Can you please describe or explain to me what is a Tillaux ankle fracture? Our 14-year-old daughter who is a budding gymnast just had a crash landing and this was the result. What does it mean for her?

The Tillaux fracture describes a specific bone, location, and amount of damage done. The bone affected is the tibia (the large “shin” bone in the lower leg). The fracture is at the bottom of the tibia just above the ankle. The fracture affects the front and side of the bone and extends through the growth plate right into the joint.

A strong force along the outside of the ankle tears the ligament that attaches to the growth plate. Without this ligament to protect the bone, the force of the injury extends the fracture line straight up into the joint.

The first tell-tale sign of a Tillaux fracture is the fact that the child cannot put any weight on the foot/leg. Swelling and bruising are visible along the front of the ankle. There is exquisite tenderness where the fracture is located and the entire ankle hurts.

X-rays and CT scans are used to show the full extent of the injury. These imaging studies are helpful when planning surgery. If there is displacement (separation) of the bones at the fracture site, then more extensive surgery with fixation using pins, screws, and/or wires may be required. Nondisplaced fractures may be managed with a non-weight-bearing cast.

With early diagnosis and appropriate treatment, long-term results are reportedly good. The closer the child/teen is to full growth, the less risk of damage to the growth plate. Sometimes early arthritis develops but this occurs later in life and does not prevent return to participation in sports activities after rehabilitation.

Do you think it’s true that people of color are more likely to die from spinal fusion surgery for scoliosis compared with whites? I know this sounds like a weird question but our adopted child (who happens to be Hispanic) is scheduled for this kind of surgery. We are looking for any information we can find on the Internet about this surgery and found this stuff about deaths. Now I’m having second thoughts.

You might be referring to a recent study conducted by the staff at the Department of Neurosurgery, Cedars-Sinai Medical Center in Los Angeles, California. They wanted to assess national trends in the surgical treatment of idiopathic scoliosis, so they used information from the Nationwide Inpatient Sample or NIS to compare the number and types of patients who had spinal fusion surgery for idiopathic scoliosis.

The NIS is a computer database with information collected on all patients who enter a hospital. Patient demographics (e.g., age, sex, race, income, insurance information, education) and hospital characteristics (e.g., size, bed capacity, teaching versus nonteaching) can be evaluated. They also analyzed information from the NIS on postoperative complications.

According to this study, there were some socioeconomic and racial trends suggestive of health care disparities. For example, if you have idiopathic scoliosis, you are more likely to be treated surgically if you are 1) white, 2) have private insurance, and 3) have access to a large hospital.

Whites (or Caucasians) had the highest rate of surgery for idiopathic scoliosis. Patients with private insurance were two times more likely to have spinal fusion surgery for this condition. Non-Caucasians (African Americans, Hispanics, Asian/Pacific Islanders, Native Americans) were much more likely to have complications after surgery.

Hispanic patients had the highest rate of complications. In all age groups and for all races and income levels, pulmonary (lung) problems were the most common followed by hematoma (bleeding). African Americans were more likely to suffer cardiac complications. Their death rate was also the highest. This finding was attributed to “less frequent use of effective cardiac medications” and “poorer overall quality of care” for this group.

There are some limitations of this study because all the information wasn’t always collected and entered on each patient. The lack of complete data entry can be considered a weakness of the system and possibly misrepresent the true outcomes studied. Data collected in the NIS do not reflect the severity of each person’s scoliosis, the presence of other spinal problems, or the reasons why surgery was done.

But the authors still concluded that surgical treatment of idiopathic scoliosis follows a similar trend observed with other medical problems: health care disparities do exist based on race and ethnicity and they can be significant.

Bringing these patterns to the awareness of policy makers may help solve this complex problem. There may be cultural reasons for some of the differences that must also be addressed. For example, minority patients are less likely to accept recommended services or treatment and less likely to follow through with treatment suggestions.

Future studies using the National Inpatient Sample (NIS) will need better control over missing data, especially if the information is related to important data about patient income, race, and age. A closer look at the high rate of complications (causes and risk factors) might be helpful in preventing or reducing postoperative problems.

Before cancelling any plans you may have in place, talk with your child’s neurosurgeon. Ask him or her to review with you the potential problems your child might experience and perhaps the likelihood that any of these could develop. Death during or after any surgery is a very serious thing and deserves attention so that all concerned are comfortable and confident in any decisions made that affect the plan of care.

I live in California and teach in a local high school. My partner teaches in a private school. Sometimes we compare notes about equalities and inequalities we think we see. One of those is health care. I never see anyone in my classes wearing a brace for scoliosis and certainly never having surgery for this problem. My partner reports this is much more likely in the private sector. The reason I ask is because my daughter has scoliosis, too so this problem has caught my eye. What do you know about this kind of difference in treatment?

Your observations may be more on the mark than you think! And, in fact, other folks in your area have noticed the same thing. Researchers at Cedars-Sinai Medical Center in Los Angeles, California used information from the Nationwide Inpatient Sample or NIS to compare the number and types of patients who had spinal fusion surgery for idiopathic scoliosis. They also analyzed information on postoperative complications.

The NIS is a computer database with information collected on all patients who enter a hospital. Patient demographics (e.g., age, sex, race, income, insurance information, education) and hospital characteristics (e.g., size, bed capacity, teaching versus nonteaching) can be evaluated. Data collected in the NIS do not reflect the severity of each person’s scoliosis, the presence of other spinal problems, or the reasons why surgery was done. But trends in treatment can be detected.

According to this study, if you have idiopathic scoliosis, you are more likely to be treated surgically if you are 1) white, 2) have private insurance, and 3) have access to a large hospital. These racial and socioeconomic trends represent differences in treatment between white and non-whites referred to as disparities in health care.

