FAQ Category: Child

Without knowing the particulars of your son’s case, we can’t really say what happened. This is a question the surgeon may be able to answer. We can provide you with some information from a recently published study on risk factors for rod breakage in children with scoliosis. You might find something (or several somethings) in this list that match your son’s situation.

The study was done by a group of 10 pediatric orthopedic centers. They put together a growing rod database by combining all the information they had from 327 children treated with growing rods throughout all 10 centers.

By putting information about each case into a computer database, they could study and analyze the data. In this study, they looked for risk factors for rod breakage. The hope was to find ways to prevent this complication.

The first thing they noticed was the percentage of children who experienced growing rod fractures: 15 per cent. Then by comparing children with breakage against children without rod fractures, they isolated the risk factors. Here’s what they found:

It is likely the condition refers to a problem referred to as Legg-Calvé-Perthes (LCP) disease. Over 100 years have passed now since Drs. Legg, Calvé, and Perthes first described a hip condition in children now referred to as Legg-Calvé-Perthes (LCP) disease. In those 10 decades, three things have become much clearer: what causes the problem, who is affected, and which treatment approaches work best.

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. But in the meantime, there can be severe pain, an obvious limp, loss of motion, and change in function.

How the bone heals determines what problems the condition will cause in later life. Perthes disease may affect both hips. In fact, 10 to 12 percent of the time the condition is bilateral (meaning that it affects both hips). This condition can lead to serious problems in the hip joint later in life.

Seventy-five years ago tuberculosis (TB) was still a problem in this country. Hip problems associated with TB had to be diagnosed and differentiation from Legg-Calvé-Perthes disease. X-rays were used to accomplish this task.

Your family member may have been diagnosed by Dr. Legg himself (or someone who worked or trained with Dr. Legg) to get this diagnosis of Legg hip affliction. At least that’s our best guess given the information you have provided and knowledge of the history of this disease.

Bracing as a means of treating Perthes hip disease was a popular treatment approach 35 years ago. But according to a recent review, opinions are shifting on this one. The authors of the article did an extensive search of the published literature on this topic.

What they found was that treatment should be based on a classification system that divides patients by age and severity of disease. Mild disease (determined by X-rays) in younger children (five years old or younger) doesn’t really need active treatment. Careful observation may be all that’s required.

Bracing just doesn’t seem to change the anatomy or alignment of the hip. There are some children who might benefit but they must be evaluated carefully and selected individually for this type of treatment.

Eligible children are younger and have significant (more than 50 per cent) of the epiphysis affected. They also have chronic inflammation of the synovial fluid in the joint and partial hip dislocation. X-rays show involvement of the lateral pillar (outside portion of the femoral head). Children who meet these criteria may be the best candidates for bracing. Results should be followed closely and discontinuation of bracing if no benefit is observed.

Legg-Calvé-Perthes (known as Perthes for short) is caused by a loss of blood supply to the epiphysis (growth center) of the hip. Without enough blood to nourish and replenish the bone, necrosis (cell death) occurs.

Deformity of the femoral head (round ball of bone at the top of the thigh bone) occurs. The affected bone starts to break apart (a process called defragmentation) and collapse. The end-result can be a change in the shape from a round femoral head to an oval or ovoid shape.

Instead of a ball in the socket with smooth, circular motion, the patient develops more of a mushroom-shaped hip. The femoral head is no longer encircled fully by the hip socket. Uneven wear on the oval-shaped head eventually leads to degenerative osteoarthritis. In some cases, severe arthritis develops early in adult life.

The goal of treatment is to prevent these complications. But the best way to do this remains unclear. As you experienced with your son, braces have been used to keep the hip fully in the socket and prevent changes in the shape of the femoral head. The idea in mind was to preserve the round head during the regeneration process. Bracing also limited how much weight the child could put on the hip. Less pressure through the hip was thought to help keep the round head of the femur in a spherical shape.

And, in fact, studies have supported the idea of keeping weight off the hip as necessary for a good result. At first, children were kept off their feet altogether. They did daily hip motion exercises and were able to keep the natural shape needed for hip mobility and flexibility. But staying in bed for a young, normally active child can be difficult and doesn’t seem like a really good idea.

Right now, the prevailing thought is that treatment is advised when more than half the epiphysis is affected. Bracing may be recommended if the child is six years old or younger. Surgery may be a better option for children who are seven or older and who have severe disease. Most of the studies support the idea that treatment of any kind just doesn’t seem to make a difference for mild-to-moderate disease in younger children.

