Showing papers in "Journal of Pediatric Orthopaedics in 2008"

The impact of the current epidemiology of pediatric musculoskeletal infection on evaluation and treatment guidelines.

Abstract: Background Methicillin-resistant Staphylococcus aureus is thought to have led to an increase in the incidence of severe musculoskeletal infection in children Our purpose was (1) to compare the current epidemiology of musculoskeletal infection with historical data at the same institution 20 years prior and (2) to evaluate the spectrum of the severity of this disease process within the current epidemiology Methods Children with musculoskeletal infection, treated between January 2002 and December 2004, were studied retrospectively Diagnoses of osteomyelitis, septic arthritis, pyomyositis, and abscess were established for each child based on overall clinical impression, laboratory indices, culture results, radiology studies, and intraoperative findings Comparison was made with the experience reported at the same institution in 1982 Children within each diagnostic category were compared with respect to mean values of C-reactive protein and erythrocyte sedimentation rate at admission, number of surgical procedures, intensive care unit admissions, identification of deep venous thrombosis, and length of hospitalization Results Five hundred fifty-four children were studied (osteomyelitis, n = 212; septic arthritis, n = 118; pyomyositis, n = 20; and deep abscess, n = 204) The annualized per capita incidence of osteomyelitis increased 28-fold, whereas that of septic arthritis was unchanged when compared with historical data from 20 years prior Methicillin-resistant Staphylococcus aureus was isolated as the causative organism in 30% of the children We identified increasing severity of illness according to a hierarchy of tissue involvement (osteomyelitis > septic arthritis > pyomyositis > abscess) and according to the identification of contiguous infections within in each primary diagnostic category Conclusions The incidence of musculoskeletal infection appears to have increased within our community We found that a more comprehensive diagnostic classification of this disease is useful in understanding the spectrum of the severity of illness and identifying those who require the greatest amount of resources Magnetic resonance imaging is useful early in the diagnostic process to enable a more detailed disease classification and to expedite surgical decisions The recognition of the incidence of methicillin-resistant Staphylococcus aureus within our community has also led to a change in empirical antibiotic selection

Early outcomes after hip arthroscopy for femoroacetabular impingement in the athletic adolescent patient: a preliminary report.

Abstract: Background Hip arthroscopy is becoming a more popular method of treatment of pediatric hip disorders. We report on the treatment of femoroacetabular impingement (FAI) in the adolescent population. Methods Between March 2005 and May 2006, 16 patients (aged 16 years or younger) underwent hip arthroscopy for FAI. There were 14 female adolescents and 2 male adolescents, with 1 patient undergoing a bilateral procedure. Five patients had isolated pincer impingement, 2 had isolated cam impingement, and 9 had mixed pathology. All patients had labral pathology. Seven patients were treated with suture anchor repair of the labrum and 9 with partial labral debridement. Subjective data were collected from each patient during their initial visit and at follow-up after surgery. Subjective data included the modified Harris hip score (MHHS), patient satisfaction, and hip outcome score (HOS) activities of daily living (ADL), and sports subscales. Results The mean age at the time of arthroscopy was 15 years old (range, 11-16 years). The mean preoperative MHHS was 55 (range, 33-70), HOS ADL was 58 (range, 38-75), and HOS sport was 33 (range, 0-78). The mean time from injury to surgery was 10.6 months (range, 6 weeks-30 months). The mean time to follow-up was 1.36 years (range, 1-2 years). The mean postoperative MHHS improved 35 points to 90 (range, 70-100; P = 0.005), postoperative HOS ADL improved 36 points to 94 (range, 74-100; P = 0.001), and postoperative HOS sport score improved 56 points to 89 (range, 58-100; P = 0.001). The mean patient satisfaction score was 9 (range, 9-10). Conclusions Hip arthroscopy for FAI in the adolescent population produces excellent improvement in function and a high level of patient satisfaction in the short-term.

Changing trends in acute osteomyelitis in children: impact of methicillin-resistant Staphylococcus aureus infections.

Abstract: Background: Staphylococcus aureus remains the most common etiologic agent of acute osteomyelitis in children. Recently, methicillin-resistant S. aureus (MRSA) has emerged as a major pathogen. Methods: Records of all children admitted with acute osteomyelitis from January 1999 to December 2003 were reviewed. For the comparative analysis, the study population was evenly distributed in 2 periods: period A, January 1999 to June 2001; n= 113; and period B, July 2001 to December 2003; n = 177. In addition, clinical findings of MRSA osteomyelitis were compared with non-MRSA osteomyelitis, including methicillin-sensitive S. aureus infections. Results: Two hundred ninety children (60% male subjects) with acute osteomyelitis were identified. Median (25th-75th percentile) age at diagnosis was 6 years (range, 2-11 years). Significant clinical findings included the following: localized pain (84%), fever (67%), and swelling (62%). Affected bones included the following: foot (23%), femur (20%), tibia (16%), and pelvis (7%). Thirty-seven percent of blood cultures were positive, and a bacterial isolate was obtained in 55% of cases. Bacteria most frequently isolated included the following: methicillin-sensitive S. aureus (45%) (57% in period A vs 40% in period B), MRSA (23%) (6% in A vs 31% in B; P < 0.001), Streptococcus pyogenes (6%), and Pseudomonas aeruginosa (5%). Children with MRSA compared with those with non-MRSA osteomyelitis had significantly greater erythrocyte sedimentation rate and C-reactive protein values on admission and increased length of hospital stay, antibiotic therapy, and overall rate of complications. We observed significant changes in antibiotic therapy related to increased use of agents with activity against MRSA. Conclusions: Methicillin-resistant S. aureus was isolated more frequently in the second study period and was associated with worse clinical outcomes.