As mentioned, whites or Caucasians had the highest rate of surgery for idiopathic scoliosis. Patients with private insurance were two times more likely to have spinal fusion surgery for this condition. Non-Caucasians (African Americans, Hispanics, Asian/Pacific Islanders, Native Americans) were much more likely to have complications after surgery.

Hispanic patients had the highest rate of complications. In all age groups and for all races and income levels, pulmonary (lung) problems were the most common followed by hematoma (bleeding). African Americans were more likely to suffer cardiac complications. Their death rate was also the highest. This finding was attributed to “less frequent use of effective cardiac medications” and “poorer overall quality of care” for this group.

The authors concluded that like so many other studies that show health care disparities based on race and ethnicity, surgical treatment of idiopathic scoliosis follows the same trend. Bringing these patterns to the awareness of policy makers may help solve this complex problem. There may be cultural reasons for some of the differences that must also be addressed. For example, minority patients are less likely to accept recommended services or treatment and less likely to follow through with treatment suggestions.

Our 13-year-old daughter has scoliosis they call “idiopathic” because we don’t know what caused it. She never complains of pain but she is very self-conscious about her appearance. Is this ever a reason to have surgery to straighten her spine if there isn’t any pain?

This is a very good question. Treatment for scoliosis (curvature of the spine) is usually directed toward preventing deformity and minimizing any effects of the condition on daily function and quality of life (QOL).

Quality of life covers a lot of territory including self-confidence, self-esteem, mood, and body image and appearance. So treatment isn’t always just for pain, loss of motion, structural deformity, and/or loss of function.

To measure health-related quality of life (HRQOL) in teens and young adults with idiopathic scoliosis, the Scoliosis Research Society (SRS)-22 survey is often used. This tool was first published as a valid, reliable instrument back in the late 1990s. It is a simple and practical way to assess how patients with this particular condition perceive themselves in terms of pain, self-image, and function.

Research has been done to see if this tool can help direct treatment (surgical versus nonsurgical). Results from a recent study showed that the questionnaire is a good tool to use when assessing differences in pain and body image between patients with small versus large spinal curves. It does not sort out differences between the two groups when it comes to measuring effects on function or mental health.

The SRS-22 really does not show differences with small changes in the severity of the spinal curvatures but it is still a good tool for measuring some things (body image and pain between small and large curves). It’s easier to use the SRS-22 to identify patients with larger curves who will need surgery but not as effective for smaller (mild to moderate) curves.

Whenever treatment decisions are being made for children with idiopathic scoliosis, it is good to remember that results of treatment may be affected by other factors that are not measured by the SRS-22. This can include socioeconomic status, body mass index as a measure of obesity, self-esteem, self-confidence, and/or mood (depression, anxiety).

In this age group, self-image is often more important than physical pain or loss of motion. When planning treatment, these other behavioral, psychologic, and social health-related qualities are also important. And surgery isn’t the only option for this condition. Physical therapy, bracing, and exercise may be helpful in some cases. Most of the time, the severity of the curvature is the deciding factor when someone needs more than conservative (nonoperative) care.

Together with the team of health care professionals involved in your daughter’s care (e.g., orthopedic surgeon, physical therapist, neurosurgeon), all of these factors should be evaluated and discussed when making treatment decisions.

We took our 11-year-old daughter to a special spine clinic to have her scoliosis evaluated. They gave her a special questionnaire called an SRS. What is this and what does it measure? Does everyone take this test or only certain ones with scoliosis?

Every medical condition needs a tool to measure success of treatment. With idiopathic scoliosis (curvature of the spine with no known cause), the Scoliosis Research Society (SRS)-22 survey is often used. This tool was first developed and then published as a valid, reliable instrument back in the late 1990s.

The SRS-22 questionnaire has been used to measure health-related quality of life (HRQOL) in teens and young adults. It is a simple and practical way to assess how patients with this particular condition perceive themselves in terms of pain, self-image, and function.

Since idiopathic scoliosis is not life-threatening, the goals of treatment are not to save the life of the child or even cure him or her of this problem. Treatment is more of a management approach to limit how severe the spinal curve becomes, to prevent deformity, and to minimize any effect of the condition on daily function and quality of life.

The question: can the SRS-22 be used (and relied upon) to guide management decisions has been studied. In other words, how useful is the SRS-22 in making treatment decisions?

This tool has been tested with patients who were treated without surgery (nonoperative group) and those who had surgery based on severity of their spinal curves.

It turns out the questionnaire is a good tool to use when assessing differences in pain and body image between patients with small versus large spinal curves. It does not sort out differences between the two groups when it comes to measuring effects on function or mental health.

The SRS-22 is a good tool for measuring some things (body image and pain between small and large curves) but it does have some limits. Different scores are not as likely with small changes in curves. It’s easier to use the SRS-22 to identify patients with larger curves who will need surgery but not as effective for smaller (mild to moderate) curves.

Results of treatment may be affected by other factors that are not measured by the SRS-22 (e.g., socioeconomic status, body mass index as a measure of obesity, self-esteem, self-confidence, mood). In older children, teens, and young adults, self-image is often more important than physical pain or loss of motion. Since these other behavioral, psychologic, and social health-related qualities are also important, it may be necessary to use more than just the SRS-22 to assess change but the SRS-22 is a good place to start.

Our 23-month old son is having surgery on his little clubfeet because casting and splinting didn’t work. The surgeon is thinking that only one surgery will be needed but of course, no one knows for sure. What are the reasons why a child with this problem might need a second surgery? I’m not really sure how this works.

Clubfoot (also known by the medical term: equinovarus) describes a condition in which the foot is turned under and towards the other foot. Equinus means that the toes are pointed down and the ankle flexed forward (sort of like the position of the foot when a ballet dancer is on her toes). Varus means tilted inward. The ankle is in varus when you try to put the soles of your feet together.