So the use of bracing was introduced. Well, actually the first orthopedic surgeons to study this approach (back in the 1970s) used plaster casts on both hips and legs. The child’s legs were held far apart with a bar between the legs. Later a special “hip hinge” was developed to accomplish the same thing but allow better movement. They could walk with a walker and with limited weight through the hips.

The early results were positive and more studies were done trying all sorts of different casting and bracing ideas. Twenty years later (in the 1990s), several studies were done to review the results of this treatment approach. As it turns out, the results were actually pretty poor. Two-thirds of the children were not helped by the bracing. Analysis of the data showed that bracing should not be used with severe deformities.

New questions came up: are the results of using the casting method better, same, or worse compared with using braces? When should bracing be used? How long should braces be used? How can you know when it’s time to start weaning the child off the supports? What factors make for the best results?

More studies were done. Over time, a clearer picture emerged. They found that treatment should be based on a classification system that divides patients by age and severity of disease. Mild disease (determined by X-rays) in younger children (five years old or younger) doesn’t really need active treatment. Careful observation may be all that’s required.

This may be the case with your grandson.

Children with Perthes disease of the hip may recover fully without further hip problems later. But those with growth disturbance of the femoral head and altered shape of the normally round femoral head (top of the thigh bone) may end up with femoroacetabular impingement (FAI).

Surgery to correct the impingement is a possible treatment option. Careful assessment of all deformities and damage present in the hip complex can be done best with surgical dislocation.

The surgeon must look at both sides of the hip: the femoral head and the acetabulum (socket). It may be necessary to make surgical corrections of both areas. And that means surgically dislocating the hip in order to visually inspect everything and form a surgical plan.

On the femoral side, the surgeon may change the length or angle of the femoral neck. The misshapen and enlarged head may have to be corrected, a procedure called osteochondroplasty. This also requires surgically dislocating the hip. That sounds pretty dramatic but it can be done safely and is quite effective.

While correcting the deformity that causes impingement, the surgeon will also look for any other areas of soft tissue damage. There may be a tear in the labrum that needs attention. The labrum is a rim of cartilage around the hip socket designed to give the socket a little bit more depth and the hip greater stability inside the acetabulum.

The ultimate goal of surgery for femoroacetabular impingement in the Perthes hip is to improve hip joint motion. Reducing pain and improving joint stability are also important. The surgery can become quite complex when there are numerous changes in the hip to be addressed.

Classification of any condition like Perthes is useful because it helps give a picture of what is happening for each individual patient. Using a classication system allows us to look at groups of patients with Perthes to predict results with and without treatment.

As you have pointed out, it’s best to have one classification system to study all patients. Treatment depends on a careful classification to determine severity. The natural history and prognosis for final outcomes depend on an accurate classification.

Right now, there isn’t one standard classification method for Perthes used by everyone. Instead, there are a half dozen classification methods described for Perthes disease in the literature. There’s the Catterall, Salter-Thompson, lateral pillar (Herring), Mose, and Stulberg classifications. These methods all rely on X-ray evaluation of the hip.

The Catterall classification takes a look at the location and amount of bone collapse. Patients are placed in one of four groups based on the specific effects of Perthes on the epiphysis (growth center). The presence of collapse, degeneration, absorption, and regeneration are described with this system.

The Salter-Thompson classification model is much simpler. There are only two groups based on how much of the femoral head is involved (less than half or more than half). The Stulberg classification places children in one of three categories based on the shape of the femoral head. The Stulberg classification method has been tested, modified, and eventually expanded to include five groups instead of the original three.

Herring also took Stulberg’s original three-group classification method and revised it and published several studies. Focus has shifted now to using the Herring (lateral pillar approach) because it has good interobserver reliability. In other words, different radiologists using X-rays to classify the disease using this method came up with the same results.

There is another type of classification based on bone scintigraphy. Bone scintigraphy looks at the distribution of blood flow and active bone. It helps show blood flow to and through the bone and shows places throughout the skeletal system where the bone is actively metabolizing.

The advantage of bone scintigraphy is that changes in bone metabolism show up on the bone scan before structural changes would appear on an X-ray. Conditions such as fractures, infections, tumors, and Perthes can be recognized with a bone scan long before they can be seen with plain radiographs.

Scintigraphy is not used routinely because it is an invasive test. It requires injecting radioactive tracers in the child’s blood. It is also much more expensive than plain radiographs (X-rays).

Although the Catterall classification has been used most often in the past, there’s a shift now toward using the Herring (lateral pillar) method instead. The Herring method has been shown to have good interrater reliability as well as the ability to predict final outcomes.

