News Category: Child

Sixteen studies were deemed acceptable in quality and design to be included in a systematic review of osteochondritis dissecans (OCD) of the knee. The review was conducted by a panel of pediatric orthopedic surgeons from all over the United States.

Out of these 16 studies comes 16 recommendations called clinical practice guidelines (CPGs) for the treatment of osteochondritis of the knee in children.

Osteochondritis dissecans (OCD) is a problem in the cartilage of the knee that affects the end of the femur (big bone of the thigh). The problem occurs where the cartilage of the knee attaches to the bone underneath.

The area of bone just under the cartilage surface is injured, leading to damage to the blood vessels of the bone. Without blood flow, the area of damaged bone actually dies. A joint surface damaged by OCD doesn’t heal naturally.

Even with surgery, OCD usually leads to future joint problems, including degenerative arthritis and osteoarthritis. That’s why proper treatment (based on evidence of what works and what doesn’t) is so important.

But as this report shows, what we don’t know about the treatment of OCD far outweighs what we do know. Most of the recommendations made by this group were graded as inconclusive — meaning there’s not enough evidence to say for sure. Based on clinical experience combined with data from the studies collected, the panel was able to agree (consensus) on four recommendations.

We’ll start with those four consensus recommendations and then fill you in on what the group had to say about future directions in research. The way the authors reported their consensus recommendations was to say, “In the absence of reliable evidence, it is the opinion of the work group that…”

Pills that taste bad or are too hard to swallow can be difficult to get down even for adults. But when it comes to giving meds with similar problems to children, the task can be impossible.

That’s why scientists have started finding alternative ways to administer medications. One of those ways is called intranasal atomized medications. As the word intranasal suggests, the medication is delivered into the nose. Atomized tells us the drug is broken down into tiny particles that are sprayed into the nasal passages.

The drug still has to be sprayed twice (once on each side) but the amount of medication that is absorbed is much greater than with nose (nasal) drops. The child tolerates intranasal atomized medications well because a special device called a mucosal atomizer is used. This tool is inserted into the nasal opening and delivers the drug quickly and easily.

Intranasal atomized medications can be used for drugs that must be given over a long period of time (e.g., daily seizure medication). They can be used for more immediate problems like nosebleeds or a narcotic drug overdose. Orthopedic surgeons like this method of drug delivery to manage pain and for sedation before and during surgery.

Surgeons say that atomized intranasal pain relievers are really appreciated when the child is in severe pain from bone fractures, joint dislocations, or other orthopedic emergencies.

Other physicians sing their praises when it comes to managing pain from burns or large surface injuries to the skin (called abrasions). And during an emergency, using a spray on a child rather than poking around to gain access to a vein for an intravenous delivery significantly reduces anxiety and trauma associated with the injury and its treatment. The intranasal spray is also helpful in first calming a child when an IV is unavoidable.

There’s one other big advantage in using intranasal atomized medications in children and that’s reducing parental distress. When the child is sedated before surgery, there is less distress in separating the parent and child in order to take the child into the operating room.

There are other uses for atomized intranasal medications besides surgery. This type of drug administration can be used before subjecting children to procedures that may frighten them (e.g., imaging studies such as MRIs or CT scans). Dentists and oral surgeons may find the device helpful when it is necessary to give the child an anti-anxiety medication.

Most medications administered for pain control are tasteless and odorless. Even so, some meds are just plain nasty to taste. Avoiding unpleasant taste may be impossible even with an intranasal spray. When burning sensation is a problem, a small amount of numbing agent such as lidocaine can be added to the atomizer device.

Studies show that intranasal drug delivery isn’t as effective as intravenous administration (with a needle into the vein). But that can be remedied by increasing the amount of drug (dosage) atomized into the nasal passageways. The sedating (calming) effects of drugs given intranasally are slower than the intravenous (IV) route but not by much.

Intranasal medication for children has not received approval by the Food and Drug Administration (FDA) yet. That doesn’t mean physicians can’t use this method of drug delivery. Proper equipment must be used by health care professionals who are trained and skilled in using this form of drug delivery. With continued studies enough evidence will eventually be gathered to support FDA approval.

When it comes to traumatic injuries, children have amazing recuperative powers. In many situations, they heal faster with fewer problems than adults with the same injuries. One injury where this advantage may not hold true is with avulsion (traumatic amputation) of the digits (fingers).

Smaller blood vessels in children with digital avulsion injuries that get crushed or severely damaged don’t just spring back. The loss of blood supply to the area makes recovery with replantation (reattaching the finger) difficult. Success rates reported in the published literature on this topic remain low (53 per cent).

In this study, hand surgeons who performed microsurgery in children with traumatic digital avulsion report their results for 23 patients. In one-third of the cases, they were unable to save the finger and the child was left with an amputated stump.

Looking back at the results and comparing them to the records of patients may help identify key factors that would predict problems ahead. These items are referred to as prognostic factors for survival.

One of the main prognostic factors was the number of arteries that could be reconstructed. Only having one working artery to supply blood to the finger is linked with poor finger survival. Being able to repair the blood vessels without using a graft contributes to a better outcome. And, as mentioned, the smaller the damaged blood vessel is, the worse the prognosis for survival.

Other factors that can have a negative effect on the results are the presence of pain, which in turn, increases anxiety. When pain and anxiety occur together, spasming of the blood vessels develops. The net result is reduced blood supply to the replantation (i.e., reattached finger). This development can also affect the replanted finger that is trying to recover.

Not too surprising is the fact that a long delay between the traumatic injury resulting in amputation and the reconstructive surgery needed to reattach the digit lowers the success rate. When both skin and bone must be reconnected, the risk of failure is greater.

Surgical management of such injuries is not always easy to plan out. In some cases, the reattached finger takes beautifully. In those children who do not have a successful outcome, a second surgery to remove the dead tissue is required. Parents and children who are old enough to understand should be informed of the risks, factors predicting success or failure, and possible prognosis.

The good news is that these days it is possible to perform replantation surgery for amputated digits (fingers). That wasn’t possible in years past. With the development of microsurgical techniques (using a very high-powered microscope) and special surgical tools, this type of surgery is both possible and successful now.

Despite some reports of low survival rates, there are others who have published studies with an 80 per cent success rate. In those cases, the reattached finger continues to grow as well.

The authors conclude there may be times when an amputated finger in a child just cannot be replanted. And by assessing all patient factors as described, it may be possible to predict when it is best to leave the amputation as is and close up the stump versus attempting replantation.

Most adults think about having a hip arthroscopy exam for hip pain from age-related degenerative osteoarthritis. Many are thinking they might need a hip replacement. But, in fact, inserting a surgical scope into the hip of a child or adolescent can be a very useful diagnostic tool.

Children can have many different hip disorders that would be better treated if the surgeon could look inside the hip and see exactly what’s going on. That’s what arthroscopy offers over a simple X-ray or even the more detailed CT scan or MRI.

Hip problems in patients 18 and under range from juvenile rheumatoid arthritis and fractures to labral (cartilage) tears and tendinitis. Treatment of specific hip diseases such as Legg-Perthes and slipped capital femoral epiphysis (SCFE) is also aided by arthroscopic exam.

For parents facing this type of surgery for their child or teen, the natural question is always, “What could go wrong?” This study was done to find out the rate and type of complications from hip arthroscopy in this age group.

They pulled the records of 175 patients who had this procedure done at the Children’s Hospital in Boston. A total of 218 arthroscopic procedures performed by one surgeon were reviewed. Taking a look back like this after the events is called a retrospective study.