Musculoskeletal manifestations in pediatric acute leukemia.

Abstract: Background: In children, acute leukemia (AL) at presentation can mimic several orthopaedic pathologies, so that a variable delay of the correct diagnosis is often reported. Methods: To define more clearly the clinical and radiological musculoskeletal manifestations of leukemia in children, 122 affected children referred from 1984 to 1999 to our Pediatric Onco-Hematologic Clinic were retrospectively reviewed. Average age at diagnosis was 6.6 years (from 7 months to 17 years). Seventy-three (60%) were boys and adolescent boys, 49 (40%) were girls and adolescent girls. One hundred two (83.6%) had acute lymphoblastic leukemia, 20 (16.4%) had acute myeloid leukemia. The mean follow-up was 8.2 years for the 104 survivors and 2.5 years for the 18 nonsurvivors. The x 2 test was used to perform the statistical analyses. Results: At presentation, complaints related to the musculoskeletal system were frequent (38.3%), including pain (34.4%), functional impairment (22.9%), limping (12.3%), swelling (10.6%), and joint effusion (5.7%). At presentation, 40.2% of children had at least 1 radiographic abnormality. In order, they were osteolysis (13.1%), metaphyseal bands (9.8%), osteopenia (9%), osteosclerosis (7.4%), permeative pattern (5.7%), pathological fractures (5.7%), periosteal reactions (4.1%), and mixed lysis-sclerosis lesions (2.5%). Different from previous reports, late radiographic lesions were uncommon (5.7%), probably because of milder newer medication protocols. They included avascular necrosis (3.3%), vertebral collapses (1.6%), and osteolysis (0.8%). Conclusions: Both clinical and radiological changes had various and no uniform localization. Poor correlation was found between symptoms and radiological lesions. Survival rates in children with AL were 95.8% at 1 year, 89.6% at 3 years, 85.8% at 5 years, and 83.4% at 10 and at 13 years. Radiographic abnormalities (P = 0.400), type of leukemia (P = 0.291), sex (P = 0.245), and white blood cell count at presentation (P = 0.877) were not prognostic factors. The presence of multiple bone lesions did not affect the survival rate (P = 0.632). As early diagnosis significantly decreases morbidity and mortality of AL, the orthopaedist should suspect AL in any child with unexplained persistent skeletal pain or radiographic alterations. Accurate history, general physical examination, and complete blood cell count tests should address the suspicion, which is confirmed by a peripheral and/or iliac crest bone marrow biopsy.

Guided growth for pathological physes: radiographic improvement during realignment.

Abstract: Background Children with rickets are prone to having deformities of the lower extremities that are bilateral and often symmetrical. Although initially attributed to pathological or "sick" physes, the deformities are eventually seen in the metaphyses and diaphyses of the long bones; if left untreated, they may result in bone pain and stress fractures. The orthopaedists' role in managing these children is to correct and maintain alignment. Alternatively, we have exploited the use of hemiepiphysiodesis or guided growth, using staples or, more recently, the 8-plate (Orthofix, Verona, Italy). While gradually normalizing the mechanical axis, we have noted improvement in the appearance and width of all of the ipsilateral physes, not only at the knee but at the hip and ankle as well. This report summarizes our observations of the effects on the pathological physes in a group of patients with rickets who were preferentially treated with guided growth, often starting at a young age. Method This retrospective review approved by an institutional review board included 14 children with rickets, including 10 treated with staples and 4 with 8-plates, who collectively underwent a total of 68 hemiepiphysiodeses (guided growth) and 35 osteotomies. Each was under appropriate medical management during the entire course of treatment, before and after surgery. We measured the mechanical axis deviation and anatomic angles of the femur and proximal tibia, noting the width and appearance of their physes at the hips, knees, and ankles preoperatively and upon correction of the axis. Results Of the 10 stapled patients, we noted 24 (45%) of 53 migrations and 41% rebound deformity. Four patients with 15 deformities that corrected with 8-plates experienced no hardware migration; for them, it is too early to comment on rebound deformity. While gradually correcting the mechanical axis, we have noted improvement in the appearance and width, not only of the pan-genu physes but also of remote physes at the hip and ankle. We suspect that the improved quality of the physes reflects not only the normalization of the mechanical axis but also the corresponding resolution of the waddling (varus) or circumduction (valgus) gait pattern. Conclusion We recommend early intervention, via guided growth, to restore and preserve a neutral axis so that the child can enjoy a normal lifestyle while maximizing the growth potential of his or her physes, not only of the knees but the hips and ankles as well. We believe that by correcting and maintaining alignment, secondary bony deformities may be ameliorated and osteotomies for angular correction deferred if not avoided altogether. Level of evidence IV (retrospective clinical series).

Clinical presentation of femoroacetabular impingement in adolescents.

Abstract: Femoroacetabular impingement (FAI) is a recently recognized hip disorder resulting from an abnormal morphology of the proximal femur and acetabulum. This morphology results in increased hip contact forces with hip motion, specifically flexion. This may lead to labral-cartilage injury and pain. The purpose of this study is to describe the clinical presentation and diagnosis of FAI as a cause of hip pain in adolescents.Thirty-five patients with FAI as the etiology of chronic hip pain from one institution were reviewed. The common symptoms, physical examination, and radiographic findings were analyzed.The age range was 13 to 18 years. There were 30 girls and 5 boys. All patients complained of anterior groin pain. All patients performed a sport/activity that contributed to the symptoms such as dancing. Patients had decreased flexion and limited internal rotation on physical examination. All patients had a positive impingement test. Fifteen patients (43%) had primarily pincer impingement with a crossover sign or acetabular retroversion. Cam impingement was the primary type in 2 patients (6%). There were findings of cam and pincer in 18 patients (51%). Sixteen of 28 patients had a positive labral tear on magnetic resonance imaging (57%). Femoroacetabular impingement is a cause of hip pain in the adolescent population. The diagnosis can be derived from reproducible history, physical examination, and radiographic findings. It is more common in female adolescents, and pincer type is more prevalent.

