Long-Term Effects on Adult Foot Function After Tibialis Anterior Tendon Transfer for Relapse of Idiopathic Clubfoot Deformity Treated with the Ponseti Method.

Talipes equinovarus (clubfoot) is an abnormality that is congenital (present at birth) in which the foot is twisted out of shape or positioning. The Ponseti method of treatment includes serial manipulations and application of casts and braces. Relapse of the deformity has been reported in a prevalence of 7-56 per cent. Relapses are often found to be the result of inadequate, short-term use of bracing and nonadherence to bracing recommendations. Further bracing can be utilized, however, proves challenging as the child ages and is less tolerant of bracing. The use of a tibialis anterior tendon transfer to the outside of the foot can be utilized to maintain the improved positioning that was accomplished with repeated casting. A retrospective review of prospectively collected data was performed to evaluate long-term outcomes on foot function in adults who had been treated for relapsed idiopathic clubfoot in childhood. This review collected data on all patients treated for idiopathic clubfoot using the Ponseti method at the University of Iowa from 1950 through 1967. All aspects of treatment were performed by Dr. Ignacio Ponseti. Follow-up data was obtained on thirty-five of the original 126 patients whom medical records were reviewed. Of this thirty-five, forty percent had underwent the tibialis anterior tendon transfer and served as the study group while the remaining sixty percent who did not undergo the tendon transfer served as the reference group. The average duration of the time between tibialis anterior tendon transfer and follow-up was forty-three years.

In follow-up, patient’s completed three outcome questionnaires: the American Academy of Orthopaedic Surgeons (AAOS) Foot and Ankle Outcomes Questionnaire, the Laaveg-Ponseti questionnaire, and the Foot Function Index (FFI). They also underwent a thorough physical examination, standing radiographs, a pedobarograhic analysis with pressure sensor as they walked freely across the room and surface electromyographic (SEMG) patterns were obtained from the tibialis anterior, lateral gastrocnemius and peroneus longus muscles. Results demonstrated that no patients in the tendon transfer group had a relapse or had required additional treatments for clubfoot at time of final follow-up. There was no statistically significant difference in the number of casts required in the initial treatment between the transfer and reference group. Questionnaire results showed no significant differences between the tendon transfer group and the reference groups on the AAOS Foot and Ankle Outcome or FFI. The Laaveg-Ponseti functional ratings were similar in both groups. Physical findings demonstrated that there was no significant difference in passive ankle plantar flexion-dorsiflexion and forefoot inversion. Nor was there significant difference in passive ankle dorsiflexion at any level of applied torque. Motor strength of the tibialis anterior and peroneal muscles was comparable between the tendon transfer and reference groups. Radiologic findings demonstrated that those whom underwent tendon transfer did have significantly smaller anteroposterior talocalcaneal angle than the reference group. They also demonstrated more talar flattening than the reference group of statistical significance. With the exception of more moderate to severe osteophyte (bone spur) formation in the navicular-cuneiform joint in the tendon transfer group overall degenerative changes and bone spur formation were similar between groups. Pedobaraographic analysis did not show any difference of significance between groups. Additionally there was no difference between the two groups in regards to SEMG data for firing times, nor when the tendon transfer group was compared to healthy college age students.

The authors of this study conclude that the results establish the effectiveness for the tibialis anterior tendon transfer in that there was no subsequent relapse of requirement of additional casting or surgical intervention for clubfoot. They noted that while there was greater bone spur formation at the navicular-cuneiform joint and talar flattening was more present upon radiographic evaluation in the tendon transfer group this did not have association with increased pain, greater medication use or difficulty walking. Several limitations were present in this study particularly the low patient follow-up rate of 28 per cent.

New Guidelines for Treatment and Management of Developmental Dysplasia of the Hip in Pediatrics

The American Academy of Orthopaedic Surgeons (AAOS) recently published its clinical practice guideline for detection and nonoperative treatment of developmental dysplasia of the hip (DDH) in pediatric patients. It has been officially endorsed by the American Academy of Pediatrics (AAP), Pediatric Orthopaedic Society of North America, Society of Diagnostic Medical Sonography and the Society for Pediatric Radiology. The intent of the guidelines was to improve treatment and management based on current evidence. The current guidelines used an intense standardized methodology that led to nine recommendations. These recommendations were based on the quality of the evidence. This guideline as well as the AAP Technical Report guideline developed in 2000 continue to support clinical screening of children for DDH. There are some differences between guidelines, though, specifically the age shift in targeted population in the new guideline to include infants only up until six months versus walking age. The nine recommendations include: Universal ultrasound screening, evaluations of infants with risk factors for DDH, imaging of the unstable hip, imaging of the infant hip, surveillance after normal infant hip exam, stable hip with ultrasound imaging abnormalities, treatment of clinical instability, type of brace for the unstable hip, and monitoring of patients during brace treatment. The first two recommendations are the most significant as they are of moderate strength meaning that the benefits exceed the potential harm. Universal ultrasonography screening of newborn infants is not recommended but performing imaging studies before six months of age in infants with significant risk factors is recommended. Risk factors that were determined significant include; breech presentation, family history, and a history of clinical instability. The remaining seven recommendations are of limited strength. These focus on early intervention and management. Only forty-two articles of the 3,990 citations found in peer-reviewed literature fit the rigorous inclusion criteria. It is the authors recommendations that a “concerted and collaborative research effort” is required from the orthopaedic surgeon community to improve the evidence and strengthen the recommendations for future updates of the new guidelines. Readers are encouraged to consult the full guidelines at www.aaos.org/guidelines as discussion of how each recommendation was made as well as the complete evidence report.

Back Pain in Children: What to Do About It and How to Prevent It

Parents and health care providers that treat children will often hear complaints of their aches and pains. Studies have found that low back pain (LBP) in kids is quite common in kids past the age of eight (varied reports range from six to 33 per cent) and climb as high as 39-71 per cent by the time the child reaches 15 years. Researchers in the Physiotherapy Department at Monash University in Australia decided to comb the research for preventing repeat difficulties of LBP in children. Unfortunately, the existing studies are limited in what health care providers can do to delay or decrease this problematic condition in children.
 
Hill and Keating a PT/PhD team set about to improve our understanding of the research on specific or modifiable risk factors that increase back pain in children. They found nine predictors of future bouts of LBP in the prior literature, but none of them were supported by follow up independent research reports. Exercise, posture, education, and decreasing causes back pain were studied; however the reviews on what to do about it concluded that more research was needed.

This study looked at 708 participants between the ages of eight and 11, which is the age bracket with the most rapidly increasing prevalence in LBP. They were motivated to focus on an intervention in the study group that encouraged kids to pay attention to their spine posture throughout the day, incorporate a basic back movement program into their daily routine (much like the three-times-per-day teeth brushing model), and educate them on behaviors associated with a healthy back.  The control group was only provided with a basic spine education program.