In a recent review of Perthes classification methods, the author pointed out there is room for improvement in adopting a standard way to classify Perthes disease based on X-rays. For example, it’s very easy to have slight differences in the child’s hip position when the X-ray is taken.

What the radiologist sees of the hip can be very influenced by a subtle difference in hip rotation. The child could also be standing or lying down and that makes a difference. You may want to take this information with you and ask your group of radiologists for their ideas and opinions as well when planning the research design for your study. Good luck!

Perthes disease affects children between the ages of four and eight most often. It involves a loss of blood supply and the death of bone at the top of the femur (thigh bone). The condition can range from mild-to-severe. The round head of the femur may collapse and shift and become more oval shape. Later in life, these children can develop early and sometimes severe hip arthritis.

Treatment depends on a careful classification to determine severity. Classification of any condition like Perthes is useful because it helps give a picture of what is happening for each individual patient. Using a classication system allows us to look at groups of patients with Perthes to predict results with and without treatment.

It’s best to have one classification system to study all patients. But there isn’t one standard classification method used by everyone for Perthes. Instead, there are numerous ways to classify this condition. You are probably seeing different descriptions based on two classification methods. These methods rely on X-ray evaluation of the hip.

Group A most likely refers to a method called the Salter-Thompson classification. This approach divides X-rays of Perthes hips as Group A (less than half of the femoral head involved) and Group B (more than half the femoral head is affected). This is a fairly simple approach based on how much of the bone is changed.

A more detailed description is provided by looking at the shape of the femoral head. There are five classes from mild (class I) to severe (Class V). In Class I, the normally round shape of the femoral head remains round and symmetric. Patients with Class I Perthes have not developed any signs of early arthritis.

So using both methods for your son gives the orthopedic physician an idea of how much of the hip is affected and provides a bit of a prognostic outlook. Treatment decisions can be made using these systems.

Perthes disease (also known by the longer name: Legg-Calvé-Perthes) affects the hip (or hips) of children between the ages of four and eight most often. But the disease can show up later in the teen years. The condition develops after there has been an interruption in blood flow to the growing centers of the hip.

Those growth centers (called the capital femoral epiphyses are located at the round top of the femur (thigh bone). Without enough blood, the bone starts to die, a process referred to as necrosis.

The dead bone cells are eventually replaced by new bone cells but this can take several years. In the meantime, pressure and load from weight on the bone causes it to flatten. The smooth, round head of the femur that sets inside the hip socket (acetabulum) becomes oval-shaped (ovoid) or misshapen. Instead of fitting tightly inside the acetabulum, bone extrudes or expands outside the confines of the socket.

In severe cases (and especially in children who develop this condition after age eight), the deformed hip may develop early arthritis. In a small number of children who don’t have signs of Perthes until into their teen years, the chances of full recovery is very slim. That’s because the bone never gets the full blood flow back that it needs to remodel.

In all cases, the more flattened the bone and the more misshapen the round femoral head becomes, the more likely degenerative arthritis will occur at an early age. The reason for this is that joint surfaces need to be evenly matched or congruent. Without this tight fit, the bones rub against each other unevenly. Over time with repeated movements, the joint degenerates where the greatest amount of pressure has been applied.

That may sound like a grim picture. Don’t let this information discourage you. The upside is that the disease is usually self-limiting (the body heals itself). Giving the hip every opportunity to heal itself by limiting load on the joint may prevent the flattening of the femoral head and deformity that can develop.

The healing process can take two to four years for the necrotic bone to get resorbed and replaced by new bone. Studies show your best chances for recovery are to follow your physician’s advice carefully and give yourself a chance to heal naturally.

Everyone is different — there are different stages and severity of this condition. Your physician is the best one to give you more information as it relates specifically to you. It sounds like he or she is willing to level with you so don’t hesitate to ask for more information at your next appointment.

Legg-Calvé-Perthes (or Perthes) disease affects the hip (or hips) of children between the ages of four and eight most often. The condition develops after there has been an interruption in blood flow to the growing centers of the hip.

Those growth centers (called the capital femoral epiphyses) are located at the round top of the femur (thigh bone). Without enough blood, the bone starts to die, a process referred to as necrosis. The dead bone cells are eventually replaced by new bone cells but this can take several years.

Age is the determining factor in this condition. Recovery is more likely in children under the age of eight. Many children have mild LCP, and they are able to heal and recover fully even without treatment. The hip actually remodels itself and remains smooth moving. Early degenerative hip arthritis does not always occur and these children have no hip problems in adulthood related to their childhood history of Perthes disease.