The rate of complications was low (1.8 per cent). That’s about what rate of complications occur in adults (reported between 1.4 and 1.6 per cent). The difference is that in children there is the potential for disturbing the growth plate, altering bone growth, damaging developing cartilage, and causing osteonecrosis (bone death).

Fortunately, none of those problems occurred in this group. Temporary nerve palsy was the most common complication (affected two patients). Single cases of abscess around the stitches and a broken scope were the only other mishaps. Everyone was followed for a full year and no further problems related to the arthroscopic procedure were reported.

Hip arthroscopy is not a simple in and out procedure. Special training is required to learn how to perform this challenging procedure safely. Care must be taken when performing hip arthroscopy in children with abnormal hip anatomy. Fluoroscopy (real-time X-rays) and surgical tools designed for this procedure aid the surgeon.

The authors conclude that hip arthroscopy in children and adolescents 18 years old and younger is a valuable diagnostic tool. It is safe and effective in the hands of a skilled and highly trained orthopedic surgeon.

More and more children are participating in sports and activities that affect the hip such as gymnastics, ballet, track and field, and horseback riding. It is expected that the need for arthroscopic exam to diagnose and treat a variety of hip disorders will continue to expand its use in the future.

Studies like this help identify what to expect and allow surgeons to counsel patients and parents about what complications could (but most likely won’t) occur.

When it comes to scoliosis in very young children, things are changing in the world of pediatric orthopedics. The traditional treatment with spinal fusion, casting, and bracing is being replaced by growing rods and devices that help the chest wall expand with good spinal alignment.

Those are the main points taken from an on-line survey completed by 195 pediatric orthopedic surgeons who are members of the Pediatric Orthopaedic Society of North America (POSNA).

Early onset scoliosis (EOS) is a challenging problem. Rapidly progressive spinal curves in young children (age five years old and younger) can compromise lung development. When curvature of the spine measures 20 degrees, the ribs start to rotate.

With large curves (60 degrees or more), spinal alignment is severely compromised and along with it, the chest. Decreased chest space for the lungs and other organs in the chest and abdomen get compressed or squashed together. Movement, function, and growth of the organs are all affected. At that point, the health and in some cases, even the life of the child is in danger.

Treatment varies depending on two major factors: the age of the child and the type of clinic or hospital where treatment is delivered. For example, children under the age of two are more likely to be treated conservatively (nonoperative care). This is true even if there is a severe curve. But by age five, surgeons choose surgery more often to treat severe curves.

Children receiving care at a pediatric orthopedic specialty hospital are more likely to be placed in a series of casts designed to gradually straighten the spine as much as possible. Care received at a university-based or private pediatric hospital is more likely to be with bracing.

Some of the treatment choices do depend on the equipment present in various settings. Casting tables, halo traction, and customized devices that help regulate the amount of traction force applied aren’t always available. Most of the surgeons who responded to this survey had the necessary equipment and made use of it.

Many surgeons today have taken advanced training in the use of growing rod technology. Just as the name implies, growing rods placed along the spine straighten the curve and can then be lengthened as the child grows. Growing rod techniques are a great improvement for young, growing children over the previous approach of fusion, which can stop growth.

Only about 20 per cent of the membership of this group responded to the survey. That’s only one out of every five pediatric orthopedic surgeons. The responses to questions asked may be biased by those who chose to participate.

For those who did reply, the most common treatment approach to early onset scoliosis was bracing (89 per cent), followed by casting (62 per cent), and growing rods (64 per cent). Chest expansion devices (39 per cent) and halo traction (27 per cent) were clearly used much less often.

The intent of treatment for early onset scoliosis (EOS) is to keep the spine as straight as possible using nonoperative approaches until fusion can be done. Serial casting works better for younger children. Older children may need halo-gravity traction first before casting.

Growing spine- and chest-wall surgeries do involve surgery but still make it possible to delay fusion while the child is growing. The authors summarize all of their findings by saying that there aren’t enough studies to truly show what works best for each level of severity of scoliosis.

Surgeons may be basing their treatment choices on what is available at their particular center. The gradual move toward greater use of surgery over the last 10 to 15 years may be swinging back toward conservative care.

It may turn out that casting and bracing are more effective and less problematic because complications from growing and expansion techniques can result in worse outcomes. Each child should be evaluated individually and decisions made in the best way possible with the information currently available.

If once a week treatment for clubfoot works well, would twice a week get better, faster results? That’s the question Dr. Rui Jiang Xu from the Department of Pediatric Orthopaedic Surgery in Beijing, China asked and answered.

The clubfoot is an unmistakable deformity present at birth. The foot is twisted (turned under and towards the other foot). The medical terminology for this position is equinus and varus. Equinus means that the toes are pointed down and the ankle flexed forward (like the position of the foot when a ballet dancer is on her toes). Varus means tilted inward. The ankle is in varus when you try to put the soles of your feet together.

The medical term for clubfoot is Congenital Talipes Equinovarus. Congenital means that the condition is present at birth and occurred during fetal development. Clubfoot mainly affects three bones of the foot: the calcaneus (heel bone), talus (just above the heel bone), and navicular (bone next to the talus).

The standard treatment for a clubfoot deformity in infants and young children is a procedure called the Ponseti Method. Developed in the 1950s by an an orthopedic surgeon (Dr. I. Ponseti from the University of Iowa), the Ponseti Method involves manipulating (moving) the bones of the foot and ankle toward a neutral position of alignment. The bones are then held in place by a cast.

Each week the cast is removed, the bones are moved again as close to normal as possible and another cast wrapped around the leg to hold everything in place. This weekly treatment continues for about five to six weeks (or until maximum correction possible is achieved).

Dr. Xu applied the standard once-a-week Ponseti treatment to 32 clubfeet and compared the results against another group of 40 clubfeet treated with the modified (twice weekly) approach. Children in the modified Ponseti group were corrected in three weeks compared to five weeks for the standard Ponseti group.

That is a significant difference and a big cost savings. This is true for families in China, or America, or any country who must travel from outlying (rural) areas to a more centralized hospital or clinic where this service is offered.

Taking a closer look at the two groups, the author reports the severity of deformity was the same between these two groups. Age ranged from seven days (one week old) to six months in the standard group and seven days (one week) to 18 months old in the modified group.

Children in the modified group were slightly older and yet still responded well to the treatment. The modified group came from a farther distance away, so in some cases, diagnosis and treatment were delayed.

It is well documented from previous studies that many (not all) children who have the Ponseti method of treatment for clubfeet must still need surgery to lengthen the Achilles tendon.

The Achilles tendon attaches to the calcaneus (heel bone) and pulls the foot into the equinus (toes down) position. Manipulation works well to stretch the joint capsule ligaments, tendons, and muscles in infants and young children. The Ponseti method corrects the abnormal relationships of the bones in the foot.

But the treatment is not always enough to stretch the Achilles tendon and restore full ankle dorsiflexion. Dorsiflexion is the movement of foot and toes towards the face. This is the opposite direction from the pointed (equinus) position.

In this study, an equal number of children in each group (87.5 per cent) required a percutaneous Achilles tenotomy (lengthening the tendon by entering through the skin and cutting it).

In all cases, after surgery, feet were maintained in the corrected position using a special brace or splint called Dennis Browne abduction boots. High-top shoes attached to a bar between the shoes hold the child’s feet and ankles apart. The splint is worn 24 hours/day everyday for three months. After three months, the brace is only applied at night while the child is sleeping. Bracing was continued for two more years.

The final measure of effectiveness for the modified Ponseti versus standard Ponseti method is a long-term look at outcomes. In this study, all the children were followed for an average of four years (range: two to six years). Dr. Xu found that in either group, if the Dennis-Browne splint was not worn as prescribed for the full two years, then the foot slipped back into the deformed clubfoot position.