The results of this study found no relations on the percentage of children reporting LBP throughout the study period following participation in the simple spine exercises, posture and education group. The children in the experimental exercise plus education group did however report less problems with LBP and less first episodes of LBP than their classmates in the education only control group. This study also found support in treating children that are prone to have another bout of LBP if they have had a prior history of LBP.  Five per cent of the subjects with LBP missed school due to their pain, nine per cent missed out on sport participation, and another nine per cent had LBP that was bad enough to visit a health care provider. Thus, any benefit the experimental group may have gained by doing the more active spine program cannot be connected to doing the exercises.  The bottom line found that regular exercise and education appear to decrease low back pain in children between eight and 11 more than education alone.

Management and Treatment Options for Children with Flat Feet

People with flatfeet make up about 20 per cent of the adult population. A flat foot deformity is defined as a foot lacking the normal arch of the foot and a sinking inward of the heel.  A good indication of if you have flat feet is to look at your footprint after walking in water–the lesser the curve on the instep, the flatter your foot is. Infants are born with flat feet and arches do not typically fully develop until around age five. Flat feet are more prevalent in males and the obese population.  Normally flat feet are very flexible and the tiny foot muscles work well.

Rarely do people with flat feet have foot pain because of the shape of their feet, however there is a small group of people (less than one per cent) who present with a stiff flatfoot and a short achilles tendon which have an increased prevalence of pain and dysfunction in adulthood.

Often flat feet are brought to an orthopedist’s attention in childhood or adolescence, primarily out of concern for cosmetic reasons, future pain or dysfunction in adulthood. However, the latest evidence suggests that because only a small portion of the flat foot population has pain no treatment is necessary, orthotics or otherwise. If a child does present with pain, then they do need to be treated but it is important to find out the cause of the pain.  In a flexible flat foot when long term orthotics are indicated, over the counter orthotics helping to create an arch are sufficient. Custom orthotics should only be utilized when over the counter orthotics or other nonsurgical treatments do not work. Orthotics correcting the arch for a rigid flatfoot or for a flexible flatfoot with a shortened achilles tendon will actually exacerbate the problem. Conservative treatment for a shortened achilles tendon typically involves a specific daily stretching program.

In the very rare case where pediatric surgery for flatfeet is indicated, standards are strict for eligibility and prior to surgical correction all other conservative treatments must be attempted.  Soft tissue corrections, like achilles tendon lengthening, are rarely successful. Ankle fusion to a more neutral position will speed arthritis and decrease overall function and mobility. Restriction of the primary joint causing the flat foot, called an arthroereisis, shows poor promise and is not well studied.  Osteotomy, or the lengthening or shaving of certain foot bones, is the gold standard treatment and has excellent outcomes with well-trained surgeons.

Studying the long-term outcomes in developmental infant hip dislocation.

Currently the aims for treatment for late-detected developmental hip dislocation are to obtain proper alignment with good femoral head coverage and to avoid complications. In the past, closed reduction with or without traction was common however more open reductions are being performed today. Both closed and open reductions are often followed up by femoral and pelvic osteotomies. This recent study by Terjesen et al aimed to provide more information about the fifty-year outcome of adults who were treated as children for late-detected developmental dislocation of the hip. There have been no studies with this duration of follow-up and it may provide further ideas about what factors at diagnosis might help predict the long-term outcome.

This study looked at seventy-one patients (ninety hips) that were treated between 1958 and 1962 by one group of orthopedists. The patient ages ranged from two months up to five years old at the time of diagnosis. Every patient was treated with open reduction of skin traction at the facility, and the average time in traction was thirty-three days. Following traction a bilateral hip spica cast was applied which effectively casted the hips, knees and feet in slight flexion and abduction. The patients were in the spica cast for a mean time of nine and a half months. After this, further treatments included open reductions (five hips at a mean age of 25.4 months), derotational femoral osteotomy (fifty-four hips within three years of the initial traction treatment), and further reconstructive surgery after the first three years (thirty hips at a mean age of eleven years old); indicating that it was common for there to be an open reduction performed in addition to the conservative traction and spica cast treatment. Total hip replacement is also common later in life for these patients. At the time of this fifty-year follow-up study twenty-six percent of the hips had been replaced.

Interesting findings from this study include a strong association between the results of x-ray and the patient reported functional outcomes. Residual subluxation is seen in this study as a risk factor for the development of osteoarthritis, and one debatable point is how to treat such hips. It has been shown in other studies that without surgical correction such hips will eventually develop arthritis. And it remains the current policy of this particular group of orthopedists to perform a pelvic osteotomy for patients who are under ten to mitigate this risk as best possible.

Over the years the common treatment for late-detected hip dislocations remains closed reduction with traction. However a shorter time period is used and there is no longer routine femoral derotation. This has changed in the past fifty years due to various reasons, including inconvience for the families and fewer beds in the facility. The consequence of this shorter traction period has been that open reduction surgery has become much more common.

The most useful observation made from this retrospective study is the significant improvement in outcomes, both as observed on x-ray and by patient report, if the diagnosis was made before the age of one and a half years (eighteen months). Of the patients who were younger than eighteen months, only nine percent developed arthritis, whereas if the patients were older, forty nine percent developed arthritis. This is a pretty strong argument that if such diagnosis is made before eighteen months, the more conservative treatment may be quite effective.

A Closer Look at Management Following Shoulder Dislocation in Children

A recent review of the literature found that immobilization followed by physical therapy remains the standard treatment following shoulder dislocation in young children.  The review did find a paucity of evidence regarding the appropriate treatment, possibly due to the fact that shoulder dislocation in the younger population is rare with about 20 per cent of all dislocations occurring in the less than 20 year old population and .92 per vent of those occurring in less than nine year olds.

Your upper arm bone, known as the humerus, continues to form after birth. The end of the bone that makes up part of your shoulder joint has two bone-forming centers called ossification centers.  One of these centers stops laying down bone when a child is between five and seven years old and the other stops between 14 and 17 years old.  This is significant because if these centers are disrupted prior to them finishing their job trouble can result.  Once these centers, along with others located in other parts of the skeleton are closed, a person is considered “skeletally mature.”

The shoulder joint relies heavily on a joint capsule, shoulder rotator cuff muscles and ligaments to hold it together.  The combining motion of these structures allow for us to have a great range of motion at our shoulder joint.  If any of these structures fail, due to trauma or laxity, the shoulder joint can dislocate.  A true dislocation involves the humeral head slipping outside of the capsule and it requires someone to “reduce” it or put it back in place. Sometimes the humeral slips out of the capsule slightly, or jumps its normal track, and this is called a subluxation.  A subluxation does not normally require a reduction and the person can usually move their arm around to get it “back into place.”  The direction of the location is also important to note, with the most common being the humeral head slipping out towards the front of the armpit.

In a child, tissues tend to be more elastic which can be more forgiving during an injury.  If an injury does occur, it is typically a fracture as children’s ligaments are often stronger than their bones. The anatomical shoulder capsular attachment site also adds for more stability than in an adult.  These factors make shoulder dislocation difficult to happen in children and less likely to re-occur once it does happen.  That being said, however, when a traumatic dislocation does happen part of the front of the capsule can tear, called a Bankart lesion.