It’s best if the treating physician can follow the child closely. X-rays and MRIs help show the four stages of Perthes disease. These four stages are 1) necrosis (death of bone cells), 2) fragmentation (breakdown of dead bone), 3) regeneration of bone (new bone forms), and finally, 4) healed replacement of normal bone tissue.

There are some complications that can develop along the way. Recognizing and treating these early on can prevent problems later. There are changes in our health care system now that are meant to protect children whose families do not have health care coverage.

Contact your local public health department and find out where you can go to get the services your child needs. Don’t assume there are no answers to this dilemma you face or that you have to figure it out by yourself.

There are also physicians who take cases on a pro bono (free) basis. Everyone understands there can be tough economic times that call for a community solution to an individual’s needs. Just asking the question in this forum is a good place to start!

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-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. The blood supply eventually returns, and the bone heals. How the bone heals determines what problems the condition will cause in later life. Perthes disease may affect both hips.

Perthes disease results when the blood supply to the capital femoral epiphysis is blocked. There are many theories about what causes this problem with the blood supply, yet none have been proven.

Clearly the problem is one of blood loss called ischemia. The area affected most is the head of the femur (thigh bone). This has been confirmed with today’s modern imaging studies. As a result of this blood loss, the bone dies and starts to collapse. Soon the smooth, round head of the femur starts to
flatten and deform.

But what causes the decreased vascularity (blood flow) and can it be stopped before the damage is done? Many experts believe LCP is the result of several or even many factors. Another way to say this is that LCP is a multifactorial disease with both genetic and mechanical contributing factors.

On the genetic side, there are families with many members who have LCP as a result of a mutation in a particular gene. The affected gene controls the strength of collagen tissue. Collagen fibers are what make up all of the soft tissues in the body, including joint cartilage, ligaments, muscles, tendons, and blood vessels. One miscoding in the gene and the hip joint cartilage and its blood vessels don’t form correctly.

Another biologic factor that contributes to some cases of LCP is a protein deficiency. Without the proper sequencing of these important proteins, affected individuals have abnormal coagulation (blood clotting). Abnormal blood clotting can cut off blood supply to the femoral head.

With this much information in hand, further studies were done. Now there is some evidence that LCP can develop after a single episode of ischemia (blood loss) no matter what the cause. But the risk goes up with repeated (multiple) episodes of blood loss. If this proves to be true, then it is essential to predict, recognize, and stop all ischemic episodes.

Although Legg-Calvé-Perthes disease may sound like a simple problem, there’s still so much we don’t know about what causes it and how or why it develops. More and more, it’s looking like a complex biologic problem with multiple contributing factors and/or “triggers”. Hopefully, in time, scientists will be able to uncover important facts that can change treatment and results for those (like yourself) who have this condition.

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. Perthes disease may affect both hips. In fact, 10 to 12 percent of the time the condition is bilateral (meaning that it affects both hips). This condition can lead to serious problems in the hip joint later in life.

Clearly the problem is one of blood loss called ischemia. The area affected most is the head of the femur (thigh bone). This has been confirmed with today’s modern imaging studies. As a result of this blood loss, the bone dies and starts to collapse. Soon the smooth, round head of the femur starts to flatten and deform.

There is some evidence that LCP can develop after a single episode of ischemia (blood loss) no matter what the cause. But the risk goes up with repeated (multiple) episodes of blood loss. If this proves to be true, then it is essential to predict,
recognize, and stop all ischemic episodes.

Some experts suggest that one way to help prevent the damage done to the hip by this problem is to avoid mechanical pressure on the compromised blood vessels. That could mean keeping the child off his or her feet in a nonweight-bearing state. Limited weight-bearing will protect more than the blood vessels. Compression and load on the joint cartilage, growth plate, and bone will also be reduced.

Although these guidelines make sense, how much pressure and force are put on a child’s hips with different activities is not clear. Your question is a good one. Is running a bigger problem than walking? Is it how often the child is weight-bearing that makes a difference? Or could it be the number of steps taken each day should be limited? And how much does the child’s body weight play a role?

These are just some of the questions that need answers before early and more effective treatment can be prescribed for LCP disease. In the meantime, non-weight-bearing doesn’t have to mean becoming a couch potato.

Swimming, biking, and resistance exercise for the arms are still very acceptable forms of exercise for children with this condition. If you need help designing a program for your son, see a physical therapist. These health care professionals understand this condition and are skilled in prescribing individual exercise programs for specific problems like Legg-Calvé-Perthes disease

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-Calvé-Perthes disease in honor of the three physicians who each separately described the disease 100 years ago.