Elastic stable intramedullary nailing of tibial shaft fractures in children.

Abstract: Most pediatric tibia shaft fractures are amenable to nonoperative treatment with satisfying results, yet surgical stabilization is necessary in certain cases. The purpose of our study was to determine the effectiveness and the complications associated with elastic stable intramedullary nailing in severe pediatric tibial fractures. We retrospectively reviewed 24 tibia shaft fractures in 24 patients that were treated operatively by elastic stable intramedullary nailing between 1997 and 2005 at our institution. Extensive review of all charts and radiographic data was completed at Cincinnati Children's Hospital Medical Center. There were 8 closed and 16 open fractures. The average union time for all tibia fractures was 20.4 weeks. The average union time for closed and open fractures was 21.5 and 20.2 weeks, respectively. Complications include 2 (8%) neurovascular, 2 (8%) infections, 2 (8%) malunions, and 1 (4%) leg-length discrepancy. Although complications do exist, elastic stable intramedullary nailing of pediatric tibia shaft fractures using Nancy nails is an effective treatment option.

Guided growth for fixed knee flexion deformity.

Abstract: Background: Fixed knee flexion deformity (FKFD) is an insidiousproblem that may complicate the management of patients withneuromuscularcompromiseduetocerebralpalsy,spinabifida,arthro-gryposis, and other conditions. The energy costs associated withcrouch gait may become prohibitive and, with the inexorable pro-gression of fixed knee flexion, secondary pain may ensue as a resultof fragmentation of the patella and/or tibial tubercle. Concomitantor compensatory flexion deformity of the hips and lumbar lordosismay develop, along with Bpseudo equinus[ of the ankles. Recom-mended treatments for FKFD have included bracing; physicaltherapy; and, in recalcitrant cases, distal femoral osteotomy, posteriorrelease, or frame distraction. However, these latter modalities arefraught with potential complications including neurovasculardamage, loss of fixation, undercorrection malunion, fracture, andrecurrent deformity. Considering that FKFD is often bilateral, thecomplication risks for a given patient are doubled. In a previousstudy, the senior author reported successful hemiepiphysiodesis ofthe distal anterior femur using staples. However, further experiencehas demonstrated some of the limitations of stapling including rel-atively slow correction and occasional hardware migration. This ledto the development of a more versatile and reliable solution using apair of anterior tension band plates.Methods: Inthisretrospectiveclinicalstudy,wearereportingthisnewtechnique of promoting gradual correction through guided growth ofthe distal femur, using a pair of anterior 8-plates. The correction isaccomplishedsimultaneouslyandbilaterally,withoutimmobilization,and may be combined with other operative procedures as indicated.We reviewed the charts, radiographs in a group of patients treatedaccordingly.Results: In this group of 18 patients with 29 deformities, we notedcorrection averaging 1.3 degrees (range, 0.0 [1 patient]Y4.8 degrees),with minimal complications. No inadvertent coronal plane deformi-ties were created. Upon full correction, the plates were removed so asto avoid recurvatum.Conclusion: As an alternative to posterior capsulotomy or supracon-dylar extension osteotomy, we have found that guided growth is aneffective and safe method of gradually correcting FKFD in growingchildren and adolescents.Level of Evidence: 4 (retrospective clinical series)Key Words: crouch gait, fixed knee flexion deformity, guidedgrowth, hemiepiphysiodesis, cerebral palsy, spina bifida,arthrogryposis, 8-plate(J Pediatr Orthop 2008;28:626Y631)

How to determine the upper level of instrumentation in Lenke types 1 and 2 adolescent idiopathic scoliosis: a prospective study of 132 patients.

Abstract: Background The selection of fusion levels continues to be controversial in adolescent idiopathic scoliosis (AIS). The classifications of King and Lenke remain the most widely used, but recent studies have demonstrated their shortcomings, including poor interobserver reproducibility. We propose a method of preoperative planning that is independent of anatomical classifications, based on the anticipated effect of curve reduction. The objectives of this preoperative strategy are (1) to achieve satisfactory T1 tilt and shoulder balance and (2) to restore balance in the coronal and sagittal planes. The purpose of the present study was to evaluate the results of our strategy of deciding the proximal level of arthrodesis in Lenke types 1 and 2 AIS. Methods We included 132 adolescents operated on for thoracic AIS by posterior instrumentation. The choice of the proximal fusion level was based on preoperative analysis of the rigidity of the proximal curvature, T1 tilt, and shoulder balance. The preoperative, postoperative, and last follow-up radiographs were digitized then analyzed using computer software. Radiological parameters were compared using paired t tests. Results Average age at the time of surgery was 15.2 years (SD, 1.7 years). Mean follow-up was 30.2 months. The clavicle angle and T1 tilt were significantly improved in both Lenke types 1 and 2 curves. No correlation was found between T1 tilt and shoulder balance. At last follow-up, 89% of the patients satisfied all criteria for balance. Conclusions The results of the present preoperative strategy, to which we adhered in 97% of cases, are encouraging and show that the systematic instrumentation of the entire proximal curvature is not justified in Lenke type 2 curves. However, long-term consequences of the residual T1 tilt need to be studied further.

