic differentiation of bone marrow cells39. Ohno et al., in an investigation of the effect of distraction on the rat sciatic nerve, showed slower conduction and axonal degeneration of unmyelinated fibers as well as downregulation of mRNA expression of tetrodotoxin-resistant-type sodium-channel Nav1.8 mRNA in dorsal root ganglion, a finding associated with pain and paresthesia in other studies of neuropathy40.

Khakharia et al. evaluated the transition from traditional long-leg radiographs to digital imaging for the evaluation of angular deformity by comparing standard measurements on the PACS (picture archiving and communication system) with standard fifty-one-inch radiographs. Both techniques showed excellent intraobserver and interobserver reliability41. Sabharwal et al., in an investigation into the hip-knee-ankle angle and femoral-tibial axis measurement on the long-leg radiographs of 354 limbs of children ranging from one to eighteen years of age, reported approximation of adult values by seven years of age42. Age-specific measurements are probably necessary only for children younger than seven years. Rozbruch et al. evaluated the efficacy of the Taylor Spatial Frame in a study of 122 patients with both proximal and distal deformities undergoing proximal, middle, or distal tibial correction and reported accurate correction in both coronal and sagittal planes, with minimal residual deformity43. Shyam et al. investigated the effect of distraction-resisting forces on knee laxity and valgus angulation following sixty-six tibial lengthenings performed with use of the Ilizarov technique and sixty-five lengthenings performed over an intramedullary nail and found that 25% of the segments had lateral laxity and 7% had fibular subluxation, with 86% of laxity reported in skeletally immature patients44. Patients undergoing lengthening over nails had less knee laxity and valgus angulation. Fixation of both the proximal and distal tibiofibular joints with use of Ilizarov wires and limiting the lengthening percentage decreased late-onset knee laxity and tibial valgus. In the study by Khakharia et al., the use of limited-incision quadricepsplasty to facilitate the return of range of motion of the knee following femoral lengthening was compared with historical controls and was found to result in a faster restoration of motion, potentially limiting bending forces on regenerate bone and patellofemoral stress45.

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Shoulder

The diagnosis and treatment of brachial plexus birth palsy remains an important part of pediatric orthopaedics. Abzug et al.46, in a study of twenty-three children with brachial plexus birth palsy, noted that external rotation osteotomy of the humerus, performed through a cosmetic medial skin incision, produced a significant improvement in external rotation and function of the shoulder in older children with brachial plexus palsy residuals.

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Neuromuscular Disease

Gose et al.47, in a study of seventy-five children with cerebral palsy, developed a method of using three-dimensional computerized tomography to measure head migration as well as the lateral opening angle in order to document the severity of hip dysplasia. Eighty-two percent of the femoral heads were positioned posteriorly, superiorly, and laterally. As expected, hip dysplasia and subluxation were more severe in patients with Gross Motor Function Classification System (GMFCS) Level-IV and V involvement.

Gorton et al.48 performed an important prospective comparative study to determine if lower limb surgery improves function in children with cerebral palsy who are able to walk. Seventy-five operatively managed children were compared with a similar group of nonoperatively managed children on the basis of gait analysis, gross motor function measurements, and parental questionnaires. Operative treatment methods ranged from tendon lengthenings alone to multilevel osseous surgery and/or soft-tissue procedures. There was a significant improvement in function after one year for the operative treatment group as compared with the nonoperative treatment group.

Godwin et al.49 studied the effect of single-event, multilevel surgery (SEMLS) on children with cerebral palsy and found lower GMFCS scores (improved function) after surgery. The scores were maintained even at the time of the five-year follow-up. Children with Level-I function (very mild cerebral palsy) and Level-V function (very severe cerebral palsy) showed less likelihood of having a change in the functional scores after surgery.