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 area affected most is the head of the femur (thigh bone). This has been confirmed with today’s modern imaging studies. As a result of this blood loss, the bone dies and starts to collapse. Soon the smooth, round head of the femur starts to flatten and deform.

How the bone heals determines what problems the condition will cause in later life. Perthes disease may affect both hips. In fact, 10 to 12 percent of the time the condition is bilateral (meaning that it affects both hips). This condition can lead to serious problems in the hip joint later in life.

That’s why every effort is being made to continue studying this problem so that today’s children affected by Perthes disease will have a good outcome. Though no cure has been found, but early detection and intervention may make a difference. Research is ongoing to find more effective ways to restore the natural shape and strength of the hip.

Your observations have been noted and reported by others as well. Girls do seem to have a greater reaction to the unpleasantness of the after-surgery pain and symptoms than boys do. They don’t seem to experience greater intensity of pain, just exhibit a greater reaction or response to the pain.

Of course, gauging pain in children can be a challenge since they don’t always have the words to express themselves. This is especially true in younger children. That’s why nursing staff most often use the Faces Pain Scale to assess and measure pain in children. The child points to the face that best describes their pain from a happy, smiling face (no pain) to a very sad, frowning face (worst pain).

But researchers are exploring better ways to reliably measure pain in children and teens. One tool that is being modified and tested is the Child Pain Anxiety Symptoms Scale or CPASS. It is a way to gauge how much pain, anxiety, and pain-anxiety children have and how sensitive they are to anxiety.

Anxiety sensitivity is the extent to which anxiety-related symptoms can predict a poor outcome. In other words, the presence of anxiety symptoms such as increased heart rate and feeling nauseated is linked with physical ailments, psychologic disturbances, and the development of chronic (long-lasting) pain.

Assessing children for pain anxiety in the early stages of pain might help us identify who is at risk for poor outcomes related to pain. Then we could potentially do something about it as soon as possible. When the CPASS was used with children after surgery, they found exactly what you are reporting.

They found that after orthopedic or general surgery girls have more general anxiety and anxiety sensitivity than boys. Girls were more likely to experience pain right after surgery as more unpleasant (but not more intense) than boys. Two weeks later (after discharge from the hospital), they scored their pain the same as boys.

Analysis of the test and test scores showed that the CPASS measured responses equally between boys and girls. In other words, the differences reported weren’t because of the test but a true measure. The test was able to measure the changes experienced by the children from early on after surgery to the two-week post-operative time period.

So anxiety and the child’s interpretation of his or her symptoms may be part of the differences between boys and girls. But what makes girls more susceptible to the effects of anxiety remains to be determined.

There may be other factors that determine the difference between boys’ and girls’ responses to pain. The CPASS was originally designed for adults and then modified for children, so it’s possible that there are other dimensions of the pain experience (besides anxiety) that are important. Further study is needed to sort this out as well.

The nurse may have been evaluating the child’s level of pain and anxiety about that pain. Pain is a subjective symptom, meaning you can’t see it or take a picture of it. Describing pain becomes something we trust that the person who is telling us about their pain is accurate. Measuring pain in adults is difficult enough. Imagine getting a similar report from children who may not even have the words to describe what they are feeling.

There are several tools health care professionals can use when evaluating pain in children and teens. It sounds like the nurse may have been using one called the Child Pain Anxiety Symptoms Scale or CPASS. It is a way to gauge how much pain, anxiety, and pain-anxiety children have and how sensitive they are to anxiety.

The test has several subsections designed to help sort out anxiety, sensitivity to anxiety, depression pain levels, function, and disability. The children do rate statements like “It scares me when I throw up” or “I feel helpless about my pain” on a scale from “not at all” to a lot”.

Activities and function (“I can walk to the bathroom by myself” or “I can eat regular meals”) are measured on a five-point scale from zero (no trouble with the task) to five (impossible).

Assessing children for pain anxiety in the early stages of pain might help us identify who is at risk for poor outcomes related to pain. Then we could potentially do something about it as soon as possible.

Measuring how much children misinterpret pain and anxiety symptoms as harmful is a good way to predict pain intensity and unpleasantness after surgery. Of course, the goal is to alleviate the child’s pain and suffering. Giving them an opportunity to express how they feel may be suggestive but more likely helpful in getting them the treatment they need to keep the pain and anxiety at a minimum.