This twisted position of the foot causes other problems. The ligaments between the bones are contracted, or shortened. The joints between the tarsal bones do not move as they should. The bones themselves are deformed. This results in a very tight stiff foot that cannot be placed flat on the ground for walking. To walk, the child must walk on the outside edge of the foot rather than on the sole of the foot.

To avoid these problems, infants born with this condition are treated with a nonsurgical treatment approach called the Ponseti method. The Ponseti method is a series of casts put on the lower leg and foot to gradually straighten the bones out and restore normal motion and alignment of the foot and ankle. The technique works well for about 90 to 95 per cent of children with a clubfoot deformity.

But if correction is not successful with this nonoperative care, then surgery is needed. Some of the soft tissues (tendons, ligaments, joint capsule) in the foot and ankle are cut. The surgeon may realign the bones and hold them in place with wires. Splinting and casts are used to maintain the correct position until healing takes place.

A second surgery could be needed if, for example, the deformity isn’t corrected or the toes start to drift inward (a condition called metatarsal adduction). Studies show that about two-thirds of the children who need the first surgery do fine and need no further treatment. But the remaining one-third still need some surgical follow-up to achieve the best results. Sometimes, this is something as simple as a tendon release. In other cases, the surgeon has to cut the joint capsule to allow for better joint motion.

Recent research has shown that early, aggressive surgical treatment gives better correction, thus reducing the need for further surgeries. It sounds like your surgeon has a plan in mind that he or she thinks will be the only procedure needed and one that will be successful!

Our daughter had surgery at age 18 months to correct a clubfoot that didn’t get better with casting. She’s now 11-years-old and wants to try out for the local girls’ soccer team. Should we try to discourage her and shield her from possible failure? Or let her try out and see what happens? I’m just not sure the leg is strong enough or that the surgery will hold up.

There aren’t a lot of studies with long-term results for surgical correction of clubfoot. Like your daughter, infants with equinovarus (medical term for clubfoot) are treated first with a conservative approach called the Ponseti method. This involves a series of casts used to gradually correct the alignment of the ankle and foot. This treatment is effective for 95 per cent of children born with this condition.

But if correction is not successful with this nonoperative care, then surgery is needed.
There are different surgical techniques used by different surgeons and results may vary because of that. For example, extensive soft-tissue releases may be performed to lengthen the tendons (e.g., Achilles, posterior tibialis, abductor hallucis brevis tendons) around the ankle.

The capsule (a tough fibrous structure) around the ankle joints may be cut. One surgeon from Northwestern University School of Medicine recently published long-term (20-year) results using a technique that involved these kinds of soft-tissue releases and wires to hold the bones in proper alignment.

There were a total of 80 children in the study. Some had bilateral clubfoot (both feet affected), so there was a total of 120 feet surgically corrected. For two-thirds of the group, the authors described the results as “acceptable” and “durable.”

The remaining one-third had to have additional surgery because the deformity was not fully corrected. No one needed to have the ankle fused. For the children who only had one foot involved, there was a significant difference in motion, calf size, leg length, and foot length between the two feet at the final check-up years after the surgery. Muscle strength was normal for half the group.

The possible weakness and difference in leg length, foot size, and coordination on the surgical side may impair your daughter’s playing ability. A physical exam involving tests and measurement of ankle/foot range of motion, strength, coordination, and proprioception (position sense of awareness) might be a good idea. It’s possible she will be fine to start out now and build strength with practice and play. But if she needs any further rehab to prepare her for safe sports participation, now is the time to find out.

Can you please explain “islands of ossification in the posterior acetabulum” to me? I’m reading the MRI report on my 10-year-old son’s hip. He has been complaining of pain for months and we finally decided it wasn’t just “growing pains.” Now I see he has islands of ossification. Could that be causing the pain?

Hip pain in growing children isn’t always from “growing pains.” Children and young teens active in sports training and competition who have not yet completed their growth often develop hip pain. The bones are not fully formed yet.

Formation of the bone in the posterior (back wall) of the acetabulum (hip socket) is important because this portion of the hip socket is located at the juncture where three other bones meet (the ilium, the ischium, and the pubis). The pattern of development of the posterior acetabulum depends on the coordination and timing of development of these three bones as well.

The posterior (back) wall of the hip socket (acetabulum) develops in four distinct phases. At first (in the young child before age eight), the acetabulum is made up of 100 per cent cartilage. Around age eight or nine, the cartilage starts to turn to bone. That process is called ossification. MRI images showed a cobblestone formation with islands of bone ringed by areas of cartilage. This is the “islands of ossification” the radiologist observed and commented on in the report. It tells the surgeon (or other physician reading the report) what phase of bone formation and development your son is in.

By age 12 or 13, the three bones (ilium, ischium, pubis) that join together to form the acetabulum have met together and fused. At this point, there is still a rim of bone forming (ossification) around the upper back (posterior) portion of the acetabulum. This is referred to as the posterior rim sign. The final step is closure of the cartilage between the three bones called the triradiate cartilage. This last phase occurs in girls by age 12 and in boys by age 14.

MRI studies have made it clear that the posterior aspect of the acetabulum (hip socket) develops and progresses in an orderly fashion. It goes from cartilage to bone more slowly (and after) the same process takes place in the front (anterior) portion of the socket. But it is a predictable series of four phases. Boys tend to complete this ossification process later than girls (one to one and a half years later).

If a surgeon needs to know the shape and developmental phase of the acetabulum before that final phase (before closure of the triradiate cartilage), then an MRI (not X-rays or CT scans) will be needed. Children younger than eight won’t need an MRI since it is known the socket is all cartilage. Children between nine and 14 must be evaluated on an individual basis keeping their gender in mind (remember, girls complete the fusion process at a younger age than boys).