The evidence is very inconsistent regarding redislocation rates for skeletally immature children, with studies siting anywhere from 0-100 per cent.  One study delved further into the dislocation recurrence rate and looked at the differences in age when the dislocation occurred.  They found that the younger the child was at the time of dislocation, the less likely they were to re-dislocate in the future and that they had less actual damage to their capsule, which was probably due to the elasticity of their tissues.

Following reduction, patients are put in a sling to allow for the stretched joint structures to rest. The length of time in the sling is still debated, but often ranges from one to six weeks. This length of time has not been investigated in relation to re-dislocation rates. The direction that the arm is held in the sling is also controversial, the most common direction being palm towards the stomach with the elbow away from the side of the trunk.  However, a recent study found better results for dislocations that happen to the front to be placed in a sling in the opposite direction, or external rotation.

Physical therapy is the gold standard treatment following the immobilization period and includes strength progression. A study following shoulder dislocation treatments in children less than 16 years old found that physical therapy was effective for six per cent of first time dislocations, with the remainder requiring surgical intervention.

Surgery is considered when more conservative treatments fail to prevent future instability incidences.  Any tears in the tissue are repaired and the surgery is the same as repairs in the adult population.  Outcomes of these repairs are excellent in the two studies cited in this article, however the studies conducted were only on a small sampling of patients.

Central to the debate of preventing recurrent shoulder instability in the non-skeletally mature patient is to have surgery or not.  Results are favorable for preventing recurrent dislocations for adult patients, but are mixed with the younger populations. Immobilization followed by physical therapy remains the gold standard treatment in populations less than 14 years old without a Bankart lesion who have only dislocated one time.  Surgery becomes an option with recurring incidences of instability or with a coinciding Bankart lesion.

Special Considerations With Shoulder Arthroscopy in Children and Teens

Children and adolescents are not “mini-adults” and must be treated with special consideration when performing arthroscopy on the shoulder. With more and more sports injuries, the use of arthroscopic examination and treatment in this age group is on the rise. In this review article, two pediatric orthopedic surgeons provide surgeons with guidance on the principles of shoulder arthroscopy in children and teens.

Discussion of equipment, patient positioning, and portal placements is provided. Details on surgical technique are given for specific conditions such as the septic (infected) shoulder, brachial plexus palsy, labral injuries, shoulder instability, and rotator cuff pathology. Arthroscopic images with various camera placements and different diagnoses are also provided with descriptions of arthroscopic findings.

Special attention is given to young patients who have special needs because of medical conditions including hemophilia, cystic fibrosis, Down syndrome, Marfan syndrome, muscular dystrophy, seizure disorder, and other neurologic conditions. The authors provide a useful table of concerns that must be addressed when planning arthroscopic evaluation and/or treatment.

For example, intubation (insertion of a tube into the trachea to assist breathing) may be difficult with children who have neurologic conditions. Children with autism may need to be sedated ahead of time in order to improve cooperation. Children with any deformities or heart problems must be monitored closely during and after any surgery. Likewise, anyone with a seizure or bleeding disorder will need extra attention.

As for surgical techniques, the authors describe the size of arthroscope they recommend using for each procedure. Placement must be individualized for each patient since anatomy varies from child to child. The basic arthroscopic skills learned during training may not always apply to this age group.

When scopes are placed through the anterior (front) of the shoulder, soft tissue structures must be released in a particular order in order (as described) in order to preserve and protect them. The surgeon must also be careful to avoid damaging the physis (growth plate) or joint in any child or teen who has not completed skeletal growth yet.

The authors advise using traction “sparingly” in order to prevent stress to the growth plate. Steroids, local anesthetics, and implants or suture anchors should not come in contact with the physis. Any drilling across the plate must be done with the smallest drill bit possible.

There are many advantages of arthroscopic surgery. Arthroscopic examination gives the surgeon the opportunity to carefully and thoroughly examine the shoulder. As a result, damage or injury to the shoulder structures that might have gone undetected is identified and treated.

With smaller incisions possible, there is less pain and stiffness following arthroscopic procedures (compared with open incision surgeries). And studies show that with arthroscopic stabilization of a chronically dislocating shoulder, there are fewer recurrences of dislocation after arthroscopic surgery compared with nonsurgical treatment.

The authors conclude by reminding surgeons that the use of shoulder arthroscopy in the pediatric population is a valuable tool that must be used carefully and judiciously. In all aspects of treatment (evaluation, preoperative and postoperative care, and the surgery itself), this age group must be treated individually and not automatically regarded as adults in small bodies. This is an important concept as more and more children are developing sports-related shoulder injuries previously only seen in the adult population.

Treatment of Arm Fractures in Children: What’s the Evidence?

Every now and then it’s a good idea to step back and make sure we are on the right track with treatment of medical problems. And that’s exactly what these authors did in this study from Cincinnati Children’s Hospital. Using information presented at annual meetings of two orthopedic groups, they summarize current trends in treatment and evidence-based recommendations for management of these injuries.

Abstracts on the treatment of pediatric upper extremity fractures were reviewed from the Pediatric Orthopaedic Society of North America (POSNA) and the American Academy of Orthopaedic Surgeons (AAOS). The time period selected was from 1993 through 2012 (20 years).

Papers, posters, and abstracts were included with evidence from all Levels (I through IV). Level I and II were prospective, randomized controlled trials (RCT). Level III were case-control studies and retrospective comparative studies. Level IV was only case series.

Two pediatric orthopedic surgeons with special skill and training in the treatment of pediatric upper extremity fractures rated the treatment recommendations made in each publication as: 1) more aggressive, 2) less aggressive, or 3) neutral. More aggressive meant there were more diagnostic studies performed, more medications prescribed, surgery more often than conservative (nonoperative care), and faster time to surgery. Other criteria for a classification of more aggressive included treatment by a specialist and more invasive surgery (open incision, use of pins and plates).

What they found was a clinical trend toward more aggressive treatment despite research evidence that less aggressive treatment is just as effective. Large studies that compared operative versus nonoperative treatments concluded that less aggressive care is safe and effective. More aggressive treatment is not recommended. Case studies of individual patients with specific concerns were more likely to advise the use of more aggressive treatment.

Of all the bones in the upper extremity from the humerus (upper arm bone) down to the wrist, forearm fractures were the most likely to be treated surgically. Yet less than one-third of the studies favored operative care for forearm (shaft) fractures.

This study did not answer the question of why this trend (of more aggressive treatment despite evidence supporting a less aggressive approach) exists. The authors suggested several possible explanations. First, sometimes it just takes a while for research evidence to trickle down into clinical practice. Quality of studies has improved over time but many studies are still based on physician observation (not hard data). So, there can be a tendency to ignore recommendations based on Level III and IV evidence.