Dr. Xu’s conclusion at this point is that the modified (twice weekly) Ponseti treatment for clubfeet is safe and effective. This approach shortens treatment time by a full two weeks. Family cooperation with applying the brace is equally important. Long-term results after further follow-up will be reported for these two groups in a later publication.

In this report, orthopedic surgeons present three cases of a rare problem: septic arthritis in children after a bone fracture. Septic arthritis is destruction of a joint from an infection such as staphyloccocus, streptococcus, or salmonella inside the joint.

What makes these cases unique is the fact that the fractures were closed. There was no disruption of skin or other soft tissues. In other words, there was no obvious or known way for the bacteria that caused the infection to enter the body.

In some cases (usually adults), septic arthritis develops after the person has had an infection somewhere else in the body. For example, pneumonia, urinary tract infections, or an infected IV in a hospitalized patient is the source of the bacteria. In children, strep throat, measles, tonsillitis, or upper respiratory infections are more likely to cause bacteria that can move through the blood system to a joint.

But there was no history of any of those potential problems or causes in these three cases. The lack of a known mechanism for the infection that occurred inside the joint (called an intra-articular infection) was a puzzle.

Some theories put forth included bacteria from a hematoma (pocket of blood caused by the fracture) might have entered the joint. Or in one case, it looked like a pin used to hold the joint together left a pathway into the joint.

In all three cases, the infection developed days to months after the original injury. Symptoms of persistent pain, fever, and erythema (redness of the skin) brought the children back to the surgeon for further follow-up.

The injuries themselves and joints affected were all different. There was a stubbed big toe while playing soccer and an ankle fracture during football in two 14-year-old boys. The third case occurred in a two-year-old who took a fall and broke his elbow.

In the case of the football player, treatment with antibiotics and surgery to repair the fracture appeared to be successful. Two screws used to hold the broken ankle together were removed five months after surgery. He was back to his regular sports activities by the end of six months.

Then two months later, he developed a fever along with ankle pain and swelling. Septic arthritis was diagnosed and he was successfully treated with another round of antibiotics and surgery to clean the joint out. The procedure used to remove all pus and bacteria from inside the joint is referred to as irrigation and debridement.

The soccer player wasn’t so lucky. The fractured big toe joint never did heal properly. Despite efforts to save the joint, infection destroyed so much of the joint surface it was necessary to fuse the joint. On a positive note, he was free of pain at his two-year follow-up appointment.

The authors offer this summary of three case reports involving septic joint arthritis after a closed fracture. The condition is rare and taking a look back and describing what happened may help other surgeons recognize the problem sooner than later. The goals of early diagnosis and treatment are to identify the bacteria present, prescribe an organism-specific antibiotic, and debride the joint in order to preserve it.

Vitamin D has been in the news a lot lately. Are we getting enough? Should we take supplements? What about people who can’t get enough sunshine to make vitamin D needed for bone health? And what about children? What are “normal” levels of vitamin D for them?

This study from the Shriners Hospital for Children in Texas addresses concerns about vitamin D levels in children having bone surgery. The goal was to find out how much vitamin D children had who were admitted for orthopedic surgery. Measurements were taken from blood samples of 70 children ages two to 19 years old before surgery.

Vitamin D helps regulate calcium absorption from the gut (gastrointestinal tract). Calcium is an essential ingredient in strong bones. The skin makes vitamin D but relies on sun exposure to do so. With so much time spent indoors and lower sunlight levels year round in the northern hemispheres, many children around the world have either vitamin insufficiency or deficiency.

The difference between insufficiency and deficiency is a matter of degree. Vitamin D insufficiency is defined as a blood level of 25-hydroxyvitamin-D (25 OHD) that falls below 32 ng/mL. 25 OHD is a chemical compound that must be present in the body in order for vitamin D to be made. It is called a precursor (comes before) chemical.

Vitamin D deficiency occurs when 25 OHD levels fall below 20 ng/mL. The levels for insufficiency and deficiency are actually determined by another factor — and that is the amount of 25 OHD needed to keep parathyroid levels in the normal range. Without going into the complex physiology of the body to explain the interactions between the hormonal systems, suffice it to say that vitamin D levels and parathyroid function are intimately linked together.

Other risk factors for decreased vitamin D include obesity, increased skin pigmentation (dark skin), older age, and not enough vitamin D in the diet. Children with metabolic bone disorders such as osteogenesis imperfecta (weak and brittle bones) and rickets are at a much greater risk for poor bone healing, which can be compounded by low vitamin D levels.

Finding out preoperative levels of vitamin D may be important because bone healing after fractures and surgical procedures depends on sufficient levels of vitamin D. In order to look for other factors that might affect vitamin D levels and/or bone healing, the researchers conducting this study also gathered additional information on each patient.

Age, sex (male or female), ethnicity, body mass index (BMI), diagnosis, and geographic location (where they normally lived: United States or Mexico) were included in the sampling. Vitamin D levels collected were also compared to the season.

They found that African American children were at greatest risk for vitamin D deficiency. As shown in other studies, vitamin D levels were at their lowest during the winter season.

Age and ethnicity combined was a major risk factor. For example, African Americans between the ages of 12 and 19 years old were 20 times more likely to be vitamin D deficient compared with Caucasians (whites). Seasonal levels of vitamin D did fluctuate with lower levels measured in the winter.

There was no obvious or statistically significant link between vitamin D levels and type of orthopedic diagnosis or body mass index (BMI). The kinds of orthopedic conditions children were treated for included scoliosis and other spine problems, cerebral palsy, hip dysplasia, leg length difference, and other (unspecified) orthopedic (bone) problems.

The authors did not examine complications or problems with bone healing after surgery compared with vitamin D levels. That will be the topic of the next study. The first step was just to see if vitamin D levels were normal or abnormal prior to surgery.

Future studies will be done to determine the implications of these findings. Clinical practice guidelines (what to do) will be developed after that. Routine monitoring of blood levels of vitamin D before and after pediatric orthopedic surgery may become necessary.

Ways to reduce risk factors and providing patient/family education are likely to be developed. These programs will be conducted as part of future preop programs for children undergoing orthopedic surgery involving bone. The protocol for all procedures requiring good bone healing for the best outcome will be reviewed as well.

Many’s the time a parent has told a child complaining of leg pain that they are having “growing pains” and it will pass. No one has a better explanation for this. Even the bone scientists agree there may be some truth to the idea. New discoveries in the last 10 years about how bones grow might eventually shed some light on this subject.

To help us understand bone growth in children, the authors of this article review the anatomy and physiology of the physis (growth plate). By understanding how growth factors and regulatory factors control physeal expansion, it may be possible to deal with physeal abnormalities, growing pains, deformities, and injuries.

The physis is a complex structure with many different types of cells (bone, cartilage, collagen) and multiple layers. There is a network of tiny blood vessels called capillaries to supply the area with nutrients and oxygen.

The physis is unique because it must be flexible enough to grow (i.e., it has not yet hardened into bone). But it must also be strong enough to withstand tension, compression, and shear loads placed on it during the many and varied activities of children.

Growth is regulated by hormones, feedback loops, and factors that signal when to increase or decrease cell growth and when to stop growth altogether. In order to turn collagen into bone, there has to be just the right amount of calcium, alkaline phosphatase, and matric metalloproteinase.

There are actually tiny packets called vesicles inside the chondrocytes (cartilage cells) that contain these chemicals. By some mechanism at the cellular level, these vesicles open up and release their contents at just the right moment for mineralization of the bone.