Using only X-rays during phases two and three (ossification and fusion but before closure of the cartilage) can lead to problems. There can be false positives for femoral anteversion (twist in the angle at the top of the femur or thigh bone) and false negatives for damage to the posterior wall of the acetabulum from acute traumatic injury. Misjudging either of these signs can cause delays in diagnosis and treatment for these children.

Ask your physician to explain the MRIs and the written results to you. The observation of islands of ossification is a normal finding at this age. There may be other information contained within that report of interest in diagnosing your son’s hip pain.

If you can believe this, our seven-year-old daughter actually dislocated her hip playing softball (she slid into someone standing at home plate). The X-ray department took an X-ray but the radiologist refused to do an MRI (as suggested by another person evaluating our daughter). The radiologist said there’s nothing there but cartilage and it wasn’t “medically necessary.” Is that true?

There is some debate about what type of imaging studies are useful, needed, and helpful in diagnosing acute traumatic hip injuries in children. Age and gender (boys versus girls) are two important variables and we’ll explain why here in a minute.

Children and young teens active in sports training and competition who have not completed their growth will need some special consideration when being evaluated because the bones are not fully formed yet.

For example, when the hip socket (known as the acetabulum) is still more cartilage than bone, X-rays may falsely show what looks like a rotated angle of the hip. It is easy to mistake the hip pain as coming from a problem known as femoroacetabular impingement when that’s not it at all.

In another example, X-rays and CT scans looking for a fracture of the backside of the acetabulum may not show a torn labrum (fibrous rim of cartilage around the hip socket) or a loose piece of cartilage in the joint. Only an MRI will show that.

So when should an X-ray versus CT scan versus MRI be ordered for a child with hip pain associated with trauma (accident, injury, or sports overuse)? Recently, a group of orthopedic surgeons from the Hospital for Special Surgery in New York City did a study to sort this out.

They found medical records for 180 patients between the ages of four and 15 with hip pain who were evaluated by X-ray and MRI. They compared the findings and results. In the process of collecting this information, they were able to determine the order, speed, and age(s) at which the backside and rim of the acetabulum (hip socket) develops.

They found that the posterior (back) wall of the hip socket (acetabulum) develops in four distinct phases. At first (in the young child before age eight), the acetabulum is made up of 100 per cent cartilage. Around age eight or nine, the cartilage starts to turn to bone. That process is called ossification. MRI images showed a cobblestone formation with islands of bone ringed by areas of cartilage.

By age 12 or 13, the three bones (ilium, ischium, pubis) that join together to form the acetabulum have met together and fused. At this point, there is still a rim of bone forming (ossification) around the upper back (posterior) portion of the acetabulum. This is referred to as the posterior rim sign. The final step is closure of the cartilage between the three bones called the triradiate cartilage. This last phase occurs in girls by age 12 and in boys by age 14.

If a surgeon needs to know the shape and developmental phase of the acetabulum before that final phase (before closure of the triradiate cartilage), then an MRI (not X-rays or CT scans) will be needed. Children younger than eight won’t need an MRI since it is known the socket is all cartilage. Children between nine and 14 must be evaluated on an individual basis keeping their gender in mind (girls complete the fusion process at a younger age than boys).

The authors of this study suggest surgeons should NOT rely on anything but MRIs when evaluating the hip socket in older children and young teens who do not have a fully closed triradiate cartilage. The radiologist is correct that your daughter probably doesn’t need an MRI at this time for the reason stated.

I just saw on Facebook that my neighbor’s son is in surgery for a cut nerve in the forearm. He is a super basketball player and extraordinary musician. Will this put an end to all that? I want to be as supportive as possible and not ask too many questions like this so I thought you might be able to help fill in the gaps for me.

Nerve damage in the forearm from crush injuries or cuts can lead to significant disability. But nerves do heal even if at a very slow rate. In fact, studies show that with nerve repair, improvement can continue up to five years after the surgery. The keys to best outcomes are age at the time of injury and time between injury and surgery. Younger patients who have surgery soon after the injury have the best results.

A recent study from Sweden has provided us with information on what happens 30 years after nerve injury and repair in childhood or adolescence. They followed 45 patients who had a complete (nerve cut clear through) nerve injury of the median and/or ulnar nerves in the forearm. They measured outcomes in terms of sensory and motor function, level of pain or discomfort, and impact on the patient’s life (education, work, recreation).

They found that children who were younger at the time of the injury and repair (younger than 12 years old) had significantly better results. Complete recovery occurred in 87 per cent of the younger children compared with only 67 per cent of the teens (12 or older). Which nerve was cut (median or ulnar) didn’t seem to matter; age was the main prognostic factor.

Surgery was done in all cases to either repair (stitch the two ends of the cut nerve together) or reconstruct (use a grafted nerve to help the two ends meet) the injured nerves. In some cases, reconstruction had to be done right from the start because of the extent of the damage. In other patients, enough time had passed (up to 15 months in some cases) that the two nerve endings had retracted (pulled away) enough that stretching the nerve ends to meet was no longer possible.

When nerve grafting (reconstruction) was done in both age groups, the younger children still had better results. That was true regardless of whether one nerve (either one) or both were injured. Fortunately, motor function was preserved in all the patients no matter what age they were or which nerve was injured.

Cold sensitivity wasn’t a big problem. A few patients still had less tolerance to cold. The older group was affected the most and they reported that this problem gradually got better over time. Hand size was not different among any of the participants. The older group also said the injury influenced their leisure activities and choice of career but not how far they went in school (high school versus college).

The authors concluded that children who sustain nerve injuries at a younger age have a better chance for full recovery and function. Which nerve was injured doesn’t seem to make a difference in long-term results. But when both nerves were cut, patients reported a greater impact on education and recreation.

The authors mention that today’s patients facing similar nerve injuries may have even better long-term results compared with children and teens treated 30 years ago. It is now recognized that associated injuries (e.g., tendons, arteries) must be repaired as well. Newer surgical techniques and tools may also aid in better outcomes.