Accuracy in the prediction and estimation of adherence to bracewear before and during treatment of adolescent idiopathic scoliosis.

Abstract: Background: Because bracing for scoliosis may prevent curve progression, it is important to recognize nonadherence. We used temperature sensors to determine actual bracewear and examined: (1) the ability of a new pretreatment questionnaire to predict bracewear, (2) the ability of the physician and orthotist to predict bracewear before treatment, and (3) the ability of physicians, orthotists, patients, and parents to accurately estimate bracewear during the first year of treatment. Methods: Sixteen males and 108 females with adolescent idiopathic scoliosis were fitted with a Boston brace equipped with a temperature sensor and told that investigators were examining comfort. Before treatment, each patient completed an 18-item Brace-Beliefs Questionnaire (BBQ), and physicians/orthotists rated the likelihood that their patient would be adherent. During treatment, physicians, orthotists, patients, and parents provided estimates of daily bracewear. Data obtained at 1 to 3, 4 to 7, and 9 to 12 months into treatment were analyzed. Results: Scores from the BBQ were related to actual adherence (r = 0.46, P < 0.001). No patient scoring more than 1 SD below the BBQ sample mean had an adherence level more than 40%. Correlations of physician/orthotist pretreatment predictions with actual adherence were minimal. Overall, patients wore the brace 47% of the prescribed time, although they were estimated to have worn it 64%, 66%, 72%, and 75% by physicians, orthotists, parents, and patients, respectively. Physicians/ orthotists incorrectly identified at least 1 of every 4 nonadherers. Conclusions: Predicting a patient's adherence before treatment is difficult, but a pretreatment questionnaire may be helpful. During treatment, all respondents overestimated adherence. Health care providers should be mindful of overreports of bracewear and skeptical of their own assessments of adherence. Clinical Relevance: Potential nonadherence may be predicted by a brief treatment-specific questionnaire. Treatment teams should not assume that patients follow their instructions or that family members are accurate sources of adherence information during treatment. Health care providers also should not assume that they can accurately predict adherence based on subjective expectations.

Bioactive glass as a bone substitute for spinal fusion in adolescent idiopathic scoliosis: a comparative study with iliac crest autograft.

Abstract: Background Iliac crest autograft is currently the gold standard material for spinal fusion. However, its use is limited by additional operative time, increased blood loss, and morbidity. Recently, a synthetic osteoconductive bone graft material composed of bioactive glass has been described, with high effectiveness in animal models. Its ability to achieve spinal fusion in human has never been reported. The aim of this study was to compare bioactive glass and iliac crest autograft as bone substitutes in the treatment thoracic adolescent idiopathic scoliosis (AIS). Methods Eighty-eight consecutive patients underwent posterior spinal fusion for progressive thoracic AIS. There were 2 study groups based on the type of bone graft used: iliac crest autograft (n = 40) or bioglass (n = 48). A minimum 2-year follow-up was required. Medical data and radiographs were retrospectively analyzed and compared using unpaired t test and Mann-Whitney U test. Results Mean follow-up was 40 months in the autograft group and 38 months in the bioglass group. In the autograft group, there were 2 infections (5%) and 3 mechanical failures (7.5%). One infection (2%) and 1 early mechanical failure (2%) occurred in the bioglass group. Loss of correction of the main thoracic curve between immediate postoperative and latest follow-up averaged 15.5% for autograft group and 11% for the bioglass group (P = 0.025). The mean (+/-SD) gain of frontal balance between immediate postoperative latest follow-up was 0.8 (+/-9.3) mm in the autograft group and 8.1 (+/-12) mm for the bioglass group (P = 0.005). Conclusions Results of this retrospective study suggest that bioglass is as effective as iliac crest graft to achieve fusion and maintain correction in AIS. Less complications were seen in the bioactive glass group, but the difference did not reach statistical significance. Bioactive glass can be proposed in the treatment of AIS, avoiding the morbidity of iliac crest harvesting. However, clinical and radiological outcomes need to be confirmed at long-term follow-up. Level of evidence Level III.

A Biomechanical Analysis of Youth Pitching Mechanics

Abstract: Background It is estimated that nearly 6% of youth baseball participants seek medical attention for injuries sustained during play. Most injuries are overuse injuries, and 26% are to the shoulder or upper arm. By quantifying youth pitching biomechanics, knowledge can be gained concerning the manner in which these injuries are sustained during play. Methods Sixteen healthy right hand-dominant baseball pitchers participated in this study. After digitization of 21 bony landmarks, kinematic calculations were conducted using the 3-dimensional coordinates from each video frame. Data were time normalized, forcing major temporal components of the movement to occur at specific intervals. Segment-based reference frames were established, and resultant joint kinetics were projected onto each reference frame. Kinetic data were normalized and calculated along or about the anterior/posterior, medial/lateral, and proximal/distal axes. Results Maximum trunk rotation and external shoulder rotation were observed during arm cocking. Each of the remaining kinematic parameters peaked after ball release. All maximum values for joint kinetics were measured during arm cocking with the exception of compressive forces experienced at the shoulder and elbow, which peaked after the instant of ball release. Conclusions Data produced in this study indicate that youth pitchers initiate trunk rotation early in the movement, which can lead to shoulder hyperangulation. Opposing torques at each end of the humerus also produce a large net torque about the longitudinal axis of the humerus during late arm cocking and may increase humeral retrotorsion in youth pitchers. Underdeveloped musculature in the rotator cuff may lead to difficulty controlling throwing-arm deceleration, causing an increase in horizontal adduction across the torso. Clinical relevance An improved understanding of youth pitching mechanics is gained from the data collected, analyzed, and discussed in this study. Through increases in the knowledge pertaining specifically to the mechanics of youth pitchers, the opportunity to develop pitching mechanics specifically designed for preventing injuries in little league pitchers arises. Level of evidence This study is a Level 4 study describing youth pitching biomechanics and how they relate to possible injuries.