Some surgeons may take the more aggressive approach because of improved techniques and advancing technology making it easier to perform these procedures. It’s also possible that surgeons are influenced by advertising of newer surgical techniques. Patients may even be the source of pressure to be surgically aggressive if they believe “more is better”. And finally, other (as yet unknown) factors may be behind this trend. Procedures do pay more than conservative care. This notion suggests an economic reason behind surgeons’ choices.

In summary, the majority of comparative studies and case series recommend conservative (less aggressive) care for upper extremity fractures in children. Fewer diagnostic tests, less medicine, no surgery (or slower time to surgery) with less invasive surgical procedures is advised. The trend toward less aggressive care may occur naturally as research provides evidence to support this approach.

The authors recommend increased efforts to ensure quality and safety in the treatment of these pediatric injuries that are based on current evidence.

Off-Label Use of Spinal Screws in Children

Back in the 1960s, surgeons started to use a new type of fixation device to help hold the spine together during a fusion procedure: the pedicle screw. At first, this screw through the bone was only used in the lumbar spine (low back). But over time, the use of pedicle screws expanded — first to the thoracic spine in adults and then to the spine of adolescents.

Currently, the use of pedicle screws in the 13 to 18 year old patient for spinal stabilization has been approved by the Food and Drug Administration (FDA). Its use in younger children has not yet been approved because of a lack of evidence for the safety of this device in this age younger group.

However, pedicle screws are used in children ages one to 12 with scoliosis (spinal curvature) or other spinal deformities requiring spinal fusion. This use is considered off-label because of the lack of FDA approval at this time.

The pedicle is a column of the vertebra between the main body and the back half of the spinal bones. Placement of a screw through this portion of the vertebra has some risks but many advantages over other types of fixation (e.g., wires, hooks). For example, there is less movement in screws compared with wires or hooks. This increased stability of the fixation device reduces the risk that the hardware will poke into the spinal canal damaging the spinal cord. Likewise, there is less risk of injury to blood vessels in the area.

Pedicle screws are also able to give better correction of the spinal deformity by providing multiplanar correction. Vertebral bones are able to rotate, flex, and extend as well as slide and glide slightly forward, back, and sideways. Multiplanar stabilization stops motion in all directions.

Studies show that pedicle screws used in the lumbar and thoracic spines of adolescents and adults are less likely to pull out or fail compared with hooks and wires. But what we don’t know is how well these screws work in the younger population. This study takes a look at the complication rate (and types of complications) in children up to age 12 compared with children between the ages of 13 and 18.

In this study, 726 pediatric patients who had a spinal (thoracic and/or lumbar) fusion were evaluated and reviewed for complications. Results were compared for children in the younger group (ages up to and including 12 years old) with those in the older group (ages 13 to 18). Rates of infection, hardware failure, and neurovascular (nerve tissue or blood vessel) problems were reported after at least one full year of follow-up.

Overall complication rates were 13.6 per cent for the younger group and 16.9 per cent in the adolescent group. Broken down by category, there was a 0.5 per cent rate for neurovascular complications in the younger group compared with 1.92 per cent among the adolescents. Hardware-related problems were 13.4 per cent (younger group) versus 15.4 per cent (older group). And the infection rate was 9.2 per cent (younger group) compared with 11 per cent among the older patients.

Other areas examined in this study were 1) number of screws used and risk of complication (no link between these two factors), 2) timing of neurovascular complications (all occurred within the first 24 hours), and most common late complications (screw prominence sometimes requiring screw removal). Very rarely, complications such as stroke during the surgery, aspiration pneumonia, failure of wound healing, and ileus (bowel blockage) were reported. Such complications were not directly caused by the use of pedicle screws but were associated with having major (spinal) surgery.

Superior correction of spinal deformity with fewer problems make pedicle screws (as a fixation device) the preferred choice of many surgeons. The study served its purpose to compare the rate of complications from the use of pedicle screws in these two age groups.

It looks like complications from the off-label use among younger children are no different than with the adolescent group. Compared with other types of fixation (hooks, wires, rods), pedicle screws have a lower rate of complications. Pedicle screws for spinal stabilization are considered by these authors as safe, reliable, and effective. This data may help spur other studies with the eventual outcome of FDA approval of pedicle screws for spinal stabilization in young children.

Osteochondral Scaffold: A Valid Treatment for Knee Osteochondritis Dissecans

In this study, orthopedic surgeons from Italy explore the use of a minimally invasive, one-step osteochondral scaffold to repair damage to the surface of the knee joint. The level of evidence is low (rated four on a scale from one-to-four) because it is a case series. But the information about results is still valuable when a new type of treatment is introduced.

The condition being treated is known as osteochondritis dissecans or OCD. This is an acquired injury from repetitive microtrauma. A lack of blood supply to the damaged area causes separation of the first two layers of the knee joint: the cartilage that lines the joint (articular cartilage) and the subchondral bone (bone just under the cartilage).

The end-result is a hole (referred to as a “lesion” or “defect”) in the knee joint cartilage that goes down to the bone. The defect is on the bottom of the femur (thigh bone) where the femur comes in contact with the tibia (lower leg bone). Instability of the articular cartilage causes pain, swelling, and loss of knee motion and knee function. Left untreated, uneven contact of the joint eventually causes further degeneration of the joint and arthritis.

The condition affects active teenagers and young adults most often. The patients in this study ranged in ages from 18 to 33. The most effective treatment (especially for large lesions) is surgical with a wide variety of procedures currently in use. The goal of surgery is to restore the joint surface to as normal as possible (anatomically).

Placing collagen tissue (the basic building block of cartilage and bone) into the defect is one of the techniques under investigation. In this study, a three-layer scaffold made of type I collagen fibers was placed in the defect. The surgical procedure involved removing the damaged bone, placing aluminum foil inside the hole to form a template, and then implanting the hole with the exact size of collagen graft. An on-line video is available for anyone who would like to see the procedure.

The idea was to stimulate the body to fill in the scaffold as part of the natural healing process. Did it work? Let’s look at the results two years later. Outcome measures used included: patient symptoms, knee range-of-motion, status of knee ligamentous stability, and return-to-sport. MRIs were also taken to assess the actual changes at the joint. Patient symptoms and function were compared against the MRI findings.

All measures of function improved for each patient over the two-year period. In fact, continued improvements were observed between year one and year two. The MRI showed complete filling of the defect in three-fourths of the patients by the end of the first year. There was complete integration of the graft by the end of the second year. But the subchondral bone was never fully restored and changes such as edema, cysts, and sclerosis were seen in two-thirds of the patients.

Despite what might seem like a lack of complete healing response with a return to normal joint integrity, the majority of patients had no symptoms and were able to function fully. Not only that, but the size of lesion was not an issue. Even the largest defects responded well to this treatment. A few patients (three) had some minor reactions to the treatment with knee swelling and stiffness but there were no failed procedures among the group.

The authors concluded that the use of collagen-hydroxyapatite osteochondral scaffold can be beneficial to patients with all sizes of lesions from knee osteochondritis dissecans (OCD). With the typical poor prognosis of untreated OCD, finding a successful treatment with minimal adverse effects is exciting news. This procedure has the added benefits of being a simplified, one-step, and minimally invasive surgical approach.