Anything that disrupts even one of these pathways can lead to abnormal physis. Lead poisoning, metabolic bone disease, tumors, infection, and trauma head the list of reasons why bone growth can get stunted or altered. The focus of this article is on the results of physeal trauma (most often from bone fractures that go into the growth plate).

Disturbance of the growth plate resulting in stopping bone growth can lead to a limb length difference (arm or leg) from one side to the other. Studies show that up to one-third of all bone fractures in children that extend into the physis result in this type of growth disturbance.

The factors that determine growth problems after fracture include the location of the injury, whether or not the blood vessels to the physis were damaged, and how close the child was to skeletal maturity (end of bone growth) at the time of the fracture.

One of the big dangers of physeal injury is the formation of a physeal bar. In the process of healing, bone is laid down across the break in the physis. A bar of bone is created that essentially stops any further growth of the physis on one side. The other side continues to grow causing angular deformities and uneven bone growth.

Scientists don’t know a lot about physeal bar formation. They have been able to show that if only a small part of the physis is damaged, then bar formation does not occur. Until it is known the exact mechanism by which this bar forms, we are powerless to stop it from happening. Research is actively seeking ways to unlock the mysteries of this problem.

That brings us to the next topic: treatment for physeal bars once they form. The bar can be removed surgically. The surgeon must put a piece of graft tissue (often fat harvested from some other part of the body) in the space created by cutting the bar out. Without this interposition tissue, the bone will just grow right back again.

Animal studies are being done to find ways to stop physeal bar formation. Until that happens, research is also looking into finding better ways to support the physis after bar resection.

For example, efforts are underway to find a chemical bonding that will give stability without impairing growth. If the entire growth plate has to be removed, it may eventually be possible to use gene therapy to regrow normal physes. This is only one example of what’s referred to as tissue engineering.

In summary, normal growth of the physis (growth plate at the end of bones) is a complex process that is only partially understood. Growing pains without injury will eventually go away. But damage to the growth plate from bone fractures (and other nontraumatic events such as tumors or infection) creates a whole different set of problems. Problems that we don’t have an easy solution for just yet.

Ongoing efforts of scientists in the area of genetic and tissue engineering are approaching the problem from one direction. Scientists studying the cellular processes involved in the formation of bone may also have some success. They hope to crack open the mystery and find the key to preventing physeal bar formation. Then it would be possible restore normal bone growth and repair.

As children, some of us may have fussed about being “too short” or “too tall”. But those problems pale in comparison to the child who is developing bone deformities or leg length differences. Such difficulties will cause many more problems than simply being a height you don’t like.

In this article, a pediatric orthopedic surgeon describes a new surgical technique for the treatment of angular deformities. Angular deformities include too much outward bowing of the bones that make up the knee joint or an excess inward angle we refer to as being “knock-kneed.” The treatment is called guided growth. It replaces the previous “gold standard” treatment of surgical osteotomy.

The specific focus is on the legs of children who are still growing. With X-rays and photos, the author shows clearly the positive effect of the new guided growth system. Instead of cutting a piece of bone out and realigning the affected bones and joints (that’s what an osteotomy does), a special device called a flexible tension band is used instead.

The band spans each side of the knee joint and is held in place with two screws. The band doesn’t prevent bone growth but it slows growth down. This treatment makes it possible to slowly but safely correct the alignment problem. This can be done without surgery and without halting growth altogether.

The flexible band and screws can be taken out when the child has reached neutral alignment and/or full skeletal maturity. Skeletal maturity means the growth plates at the ends of the bones have closed, and the child is no longer growing.

Sometimes the guided growth system is removed when the bones are in neutral alignment but the child is still growing. If X-rays show the problem (angular deviation) is coming back, the procedure can be repeated.

X-rays are also used to estimate bone growth and plan the guided growth process. The goal is to find the most optimal time while there is still enough bone growth left to make a difference. The author suggests at least one year of bone growth left is ideal. It may be best to use this approach earlier than later but the exact best timing is still unknown.

In order to avoid recurrence, orthopedic surgeons look for any other problems that might contribute to the angular deformity. They check both sides as well as the joints above (hips) and below (ankles and feet). The child’s gait (walking) pattern is examined and corrected.

Specific step-by-step details of the operation are provided for interested surgeons. Recovery and postoperative management are also discussed. Families can expect their child to spend a day or two in the hospital. The children are allowed to get up and walk as soon as they feel up to it.

A physical therapist may be involved during the hospital stay and at the follow-up appointments every three months. During the follow-up period, the surgeon will monitor closely for rebound growth.

Rebound growth means the bone may deform in the opposite direction. It is impossible to tell if and when this is going to happen, so close monitoring is advised until the child has reached full skeletal maturity.

The author concludes by saying that early results of the guided growth system are positive. The technique is much less invasive than surgical osteotomies. Unlike an osteotomy (which is permanent), guided growth is reversible (by removing the band). No bone is lost or destroyed with guided growth. In essence, bone growth is only “restrained” or slowed down.

We don’t have long-term studies yet to show what happens over time using this management technique. Children grow at different rates and that variability may affect the long-term results. Likewise, putting weight on the leg alters bone growth. More active children may have a different final outcome than less active children.

Predicting bone growth is not an exact science and can be inaccurate. The effect of the guided growth system on the patella (knee cap), ligaments, and other surrounding soft tissues has not been assessed either. These are all factors that will be investigated and studied in depth. The potential for correction of angular deformities without osteotomies makes this technique worth pursuing.

Health care professionals look to their specialty organizations to provide guidelines for treatment of various diseases, illnesses, and conditions. Orthopedic surgeons rely on the American Academy of Orthopaedic Surgeons (AAOS) to provide such guidelines whenever possible.

In this article, we find out that Clinical Practice Guidelines (referred to as CPGs) are now available for a knee problem called osteochondritis dissecans or OCD. The American Academy of Orthopaedic Surgeons has approved the 16 recommendations that make up the CPG.

Osteochondritis dissecans (OCD) is a problem that affects the knee, mostly at the end of the big bone of the thigh (the femur). The problem occurs where the cartilage of the knee attaches to the bone underneath.

The area of bone just under the cartilage surface is injured, leading to damage to the blood vessels of the bone. Without blood flow, the area of damaged bone actually dies. A joint surface damaged by OCD doesn’t heal naturally.

Even with surgery, OCD usually leads to future joint problems, including degenerative arthritis and osteoarthritis. That’s why proper treatment (based on evidence of what works and what doesn’t) is so important.

The new guidelines report how the recommendations were developed, reasons why each recommendation was made, and any supporting evidence for each one. The task force in charge of reviewing the research and putting these guidelines together labeled the strength of the evidence for each of the 16 guidelines.

The three main levels of strength of recommendation are: weak, inconclusive, and consensus. As the names suggest, weak evidence has been gathered for the guideline but more research is needed to study the area more completely.

In the case of OCD, there is weak evidence that X-rays and MRIs are two options for examining the damage. Information obtained from these imaging studies may help direct treatment.

Inconclusive evidence may reflect the fact that some studies result in one outcome while other studies on the same topic draw opposite conclusions. There isn’t enough evidence to recommend for or against the item being reviewed.

For example, should treatment be surgical or nonoperative, should the condition be treated if it’s not causing any pain or other symptoms, what type of treatment is advised for someone with OCD with pain versus patients with OCD who don’t have pain. There wasn’t strong evidence to support a clear answer to these questions.

And a consensus strength of recommendation means the group as a whole agreed on a particular guideline when there wasn’t enough reliable evidence for or against the recommendation. There was consensus that surgery is an option for patients with unstable OCD or displaced lesions (piece of bone has detached and shifted).