Lower limb alignment in children: reference values based on a full-length standing radiograph.

Abstract: Background A full-length standing anteroposterior radiograph of the entire lower extremity has become the standard imaging modality for assessing lower limb alignment. Although reference values of frontal plane deformity parameters based on adult subjects have been established, such values may not be applicable to the pediatric population. The purpose of our study was to establish the reference values of frontal plane alignment and joint orientation angles in children based on a standing full-length radiograph. Methods A database at a single institution was searched for patients who were aged between 1 and 18 years at the time of undergoing a standing full-length radiograph of the lower extremities. Radiographic analysis of lower extremities without any abnormalities was performed by a single observer. Mechanical axis deviation, lateral distal femoral angle (LDFA), medial proximal tibial angle (MPTA), tibiofemoral angle, joint line convergence angle, and mechanical axis station were calculated at yearly intervals. The data were summarized using descriptive statistics, and simple regression analysis was performed to determine the relationship between the patients' age and the magnitude of LDFA and MPTA. Results A total of 354 unaffected lower extremities in 253 children were analyzed. Between the ages of 1 and 2 years, the tendency for varus alignment of the lower limb was related to the varus orientation of the distal femur with a mean LDFA of 95 degrees (95% confidence interval [CI], 93-97 degrees). By the age of 3 years, the limb alignment changed to valgus related to a combination of decreasing varus orientation of the distal femur and a mild increase in valgus orientation of the proximal tibia with the mean MPTA changing from 89 degrees (95% CI, 88-90 degrees) to 91 degrees (95% CI, 90-92 degrees). After the age of 7 years, all joint orientation angles were noted to be within the range of reference values that are available for the adult population. Despite changes in limb alignment with growth, the mean mechanical axis of the lower extremity remained within the central half of the knee joint in children older than 1 year of age. Conclusions The change in alignment of the lower limb from 1 to 4 years of life from varus to valgus is primarily related to a progressive decrease in varus orientation of the distal femur. In children younger than 7 years old, age-specific reference values for joint orientation angles of the lower extremity should be used instead of values derived from adult subjects.

Diagnostic modalities for the evaluation of pediatric back pain: a prospective study

Abstract: Background:The commonly taught premise that pediatric back pain frequently has an underlying diagnosis has been recently challenged. Previous studies have suggested that up to 84% of children with low back pain have associated serious diagnoses. Children with back pain, therefore, have frequently un

Increased intracapsular pressures after unstable slipped capital femoral epiphysis.

Abstract: Background: Osteonecrosis of the femoral head is the most dreaded complication associated with an unstable slipped capital femoral epiphysis (SCFE). We hypothesize that the hip joint pressure will be increased in unstable slips, confirming that emergent treatment and decompression are warranted. Methods: Thirteen unstable SCFE hips were evaluated. Hip pressure monitoring was performed. Postcapsulotomy measurements were also performed in all of the patients. Five of these under gentle manipulation. Six patients underwent measurement of the hip pressure on the unaffected side. Results: The mean pressure on the affected hip was 48 mm Hg. The mean pressure on the unaffected side was 23 mm Hg. There was a significant increase in intraarticular hip pressure after attempted manipulation (mean, 75 mm Hg). Discussion: Hip pressures are increased in unstable SCFE to levels higher for those of a compartment syndrome probably causing a tamponade effect. There is a need to perform a capsulotomy if manipulation is performed.

How safe is the operative treatment of Gartland type 2 supracondylar humerus fractures in children

Abstract: Background: Whereas operative treatment of supracondylar fractures is now standard of care for Gartland type 3 supracondylar humerus fractures in children, the treatment of type 2 fractures remains somewhat controversial. The purpose of this article was to examine the safety and efficacy of closed reduction and pinning of type 2 supracondylar humerus fractures in children. Methods: We performed a retrospective review of 189 type 2 supracondylar humerus fractures operatively treated at one tertiary care children's hospital from 2000 to 2006. Data were acquired from a review of radiographs and clinical notes. Results: We found no intraoperative surgical or anesthetic complications in our series. None of our cases lost reduction after closed reduction and percutaneous pinning. There were 4 pin tract infections (2.1%) in our series: 3 were treated with antibiotics, and 1 needed irrigation and debridement in the operating room. This was the only patient who required reoperation for any reason. Conclusions: In this study, the largest reported series of type 2 supracondylar humerus fractures in children, we found an extremely low rate of complications after closed reduction and percutaneous pinning; secondary operations were also uncommon (0.5%). Our series demonstrates a high probability of satisfactory outcome after operative treatment of type 2 supracondylar fractures compared with previous studies of children treated by closed reduction without pinning. Level of Evidence: Therapeutic study, level 4 (case series [no or historical control group]).