Murnaghan et al., from Melbourne, tested the reliability of their recently reported six-grade classification system for the degree of hip dysplasia in children with cerebral palsy, which ranges from Grade I (normal hip) to Grade VI (complete dislocation, treated with salvage surgery)50. The interobserver and intraobserver reliability findings demonstrated that this classification system is predictable and can be used to grade hip subluxation and dislocation in patients with cerebral palsy. This validated tool will be important for research studies and complements the GMFCS for clinical function in cerebral palsy that has been popularized by the Melbourne group.

Chang et al.51, in Taiwan, studied hip subluxation in children with cerebral palsy with use of computerized tomography (CT). Vigorous passive hamstring stretching in the hip-flexed position resulted in dynamic posterior displacement of the femoral head, especially in children who already had a higher migration percentage on radiographs. Chung et al.52 performed a study to assess proximal femoral geometry in Korean children with cerebral palsy. Thirty-six consecutive patients had a careful clinical examination to assess hip rotation, including the position of the greater trochanter, plus an internal rotation hip radiograph. This method was compared with two-dimensional CT studies of femoral rotation. The trochanteric prominence angle showed excellent validity in relation to the radiographic studies. The authors concluded that the physical examination for the determination of femoral anteversion, combined with measurement of the radiographic neck-shaft angle on the internal rotation hip radiograph, was satisfactory for determining the degree of anteversion in children with cerebral palsy. They suggested that computerized tomographic examination to determine the rotational profile can be replaced by physical examination and an internal rotation radiograph of the hip in patients with cerebral palsy who are able to walk.

El Hage et al.53, in Beirut, performed a prospective comparative study of twenty-seven patients (fifty hips) to determine if percutaneous adductor tenotomy was as safe and effective as an open tenotomy. In this unique study, a pediatric orthopaedic surgeon first performed a percutaneous adductor tenotomy, with a second surgeon then extending the wound to explore the percutaneous adductor tenotomy and to complete the tenotomy, if needed. Improvement in motion was most closely related to the completeness of adductor longus tenotomy in its proximal tendinous segment. Tenotomy in the muscular area was less effective. The authors reported that, when done correctly, percutaneous adductor tenotomy is a reliable and effective method for the treatment of adductor contracture and noted no risks in association with the procedure.

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Tumors

Further understanding of both benign and malignant bone tumors in childhood remains an important part of our specialty. Sailhan et al.54 and the French Pediatric Orthopedic Society retrospectively studied eighty-seven immature patients with chondroblastoma. The most common locations were the proximal tibial and proximal femoral epiphyses, although one-third of all lesions were apophyseal, metaphyseal, or epiphyseal-metaphyseal. Even after curettage and bone-grafting, 32% of the lesions recurred, most commonly when the lesion was epiphyseal. Tarsal bone lesions and lesions with an aneurysmal bone cyst component on histological study were most likely to recur. After a mean duration of follow-up of 62.5 months, metastasis was not found.

To clarify the risk of subsequent fracture in children with benign skeletal neoplasms, Leong et al.55 reported quantitative CT-based rigidity analysis to be more specific than criteria based on radiographs (specificity, 97% compared with 12%). CT-based analysis allows better assessment of the compensatory remodeling of host bone to a lesion, which is important for determining whether a fracture will occur. The engineering/biomechanical analysis proposed by Leong et al.55 remains complex, limiting day-to-day application of these concepts.

Hou et al.56 performed a comparative analysis regarding the efficacy of treatment for unicameral bone cyst. Forty patients were managed with one of four techniques: serial percutaneous steroid and autogenous bone-marrow injection (Group 1); open curettage and grafting with a calcium sulfate bone substitute without instrumentation (Group 2); open curettage and grafting with a calcium sulfate bone substitute with instrumentation (Group 3); or minimally invasive curettage, ethanol cauterization, disruption of the cystic boundary, insertion of a synthetic calcium sulfate bone-graft substitute, and placement of a cannulated screw to provide drainage (Group 4). The patients in Group 4 had the least invasive treatment and the highest radiographic healing rate.