Another area where there was consensus of opinion based on available research evidence relates to imaging studies. There is consensus that repeat X-rays and MRIs can be used to see if (and how much) healing has taken place. As always, tests of this type aren’t just to satisfy the curiosity of patient, family, and surgeon. They are ordered when the information gained will help direct treatment.

In summary, there isn’t enough high-quality evidence on the treatment of OCD to develop clear treatment protocols. In fact, there really isn’t a high level of evidence to support the types of treatment being used today by many surgeons for this condition.

Patients are advised to modify their activities, use bracing or splinting to immobilize the joint, and even have surgery — all without strong evidence that these common treatments are required or helpful.

The positive value of conducting a task force to develop clinical practice guidelines is that we see clearly what type of research is needed. Having an outline for future research areas helps direct money, time, and resources in ways that will ultimately benefit patients with improved results.

Children born with developmental dysplasia of the hip (DDH) are often treated with a special device called the Pavlik harness. This canvas sling holds the child’s hips and knees bent with the legs spread apart. But there can be complications with this treatment. One of those complications is a nerve palsy. The extreme flexed position of the hip can put pressure on the femoral nerve that supplies the muscles along the front of the thigh.

Developmental dysplasia of the hip (DDH), previously known as congenital hip dysplasia is a common disorder affecting infants and young children. The change in name reflects the fact that DDH is a developmental process that occurs over time. It develops either in utero (in the uterus) or during the first year of life. It may or may not be present at birth.

In this condition there is a disruption in the normal relationship between the head of the femur (thigh bone) and the acetabulum (hip socket). DDH can affect one or both hips. It can be mild to severe. In mild cases called unstable hip dysplasia, the hip is in the joint but easily dislocated. More involved cases are partially dislocated or completely dislocated. A partial dislocation is called a subluxation.

The idea of the Pavlik harness is to get the round head of the femur in close contact with the hip socket. This position helps the hip form a deeper socket that is less likely to dislocate. Many studies have been done now to show that this nonoperative approach to the problem is quite successful.

But there are times when problems like nerve palsy develop. In this study from the Texas Scottish Rite Hospital for Children, the surgeons take a look back over records of the 1218 children treated at their clinic. All were treated with a Pavlik harness for developmental dysplasia of the hip. Anyone treated over a period of 17 years from 1992 to 2008 was included.

They found a total of 30 children who developed femoral nerve palsy during this time. By taking a closer look at the factors associated with these children and comparing them to a control group, they were able to gain a better understanding of what’s going on and why this happens. The control group was made up of children with developmental dysplasia of the hip treated with the Pavlik harness who did NOT develop a nerve palsy.

This is the first study to look at femoral nerve palsy linked with the Pavlik harness. Pediatric orthopedic surgeons have been aware of the problem but no one has really studied it to find out why it happens. And there have not been any studies to follow-up and report on the final results for children with this complication.

Data collected from the medical records included 1) how soon the nerve palsy developed after the child started wearing the harness, 2) body-mass index or BMI of the child (an indication of size and weight), 3) number of days until the palsy went away, and 4) success with the harness treatment.

They found that there was a 2.5 per cent incidence of femoral nerve palsy (that’s the 30 children out of the total 1218). Most of those (87 per cent) developed in the first week after starting use of the harness. The palsy group were older, larger (taller and heavier), and had more severe dysplasia.

And to give you some idea of how important this complication is — 97 per cent of the control group (children with dysplasia who did NOT develop nerve palsy) had a successful outcome using the harness. Only 47 per cent of the palsy group had successful results with the harness. Surgery to correct the problem was required instead.

There was one other important predictive factor in the final outcomes. The number of days it took for the nerve function to come back after taking off the harness made a difference. So for example, children who regained normal function in three days had a 70 to 76 per cent chance of success with the Pavlik harness once it was removed or adjusted to take pressure off the nerve.

But the longer it took to resolve the nerve palsy (measured at day seven and again after 10, 14, 21, and 28 days), the less likely the harness would work. In fact, any child who had not recovered within a month’s time had no chance of success with the harness. Fortunately, there were no cases of permanent nerve palsy. Temporary loss of muscle function from pressure on the nerve is called transient nerve palsy.

Findings as a result of information gathered from this study can be summarized as follows:

Most parents and childcare givers know the symptoms of strep throat or a staph infection: fever and sore throat for strep and inflamed, red skin for a local staph infection. But staph infection of any joint is also possible and presents as painful joint swelling, loss of motion, warmth, and local tenderness to the touch.

The treatment is the same since the underlying problem is a bacterial infection: antibiotics. But in the case of joint infection (called septic arthritis), damage can be done to the joint surface if the infectious and inflammatory processes are not stopped quickly.

That’s where this study comes in. The authors (pediatric orthopedic surgeons and pediatric rheumatologists) tried using antibiotics along with another type of drug called dexamethasone. Dexamethasone is a powerful steroid medication often used to treat rheumatoid arthritis or other inflammatory conditions.

In this study, 49 children were enrolled. They all had septic (infectious) arthritis from either staphylococcus aureus or another bacteria called Kingella kingae. Half the children were treated with the standard antibiotic protocol. The other half received both the antibiotic and a four-day course of intravenous dexamethasone.

The children ranged in age from six months up to 13 years old. Patients in each group were matched closely so there was no difference in ages, joints affected, and length of time they had the septic arthritis. Hips and knees were affected most often. Less often, the children had elbow, ankles, or shoulders involved.

They used blood lab values and length of stay in the hospital as their measures to compare results between the two groups. In all cases, they found the children who received the dexamethasone got better faster.

They had fewer days of fever, less pain and swelling, and a shorter hospital stay. Blood values also showed lower levels of all inflammatory cells and that’s important because it means less inflammation and less damage to the joint.

There were an equal number of children from both groups who ended up having surgery to drain the joint of fluid. Surgical drainage was usually done when improvement didn’t occur within 48 hours of treatment. Surgical drainage was also advised when fluid was drained by needle aspiration but the joint filled right back up with fluid.

The authors concluded that the added use of dexamethasone along with antibiotics for the treatment of septic joint arthritis in children is safe and very effective. The drug appears to reduce the number of reactive immunological cells like T- and B-cells, cytokines, interleukins, and tumor necrosis factor. The end-result is less cartilage destruction.

There were no negative side effects from the treatment. Long-term follow-up (by phone) showed that everyone in both groups was doing well: no pain, no limping, and no limitations in joint motion or activity level. There were no deformities or differences in leg length from side-to-side.

It appears that dexamethasone (a corticosteroid drug) is chondroprotective (protects the joint surface). Early use is advised for rapid recovery and lowered medical costs for the family.

Sometimes scoliosis (curvature of the spine) occurs in children for unknown reasons. But it can also develop when there are deformities of the bone such as a hemivertebra. Hemivertebra means only half of the spinal bone formed. The other side is missing, which causes the bones above and below the deformed bone to tip or collapse to one side. The result is a curved spine.

If this problem is diagnosed early (before age six), the deformed half of a vertebra can be removed surgically. Studies show that these children have excellent results with this procedure. But this approach doesn’t work when the problem isn’t recognized until the child is older. Treatment is especially challenging if the spine has matured (bone growth is complete or nearly complete).

In this study, spinal surgeons from the University School of Medicine in Shanghai, China try a new technique to correct the problem of late diagnosed congenital spinal deformity. It’s called a posterior unilateral pedicle subtraction osteotomy of hemivertebra for the correction of adolescent congenital spinal deformity.

To understand what’s done, imagine the surgeons entering the spine from the back rather than the front of the body. That’s what posterior means. Unilateral tells us only one side is operated on. And an osteotomy is removing a wedge-shaped piece of bone.