Spasticity (increased muscle tone) is common with cerebral palsy and can cause the muscles to pull unevenly on the hip. Over time, as the child grows and the muscles remain short and tight, the head of the femur (thigh bone) is forced out of the hip socket.

Often the hip socket (called the acetabulum) is shallow and not fully developed. This is especially common in children with cerebral palsy (or other neurologic conditions) that prevent them from standing up and walking. Walking puts pressure through the thighs into the hips and helps form the acetabulum (hip socket) and shape the femoral head that fits into the socket.

When the femoral head shifts out of the hip socket, surgery is done to reconstruct the hip and form a new, deeper socket. There are a number of different ways to do this. The procedure isn’t always successful but there are many reasons for a less than optimal outcome.

For example, what is the shape of the hip socket and where are the weak areas where the femoral head can push past the cartilage and pop out? This question must be answered when planning surgery to reconstruct the hip.

If it’s not addressed, then the same problem can happen again after surgery. There could be instability at the top of the socket (superior direction). This superior deficiency could be more toward the front (anterior) or more toward the back (posterior) part of the hip.

Then again the instability or deficiency could be multidirectional (present in more than one direction). The problem is really more complicated than that. In many cases, normal growth and development of the bones is altered in these children by the change in muscle pull and biodynamics.

For example, the femur may twist or tilt thus placing the head of the femur in the socket at an angle. Likewise, any change in the shape or orientation of the pelvic bones that form the upper part of the hip socket can have an impact on alignment.

Even with a perfect surgical result, if the child grows rapidly and the muscle tone increases even more, dislocations and deformities can occur. A second surgery is not uncommon — in fact, many children with cerebral palsy have multiple different surgical procedures as they grow and mature.

If you have any doubts about your daughter’s care, there’s nothing wrong with seeking a second opinion. If you don’t feel comfortable consulting with someone else in the same orthopedic practice, then ask your pediatrician for an alternate choice. The decision to have another surgery for your daughter is a major one and one that deserves a careful evaluation of what’s best for her.

Arthritis in children and venous malformation can present clinically with such similarity, it is very difficult to make the distinction. The knee becomes swollen and tender. Swelling and stiffness cause the knee to bend (unable to straighten fully). Loss of motion and stiffness result in a shortened leg on that side.

Juvenile idiopathic arthritis is a chronic condition of joint swelling and inflammation. The term ‘idiopathic’ tells us there’s no known cause. Venous malformation is as the name describes. Venous refers to the veins (blood vessels that return blood to the heart). The malformation is a jumble of veins often forming a clump or circle of veins. The effect of the malformation is to slow the blood down and keep it from moving through the area as it should.

Both conditions present with joint pain and swelling. When venous malformation causes these symptoms in a child, the natural diagnostic suspicion is for the more common juvenile idiopathic condition. Knee venous malformation is so rare, it is not easily recognized. But with careful study, it is possible to identify some characteristics of knee venous malformation that might be the tip off that it’s not arthritis.

MRIs and ultrasound studes are very helpful. These tests show blood filling in spaces within the muscles. This is a characteristic sign of venous malformation. Combining the results of imaging studies with biopsy of the tissue mass helps make the differentiation of venous malformation from juvenile idiopathic arthritis.

Sometimes the diagnosis isn’t made until the child is treated for arthritis without success. The more difficult cases are when the symptoms improve with antiinflammatories used for arthritis so it looks like the right diagnosis was made. It isn’t until the child is taken off the medication and the symptoms come back that a second (or third) look help reveal the true problem.

Other differentiating factors are very subtle. For example, juvenile idiopathic arthritis often affects all the large joints (knees, ankles, wrists, and elbows). Venous malformation presents at the knee most of the time. Lab tests may show some differences that can be helpful but this is not 100 per cent accurate.

Most of the time it’s the imaging studies that help define the problem. And because knee venous malformation is congenital (present at birth), the earlier MRIs are used the sooner the problem is identified correctly. Early recognition doesn’t always happen because symptoms don’t develop right away at birth. Some children don’t develop visible problems until years later.

There’s one other important clinical finding that can help tell these two conditions apart. Although both conditions cause joint pain and swelling, with knee venous malformations, there are often some skin changes that can be seen. The veins become more prominent on that side. There may be swelling above the kneecap. And the skin around the knee looks blue in color.

Knowledge of these differences can help the physician recognize the true underlying problem. Early diagnosis and treatment can help improve results. It sounds like your team of experts were well-informed and able to get to the bottom of the problem quickly!