Arkader et al.57 performed a retrospective review of seventy-nine children with Langerhans cell histiocytosis. Single-bone lesions occurred in 58% of cases, and multiple-bone lesions occurred in 42%. The authors recommended diagnostic biopsy for most lesions, curettage and grafting for some single lesions, and chemotherapy for multisystem disease. Radiation therapy is no longer advised.

Kager et al.58 and the Vienna-based Cooperative Osteosarcoma Study Group investigated the outcomes of treatment of osteosarcoma in children under the age of five years. Very young children often present with large tumors that require large surgical resections. Among twenty-eight young children who were managed with modern methods (neoadjuvant chemotherapy plus ablative surgery or limb-sparing surgery), there was a 51% five-year survival rate.

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Leg

Wiemann et al.59, in a study of sixty-three children with lower limb angular deformity who were managed with either staples (thirty-nine cases) or screw plate devices (twenty-four cases) for hemiepiphysiodesis, found no difference between the two devices in terms of the rate of correction or the rate of complications. Patients with abnormal physes (Blount disease, skeletal dysplasia) were more likely to have complications compared with children with normal physes (27.8% compared with 6.7%).

McIntosh et al.60, in a study of forty-six male patients, analyzed the treatment of adolescent tibia vara with use of lateral proximal tibial hemiepiphysiodesis. The method was ineffective in 66% of the cases. Patients who were likely to have a failure of treatment included those with an age of greater than fourteen years, those who were obese (body-mass index [BMI], >45 kg/m2), and those with greater deformity at the time of surgery. This may direct a surgeon toward osteotomy stabilized with an adjustable external fixation device as the best treatment choice for obese adolescents.

Bisphosphonate treatment to minimize fracture frequency in patients with osteogenesis imperfecta is standard in North America. Samson-Fang et al.61 performed a systematic review of the literature on the effects of bisphosphonates when used for the treatment of osteogenesis imperfecta in children. This review demonstrated improved bone density in most but not all patients in the studies reviewed, with minimal short-term side effects. The studies that were reviewed did not address the impact of bisphosphonates in milder forms of osteogenesis imperfecta or in extremely severe forms (types VII and VIII) that are not due to mutations in the Type-I procollagen gene.

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Foot and Ankle

Mubarak et al.62, in a review of sixty-nine patients (ninety-six feet), found that calcaneal navicular coalition in childhood is best treated with excision of the coalition with placement of a fat graft spacer rather than the extensor digitorum brevis muscle as previously advised. Cadaveric studies showed that a transferred extensor digitorum brevis muscle is inadequate in length and fills only 64% of the gap left after coalition excision. Also, transferring the extensor digitorum brevis muscle alters the surface anatomy of the dorsal aspect of the lateral part of the foot, creating an undesirable osseous prominence at the calcaneocuboid joint level.

The Ponseti cast method for the correction of clubfoot remains a world standard, and further studies have been developed to refine the method. In a randomized prospective trial of Ponseti cast correction, Cummings63 found that injection of Botulinum A toxin (BTX-A) did not decrease the time needed in cast, the need for percutaneous tendoachilles lengthening, or the frequency of clubfoot relapse.

Parada et al.64 noted that some surgeons prefer general anesthesia for the tendoachilles lengthening that is required as part of the Ponseti cast correction technique and studied 182 tenotomies in 137 patients for whom general anesthesia was used. All infants were under the age of one year, and eighty-nine children were under the age of three months. No apneic episodes or anesthesia-related complications occurred, establishing the safety of this approach in a children’s hospital environment.

The international interest in the Ponseti method for the treatment of clubfoot was analyzed by Halanski et al.65, who studied fifty-five children (eighty-six feet) with clubfoot in New Zealand. Forty feet were treated with the Ponseti method, and forty-six were treated with traditional short-leg casts followed by corrective surgery if needed. Forty-two of the forty-six clubfeet that were treated with traditional short-leg casts required major corrective surgery. Fourteen of the forty feet in the Ponseti group required operative intervention for the treatment if recurrence, with only four requiring major posteromedial release. The authors concluded that the Ponseti cohort had significantly less operative intervention and required less revision surgery in comparison with the cohort managed with traditional short-leg casts.