In this procedure, the surgeon removed this pie-shaped piece from the deformed hemivertebra. Along with the piece of vertebral bone, they also removed the transverse process — that’s the bony bump you feel along the back of your spine. The effect is to allow the remaining edges of bone to collapse toward each other.

The surgeon guided either side of the remaining bone fragments to move together — enough to close the gap formed by removing the piece of bone. The end result is correction of the curve. It’s called a subtraction osteotomy because only a portion of the deformed vertebra is removed or taken away (subtracted).

Then screws and rods are placed above and below the level operated on to hold them in place until healing occurs. This part of the procedure is called corrective fixation or instrumented fusion.

Doing the procedure this way saves the bone and the discs between the deformed hemivertebra and the spinal bones above and below it. Having those discs in place helps stabilize the spine.

The procedure also has the advantage of being simpler with less time in the operating room. The risk of bleeding is less and there are fewer other complications compared with removing the entire deformed half-vertebra.

When should this surgical approach be used? Well, as mentioned, older children with a painful scoliosis that has not been helped by bracing or other conservative measures may benefit. How well does it work?

The results of this first study are still considered preliminary (early). But in all cases, after four years, the fusion held and the spine remained stable. Pain relief was obtained for everyone.

Further study of this group is still needed to see what happens over a longer period of time such as 10 to 20 years after corrective surgery. Identifying the ideal patient for the posterior unilateral pedicle subtraction osteotomy must also be determined. It’s likely that the age of the patient, level of skeletal maturity, severity and location of the curve, and type of hemivertebra will be factors to consider.

In this commentary, Dr. M. N. Imrie from Children’s Hospital at Stanford University reviews congenital scoliosis — what it is and how it is treated. In addition, she offers an opinion on a new procedure called a pedicle subtraction osteotomy.

Anything “congenital” means it is present at birth. In the case of congenital scoliosis, there is a curvature of the spine caused by a defect in the vertebral (spinal) bone. There are several different types of spinal defects that can cause this type of congenital scoliosis.

The first is the failure of the vertebrae to form normally. For example, there may be only one half (one side or the other) of the vertebra. This type of defect or anomaly is called a hemivertebra (hemi means half). Or there may be a wedge shape to the normally block-shaped vertebra.

Either of these problems changes the way the vertebrae above and below the hemivertebra stack up. Without a squarish-shaped bone to rest on, the other bones tilt to one side. The effect is like dominoes: each bone shifts in position until the entire spine is listing or curved to one side.

That sounds fairly simple but it does tend to get a bit complicated when other structures are examined. The discs between the hemi- or block vertebra may be fairly normal but sometimes they are only partially there or completely missing.

Without these important supporting structures, the spine (and attached trunk) cannot grow normally. The surgeon must take all of these structural changes into consideration when forming a plan of care. But before we look at treatment options, let’s finish the discussion of types of spinal defects a child can be born with that cause scoliosis.

Besides the formation problems already discussed, there can also be what’s referred to as failures of segmentation. This means instead of each vertebral body being formed separately with discs and endplates in between each adjoining vertebra, two (or sometimes more than two) vertebra are fused together and form one unit.

Segmentation problems are divided further into two groups: block and bar. Block segmentation means both sides of the bone are solid. Bar segmentation refers to just one side (either right or left but not both) being fused. It is possible to have both types if more than two segments are involved.

Now, what about treatment? Any parent, family member, or caretaker of a child with this condition wants to know what can be done? Bracing, casting or doing nothing have not been shown helpful. The curve gets worse.

And bracing has even been shown to keep the chest wall from moving so the trunk cavity doesn’t grow properly. Rib and trunk expansion are essential for proper breathing and growth of all the internal organs. The next likely solution is surgery.

But there’s nothing simple or easy about this problem. There are many different types of surgery that can be done. Fusion-based approaches have been used for a long time with differing results. The deformed vertebra is removed and the remaining vertebrae above and below are fused together with bone graft and hardware fixation (metal plates, rods, screws).

Fusionless surgery has also been developed. The surgeon inserts “growing” rods that can be lengthened as the spine grows. This keeps the child from having stunted growth and makes room for all the organs. Each of these approaches (fusion versus fusionless) has its own advantages and disadvantages based on “indications” (i.e., when to use it). The child’s age and the severity of the deformity are key factors in the decision.

But a new approach has been proposed by a group of Chinese surgeons. The pedicle subtraction osteotomy for the treatment of mild to moderate congenital scoliosis was reportedly safe and “simple.” It’s that word “simple” that Dr. Imrie takes some exception to.

In this procedure, the surgeon removes a pie-shaped piece from the deformed hemivertebra. Along with the piece of vertebral bone, they also remove the transverse process — that’s the bony bump you feel along the back of your spine. The effect is to allow the remaining edges of bone to collapse toward each other.

The surgeon guides either side of the remaining bone fragments to move together — enough to close the gap formed by removing the piece of bone. The end result is correction of the curve. It’s called a subtraction osteotomy because only a portion of the deformed vertebra is removed or taken away (subtracted).

But there are several limitations to this procedure. First, the hemivertebra has to be large enough to allow a chunk of it to be removed. Some are too small for that. Second, since only part of the bone is removed, the curve correction is less than if it were removed completely. And third, this method won’t work if there is a rigid bar of bone present because of a segmentation deformity.

Dr. Imrie agrees that the reduced operative time and smaller blood loss are important advantages of the subtraction osteotomy. But the surgical technique described with this approach is not simple. Highly skilled spine surgeons with the right kind of experience and expertise are needed to perform such procedures.

In addition, the patient must be monitored carefully for any damage to the spinal cord or spinal nerve roots. This type of neural injury could result in sensory and/or motor loss that could even be serious enough to cause permanent paralysis.

Only 12 patients were included in the study. And only those with a defect at the T12 vertebra were operated on with this new technique. Despite the positive outcomes, Dr. Imrie urges caution before adding this procedure as a confirmed, safe treatment option.

Further comparative studies are needed with children of different ages, with different types of deformities, and comparing results to other more tried and true surgical approaches. The first report of pedicle subtraction osteotomy is important but not the final word.

More and more physicians across Canada and America are raising concerns about the use of codeine as a pain reliever for babies and children. There is evidence now that codeine isn’t really effective as a pain reliever in this age group. And with all the potential for serious side effects with codeine, it might be best to stick with Tylenol with hydrocodone or ibuprofen. When used properly, these over-the-counter medications are safe and effective for pain control.

In a recent report, deaths have been linked with codeine in infants who have an unusual gene that turns codeine into morphine. Other genetic variations among the young also make it possible to break down codeine quickly and dump a larger amount into the bloodstream than intended or tolerated. Unpredictable serious side effects including death can be the result.

In North America, physicians have access to a special test that can identify children at risk because of this genetic difference. But in other countries and places in the world (e.g., North Africa, the Middle East), the test is not always readily available. And those are the areas where this genetic-linked polymorphism (change from one form to another) is most common.

What can be done to protect our children? Some experts recommend taking codeine off the market completely for use with infants and young children. Some hospitals in Canada have already done this. This action may seem drastic but with babies and pre-verbal children who can’t communicate their symptoms, it’s the safest way to ensure no one dies as a result of codeine use. And since there are acceptable, safe, and effective alternatives, children don’t have to suffer pain unnecessarily.

In the United States, it’s not as simple as just voting to remove codeine from use with children. There are health plans that do not cover some of the liquid alternative formulations that could replace codeine in this age group. Drug regulations may also restrict the use of suitable narcotic replacements. So there’s work to be done before codeine can be taken off the market for pediatric use in the U.S..