New Study on Scoliosis from the Growing Spine Study Group

Ten years ago, the Growing Spine Study Group (GSSG) was started in an effort to improve treatment for early-onset scoliosis. Since that time, 22 Spine Centers in seven countries have joined forces to collect data on childhood and adolescent scoliosis. The group is made up of 36 specialized surgeons trained in the treatment of complex spinal deformities among the younger pediatric population (birth to age five).

The GSSG engages in comprehensive, multicenter, prospective research studies. They are committed to an international effort to perform and publish results from the highest quality research studies. Their current focus is on new techniques for spinal deformity surgery.

In this study, they compare the X-ray results of operative idiopathic early-onset scoliosis (IEOS) and adolescent idiopathic scoliosis (AIS). Idiopathic means the cause of the spinal curve is unknown. This type of scoliosis can develop at any age and is therefore named according when it occurs.

For example, spinal curvatures that develop between the ages of birth and three years is referred to as infantile idiopathic scoliosis or IIS. Juvenile idiopathic scoliosis or JIS is first seen in children between the ages of four and nine. And scoliosis that develops between the ages of 10 and 18 is referred to as adolescent idiopathic scoliosis (AIS). The added term “early-onset” refers to children five years old and younger.

Using the GSSG database of collected information, the authors reviewed the X-rays before and after spinal surgery for children diagnosed with idiopathic early-onset scoliosis (IEOS) and compared the results against a second (older) group. They used the records from another (separate) database (the Harms Study Group) for the second group of patients. The Harms Study Group collects data on children with adolescent idiopathic scoliosis (AIS).

In this way, they could identify differences in the characteristics of the spinal curvatures between these two age groups (birth to age five from the Growing Spine Study Group and 10 years to 18 years from the Harms Study Group). Various spinal angles, lines, curve directions and curve locations (thoracic spine, lumbar spine, thoracolumbar spine), and severity (magnitude) of spinal curves were measured and compared.

Here is a brief summary of the observations made between these two groups:

  • Children with idiopathic early-onset scoliosis (IEOS) had larger spinal curves and larger kyphosis (forward-bending curve).
  • Children in the younger age group were more likely to have one C-shaped curve with the center of the curve located near the place where the thoracic spine meets the lumbar spine (referred to as the thoracolumbar junction).
  • In general, children in the younger group had lower curves (most stable vertebra was in the lumbar spine).
  • Children in the older age group had double curves (S-shaped rather than C-shaped). This is typical as the spine compensates over time for an initial C-shaped spinal curve that eventually becomes an S-shaped (double) curve. The S-shaped curve makes it possible for the head to stay centered over the sacrum/pelvis.

    When the main curve was in children with idiopathic early-onset scoliosis (IEOS), it was to the left in two-thirds of the cases. This compared with 95 per cent of the older (adolescent) children who had a right-sided curve.

    What are the implications of these findings? First, the authors suggest that the lower curves in younger children may require a more distal (lower down) spinal fusion. There are some distinct disadvantages or drawbacks (as the authors refer to them) in doing spinal fusion surgery in the lower lumbar spine. For example, this type of fusion limits spinal flexibility and movement while concentrating stress on one area of the spine.

    Second, with the larger degree of kyphosis in the idiopathic early-onset group, there is a greater chance for pull-out anchors used in the fusion surgery to pull out. This can create a less-than-stable result. The authors suggest the use of carefully placed proximal anchors in such cases.

    Third, the larger curves in the younger children may suggest a tendency to delay surgery in younger groups. But the question is: what’s best for the child in the long-term? Does postponing surgery except in the most severe spinal deformities create more problems later? These are questions that must be addressed in future studies.

    Surgeons treating children with idiopathic scoliosis (whether early-onset or adolescent) may want to follow the work of these two research groups. Treatment approaches and surgical techniques with the best outcomes will be the focus of these multicenter research studies. Membership and participation in these study groups is available for those interested and qualifying individuals and centers.

  • Diabetes Isn’t the Only Problem Overweight Teens Face

    It’s a fact that more and more children, pre-teens, and teens are obese and developing diabetes early in life. But diabetes isn’t the only problem overweight adolescents face. Blount disease (severe bowlegged deformity) is another possible adverse effect of obesity. And it can lead to growth arrest at the knees, leg length differences, and early degenerative arthritis.

    According to Dr. J. G. Birch from Texas Scottish Rite Hospital for Children, there are actually three distinct forms of Blount disease (infantile, adolescent, and juvenile). Dr. Birch provided a review article of Blount Disease presenting information on all three types. Cause, clinical features, natural history, and treatment (conservative and surgical) are discussed for each type.

    The infantile form appears between ages two and five (boys are affected more often than girls). This type can be (but is not always) related to obesity. In fact, the cause of infantile Blount disease is still a mystery.

    All of a sudden, growth at the proximal end of the tibia (upper portion of the lower leg at the knee) slows down or even stops. This change in growth is referred to as physeal arrest). Along with physeal arrest comes a curving (bowing) or varus deformity and internal rotation (“torsion”) of the tibia.

    The child doesn’t usually complain of pain. The deformity is obvious and the way the child walks tips the parents (or pediatrician) that something is wrong. X-rays help the physician make an accurate diagnosis. About half of the children have Blount disease on both sides with an equal number only affected in one leg. The femur (thigh bone) does not have similar deformities but it will change over time to accommodate changes in the tibia if the Blount disease is severe.

    Treatment for infantile Blount disease is on a continuum from wait-and-see (sometimes the problem corrects itself) to conservative (nonoperative) care using braces and finally, surgery to correct the deformity. Dr. Birch presents a full description and discussion of the various types of surgeries that can be done, when surgery should be considered, and expected outcomes.

    In the case of adolescent Blount disease, as the name suggests, the condition develops later during the teen years. It is more likely to be linked with obesity and presents differently than infantile Blount, so that treatment is different as well. The growth disturbance is not as much but the deformity can be more severe if the changes affect the femur as well as the tibia. The distal (bottom end) of the tibia may become deformed, too. Adolescents who develop Blount disease are usually treated surgically as the condition does not resolve or correct itself and bracing is not effective.

    The juvenile form of Blount disease is a bit more controversial. It is really a variation of Blount disease that fits in-between the infantile and adolescent forms. Many experts don’t even make this distinction, instead only using the infantile or adolescent forms to describe the child’s condition.

    Juvenile Blount disease occurs between the ages of four and 10 years. It presents a little like the infantile form of Blount disease (growth disturbance) and a little like the adolescent form (later age with more involvement of the femur). There is a need to rule out other bone diseases such as metabolic bone disease and skeletal dysplasias until the differential diagnosis can be clearly established as juvenile Blount disease.

    Treatment is usually surgical since these children are older and larger (compared with children who have infantile Blount disease). The author reports that his surgical approach is similar to the one used for adolescent Blount disease (e.g., growth modulation, gradual correction of the deformity, high tibial osteotomy with hardware fixation).