Incidence of biopsy-proven bone tumors in children: a report based on the Dutch pathology registration "PALGA"

Abstract: Introduction: Data on childhood bone tumors are mainly confined to reports on malignant tumors or on institutional registries. Incidence figures on both benign and malignant bone tumors in childhood are lacking. Methods: From January 1999 to December 2003, 1474 newly diagnosed bone tumors in children up to 18 years were registered in Pathologisch Anatomisch Landelijk Geautomatiseerd Archief (the nationwide network and registry of histopathology and cytopathology in The Netherlands). Data provided were diagnosis, date of birth, age at diagnosis, and localization. For incidence calculations, data on age and sex in each year of investigation were obtained from the StatLine database of Statistics Netherlands (www.cbs.nl). Results/Conclusions: Incidence of pathology-proven bone tumors in children is low. Incidence of pathology-proven bone tumors in The Netherlands is 79.3 per 1,000,000. From the very first year of life, incidence increases from 3.9 per 1,000,000 to a peak at 13 to 15 years of 142.9 per 1,000,000. Osteochondromas are the most prevalent tumors, followed by aneurysmal bone cysts. The overall incidence is higher for male compared with female patients, mainly due to different frequencies found in aneurysmal bone cysts, Ewing sarcoma, and osteochondroma. Shifts in incidence differ among the various tumors. In infants, bone tumors are mainly chondromas and fibrous dysplasia, which both show a steady increase at older ages. Tumors most prevalent at older ages are osteochondromas, osteosarcomas, osteoid osteomas, and chondromas. A peak incidence at approximately the age of 10 is noted for solitary bone cysts, nonossifying fibromas, and osteoblastomas. Small children more often have localizations in the skull and facial bones. Comparison with literature data showed significant differences due to referral-based institutionally bias, whereas tumor registries only give data for specific tumor types.

Comparison of intramedullary nailing to plating for both-bone forearm fractures in older children.

Abstract: Background:When operative stabilization of forearm fractures in older children is necessary, the optimal method of fixation is controversial. This study compared the radiographic and functional outcomes of intramedullary nailing to plating of forearm fractures in children between 10 and 16 years of

Health-related quality of life in children with thoracic insufficiency syndrome.

Abstract: Background: The traditional techniques to treat thoracic insufficiency syndrome (TIS) are not able to stabilize or improve chest wall size or pulmonary function while allowing spine growth. To this end, vertical expandable prosthetic titanium rib (VEPTR) was specifically designed to treat TIS by allowing growth of the thoracic cavity and control/correction of spine deformity. The purpose of this study was to determine quality of life (QOL) of children with TIS and its impact on their parents before and after implantation of the VEPTR and also compare these results to those of healthy children. Methods: As part of the original multicenter evaluation of the VEPTR, a Child Health Questionnaire (CHQ) was collected preoperatively on 45 patients who were subsequently treated with expansion thoracoplasty using the VEPTR. The average age was 8.2 ± 2.6 years, and the parent form of the CHQ was filled out by the primary caretaker. Patients were divided into 3 diagnostic categories: rib fusion (n = 15), hypoplastic thorax syndromes (n = 17), and progressive spinal deformity (n = 13). Results: There were significant differences between the study patients and healthy children in physical domains. Compared with parents of healthy children, parents of children with TIS experienced more limitations on their time and emotional lives due to their children's health problems. There were no significant differences in CHQ before and after the surgery except for a significant decrease in the self-esteem among a subgroup of patients with hypoplastic thorax syndromes. There were no significant differences in postoperative QOL between patients who had VEPTR-related complications and patients who did not have the complications. Conclusions: The children with TIS had lower physical scores and higher caregiver burden scores than healthy children. However, the scores in psychosocial domains were similar to those in healthy children. Our study demonstrated that QOL of children and burden of care in their parents remained the same after VEPTR instrumentation. Children's QOL seemed to be not affected by whether they had VEPTR-related complications or not.

Sequelae of septic arthritis of the hip in children: a new classification and a review of 41 hips.

Abstract: Background The sequelae of septic arthritis of the hip in children are diverse and represent a complex problem. A classification of the deformities is important to plan treatment and to give prognostic information. The radiographic main classification used provides detailed information of the deformities, but it is complicated and not feasible to apply in young children. The authors developed a simple and reliable method of classification and present the results of a large series of patients. Methods The authors reviewed 37 children with 41 hips with sequelae of septic arthritis of the hip. Twenty-four were male subjects, and 13 were female subjects. Twenty-five had the acute infection at the neonatal period, and 16 were aged between 1 month and 3 years. None of them received adequate treatment at the acute process: 20 hips were not treated, and the other 21 had delayed drainage (at least 5 days after the onset of the infection). The hips were classified into 2 groups on the basis of radiographic appearance. Hips with sequelae grade 1 were reduced hips, with femoral head preserved (1A) or absent (1B); hips grade 2 were dislocated hips, with the femoral head preserved (2A) or absent (2B). There were 10 hips with grade 1A, 11 with grade 1B, 3 with grade 2A, and 17 were grade 2B. We compared our material and results with those presented by Choi et al and also compared the reliability of both classification. The criteria for satisfactory results were stability, range of motion of 50 degrees or more of flexion, a flexion contraction below 20 degrees, and a painless hip. Results Our classification presented a greater concordance (25 of 41 hips against 7 in 41 for the Choi et al classification; P = 0.01). Thirty-seven hips were pain-free, and 4 had occasional pain. Thirty-seven hips had a satisfactory range of motion (90.2%). Stability was present in 29 hips (70.7%). Final results showed 24 hips classified as satisfactory and 17 as unsatisfactory. Our material and end results were comparable with those reported by Choi et al.Septic arthritis of the hip developed at the newborn period produced more severe sequelae. Hips with sequelae grade 1 have a good prognosis. Surgical procedures in these grades were necessary to correct acetabular dysplasia and improve congruency. Fifteen of 20 hips with sequelae grade 2 (unstable) underwent reconstruction. At a mean follow-up of 6.9 years (range, 2.7-11.3 years), satisfactory results were obtained in 8 of them. Conclusions The classification we proposed showed to be simpler and more reliable than the classification proposed by Choi et al. It may be useful to guide treatment and prognosis. Longer follow-up is needed to assess the real benefit of the reconstruction for unstable hips.