The concept that flatfoot deformity in childhood is often associated with a systemic condition or can be made worse by lower limb rotational alignment issues is well recognized. Zafiropoulos et al.66 completed a prospective analysis of 569 normal children with an age of three to six years to determine the prevalence of flatfoot and the relationship between flatfoot and femoral anteversion. Ninety-five (16.7%) of the 569 children had flatfoot, and these children had significantly increased internal rotation of the hip on clinical examination. When assessing flatfoot in childhood, the entire limb should be examined to best understand overall limb mechanics.

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Spine

The optimal treatment of infantile idiopathic scoliosis remains elusive; the past focus has been on operative techniques, but complications are common. There has been a resurgence of interest in nonoperative methods. Sanders et al., in 2009, reported on the use of Cotrel casting for the treatment of infantile scoliosis and demonstrated full correction of large curves if treatment was started before the age of twenty months67. In addition, partial correction delaying definitive surgery can be expected in patients with non-idiopathic curves or in older children. Casting is used to obtain correction with bracing to maintain correction. In comparison with isolated bracing, the authors suggested that casting may be superior as a result of forced compliance with cast treatment.

Similarly, compliance appears to be the critical factor influencing the results of bracing for the treatment of adolescent idiopathic scoliosis. Katz et al., in 2010, prospectively studied the results of treatment with Boston braces that were worn by patients whose compliance was recorded with a heat sensor68. The total number of hours of brace wear correlated with the lack of curve progression. That study confirmed that brace wear at school and afterwards for at least twelve hours a day was more likely to halt curve progression in younger patients (Risser 0 or 1) who are at risk for progression. Recent analysis of the Risser sign as a predictor of growth acceleration demonstrated that patients who are at Risser 0 with a closed triradiate cartilage or who are at Risser 1 are likely at the beginning of the growth-acceleration phase69.

The use of thoracic pedicle screw fixation has been shown to increase coronal curve correction at the potential expense of thoracic kyphosis. Loss of thoracic kyphosis is associated with decreases in lumbar lordosis and may potentially increase kyphosis above the fusion site. A review of a multicenter database demonstrated higher rates of proximal junctional kyphosis, especially in all-screw constructs as compared with hook or hybrid constructs70. This finding may have been the result of ligamentous disruption and disruption of the adjacent facet joints with pedicle screw placement. The most common immediate complication associated with spinal deformity surgery is infection. Cahill et al., in a review of the thirty-year experience at a single institution, reported infection rates of 0.5% in patients with idiopathic scoliosis, 19.2% in patients with myelomeningocele, 4.3% in patients with myopathies, and 11.2% in patients with cerebral palsy71.

A recent study demonstrated that 75% of patients who had Harrington instrumentation had back pain at a minimum of ten years of follow-up; this rate was slightly higher than the rate in controls72. Also concerning, recent studies have demonstrated elevated chromium levels in patients who have had fusion with stainless steel implants73 and that these levels appear to be related to the amount of material used during fusions74. The implications of higher chromium levels are unknown, but high levels in animals have carcinogenic and mutagenic effects. Long-term follow-up is needed, although chromium levels do appear to decrease over time74.