    Growth modulation refers to the use of small tension band plates and screws to guide growth and correction of the deformity. The most common surgical procedure done (before permanent damage occurs) is called a tibial osteotomy.

    In an osteotomy, a wedge-shaped piece of bone is removed from the medial (inner) side of the femur (thigh bone). It’s then inserted into the tibia to replace the broken down inner edge of the bone. Hardware such as pins and screws may be used to hold everything in place.

    If the fixation is used inside the leg, it’s called internal fixation osteotomy. External fixation osteotomy describes a special circular wire frame on the outside of the leg with pins to hold the device in place. For more details on treatment, see our publication A Patient’s Guide to Blount’s Disease in Children and Adolescents.

    In summary, this review article covers all aspects of clinical presentation, differential diagnosis, and management of Blount disease in its various forms. Dr. Birch provides a detailed discussion of each content area along with X-rays and photographs demonstrating treatment techniques. Before and after results of surgery are also included.

    He suggests treating infantile Blount disease when deformity is asymmetric (different from one side to the other) or if the problem persists after age 18 months. Bracing can be used effectively for children up to age three. Older children or children who do not respond to the bracing are candidates for surgical correction. Recurrence of the condition and/or irreversible growth disturbance are two problems that create a challenge to successful treatment.

    Update on Spinal Injuries in the Growing Child

    As our title suggests, the currently available case studies and review articles on the topic of pediatric spinal injuries was reviewed. A specific focus on nonfusion (surgical) treatment is included. As with other pediatric injuries that can also affect adults, spinal injuries in the very young aren’t the same as in the fully grown adult. There are different anatomical features to consider along with differences in healing responses to trauma.

    Two of the most important factors that influence the management and outcomes of serious spinal injuries include the extensive bone and soft tissue remodeling that goes on and the fact that the child is still growing. The growth factor alone can make deformities and complications better or worse.

    By “serious” spinal injury, the authors mean vertebral fractures with or without dislocation and/or with or without spinal cord injury. Spinal cord injury without radiographic abnormality (SCIWORA) is the term used to describe spinal cord injury without bone fracture. And one of the later developments of a spinal cord injury in children without apparent bone involvement is spinal deformity (scoliosis). This type of subsequent deformity can be very severe.

    Car accidents, falls from a height, and sports trauma are the three most common causes of such serious injuries. The lack of strength, increased laxity and mobility, and decreased spinal stability in children (as compared with adults) are additional reasons why pediatric and adult spinal injuries differ.

    In children, ligamentous laxity in the spine is greater than the ability of the spinal cord to stretch. In other words, the ligaments can stretch with the force of the distraction from the injury but the spinal cord only has so much give before it is injured as well.

    Likewise, the growth plate (physis) can be damaged but the discs and bony vertebra remain unharmed. The result can be a spinal cord injury without fracture of the surrounding bone. This type of injury has been reported in children as young as six months old resulting in permanent paralysis.

    Treatment of children with spinal cord injuries is not by a cookbook or cookie cutter approach. The authors recommend early surgery to stabilize a rapidly progressing spinal deformity. But if the child is still growing, they also advise waiting to do a spinal fusion until the spine has reached near maturity.

    Whenever possible, a nonoperative treatment approach should be taken. This could involve bracing or growth-sparing (growing) rods. When the spine can’t be stabilized by conservative means, then nonfusion surgery may be appropriate. The surgeon lines everything up as normal as possible and uses instrumentation (pins, rods, wires, screws) to hold it in place. As soon as bone healing occurs (as seen on X-ray), the form of fixation used is quickly removed to avoid (spontaneous) spinal fusion.

    Studies show that stable vertebral fractures treated conservatively (without surgery) can be successful. Long-term follow-up did not show any faster or greater disc degeneration in these children as adults (compared with other adults who never had this type of serious spine injury).

    Individual case reports also suggest that conservative care of fracture-dislocations of the thoracolumbar vertebrae in young children can also be quite successful. It is possible to preserve normal spinal motion and spinal stability. In general, the results (and therefore prognosis) are quite good in children under the age of 10. They heal and recover quickly. The potential for remodeling and regaining normal vertebral height without deformity and without neurologic involvement is also greater in this age group. The exception is the child with a serious neurologic injury right from the start.

    In summary, the authors provide surgeons with a very complete review of pediatric spinal injuries. They explain the ability to treat many spine traumas in this age group conservatively or with nonfusion (surgical) management. Major differences between children and adults are reviewed along with a presentation of results obtained so far (mostly for individual cases and sometimes as part of case series).

    First Report on Complications Following Ligament Reconstruction in Young Patients

    Athletes of all ages are at risk for knee injuries, including young children and teens. One of the soft tissue injuries under study is the medial patellofemoral ligament (MPFL). This ligament is the main reason the patella (knee cap) stays in front of the knee joint and doesn’t shift off to the side.

    Trauma or injury that results in patellar dislocation usually also disrupts the medial patellofemoral ligament (MPFL). And since ligaments don’t heal well on their own, surgery is often needed to repair (or more often) reconstruct the torn tissue. Medial patellofemoral ligament reconstruction is a fairly new procedure. Reports of complications early after surgery (within the first three years) are rare.

    This large case series (179 knees) is the first report of its kind. And although it offers level four evidence (low level), it is still significant in the information offered. One surgeon performed all of the procedures using a single medial-sided patellar tunnel screw fixation.

    The tissue graft used to replace the MPFL came from the hamstring tendon. The author provided a detailed description of the procedure with a schematic diagram to aid the reader in visually understanding what was done. Follow-up X-rays, photos taken during arthroscopic exam, and MRIs are also used to show problems that developed and help explain the cause of those problems.

    Statistically, 16 per cent of the group had complications. Most of those were major problems (i.e., requiring further treatment, most often another surgery). The list of both major and minor complications included patellar fracture, hematoma, patellar instability (subluxation or dislocation), poor wound healing, scar formation, pain, reaction to the sutures, blood clots, and complex regional pain syndrome.

    Almost half of all complications (47 per cent) for all 179 knees were the result of surgical technical factors. Placement of the tunnel drilled through the bone for the graft and graft tension were the most common technical problems. The surgeon considered these complications to be the result of improper technique and therefore preventable.

    Patients who had both knees (MPFL ligament) reconstructed at the same time were at the greatest risk for complications. One other risk factor that was considered statistically significant included gender (females at greater risk than males). Most likely anatomic differences in the shape of the patella contribute to the gender difference.

    Age did not seem to be an important variable in the number or type of complications that developed. This information is significant because younger patients who have not completed growth are at risk for growth disturbance with any surgery around the growth plate. There were no cases of growth disturbance observed in this study — at least not in the first three years.

    The group will be followed longer to see what further problems develop over time. The surgeons have already changed their surgical technique based on these outcomes. They may make other changes if/when long-term results indicate the need for further refinements of surgical technique.