Sometimes one disease mimics another one so closely, it is difficult to tell them apart. That’s the case with these two separate knee problems that look very similar. Juvenile idiopathic arthritis is a chronic condition of joint swelling and inflammation. The term ‘idiopathic’ tells us there’s no known cause. Venous malformation is as the name describes.

Venous refers to the veins (blood vessels that return blood to the heart). The malformation is a jumble of veins often forming a clump or circle of veins. The effect of the malformation is to slow the blood down and keep it from moving through the area as it should.

Both conditions present with joint pain and swelling. When venous malformation causes these symptoms in a child, the natural diagnostic suspicion is for the more common juvenile idiopathic condition. Knee venous malformation is so rare, it is not easily recognized.

By taking a look back, it’s possible to identify some characteristics of knee venous malformation that might be the tip off that it’s not arthritis. Of course, as the old saying goes: “Hindsight is 20-20.” In other words, it’s much easier to look back at what was really going on but difficult to understand at the time it was happening.

Even when the malformation creates a mass that is removed, the jumble of blood vessels can look so much like a hemangioma (benign blood tumor) the diagnosis remains clouded. Sometimes it’s not until the mass grows back or the family seeks a second opinion that the real diagnosis is made.

Sometimes the diagnosis isn’t made until the child is treated for arthritis without success. The more difficult cases are when the symptoms improve with antiinflammatories used for arthritis so it looks like the right diagnosis was made. It isn’t until the child is taken off the medication and the symptoms come back that a second (or third) look help reveal the true problem.

There is one recent study we can cite in giving you an idea how rare the problem is and how often misdiagnosis occurs. This study took place at a large children’s hospital in the Northeast (Boston Children’s).

A review of their records for an 11 year period of time showed that of all the children seen at the hospital for 11 years, only 56 children had venous malformations of the knee. Six of those children were treated as if they had juvenile idiopathic arthritis before the accurate diagnosis was made. That’s a misdiagnosis rate of 11 per cent (very high).

Your situation sounds fairly typical given the rarity of the venous malformation condition. Given the similarity of signs and symptoms, tt’s easy to make the mistake of thinking the child has arthritis. Thankfully your granddaughter’s diagnosis has been cleared up and the correct treatment applied.

A hip subluxation (partial dislocation) in a child with cerebral palsy is likely going to require surgery. That could be the reason for all the tests. Before trying to rebuild or reconstruct a hip subluxation, the surgeon must map out every detail of the hip itself.

In order to prevent future problems, the surgeon must understand now what went wrong. In other words, why did the hip start to dislocate? And where are the weak or deficient places in the hip socket where the head of the femur has popped out?

These questions must be answered when planning surgery to reconstruct the hip. Otherwise, the same problem can happen again after surgery. There could be instability at the top of the socket (superior direction). This superior deficiency could be more toward the front (anterior) or more toward the back (posterior) part of the hip.

Then again the instability or deficiency could be multidirectional (present in more than one direction). The problem is really more complicated than that. In many cases, normal growth and development of the bones is altered in children with cerebral palsy by the change in muscle pull and biodynamics.

For example, the femur may twist or tilt thus placing the head of the femur in the socket at an angle. Likewise, any change in the shape or orientation of the pelvic bones that form the upper part of the hip socket can have an impact on alignment.

The surgeon must take both the direction of the hip subluxation and the location of the acetabular (hip socket) deficiency into consideration when planning corrective surgery. How is this type of evaluation done? That’s where the testing you are paying for might be needed.

There are three-dimensional CT scans that allow orthopaedic surgeons to see the entire acetabulum (hip socket). The surgeon needs information on direction, depth, and degree of hip dysplasia (shallow socket). The CT scan provides depth and direction but not degree of dysplasia.

Pelvic X-rays may offer a better view to measure something called the acetabular index. The acetabular index is a measure already in use to look at the angle of the acetabular roof. Combining these two tests together (CT scan and pelvic X-ray) makes it possible to get a three-dimensional view of the angle and curve of the roof (top) of the acetabulum (socket).

How will your surgeon use this information? Using the acetabular index will give surgeons a more accurate measure of all the planes of the acetabulum. Taking this measurement in consideration along with other factors such as child’s age, function, and other deformities will help direct surgical choices when reconstructing the dysplastic hip in children with spastic cerebral palsy.

These are all very good questions that remain under investigation. You didn’t mention your son’s age but we know from a recent study done in England that this particular surgery is being used more often now in adolescents.

This approach called autologous chondrocyte implantation or ACI is quite successful in adults and rising in use among younger patients. Autologous tells us the graft was taken from the patient. A donor sample of chondrocytes comes from a non-weight-bearing section of the knee.