Potential indications for surgical correction in patients with Scheuermann kyphosis include progressive curves measuring >75° and painful curves that are refractory to nonoperative treatment. Implants and techniques similar to those used for the treatment of idiopathic scoliosis are used, but complication rates appear to be higher in patients with Scheuermann kyphosis. The Scoliosis Research Society (SRS) found a 14% rate of immediate complications in their 2001 to 2004 database75, which was higher than the 5.7% rate associated with scoliosis surgery according to previously published SRS data. Similar to scoliosis surgery, the most common complication in patients undergoing surgical correction of Scheuermann kyphosis was infection. Importantly, the rate of acute neurologic complication associated with the surgical correction of Scheuermann kyphosis (almost 2%) was significantly higher than that associated with scoliosis surgery. The complication rate in patients with Scheuermann kyphosis who were more than nineteen years of age was 22% and was significantly higher than that in pediatric patients with kyphosis. No difference was noted between posterior surgery and combined anterior and posterior surgery. That study did not demonstrate longer-term problems in patients with Scheuermann kyphosis, but Denis et al., in 2009, found that junctional kyphosis above the fusion construct (30%) or below the construct (12%) was seen when the upper or lower-end vertebrae were not appropriately chosen76.

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Trauma

The operative treatment of pediatric fractures is increasing. In a population-based study from Finland, Helenius et al. found that, over a ten-year period, there were increases of operative treatment of upper extremity, lower extremity, and axial fractures of 28%, 4%, and 11%, respectively77. The authors found that the large increase in upper extremity fractures was due to expanded indications for the fixation of forearm fractures. Similarly, Flynn et al. found a sevenfold increase in the operative fixation of forearm fractures over an eleven-year study period78. Previous studies have suggested high rates of compartment syndromes if an extended period of time is required to insert the nails. In the recent series, compartment syndrome never occurred if fracture fixation was delayed for twenty-four hours, but delayed healing was more common in older patients or patients who had open reduction78.

Tuason et al. found that 44% of all procedures performed at an urban children’s hospital were trauma-related and that this rate had increased over a seven-year period79. Similarly, Chan et al. found that, over a decade at a major teaching hospital, there was an 18% increase in orthopaedic trauma admissions per year, in contradistinction to the local pediatric population, for which the increase was 2% to 3% per year80. Chan et al. found that the bulk of the increase in patient volume was related to an increase in the number of patients sent in from outside the county80. The increase in fracture care at major children’s hospitals may reflect the unwillingness for orthopaedic offices to accept some patients on a financial basis. Iobst et al. found that only 8% of children with a forearm fracture and Medicaid insurance were able to receive prompt clinic appointments, compared with 36% of children with PPO (Preferred Provider Organization) insurance81. In addition, the rate of Medicaid insurance among patients seen primarily at their emergency room was 41%, in comparison with 47% among children sent from other emergency rooms.

Supracondylar humeral fractures are the most common elbow fractures in children, and two recent studies documented a gradual return to full motion within one year after the injury in almost all patients82,83. Motion rapidly returns to 75% of that in the contralateral elbow within the first months and may be slower in children who have surgical management or who are older. Such information can guide families who desire a rapid return to activities. In general, it may take two to three months for motion to return to a level that would allow sporting activities.

Controversy exists regarding the care of the pink pulseless hand in a child with a supracondylar humeral fracture. In a comparison between meta-analysis data and a survey review of POSNA (Pediatric Orthopaedic Society of North America) members, White et al. found that a higher percentage of these patients have brachial artery injury (70% to 82%) despite a lower percentage of pediatric orthopaedists who believe that such an injury exists (17% to 28%)84. Even though pediatric orthopaedists may underestimate the incidence of brachial artery injury, outcomes in the pink pulseless hand are still evolving; some do well and some do poorly. In a large single-institution review of supracondylar humeral fractures associated with absent pulses, all patients with a well-perfused hand did well clinically with reduction and pinning, although half did not have a return of the pulse after reduction85. The patients with poor perfusion (non-pink hand) required vascular repair and were at risk for compartment syndrome. In patients with poor pulses, concomitant median or anterior interosseous nerve injury also may be a predictor of brachial artery entrapment and may justify exploration of the artery86. If present, one should consider that concurrent nerve palsy could mask symptoms of a compartment syndrome.