We also now know that participation and motivation in the rehab process make a difference. And we have better strategies to help patients relearn sensory function based on new information about brain plasticity (ability of the brain to adapt and recover).

Your friendship and support for your neighbor and son will be a lasting gift. Reaching out without pressure for information or speculation about what might or might not happen is a wonderful idea.

What is loco-nosia? I heard this term on ESPN sports radio but didn’t catch the whole story. Evidently some basketball player cut two nerves in his forearm. There is some concern that he won’t get all his feeling back and this loco-stuff could affect his ball handling skills. Just wondering what it is…

Locognosia is the ability to tell where on the skin a person is touched (literally “knowlege of local touch”). It is one aspect of our ability to feel the difference when we are touched in two different places at the same time. This is called tactile spatial discrimination. Our touch sensation relies on the health and function of peripheral nerves (nerves in the arm, forearm, or hand) as well as the picture of our body in the brain.

Locognosia is sometimes used as a test of something referred to as “misdirection.” When nerve cells that have been cut start to regrow (regenerate), they can be misdirected at the site of the cut. The nerve ends try to reach across to each other but end up going in all different directions. The end-result is a change in the signal pattern from the peripheral nerve to the spinal cord and up to the brain. The brain then remaps the location of sensation from the hand based on these signals. Dysfunction of tactile discrimination resulting in locognosia can occur when nerve misdirection occurs.

Studies show that people who sustain nerve injuries at a younger age have a better chance for full recovery and function. Which nerve was injured doesn’t seem to make a difference in long-term results. But adults can recovery (just more slowly) because of a strong mental (cognitive) ability and motivation to succeed.

Today’s patients also benefit from updated surgical techniques and tools to aid in better outcomes. Participation and motivation in the rehab process make a difference. And there are better strategies to help patients relearn sensory function based on new information about brain plasticity (ability of the brain to adapt and recover).

It’s likely that someone whose career is followed on ESPN sports radio will benefit from the best medical treatment available. Follow-up with a hand therapist and participation in a rehab program designed to recover ball handling skills will likely yield good results.

We are adopting a child from another country who has some hip problems. She started out with a hip infection that wasn’t treated. Then the hip dislocated. They said because she was “too old” (three years old) at the time, they couldn’t do surgery. We will definitely have her checked by our pediatrician and an orthopedic surgeon. What should we expect?

Infection of the hip joint that is undiagnosed and therefore untreated can lead to a condition known as septic arthritis. In young children, dislocation of the septic hip can be a challenge.

According to a recent update on the management of septic hip dislocations from India, your adoptive daughter’s care falls well within the recommended protocols for treatment. Here’s a summary of the information provided.

Before a treatment plan can be determined, the surgeon must know for sure whether the child’s hip is truly dislocated or just not fully formed yet with an intact capital femoral epiphysis (area of growth at the top of the femur or thigh bone) still in place. Usually X-rays are not enough to make this determination so MRI, ultrasound, and/or arthrogram are required.

Treatment can range from no reconstructive surgery called closed reduction with full (spica) cast immobilization to open reduction (open incision and relocating or putting the hip back in place). The goals of stabilizing the hip versus restoring normal anatomy depend on knowing whether the capital femoral epiphysis is present or the hip is dislocated.

Treatment decisions are also influenced by the age of the child. For example, children under the age of two may be successfully treated with closed reduction. Open reduction is recommended for children older than that.

Treatment may include preoperative traction to pull the dislocated hip down to the level of the acetabulum (hip socket). Some surgeons prefer to shorten (or lengthen) the femur to accomplish this same alignment. Soft tissue structures may be needed such as lengthening of the psoas (hip flexor) muscle or tendon.

Sometimes the surgeon must do a bony osteotomy (remove a wedge-shaped piece of bone from the femur) to correct a problem with the angle of the hip. A shelf procedure may be needed to extend the bone and form a cover around the femoral head. This keeps it from migrating upward and dislocating again.

Relocation of the hip is not always the best idea. It can result in chronic hip stiffness, leg shortening, and a definite lurch in the gait (walking) pattern. Patients with oddly shaped femoral heads and poor (thin) articular cartilage from the infection often end up with degenerative arthritis and chronic pain even with hip relocation.

Patients should be selected carefully for open reduction and surgical restoration of the hip. A nice, round femoral head of good size is important. Healthy cartilage is a good prognostic factor (meaning surgical treatment is more likely to yield good results). Children older than six years old are not likely to benefit from open reduction. And finally, the patient who does NOT have stiffness before surgery has a better chance of good recovery and positive outcomes.

At age three, your child is at the upper end of ages that can be treated conservatively but she may qualify for surgical reconstruction. You won’t really know what course will be advised until she is evaluated. But this information may give you a picture of the possibilities and expected outcomes.

My seven-year-old niece had a hip infection that went undiagnosed and untreated until it dislocated. She recently came to live with us. The surgeons here are saying she’s not an “ideal” candidate for surgery. What does that mean exactly?

Infection of the hip joint that is undiagnosed and therefore untreated can lead to a condition known as septic arthritis. In young children, dislocation of the septic hip can be a challenge.

For one thing, the hip that is not fully formed can look like it is dislocated when, in fact, it’s not. If the growth center of the hip (called the capital femoral epiphysis) is not fully ossified (turned to bone and connected to the femur or thigh bone to form the round femoral head), it can give the hip the appearance of being dislocated.

Before a treatment plan can be determined, the surgeon must know for sure whether the child’s hip is truly dislocated or just not fully formed yet with an intact capital femoral epiphysis still in place. X-rays are not enough so that MRI, ultrasound, and/or arthrogram are required.