Hemiepiphysiodesis for the Correction of Angular Deformity About the Knee

Abstract: Background:It is generally accepted that the presence of angular deformity about the knee that persists into the preadolescent years will not correct spontaneously. The goal of this study was to review our experience with hemiepiphysiodesis and physeal stapling for the correction of angular deformit

Delayed healing of forearm shaft fractures in children after intramedullary nailing.

Abstract: Background: In displaced and unstable forearm shaft fractures, elastic stable intramedullary nailing represents the current treatment of choice. Delayed healing has been observed in single cases, but the incidence of healing disturbances remains unclear. Methods: Retrospective analysis of all patients with forearm shaft fractures and open epiphyseal plates, treated with elastic stable intramedullary nailing between 2000 and 2004 in 5 pediatric trauma units, was conducted. Evaluation of cases with insufficient consolidation 90 days after osteosynthesis was performed. Results: Ten (1.9%) of 532 cases showed delayed healing. Mean age (12.3 years), part of open fractures (30%), and part of open reductions (60%) were clearly higher than in a nonselected collective; the ulna was concerned in 70%. One refracture, 1 local soft tissue infection, and 1 small sequestration were found. In 5 children, nails were extracted with (2) or without (3) local surgical intervention. In the other 5 children, the nails were left in place. All fractures healed within 13 months posttrauma without relevant functional restrictions. Conclusions: Delayed healing is possible especially in open fractures or open reduced fractures of the ulna in older children, but healing takes place up to 13 months. Therefore, no change of treatment principles is necessary. Protection of ulna periost has to remain in the center of surgical focus. Level of Evidence: Retrospective comparative study, Level III.

Biomechanical comparison of four different fixation techniques for pediatric tibial eminence avulsion fractures.

Abstract: Background:Several different methods have been used to repair tibial eminence avulsion fractures. It is not clear which is the best stabilization method. The purpose of this study was to compare the biomechanical stability of tibial eminence avulsion fractures using suture, resorbable screw, resorba

Correlation of pediatric outcomes data collection instrument with measures of active movement in children with brachial plexus birth palsy.

Abstract: Background: The purpose of this investigation was to characterize the range of Pediatric Outcomes Data Collection Instrument (PODCI) scores in children with brachial plexus birth palsy (BPBP) and determine its correlation with 3 published measures of active motion and function. Methods: One hundred fifty children with BPBP between the ages of 2 and 10 years were evaluated. Active upper-extremity motion was assessed using the modified Mallet Classification (MC), the Toronto Test score (TTS), and the Hospital for Sick Children Active Movement Scale. At the time of evaluation, patients and/or families were administered the age-appropriate PODCI questionnaire, and PODCI scores were compared with published normative data. Linear regression analysis was used to assess the correlation between MC, TTS, and Active Movement Scale as predictors of PODCI scores. Results: Mean PODCI global function score in the BPBP patients was 82.4 (range, 35.1-100), significantly lower than the published value of 93.3 in healthy, age-matched norms (P < 0.01). The mean upper-extremity subscore was 70.8 versus 92.0 in healthy age-matched controls (P < 0.01). Sports/physical functioning scores averaged 81 points among BPBP patients compared with 90 points in healthy norms (P < 0.01). Mean mobility, comfort/pain, and happiness subscores were also significantly lower than normative values by 5, 7, and 4 points, respectively (P < 0.01). While significant correlations were observed between PODCI scores and all measures of active movement, the modified MC correlated most highly with PODCI global function scores in patients aged 2 to 5 years, whereas the TTSs best correlated with global function in patients aged 6 to 10 years. Conclusion: Brachial plexus birth palsy patients have lower global and upper-extremity function compared with their healthy, age-matched peers, as measured by the PODCI. Physician-derived measures of active movement correlate with the patient/parent-derived PODCI scores and may be used to predict global function, upper-extremity function, and sports/physical activity in children 2 to 10 years of age with BPBP.

Is the foot structure of preschool children moderated by gender

Abstract: Objective: Although boys are frequently reported to have flatter feet than girls, there has been little systematic research to confirm or explain this structural difference between the genders. The objective of this study was to determine whether flat-footedness was moderated by gender in Australian preschool children and, if so, to determine the cause of this between-gender difference in structure of the plantar surface of the foot. Methods: Foot anthropometry, Arch Index derived from plantar footprints, and midfoot plantar fat pad thickness measured by ultrasound were obtained for the left and right feet of 52 girls and 36 boys (mean age, 4.2 T 0.6 years). The children were recruited from 10 randomly selected preschools from the Illawarra region of New South Wales, Australia. Results: In agreement with previous research, the preschool boys displayed significantly flatter feet than the girls (P e 0.04). Although there were no between-gender differences in structural foot dimensions, the boys had a significantly thicker midfoot fat pad than the girls by approximately 0.4 and 0.5 mm on both the right and left feet, respectively. Conclusions: The increased incidence of flat-footedness in boys compared with girls of the same age seems to be caused by a thicker plantar fat pad in the medial midfoot in boys. This suggests that the development of the medial longitudinal arch may be progressing at a slower rate in boys than in girls, and that intervention for a flexible flat foot, particularly for young boys, may be unnecessary.