Education of physicians, pharmacists, health care plan administrators, and even legislators is the first step. Parents, family members, and all other caretakers of children will also need to get the word so they don’t give children in their care any adult products containing codeine.

Fractures of the femur (thigh bone) in young children often require a special hip-to-toe cast called a hip spica cast. In this study, the rate of skin problems caused by hip spica casts is investigated.

The authors are a group of nurses from Children’s Hospital in Boston. They did a chart review of 297 children who were patients at their hospital between 2003 and 2009. The children all had a hip spica cast for a femoral fracture. They divided the children into two groups and compared them.

Group one included children who did not develop any skin complications during their immobilization for fracture healing. Group two was made up of children who came back to the clinic because of skin problems. The type of skin complications seen included skin irritation, skin rash, skin redness, scratches, or blisters.

Children in both groups were between the ages of six months and eight years old. The boys outnumbered the girls three-to-one. The number one reason for the bone fracture was listed as child abuse. In a smaller number of other cases, either an object fell on the child, the parent fell while carrying the child, or there was trauma from what was described as a “high-energy collision”.

Most skin breakdown associated with spica cast application occurs as a result of urine or feces getting under the cast or soiling the edges. Moisture and chemicals from urine and stool irritate the protective outer layer of skin. Additional complications can occur if bacteria entering open cracks or sores and cause infection.

Cast pressure (too tight or too loose) or a loose object under the cast also accounts for a fair number of skin problems. The specific types of foreign objects in the cast of these children were not listed but over the years, surgeons have reported finding a wide variety of objects from small toys or crayons to rocks, money, paper clips, food, and pretty much anything children can stuff down inside the cast.

Nurses, physicians, physical therapists, and other health care professionals who work with children in hip spica casts are interested in preventing such problems as skin irritation and/or skin breakdown. Knowing who is at risk helps them monitor and identify early at-risk children.

The results of this study showed that younger children (less than two years old) and those who wear a hip spica cast 40 days or more have an increased risk of skin problems. Children who were the victims of child abuse are also more likely to develop skin irritation or breakdown. Boys were not more likely than girls to develop skin complications.

A second focus of this study was the costs associated with skin complications. Extra medical visits and the need to change the cast (remove the first cast and replace it with another) drive up the cost of care for these children. It is often necessary to hospitalize young children in need of a cast change. The procedure is done under anesthesia requiring the added costs of the surgeon, materials, medications, anesthesia, the anesthesiologist, the operating room, and the operating room staff.

In this study, group one (no skin problems) only required removal of the cast at the end of treatment. The cast was bivalved (cut in half lengthwise) and used as a splint for a short transition time. The total cost for this procedure was between $400 and $450. These costs are compared to $8600 up to $53,800 for a cast removal and recasting.

The results of this study confirm the high rate and cost of skin problems in children with hip spica casts for femur fractures. Almost one-third of the total group required early removal of the cast and recasting. The high costs of skin complications requiring a cast change may be reduced with careful attention to children identified early as “at-risk” for such problems.

Younger age (not yet potty trained) and abuse are the most significant risk factors for skin breakdown. These children should not be kept in a spica cast any longer than necessary. Cast removal is advised as soon as possible. Longer periods of immobilization raise the risk of skin problems. Close monitoring (possibly mandatory supervision) for children at risk for child abuse is suggested as a prevention measure.

Other steps in prevention of potentially costly skin complications for children with spica casts may be helpful. The authors suggest additional patient education could include written materials and videos on the proper care of cast and child. Follow-up visits may be cost-effective. Using slightly more expensive waterproof materials (liners, padding, cast) may not always be needed but could prevent problems in at-risk children.

Another 10 years has gone by and scientists still haven’t unraveled all the mysteries surrounding the diagnosis of adolescent idiopathic scoliosis (AIS). AIS describes a condition of spinal curvature (scoliosis) among teens (adolescent) of unknown cause (idiopathic). Girls are affected more often boys, especially beginning during the pre-adolescent stage of life.

Efforts have been made to find a leading factor such as hormonal, genetic, environmental, lifestyle, biomechanical, or nervous system dysfunction. With all the new information available now on motor control, some scientists are taking a second look at that area as a possible avenue of understanding.

Is there a link between diet and exercise? Too much sugar? Not enough calcium? At best, experts agree it might just be multifactorial with more than one cause linked together. Right now, treatment is still based on symptoms instead of cause, so the search for etiology (cause) is still on.

At this point, there remain more questions than answers. We will give you a sampling of both as it stands now. For example, experts in this field still don’t know why humans are the only ones to develop scoliosis or if adolescent idiopathic scoliosis (AIS) is different from other types of scoliosis. Some curves get worse while others do not. In today’s modern lingo, “What’s up with that?”

What causes the curves to start in the first place? Is the same mechanism responsible for worsening of the curve? Which part of the spinal anatomy is affected first: is it the bone itself or the muscles pulling on the bone? Or are all segments (disc, bone, muscle, cartilage) affected equally and at the same time?

What do we know to be true about this condition? Twin studies support a genetic link but gene studies show many different genes are involved. It may be possible to identify subgroups based on specific genes involved but that’s only a theory at this point. Problems in the nervous system also seem to play a part in this condition. More advanced MRIs have helped scientists pinpoint specific areas of the brain (vestibular system, pontine and hindbrain regions) where the pathology may begin.

The role of vision, balance, neuron-motor timing, and failure of postural mechanisms in spinal deformity is also under investigation. Another big area of study is skeletal and spinal cord growth — speed of growth, coordination between soft tissue and bone, and symmetry of growth have been observed and discussed.

The body of the vertebrae (spinal bones) grows faster than the bony parts along the back of the spinal segment. That process of uneven growth is referred to as relative anterior spinal overgrowth or RASO. The RASO growth pattern results in tension and tightening of the spinal cord and spinal nerve roots (called tethering).

Rib deformities, altered blood supply to the chest wall, and differences in arm length from one side to the other have all been considered as possible causes of adolescent idiopathic scoliosis (AIS). And that’s not the end of the research list. Studies have also been done looking at the effect of hormones such as growth hormone, melatonin (sleep wake cycles linked with growth and bone density), leptin (helps with energy), and calmodulin (regulates muscles).

In summary, whether there is one pathway or multiple mechanisms leading to the development of adolescent idiopathic scoliosis (AIS) remains unknown. All efforts to study this condition and unveil its origins have resulted in the conclusion that it is a multifactorial problem that requires an integrative model to understand it fully.

Clearly, there is a pattern of abnormal skeletal growth with possible genetic links and biologic as well as biomechanical factors. Research is needed to continue finding successful ways to treat this condition based on an accurate understanding of the underlying cause.

Young athletes (children and teens) who have stabilization surgery for repeated dislocations of the patella (knee cap) have a 93 per cent success rate following the procedure. “Success” means their pain is less and their function is better. Yet when surveyed, these same patients report a much lower subjective (opinion) level of satisfaction. This study is another one to show a “disconnect” between surgical success and patient’s perception of the results.

Let’s take a closer look. One surgeon performed a patellar realignment procedure on 27 knees. The 24 children and teens in the study were between the ages of eight and 18. They all had at least two (but often more than two) patellar dislocations or subluxations (partial dislocation). They did not respond to conservative (nonoperative) care, which is the usual first-line of treatment for this problem.

The stabilization procedure varies from patient-to-patient. Age, skeletal maturity, and etiology (cause) are important factors in the decision-making process. The surgeon also performs an arthroscopic exam before doing surgery in order to find out what the patellofemoral joint looks like inside. Any unknown or previously unseen problems with the soft tissue structures and joint surface are identified.