    Principles of Diagnosis and Treatment of Soft-Tissue Tumors in Children

    Small tumors of the arms and legs in children are fairly common. Fortunately, they are also usually benign. A careful and accurate diagnosis is still important. And, of course, treatment of the tumors (whether benign or malignant) is challenging. That’s why Dr. M. M. Thacker from Alfred I. duPont Hospital for Children has written this in-depth, up-to-date article on pediatric soft-tissue tumors of the extremities.

    Advances in our understanding of tumors in children have come from the use of imaging such as PET scans and whole body MRIs. Pathologic study of the tumor cells using immunohistochemistry, flow cytometry, and cytogenetic studies is helping researchers understand how tumors develop. This knowledge may eventually make it possible to specifically target and kill tumors without damaging the surrounding tissue.

    Treatment principles of soft tissue masses in children depend on several factors. These include the type of tumor (benign versus malignant, slow versus fast growing), symptoms, and age of the child. For example, small, benign tumors that are not causing any symptoms or problems may be watched and monitored without doing anything. Most benign but symptomatic tumors are removed surgically. In some cases, fast growing tumors (even if benign) may be managed with chemotherapy and/or radiation.

    Dr. Thacker provides detailed information about the most common benign and malignant soft-tissue tumors. Rhabdomyosarcoma (RMS) is the most common malignant soft tissue tumor in the 0 to 14 age group. This is one of the tumors that can be treated with chemotherapy without surgery (or minimal surgery) to avoid deformity and mutilation of the involved extremity (arm or leg). Children in the one to nine age categories have the best prognosis with this disease. There is a poor prognosis for children who have metastases to three or more areas of the body.

    Other sarcomas (malignant tumors) that are not rhabdomyosarcoma (RMS) are referred to as non-RMS soft-tissue sarcomas include synovial sarcoma, liposarcoma, and other non-RMS sarcomas. Location, histology (tumor cell characteristics), treatment, and prognosis for each of these tumor types are discussed. CT scan images, cell histology, and photos of the tumors taken during surgery to remove them are provided.

    As with most other malignant soft-tissue tumors, the potential for metastasis requires treatment. Treatment may consist of a combination of chemotherapy, radiation, and/or surgery. Targeted therapy is not available yet but may become an option in the future. For patients who experience local recurrence after treatment, radiation is the treatment of choice.

    A separate section on common benign tumors covers similar information on lipomas, lipoblastomas, three types of fibromatosis (infantile myofibroma/myofibromatosis, lipofibromatosis, and desmoid fibromatosis), neurogenic tumors, granular cell tumor, and tenosynovial giant cell tumors (TGCT).

    Benign means nonmetastasizing (does not spread to other parts of the body) but local growth can put pressure on other tissues creating other problems. And tumors can become large enough to present cosmetic problems and even deformity. Once again, every effort is made to provide treatment that does not cause mutilation of the extremity. More and more pharmaceuticals (chemotherapy-type drugs) are used in combination with surgical excision (removal) when necessary.

    In summary, Dr. Thacker provides a very excellent review of benign and malignant soft-tissue tumors of the extremities in children (birth to age 19). He suggests that the physician making the diagnosis in these cases must be very thorough as many cases are extremely challenging. Diagnostic information must be gathered from multiple sources including the clinical presentation, imaging, and tissue biopsy and cell histology. This level of detailed diagnostic information also guides non-surgical management as well as treatment with all other modalities (radiation, chemotherapy, surgery).

    Measuring Scoliosis in the Young Versus the Old

    Scoliosis (curvature of the spine) can affect young teenagers and older adults but for different reasons. In the young, the condition is often considered idiopathic (of unknown cause). In older adults (age 60 and older), degenerative processes in the spine are the most common cause of scoliosis.

    Determining the severity of the curve depends on using X-rays to measure angles. There are two different methods for this: the Cobb method and the centroid method. Each of these methods utilizes lines that form angles on the spinal X-ray. The Cobb method has been the “gold standard” in teenage scoliosis. But in older adults, measuring the angles becomes increasingly difficult as the degenerative changes alter alignment and distort the spinal column.

    To determine which method might work best for adult scoliosis, researchers from Korea compared the Cobb method against the centroid method in 60 patients. Three examiners (all were spine surgeons) independently reviewed the X-rays using both methods. They repeated the measurements two times, one week apart.

    Inter- and intrarater reliability was measured — meaning how close the results were each time the examiners measured and from one examiner to the others. Accurate measurements are important in planning the most appropriate treatment for each patient.

    Using statistical analysis of all the data collected, they were able to determine that there was:

  • Excellent correlation between both methods with both inter- and intraobserver comparisons.
  • Overall, the Cobb method was more reliable than the centroid method of this older age group.
  • The Cobb method was more a more reliable method when measuring more severe scoliosis.

    Other studies show that the centroid method is a more reliable way to measure scoliosis in adolescents. Because of the way centroid measurements are taken, distortions of the vertebra or endplates (present in the older degenerated spine) create too much variability and thus decrease reliability.

    The Cobb method relies on selecting the most appropriate vertebrae to begin and end the measuring process. Degenerative changes causing thicker endplates present in older adults (but not in adolescents) make it easier to determine where to draw the lines that form the angles in the Cobb method of measuring.

    The authors concluded that whereas a previous study they did showed the centroid method to be more reliable with adolescent scoliosis, the Cobb method is a better measuring tool for adult scoliosis. Changes in the vertebrae between young and old with scoliosis are different enough to warrant different methods of measuring the severity.

    There are however, still some contradictory results among various studies. This suggests further investigation of these two methods of measuring scoliosis based on differences in age and characteristics of the scoliosis is needed. Since treatment decisions rely on an accurate measurement of scoliosis severity, finding the most reliable method of measurement is important across the lifespan.

  • Clinical Practice Guidelines for Osteomyelitis in Children

    You may have heard (or even used) the expression: easier said than done. That phrase is never truer than when changing the way complex health problems are addressed in a hospital setting. Take for example, osteomyelitis (deep infection of bone and/or muscle) in children.

    This is a condition that requires close communication and coordination of many hospital services (e.g., admission department, medical staff, laboratory and imaging studies, surgical staff, and discharge processing). A common sense approach is always welcomed. But evidence-based guidelines for evaluation, diagnosis, and treatment are needed to ensure optimal treatment and results.

    That’s why the staff at Children’s Medical Center of Dallas Texas created their own evidence-based clinical practice guidelines (CPGs) and then tested the impact of following these CPGs. They worked together as a multidisciplinary team to develop and put into practice a method for dealing with children admitted to their hospital with possible musculoskeletal infections. The group included staff members from admissions, orthopedics, pediatrics, anesthesiology, hematology, radiology, emergency department, infectious disease, nursing, and social work.

    First, they developed a flow-chart (algorithm) to use when evaluating children with suspicious signs of osteomyelitis. The report they published of their results includes a printed copy of this chart from initial admission to final discharge. They used this method with 61 children admitted over a period of one year.