Evidence-based analysis of removal of orthopaedic implants in the pediatric population.

Abstract: Background Requested project of the Pediatric Orthopaedic Society of North America Evidenced-Based Medicine Committee. Methods The English literature was systematically reviewed for scientific evidence supporting or disputing the common practice of elective removal of implants in children. Results Several case series reported implant removal, but none contained a control group with retained implants. No articles reported long-term outcomes of retained implants in large numbers. Several small series describe complications associated with retained implants without evidence of causation. The existing literature was not amenable to a meta-analysis. By compiling data from the literature, it is possible to calculate a complication rate of 10% for implant removal surgery. The complication rate for removal of implants placed for slipped capital femoral epiphysis is 34%. Articles regarding postmarket implant surveillance and basic science were also reviewed. Conclusions There is no evidence in the current literature to support or refute the practice of routine implant removal in children.

Locking plate fixation for pediatric femur fractures.

Abstract: Background: The use of locking plates for pediatric femur fractures has not been studied. Locking plate applications for fractures associated with comminution, osteopenia, or minimal bone available for purchase have been well studied in the adult trauma population. Methods: We conducted a retrospective review of children at our institution treated with a locking plate for a femur fracture. We identified 32 patients treated at an average age of 11 years (6-15 years of age). Locking plates were chosen for comminution in 13 patients, nonmalignant pathologic fracture in 9 patients, fracture location in 7 patients, and osteopenia in 3 patients. All patients were treated with a locking plate and followed up until definitive radiologic union. Results: There were no intraoperative complications related to this technology. All patients were healed with near-anatomic alignment with the exception of 1 patient who had valgus malalignment of 12 degrees, which was of no clinical concern and required no intervention. Seven patients had the plates removed with no noted complications. Conclusions: Locking plates are a safe and effective treatment for children and adolescents with femur fractures that may not be amenable to other current means of stabilization.

The development of acetabular retroversion in children with Legg-Calvé-Perthes disease

Abstract: Background Ezoe et al showed that the prevalence of acetabular retroversion in adults with Legg-Calve-Perthes disease (LCPD) was 42% versus 6% in normal controls. Our purpose was to study the development of acetabular retroversion in children with LCPD and perhaps draw conclusions regarding cause and effect. Methods We reviewed all 271 patients with LCPD seen at our institution to identify those patients with axial imaging before closure of the triradiate cartilage. Fifty-three hips (44 patients) formed our study population; the 35 normal hips in those patients with unilateral disease served as an internal control. Acetabular version was measured on the axial cut with the largest femoral head cross-section. Diseased versus control hips were compared using a paired t test. Two disease-severity subgroups, Herring A or B (42 hips) and B/C or C (11 hips), were compared using an independent-samples t test. In those patients followed past skeletal maturity (16 of 53 hips), we evaluated final AP pelvic radiographs for acetabular retroversion (presence of a crossover sign). Results Before skeletal maturity, all but 1 patient in our series demonstrated positive acetabular version (anteversion). We found no significant difference between the diseased and control hips: mean acetabular version in LCPD hips was 13.6 +/- 4.3 versus 15.4 +/- 5.4 degrees in unaffected hips. More severe cases (B/C or C) exhibited significantly more relative retroversion (10.8 degrees) than less severe cases (14.6 degrees, P = 0.047). Of the 16 hips followed past skeletal maturity, 5 demonstrated crossover signs on anteroposterior pelvic radiographs, indicating a 31% prevalence of acetabular retroversion. Conclusion Early after diagnosis, the prevalence of acetabular retroversion in our skeletally immature children with LCPD was extremely rare (1.8%), and there was no significant difference in version between the normal hips and hips with LCPD. However, over time, a child with a more deformed femoral head is more likely to develop acetabular retroversion, suggesting a cause-and-effect relationship. Level of evidence Level III (case-control).

Correction of simple and complex pediatric deformities using the Taylor-Spatial Frame.

Abstract: Introduction: Correcting multiplanar lower-limb pediatric deformities requires complex and, in many cases, staged procedures. The Taylor-Spatial Frame (TSF) is a sophisticated external fixator system that can be used to treat simple to complex multiplanar and multiapical skeletal deformities. We describe its use in 53 children during the last 7 years in a variety of pathologies and demonstrate its ease of use and versatility. Methods: A review of medical and physiotherapy records, radiographs, and computed tomographic scans of all patients treated with a TSF between June 1999 and December 2005 at the Booth Hall Children's Hospital was conducted. Data recorded were etiology of deformity, sex, age, number of previous operations, preoperative deformity parameters, operative records and frame constructs, treatment regime, frame duration, follow-up protocol, posttreatment deformity, complications, and clinical and radiological outcome. Results: Fifty-three patients between the ages of 12 months and 16 years (mean, 10.7 years) underwent correction programs for 55 limbs (44 tibia and 11 femurs). The etiology of deformity was congenital in 39 cases and acquired in 14. We were able to achieve an acceptable correction of deformity (leg length discrepancy <15 mm, angulation <5 degrees) in 52 limbs. A number of complications were encountered, which are discussed. Discussion and Conclusion: We demonstrate its ease of use for both surgeon and patient and its versatility in a variety of pathologies. The advantages of the TSF system are many. It is a simple frame construct, and application is easy. The plan and execution are structured with precise end points; it is a single-stage correction and thus avoids frame modifications. Any residual deformity can be further corrected by use of the same frame. We conclude that the TSF is an effective and efficient way to correct a wide variety of simple and complex often obstinate pediatric limb deformities.