The cells are taken to a lab where they are grown into a larger donor patch of articular cartilage cells. This can take anywhere from four to six weeks. When there are enough lab-grown chondrocytes, the patient comes back in for part two of the surgical procedure.

In this operation, the damaged cartilage is cleaned out and the edges are shaved smooth in preparation for the graft material. The hole is filled in with donor chondrocytes and covered with a special membrane that is stitched in place, sealed, and watertight.

The number of cases of osteochondral injury in young athletes continues to rise. “Osteo” refers to bone, whereas “chondral” directs our attention to cartilage. So, the osteochondral layer is the cartilage next to the first layer of bone in the knee joint.

The increase in this type of injury is because active individuals end up with more traumatic injuries (e.g., direct blow to the knee) or repetitive minor trauma than other less active adolescents and/or adults.

When researchers go back years after the repair and take a look at the repaired site, here’s what they find. A large number of patients (84 per cent in the study from England) have excellent results regardless of the size of their lesion (large or small).

Pain is routinely less and both motion and function are improved. Of particular interest is the condition of the graft site later. Slightly more than half the English group (57 per cent) had a patch of fibrous cartilage fill in the defect.

Only one-fourth of the group (about 24 per cent) formed the desired hyaline cartilage. A smaller number of patients (19 per cent) formed a mixture of fibers and hyaline cartilage. Only one patient had a failed result requiring additional surgery. These statistics are actually quite similar to the results reported for other (smaller) studies investigating the same things.

There is some evidence that the transplanted tissue actually continues to form new cartilage even after a couple of years. So there is hope that this procedure will prove to have good long-term results as well. More studies are needed to know the final result for sure — but it looks very favorable. Time will tell!

Many different techniques have been developed to repair holes in the chondral (cartilage) surface of the knee joint. There is increasing evidence that the procedure you had on your knee (called autologous chondrocyte implantation or ACI) gives very good overall results. Autologous tells us the graft is taken from the patient him- or herself. A donor sample of chondrocytes comes from a non-weight-bearing section of the knee.

The cells are taken to a lab where they are grown into a larger donor patch of articular cartilage cells. This can take anywhere from four to six weeks. When there are enough lab-grown chondrocytes, the patient comes back in for part two of the surgical procedure.

In this operation, the damaged cartilage is cleaned out and the edges are shaved smooth in preparation for the graft material. The hole is filled in with donor chondrocytes and covered with a special membrane that is stitched in place, sealed, and watertight.

Defects in the osteochondral layer is actually a fairly common problem in active individuals. This type of problem usually develops as a result of trauma. Often there has been a direct blow to the knee. But minor trauma and repetitive motion with a shearing force can also contribute to the development of painful knee problems from osteochondral lesions in younger and younger patients.

Studies have been limited to the results of these treatment approaches in adults. A smaller number of studies have focused on teens between the ages of 14 and 18 years of age. The largest study focusing on teens between the ages of 14 and 18 showed (84 per cent) excellent results.

Eighty-four per cent (84 per cent) had decreased pain and improve motion and function regardless of the size of their lesion (large or small). In other words, patients got better just as often (and just as successfully) with small defects as with large lesions.

One-fourth of the group (about 24 per cent) formed the desired hyaline cartilage. A smaller number of patients (19 per cent) formed a mixture of fibers and hyaline cartilage. Only one patient had a failed result requiring additional surgery.

The authors took a look at some of the other factors to see if any of these affected the final result. For example, they noted that all but one patient had just a single (called isolated osteochondral lesion. But the lesions weren’t all in the same spot of the knees.

There were some lesions located (14) on the medial side (side closest to the other knee) at the end of the femur (thigh bone where it joins to form the knee). Half that number (7) were located on the back of the patella. And another six were found on the lateral side of the femur (side away from the other knee). Results did not appear to be influenced by the location of the knee either.

Interestingly enough, results measured by pain, motion, and function weren’t different (or less positive) when the repaired joint surface turned out to be just fibrous cartilage instead of the real thing. In other words, results were just as good when the repair tissue was not identical to normal hyaline cartilage covering the joint.

The researchers who conducted this study came to the conclusion that autologous chondrocyte implantation (ACI) works well in adolescents with painful osteochondrocyte lesions. This is true even when the final tissue isn’t true hyaline cartilage.

Previous studies support the surgical treatment of painful defects before further joint degeneration occurs. It’s not clear yet if lesions that don’t cause pain should be treated. In time, all the various repair and reconstructive techniques used for osteochondral lesions in adults may be studied in children and teens.