The surgeon may perform a lateral release (cuts the soft tissue along the outside edge of the patella) with or without retensioning the medial soft tissue (changing the tension on the other side of the patella closest to the other knee). Other options include an osteotomy (the surgeon removes a wedge of bone to change knee alignment), repair of any damaged patellar ligaments, or a patellar tendon transfer (changes the angle of pull on the patella).

The work may be done from above or below the knee to create the stability needed based on the cause of the problem. In some cases, the patella is reshaped by doing a patellar shaving procedure. Any loose pieces of bone or cartilage found in the joint are removed as well. Most of the children (78 per cent) had more than one thing done during the same surgery — referred to as combined procedures.

Why did patients with an apparent “successful” surgery still report dissatisfaction with the results? Could it be the measures used (standard tests of knee function, symptoms, and activity levels) don’t fit this group? The authors suggest that microscopic damage to the joint and osteoarthritic changes might have something to do with patients’ sense that the knee isn’t stable.

They did find that the younger age groups and patients who had the surgery sooner than later had better outcomes. Those particular outcomes have led the surgeon to recommend patellofemoral reconstruction after only 2 subluxation or dislocation episodes — rather than waiting until the child has had many more than that months to years after the first episode.

There was one other observation that surprised the surgeon: children who had subluxations (partial dislocation) rather than full dislocations actually had worse results. Logically, it would seem than a milder injury would lend itself toward a better final outcome. But that wasn’t the case. So, why not?

The answer is not clear but there are some possible ideas. Perhaps the milder symptoms that accompany subluxations results in more frequent episodes that the patient fails to remember and report. Recovery is often faster with subluxations but damage at the microscopic level may be worse than realized.

And this all ties in with why patients don’t necessarily come back to the surgeon and report dissatisfaction. But when asked by telephone survey later, they do report more problems than the surgeon realized when counting up the number of “successful” procedures. Dislocations don’t occur but mechanical symptoms (e.g., pain with movement) are present and activity level is less than expected.

In summary, the study presented here confirms findings from other studies: patients do not always view their surgical results as successful. But they do not return to the surgeon and report ongoing symptoms or problems. When knee assessment tools like the International Knee Documentation Committee (IKDC) or the Lysholm score are used to measure outcomes, the results look good on paper but do not always provide an accurate view of the patient’s response. More studies are needed to understand all the reasons for less than optimal outcomes reported following patellar realignment surgery.

Bracing continues to be used for children and teens with adolescent idiopathic scoliosis (AIS) but does it work? What’s the evidence for brace treatment and who should it be used with? In this review article, Dr. Paul D. Sponseller from Johns Hopkins University Department of Orthopaedic Surgery brings us up-to-date on the practice of bracing for AIS.

Dr. Sponseller presents both the results of various studies published in the past 25 years on this topic as well as current opinions on the use of bracing from orthopedic surgeons using this treatment tool. Adolescent idiopathic scoliosis refers to a condition of spinal curvature and deformity in children and teens that has no apparent cause.

The word “idiopathic” means “cause unknown”. Another word for the underlying cause of a disease or condition is etiology. There are many theories about the etiology of adolescent idiopathic scoliosis (AIS) but no clear single cause. Most experts consider AIS to have multiple linked causes including genetics, environment and lifestyle, and nervous system dysfunction with biologic and hormonal influences.

Treatment specific to the cause is usually the most effective approach. Without that, the symptoms become the focus and that’s where bracing comes in. The idea is that by placing the spine in an upright position, the forces causing the curvature can be stopped — or at least slowed. Has that ever been the case? How well does it really work?

A review of all the studies done on this topic doesn’t really answer the questions. There are many different study designs so comparing one study to another is like comparing apples to oranges. And there are many different types and styles of braces with the same problem comparing results.

What we do know is that bracing seems to work the best when the brace is worn 16 or more hours a day and that girls with smaller curves (25 to 35 degrees) have the best results. Comparing children who are braced with children who do not wear a brace seems to offer some consistent evidence that observation alone (no bracing) isn’t as effective as bracing. Long-term results (what happens five-to-10 years later) in both groups are unknown.

Waiting too long before using bracing may be a factor. Studies that show a 50 to 60 per cent success rate still leave 40 to 50 per cent of patients turning to surgery for correction. That leads researchers looking for reasons why some patients have a successful outcome in hopes of selecting patients in the future who would be good candidates for bracing.

Before we look at how surgeons decide to use bracing, it should be pointed out that when asked why surgeons use bracing without convincing evidence that it works, there is agreement that the chance to reduce the risk of needing surgery is worth the effort.

Bracing may not improve (decrease) the curve but it appears to keep the curve from progressing (getting worse) in many cases. In 25 per cent of cases, bracing does seem to reduce the risk of surgery. Most likely what is happening is the brace alters the effect of growth on the curve. Parents and even children jump at the chance to be able to do something (anything!) that might create a straight spine. Fear of deformity, pain, and surgery often leads to bracing as a nonoperative option.

That brings us back to the question of when to use bracing. Right now, based on the best evidence available, it looks like bracing should be offered to patients with curves between 25 and 45 degrees. They should be in a phase of rapid bone growth (based on X-rays). Larger curves in children with more mature skeletal growth can be offered bracing but with the warning that there is less chance to really change things.

Patients who are not likely to benefit from bracing include children who are overweight, those who have reached skeletal maturity (no further growth expected), and anyone with a high thoracic curve (above T8). Most girls have reached their peak growth rate around 11 to 12 years old. Boys are a little later at 13 to 14 years old. Curve progression is likely to be the greatest during these years. This requires close monitoring even when wearing a brace.

Other risk factors that predict no change with bracing include 1) the presence of other major health problems that could interfere with wearing the brace, 2) children who do not want to wear a brace, or 3) parents who do not accept the idea of bracing.

Once the decision has been made to use bracing, the next natural question is: which one or what kind? The brace maker (called an orthotist because orthosis is the more modern name for brace) helps guide the decision. This is done in communication with the parent, surgeon, and physical therapist. A team approach is best when looking at the whole child and taking into consideration spine, surrounding soft tissues, general health, and activity level.

Some of the more commonly used braces for adolescent idiopathic scoliosis include the Boston brace, the Wilmington brace, the SpineCor brace, the Milwaukee brace, the Triac brace, the Sforzesco brace, the Charleston brace, the Providence brace, and the Cheneau brace. Does that give you any idea of how many different ways there are to approach this problem?

Some of these braces are intended to derotate the vertebrae. Others force the spine to bend in the opposite direction of the developing curve. The Charleston bending orthosis provides this type of overcorrection and is worn only at night. Most of today’s braces are made of plastic with either metal uprights or velcro or canvas straps to hold them in place. With the exception of the braces intended only for night-use, most braces used for adolescent idiopathic scoliosis are designed for use 23 of each 24 hours. The brace is removed only for bathing, swimming, and dressing.

One of the first questions often asked when getting a brace is “How long do I have to wear this?” Braces are meant to be worn primarily during the growing phases of childhood and adolescence. Once skeletal maturity has been reached (confirmed by X-ray), the brace can be removed. All girls should be at least 2 years past the point of beginning their menstrual cycle (period). The brace can be stopped gradually or all at once. It doesn’t seem to matter but each child is monitored closely to make sure the curve doesn’t start getting worse again.

Dr. Sponseller concludes by reminding us that there is some evidence that bracing can be effective. But it is unpredictable as to how much or who might benefit the most (or at all). There is a great need for more research and especially a way to determine which patients are at risk for surgery but could benefit from bracing.