    The results of treatment were then compared with 210 children who were treated for the same problem before the clinical practice guidelines (CPGs) were developed. The two groups were carefully matched so they were similar in ages, sex (boys and girls), and diagnosis. Areas of study to evaluate outcomes included length of hospital stay, rates of positive cultures for bacteria causing the infection, timing of MRI studies (from admission to MRI), type of antibiotic used, and rate of readmission to the hospital.

    One of the reasons the group put together their own clinical practice guidelines (CPGs) is because they observed wide variations in how children were evaluated, diagnosed, and treated for this condition in their own hospital. For example, there were 33 different antibiotics used in Group I (the 210 children with osteomyelitis treated before the CPGs were developed).

    There were four areas where differences were noted between the two groups after treatment: 1) causative organism (specific bacteria responsible for the infection), 2) antibiotic selection, duration, and changes, 3) orders for advanced imaging such as MRI and time from admission to MRI, and 4) surgical intervention, length of hospital stay, and readmission rate.

    The results were so dramatic (significantly improved outcomes in group II) that the following recommendations were made and started at this hospital:

  • Tissue cultures and blood work were ordered immediately.
  • A special time slot was saved each day in the radiology department for any child suspected of osteomyelitis needing an MRI; this greatly decreased the time between admission and proper diagnosis and treatment.
  • All children suspected of osteomyelitis were placed in the same hospital unit (rather than being spread out in different units around the hospital). This allowed for improvements in communication and coordination of care.
  • Daily meetings (called “rounds”) were held by the core medical staff regarding each child in the unit. This constant monitoring of each child’s response to treatment made it possible to discharge them sooner with fewer complications. Information about treatment decisions made during this meeting was relayed to the families each day.
  • The primary pediatric attending physician was recognized as the final decision-maker with authority to make decisions when disagreements among the team occurred.

    These new guidelines made it possible to quickly and positively identify the bacteria causing the problem and then choose the best antibiotic to combat the infection. The majority of children in group II had excellent results with full and quick recovery. They returned to normal function and did not have chronic or returning infections.

    These results speak for themselves as to the value and importance of an evidence-based team approach. A short (five to 10-minute) meeting at the beginning of the day improved coordinated communication among the many departments involved in the care of these children. The trend toward shorter hospital stays means lower costs and less suffering for the child.

  • What Happens Years Later When Surgery is Needed for Clubfoot

    In this study from Northwestern University School of Medicine, one surgeon presents the long-term results of his technique for surgical correction of clubfoot. 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.

    But if correction is not successful with this nonoperative care, then surgery is needed.
    The technique used by this surgeon was described as “extensive soft-tissue releases.” Details of the surgical procedure are provided by the author. Briefly, here’s what was done. The Achilles tendon (attaches the calf muscle to the calcaneus (heel bone)) was cut in a Z-pattern and lengthened. Two other tendons (posterior tibialis tendon and abductor hallucis brevis tendon) were also surgically released.

    Then several ligaments in the ankle were divided and the capsule (a tough fibrous structure) around the ankle joints was cut. Once the bones (especially the rotated talus bone were properly aligned, a special wire (called a Kirschner wire) was passed through the talus to hold it in place. The talus is between the calcaneus (heel bone) and the rest of the ankle.

    Another wire was passed through both the talus and the calcaneus. The wires were used like a “joystick” to maintain the derotation of the talus in order to straighten the ankle and foot out. The whole leg was put in a splint for two weeks and then a long-leg cast replaced the splint for another four weeks.

    After that, the wires were taken out and the child was given a special brace called an ankle foot orthosis or AFO. An AFO holds the foot and ankle in proper position and alignment. The AFO was used for an average of one year. Some of the patients wore a special night splint called a Denis Browne bar. A few others were fitted with special tarsal pronator shoes (to help keep the bones of the foot in the middle and prevent them from drifting inwards).

    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.

    In summary, using this surgeon’s unique, uniform surgical treatment of clubfoot (extensive soft tissue releases and realignment of the bones) provided good correction of the foot and ankle. Results were best for children who had unilateral (one-sided) clubfoot and only one surgery. Pain, activity level, and disability scores were significantly worse in patients who had to have a second surgery.

    Other studies have shown gradual worsening over the years after surgical correction of clubfoot using other techniques. The long-term results obtained using this surgeon’s approach were much more favorable. More patients had fewer problems with residual deformity or need for additional surgery than has been reported in other studies using other surgical methods.

    Conservative care with serial casting (the Ponseti method) is still advised as the first-line of treatment for clubfoot. But for those children who need surgical assistance in restoring ankle and foot alignment, this surgeon recommends the type of comprehensive subtalar release and derotation described in this article. With more optimal correction early on, children get better results in their adult years.

    Racial and Socioeconomic Factors in the Treatment of Scoliosis

    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.

    Idiopathic scoliosis refers to a curvature of the spine of unknown cause. There is no underlying neurologic problem such as cerebral palsy or spina bifida. Idiopathic scoliosis is the most common type and affects about two to three per cent of the population. It tends to run in families and is more common in girls than in boys. Most often it develops in middle or late childhood during a rapid growth spurt.

    There are several ways to treat scoliosis in children: do nothing (observation), exercise, bracing, and surgery. The optimal treatment depends on the degree or severity of the scoliosis. If bracing doesn’t stop the progression of scoliosis, then surgery may be needed.

    Surgery for idiopathic scoliosis is generally suggested when the curve is 50 degrees or more and bracing fails. Surgery is recommended with two goals in mind; 1) prevent progression of the spine deformity, and 2) to lessen the existing spine deformity.

    The surgical procedure most often used to correct idiopathic adolescent scoliosis is a posterior (through the back) fusion with instrumentation (rods, hooks, screws and wires) and bone grafting. Sometimes if the curve is severe, additional surgery may be required through the front of the body.

    To assess national trends in the surgical treatment of idiopathic scoliosis, researchers at Cedars-Sinai Medical Center in Los Angeles, California used data from the Nationwide Inpatient Sample or NIS. 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 used information from the NIS to compare the number and types of patients who had spinal fusion surgery for idiopathic scoliosis. They also analyzed information on postoperative complications. 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.

    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. Having said all that, let’s look at what the study did uncover in terms of trends observed.

    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.

    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.

    Is the SRS-22 a Good Tool to Guide Treatment of 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 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 naturally arises: can the SRS-22 be used (and relied upon) to guide management decisions? In other words, how useful is the SRS-22 in making treatment decisions?

    That’s what the researchers who published this study tried to find out. They gave the SRS-22 survey to 155 patients ages 10 to 21. The entire group was made up of two separate subgroups: those patients who were treated without surgery (nonoperative group) and those who had surgery. There were further subdivisions among the groups based on severity of their spinal curves.

    They found that the questionnaire was a good tool to use when assessing differences in pain and body image between patients with small versus large spinal curves. But it did not sort out differences between the two groups when it came to measuring effects on function or mental health. And the SRS-22 really could not show differences with small changes in the severity of the spinal curvatures.

    The authors suggest that the SRS-22 is still 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 this age group, 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.