The goals of stabilizing the hip versus restoring normal anatomy depend on knowing whether the capital femoral epiphysis is present or the hip is dislocated. Treatment decisions are also influenced by the age of the child. For example, children under the age of two may be successfully treated with closed reduction. Open reduction is recommended for children older than that. But children older than six years old are not likely to benefit from open reduction.

Evidence from currently available studies suggest that relocation of the hip is not always the best idea. It can result in chronic hip stiffness, leg shortening, and a definite lurch in the gait (walking) pattern. Patients with oddly shaped femoral heads and poor (thin) articular cartilage from the infection often end up with degenerative arthritis and chronic pain even with hip relocation.

Experts advise that patients should be selected carefully for open reduction and surgical restoration of the hip. A nice, round femoral head of good size is important. Healthy cartilage is a good prognostic factor (meaning surgical treatment is more likely to yield good results). And finally, the patient who does NOT have stiffness before surgery has a better chance of good recovery and positive outcomes.

The informed surgeon will not choose to put the child through surgery if all indications are it will not be successful and could likely make the child worse. Given this information, you may want to ask your surgeon for more details of what would make a child a better candidate for restorative surgery and why your niece does not fall into that category. Don’t hesitate to seek a second or even a third opinion but be prepared to hear the same counsel from each one.

I’ve heard that multiple sclerosis is more likely to occur in people raised in the northern areas of the globe. They said on television that they think the same is true for Perthes disease (which is what I have). In fact, they said the lowest rate of Perthes is at the equator. Any idea why that would be?

Research has indeed shown us that Legg-Calvé-Perthes occurs more often in certain geographical areas. For example, children in Northern Europe have the highest rate of occurrence while children around the equator have the lowest incidence. In fact, for every 10 degree increase in latitude, the number of children affected by Perthes doubles.

Researchers have uncovered two possible environmental factors: second hand smoke from cooking stoves and tobacco as well as lower socioeconomic status. Children in families with lower incomes appear to be at greater risk.

Studies of children in England over a period of three decades (30 years) clearly showed a higher incidence among families in the northern part of the country, especially those from areas of socioeconomic deprivation. Over time, as wealth increased in those areas, the incidence of Perthes was reduced by 50 per cent.

Although these variables have been uncovered, the exact way in which these things contribute to Perthes disease remains unknown.

When surgery is recommended for Perthes disease, how does the surgeon decide what to do and when to do it?

Perthes is a condition that affects the hip in children between the ages of four and eight. The condition is referred to as Legg-Calvé-Perthes disease in honor of the three physicians who each separately described the disease.

In this condition, the blood supply to the growth center of the hip (the capital femoral epiphysis) is disturbed, causing the bone in this area to die. There is also an imbalance in bone turnover between the bone building cells (osteoblasts) and the cells that break bone down (osteoclasts).

With loss of blood supply, there is too much bone resorption (break down). The blood supply does eventually return and the bone heals. But until this happens, the bone in the femoral head (round head at the top of the femur or thigh bone) can disintegrate, crumble, and collapse.

How the bone heals determines what problems the condition will cause later in life. Understanding the effects on the bone cells during the early days of this disease helps direct treatment. A three-tier surgical approach has been proposed starting with preventive surgery to preserve the round head of the femur (thigh bone).

The surgeon may use one of several techniques to “contain” the head of the femur in the socket in order to help keep the round shape. This approach is meant to prevent deformity of the femoral head and works best for older children (age six and older). Younger children are more likely to respond well to conservative (nonoperative) care and don’t need corrective surgery.

The second surgical approach is called remedial surgery. The goal is damage control after the disease process has already started to change the bone structure. In other words remedial surgery is to minimize the effects of the deformity that has already occurred (e.g., fragmentation and/or collapse of the femoral head). The child must have good bone quality that can hold up under the stress and pressure of weight bearing. Reducing pain and improving function is possible.

The third tier of treatment referred to as salvage surgery is done to reshape the femoral head and reform the acetabulum (hip socket). This more extensive reconstructive (“joint preserving”) surgery is used for patients who have joint deformity. They are usually older and may even be adults for this type of treatment. They often also have damage to the surrounding cartilage and soft tissues.

Children who do not receive treatment early enough or for whom treatment is not effective may eventually develop degenerative arthritis. Structural changes may be too great for reconstructive surgery. That’s when total hip replacement may be indicated. Saving the joint helps put off hip joint replacement for as long as possible.

Despite this understanding of a three-tiered approach to Perthes disease, there is still much to be discovered to create the best results. Knowing that excessive bone resorption is part of the early damage associated with Perthes has led scientists to look for ways to prevent this from happening.

Medications (by mouth or by injection directly into the hip) such as bisphosphonates to prevent bone loss are being used in animal studies. These drugs may help decrease bone deformity while the body heals itself and restores blood flow to the area. Other biologic therapies to prevent bone loss are also being investigated. Someday it may be possible to treat this condition without surgery!

My four-year-old grandson has to use crutches now to keep weight off his right hip because he has something called Perthes disease. So far he has enjoyed the attention and the novelty of using crutches. But I predict this won’t last. How long will he have to use crutches to get the desired healing effect?

Treating children with Perthes hip disease presents some interesting challenges. Current approaches include non-weight-bearing (not putting any weight on the leg) for long periods of time. Age is the determining factor in the treatment of this condition. Recovery is more likely in children under the age of eight. Many children have mild Perthes disease and are able to heal and recover fully even without treatment. The hip actually remodels itself and remains smooth moving.

The primary goal of treatment for Perthes disease is to help the femoral head recover and grow to a normal shape. The closer to normal the femoral head is when growth stops, the better the hip will function in later life. The way that surgeons achieve this goal is using a concept called containment.

Containment is a simple concept. The femoral head can be molded as it heals. This is very similar to molding plastic. Plastic is poured into a molded and held in the mold as it cools. It then holds the shape of the mold. The hip socket, or acetabulum, is not affected when the femoral head loses its blood supply. It can be used as a mold to shape the femoral head as it heals.