A new lateral condylar fracture classification system based on articular congruity and displacement revealed higher complications in association with fractures that were displaced by >2 mm with articular displacement on an arthrogram87. Fractures with >4 mm of displacement were more likely to have articular displacement and may be an indication for arthrography prior to pinning. Recent evidence has shown that closed reduction and pinning can be attempted for completely displaced lateral condylar fractures, with good results in the majority of cases88. Nonunion has been the main complication to avoid in cases of lateral condylar fractures that have been treated nonoperatively, yet it is wise to counsel families that, if the fracture does heal, lateral condylar overgrowth and lateral prominence may still occur89.

Radial neck fractures in children are challenging fractures to treat as the complication rates are high and because these fractures may be seen in association with other elbow trauma (ulnar fracture). Two recent studies demonstrated good to excellent results in 87% to 100% of patients who were managed with reduction and stabilization with a retrograde radial intramedullary pin (Métaizeau method)90,91. Both studies demonstrated that minimal exposure, ease of reduction, and stabilization of the fracture allows for earlier motion and improved results. Two other studies evaluated the results of open reduction and internal fixation of clavicular fractures in children and adolescents92,93. Good results were obtained with fixation, yet the indications for this technique are evolving; most would agree that >2 cm of shortening in adolescent patients with less than two years of growth remaining is a relative indication for surgery. Medial displacement of sternoclavicular dislocations or fractures should be evaluated with CT scans, and injuries with persistent displacement should be operatively reduced and stabilized; closed reduction may be attempted for fresh injuries, but redisplacement is common94.

Flexible nailing of pediatric femoral fractures has reached mainstream acceptance, yet a recent prospective evaluation95 with advanced imaging demonstrated that >45% of patients had rotational malalignment of >15°. A recent meta-analysis of distal femoral physeal fractures demonstrated a 52% rate of growth arrest, with 30% of these growth arrests resulting in effects that are clinically significant; higher rates were noted in association with displaced Salter-Harris type-4 injuries96.

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Infection

Community-acquired methicillin-resistant Staphylococcus aureus continues to challenge patients and physicians alike. In a two-institution study, 85% of affected children had some limb involvement, all of the affected individuals required surgical treatment (with 60% requiring multiple debridements), 44% required intensive care unit support, and 15% had multisystem failure97. Kingella kingae is a fastidious bacterium, and its true incidence has been difficult to document. Recently, a real-time PCR (polymerase chain reaction) assay documented this to be the inciting organism in 82% of children less than four years of age with osteoarticular infections; Gram stain and culture were negative for all of these patients98. In more routine cases of septic arthritis, it appears that early conversion to oral antibiotics (at 7.4 days) was just as successful as delayed conversion (at 18.6 days)99. The authors suggested that all septic joints should be treated with some method of drainage (arthrotomy, arthroscopy, or arthrocentesis) and intravenous antibiotics; conversion to oral antibiotics could be considered for a patient who is afebrile for twenty-four hours, who has a clinically improving joint, and who has a decreasing C-reactive protein level.

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Upper Extremity

Elbow flexion contractures in children with obstetrical birth palsy can limit function and can be cosmetically objectionable. Ho et al. reported on nineteen patients with elbow contracture who had good improvement after treatment with therapy, casting, and splinting100. Improvements were more lasting when compliance with brace wear was noted after maximum extension was received. Kozin et al. reported their experience with biceps-to-triceps transfer for patients with tetraplegia101. They found that 75% of patients were able to obtain elbow extension for overhead activities. Phalangeal neck fractures in children can be problematic as they can limit finger flexion. Nonunion and osteonecrosis also can complicate this fracture. Al-Qattan reported that osteonecrosis appeared most commonly in the finger and in older children (mean age, 5.6 years), whereas simple nonunion tended to occur in the thumb of younger children (mean age, 2.5 years) who had late displacement despite splinting102.

Specialty Update has been developed in collaboration with the Board of Specialty Societies (BOS) of the American Academy of Orthopaedic Surgeons.

Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

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