The trick is that the femoral head must be held in the joint socket (acetabulum) as much as possible and without too much load. It is better if the hip is allowed to move and is not held completely still in the joint socket. Joint motion is necessary for nutrition of the cartilage and for healthy growth of the joint. Being non weight-bearing helps prevent further flattening and collapse of the femoral head during the healing phase.

All treatment options for Perthes disease try to position and hold the hip in the acetabulum as much as possible. The only problem is — it can take two to four years for the necrotic bone to get resorbed and replaced by new bone. And in some cases, new bone never forms. Instead, there is new granulation (healing) tissue, but that area doesn’t harden into bone, it just forms cartilage.

Many children who are diagnosed with Perthes disease do not require any treatment except careful watching. When the condition is mild, the results of not doing anything are often as good as aggressive treatment. Active treatment is advised when more than half the epiphysis is affected. Given the fact that your grandson is on crutches at such an early age, it is likely that he has more than a mild case of Perthes.

The orthopedic surgeon determines the treatment based on the child’s age and the classification of the severity of the disease. The classification is determined by the X-ray findings. Length of time in a non weight-bearing mode will probably also be determined by changes observed on repeat X-rays taken at regular intervals.

Our six-year-old son is VERY active in all kinds of sports already. But we just found out he has Perthes hip disease. Now he is supposed to stay off that leg for as long as it takes to heal. Is this really necessary? Isn’t it more important these days to stay active?

Perthes disease is a condition that affects the hip in children between the ages of four and eight. The condition is also referred to as Legg-Calve-Perthes disease in honor of the three physicians who each separately described the disease.

In this condition, the blood supply to the growth center of the hip (the capital femoral epiphysis) is disturbed, causing the bone in this area to die. The blood supply eventually returns, and the bone heals. How the bone heals determines what problems the condition will cause in later life.

Treating children with Perthes hip disease presents some interesting challenges. As you have found out, current approaches include non-weight-bearing (not putting any weight on the leg) for long periods of time. This method is not necessary for younger children (before age six) because they tend to have a good prognosis. It is reserved more for older children but who may be less compliant (cooperative) with the idea of never putting any weight on the affected leg.

A recent study that might help answer your question caught our attention. In this study, researchers used piglets to simulate Perthes disease in order to study whether or not weight-bearing is harmful to the healing process. At the same time, they evaluated the effect of non-weight-bearing compared with weight-bearing. A group of 16 piglets were surgically altered to stop blood flow to the hip. Half the group were allowed to put weight on that leg; the other half were not allowed weight-bearing.

Eight weeks later, the hips were examined closely using X-rays, microscopic analysis, and micro-CT scans. They found much more flattening of the epiphysis in the femoral head (round bone at the top of the thigh bone) in the group allowed to put weight on the hip. The non-weight-bearing group was protected from deformity but the bone wasn’t perfectly preserved.

Due to the lack of blood supply and hip joint loading (both needed to maintain normal bone balance) there were still some changes observed in the femoral head in the non-weight-bearing group. But the important finding of this study was that non-weight-bearing DOES help protect the hip and helps prevent significant deformity. Maintaining as much integrity, shape, form, and structure of the femoral head also reduces the risk of collapse of the bone.

It may seem like limiting the activity of a young child is harmful and that is normally true. But in the presence of Perthes hip disease (which can have serious long-term consequences later in life), following your physician’s guidance now will potentially pay off. There are no guarantees with this type of treatment. Some children still need surgery and some will develop degenerative arthritis early in adult life. But right now, it’s the treatment advised based on evidence from many animal and human studies.

I am sending this to you from the children’s hospital where our three year old just had hip surgery. The nurses keep pushing drugs into this kid to “keep him comfortable” — is it really a good idea to put young children on narcotics like this? How do they even know he’s having any pain when he’s so drugged up? I’m really concerned.

It is a tough sell but patients undergoing surgery for any reason must take their pain medications as prescribed. That means the full amount as often as recommended. Many Americans still subscribe to the belief that if there’s “no pain, there’s no gain”. And they feel it is better to “tough it out” rather than take drugs.

But the truth is — research shows that uncontrolled pain turns on systems in the body that result in delayed or impaired healing. In addition, there are more complications in general, breathing problems, and the risk of death is much higher.

All of these concepts also apply to children. In the pediatric post-operative group, pain increases the child’s stress. Stress hormones increase tissue metabolism and that leads to negative effects on healing. The result is that besides pain, the child ends up with a longer hospital stay, which adds more stress and keeps the cycle of impaired healing going.

Most surgical teams and postoperative hospital staff take the task of pain control among children very seriously. They may even have a team dedicated to this job. The first step is family and patient education. Everyone involved with the child’s case must understand the importance of pain control and the consequences of inadequate pain management. The surgeon, anesthesiologist, and nursing staff help parents, family members, and care givers of children understand how the pediatric body responds to pain.

From the youngest baby to the oldest child, decisions about medications for pain control are based on several individual factors. Body weight is important because the water content affects how drugs bind with proteins in the blood. Age and size determine the water-to- protein ratio and thus the amount of drug to use (e.g., anesthesia during surgery, narcotics for pain control after surgery).

There are strict guidelines for the use of pain relievers. It may seem like the nursing staff is “pushing drugs” to keep the child comfortable. But it is likely that the specifc drug and drug dosage (how much is given and how often it is administered) is carefully determined.

Nurses can monitor the child’s pain response by taking vital signs (blood pressure and pulse are especially helpful tools for assessing pain). In older children, questions can be asked about pain. A visual tool is often used with hand drawn pictures of a face with different expressions to choose from as a means of determining the child’s level of pain.

Pain control and drug usage is serious business and must be approached that way in each and every case. If you have serious concerns about what your child is being given, don’t hesitate to contact your surgeon, the child’s pediatrician, or even the physician serving as the hospitalist (if the facility has one). Your concerns and questions are important. A calm, confident parent is a necessary ingredient in a child’s recovery.

I just finished reading a handout given to us by the surgery center where our 12-year-old daughter is going to have spine surgery for her scoliosis. My head is spinning. How are we supposed to know what kind of anesthesia and medications for pain she needs? Here’s a list of all the things they say there are to choose from: nonopioid analgesia, opioid analgesia, local anesthetic injection, regional anesthesia, epidural therapy, peripheral nerve blocks, and much more. Please help!

It is not likely that as parents you will be the ones to decide what anesthesia and post-op medications your daughter will need. Most surgical teams and postoperative hospital staff take the task of pain control among children very seriously. They may even have a team dedicated to this job.

The first step is family and patient education. The handout you were given was evidently part of their effort to give you information to explain what will happen and why. Everyone involved with the child’s case must understand the importance of pain control and the consequences of inadequate pain management. The surgeon, anesthesiologist, and nursing staff help parents, family members, and care givers of children understand how the pediatric body responds to pain.

From the youngest baby to the oldest child, decisions about medications for pain control are based on several individual factors. Body weight is important because the water content affects how drugs bind with proteins in the blood. Age and size determine the water-to- protein ratio and thus the amount of drug to use (e.g., anesthesia during surgery, narcotics for pain control after surgery).

There are strict guidelines for the use of pain relievers. One important factor that affects the physician’s selection of medications is the child’s health. For example, the presence of any other health conditions (e.g., asthma, diabetes, allergies, bleeding disorders) must be considered carefully. The type of orthopedic surgery, extent of the surgery, and length of the procedure (in time) can also make a difference in postoperative selection of pain medications.

The anesthesiologist can choose from a wide variety of drugs for the actual procedure including all of the ones you listed: nonopioid (nonnarcotic) pain relievers, opioid analgesics (narcotic pain relievers), local anesthetic injection, regional analgesia, epidural therapy, and peripheral nerve blocks. Likewise, the surgeon has quite a few choices for pain control after the surgery.

It’s clear that pain is different from one child to another even when they have the same surgery for the same problem. That’s why each child is evaluated and monitored separately from all other children. It’s not a one-protocol-fits-all kind of situation.

With this handout available, you will be better able to understand when the anesthesiologist tells you which type of anesthesia is going to be used. You may receive some additional written explanations the day of the procedure and even afterwards. It sounds like your daughter’s surgical team is making an effort to provide you with helpful information. Be sure and ask any questions you may have as information is given to you that you don’t understand fully.

Our middle-school soccer team has had a bunch of knee injuries. The coach asked two of us science nerds if we would find out more about some of the knee problems kids are getting from sports injuries. We are going to give a talk on it next week. Do you have any information that might help us with what’s the latest these days?

As more and more children and teens participate in organized sports at a younger age, it is no surprise that knee injuries are on the rise. A pediatric orthopedic surgeon from UCLA School of Medicine recently reviewed four specific injuries that might be of interest to you in your report. These include: 1) anterior cruciate ligament (ACL) injury, 2) symptomatic discoid lateral meniscus, 3) juvenile osteochondritis dissecans, and 4) traumatic patellofemoral instability.

The injuries themselves are unique in that they affect a knee that is not skeletally mature. This refers to the middle-school age group who have not completed their full growth. Prevention of long-term complications such as stiffness and growth arrest are special concerns that must be addressed during treatment.

Let’s take a brief look at each of these four knee injuries in the youth athlete. In youths, anterior cruciate ligament ACL injuries can create knee joint instability, damage to the meniscus (knee cartilage), and chondral injury (damage to the bone). The ACL is one of two ligaments that criss-cross inside the knee. Together, these two ligaments stabilize and hold the knee together. When the ACL is torn during pivoting activities of the leg in this age group, two things can happen.

First, the place where the growth plate and bone meet (called the condroepiphyseal attachment) is damaged. This, in turn, can cause a fracture of the tibial spine (place where the ACL attaches to the bone). And like all fractures, the bone can be separated and displaced (shifted).

Next, injury to the discoid lateral meniscus is only treated when there are painful symptoms with snapping or clunking of the knee and/or loss of full knee extension. Children affected most often by this type of injury are usually under the age of 10. As with adults, the current thinking on this injury is NOT to remove the torn cartilage. Instead, the tissue is repaired as much as possible in order to prevent arthritic changes later.

Juvenile osteochondritis dissecans (OCD) is the third condition of interest. OCD is a problem that affects the knee at the end of the big bone of the thigh (the femur). The area of bone just under the cartilage surface is injured, leading to damage to the blood vessels of the bone. Without blood flow, the area of damaged bone actually dies. This area of dead bone is referred to as the osteochondritis lesion.

Treatment of OCD can be nonsurgical with immobilization and change in activity until healing is seen on X-rays. When healing doesn’t occur, the surgeon can drill tiny holes in the joint surface to cause bleeding and stimulate healing. If the joint cartilage is broken off with a bit of bone still attached, it may be necessary to reattach the fragment or remove it and fill in the hole left behind. Treatment really depends on the patient’s age and skeletal maturity, how long the condition has been present, and how stable (or unstable) the lesion is.

And finally, the last of our four knee disorders: traumatic patellofemoral instability. This refers to a chronically dislocating knee cap. Most of the youths who suffer this problem have some type of anatomic abnormality that puts them at risk for this condition. Most of these cases have to be treated conservatively without surgery because a good method of surgical repair has not been discovered yet. Techniques for successful reconstruction of ligaments around the knee cap are being investigated.

You can find much more information about pediatric knee problems on our website (www.eorthopod.com/public). The information we have provided here and additional information available on the website should give you plenty to work with. Good luck with your report!