The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 95, Issue 4

Specialty Update | February 20, 2013

What’s New in Pediatric Orthopaedics

Harish S. Hosalkar, MD, MBMS(Orth), FCPS(Orth), DNB(Orth)¹; Nirav K. Pandya, MD¹; Dennis R. Wenger, MD¹

¹ Department of Orthopedic Surgery, Rady Children’s Hospital San Diego, University of California San Diego, 3030 Children's Way, Suite 410, San Diego, CA 92123. E-mail address for H.S. Hosalkar: HHOSALKAR@rchsd.org

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Specialty Update has been developed in collaboration with the Board of Specialty Societies (BOS) of the American Academy of Orthopaedic Surgeons.

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, one or more of the authors has had another relationship, or has engaged in another activity, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

J Bone Joint Surg Am, 2013 Feb 20;95(4):377-383. doi: 10.2106/JBJS.L.01375

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Update

This article was updated on March 11, 2013, because of a previous error. In the section on Developmental Dysplasia of the Hip, the sentence that had read “van de Sande and Melisie¹⁴, in a study of thirty-one infants with a mean age of six months (range, five months to thirteen months) at time of diagnosis, reported that twenty (65%) of the thirty-one hips were successfully reduced with the Pavlik harness.” now reads “van de Sande and Melisie¹⁴, in a study of thirty-one infants with a mean age of eight months (range, five months to thirteen months) at the time of diagnosis, reported that twenty (65%) of the thirty-one hips were successfully reduced with the Pavlik harness.”

Basic Science

Advances in basic science continue to impact the clinical practice of pediatric orthopaedics. Aruwajoye et al. examined the mechanical and mineralization changes in the immature femoral head following ischemic osteonecrosis, but preceding subchondral fracture, in a piglet model¹. Extensive cell death and a lack of osteoblasts were seen in piglet femoral heads that had developed osteonecrosis. In addition, the nanoindentation modulus (which helps to determine the hardness of a material to deformation) within localized areas of the subchondral bone was significantly increased after osteonecrosis. These data suggest that continued loading of the hip joint during early osteonecrosis should be avoided to prevent subchondral fracture and subsequent femoral head flattening. Similarly, Kim presented new ideas regarding the use of biological treatment, perhaps in combination with limited weight-bearing, as treatment for the early biological phases of Legg-Calvé-Perthes disease².

Injuries to the physis continue to be a source of concern for the pediatric orthopaedic surgeon. Bries et al. examined the effect of a compressive load on the proximal tibial physis of rabbits to determine if changes in gene expression, cells, and extracellular components that promote physeal resilience and strength (type-II collagen and aggrecan) and cartilage hypertrophy (type-X collagen and matrix metalloprotease-13) were produced³. The authors found that the proximal tibial physes that were loaded in compression had decreased thickness, structurally disorganized chondrocyte columns, a decreased extracellular matrix, and less intense type-II and type-X collagen immunohistochemical staining. Gene expression of aggrecan and type-II and type-X collagen was decreased, with no significant changes in matrix metalloprotease-13 expression. Genetics continue to play a large role in our understanding of clinical conditions such as clubfoot and congenital scoliosis. Alvarado et al. examined the role of PITX1 (a bicoid homeodomain transcription factor) in the development of lower limb abnormalities, particularly clubfoot⁴. After breeding PITX1 knockout mice, the authors found an 8.9% penetrance of clubfoot. Associated findings in these mice included peroneal artery hypoplasia, small lateral muscle compartments, reduced tibial and fibular bone volumes, and decreased skeletal muscle gene expression.

Infection

Methicillin-resistant Staphylococcus aureus (MRSA) continues to be a major source of morbidity in pediatric patients. Ju et al. developed an evidence-based clinical prediction algorithm to differentiate MRSA osteomyelitis from methicillin-sensitive Staphylococcus aureus (MSSA) osteomyelitis⁵. In a retrospective review involving 129 children with culture-proven Staphylococcus aureus osteomyelitis, the authors found that a temperature of >38°C, a hematocrit of <34%, a white blood-cell count of >12,000, and C-reactive protein of >13 mg/L were independent multivariate predictors of MRSA osteomyelitis. The predicted probability of MRSA osteomyelitis was 92% when all four predictors were present, 45% when three were present, 10% when two were present, 1% when one was present, and 0% when none were present. These clinical criteria can help to guide patient management and provide criteria for antibiotic management.

Belthur et al. reviewed pathologic fractures in children with acute infection⁶. Seventeen patients who had a pathologic fracture in the setting of Staphylococcus aureus osteomyelitis were compared with a control group of forty-nine patients without fracture. The patients in the fracture group had a longer hospital stay (mean, 25.6 versus 12.5 days), longer durations of parenteral antibiotics (mean, 7.1 versus 5.4 days) and oral antibiotics (mean, 42.1 versus 11.5 days), a higher rate of multiple surgical procedures (mean, 65.0% versus 31.0%), and more surgical and medical complications (mean, 5.5 versus 1.3). In addition, magnetic resonance imaging (MRI) studies at the time of admission demonstrated a greater prevalence and size of subperiosteal abscesses as well as a sharp zone of abnormally diminished enhancement of the bone marrow. Patients with fractures were commonly found to have the USA300 pulsotype.

The findings of these studies suggest that patients with more severe disease presentation should be managed more conservatively in terms of activity and weight-bearing status until resolution of the infection as demonstrated by clinical, laboratory, and radiographic findings.

Trauma

Recent pediatric trauma literature has concentrated on commonly treated conditions. Leu et al. performed a prospective, randomized, controlled study examining the use of single-leg versus double-leg spica casts for the treatment of diaphyseal femoral fractures in patients between the ages of two and six years⁷. Although both techniques were associated with satisfactory radiographic healing, patients who were managed with a single-leg spica cast were more likely to fit into car seats, to sit more comfortably in chairs, and to have caregivers who needed less time off of work.

Similarly, Flynn et al. compared the use of traditional spica casts and “walking” spica casts in a prospective cohort trial⁸. The study included forty-five patients between the ages of one and six years who had low-energy femoral fractures. The authors reported that the rate of cast wedging for the treatment of fracture malalignment was higher in the “walking” spica cast group (26.3% versus 3.8%), although there was not a significant difference between the groups with regard to the final malunion rate. All patients with the “walking” spica cast were able to crawl or walk, which led to a decreased care burden and a decreased need for ambulance transport for these patients compared with the patients who had been managed with a traditional hip spica cast. These two studies^7,8 once again demonstrate the treatment dilemma that many clinicians face when managing young patients who have femoral fractures: balancing the fine line between fracture-healing and patient/family satisfaction.

Crawford et al. examined the outcomes for patients with distal radial fractures that were treated with casting in a shortened or overriding position without an attempt at anatomic fracture reduction⁹. Fifty-one children (mean age, 6.9 years) with shortened, overriding distal radial fractures (mean radial shortening, 5.0 mm; mean coronal angulation, 3.2°; mean sagittal angulation, 4.0°) were managed, without sedation or analgesia, with a short-arm cast that was molded to correct angulation. After a minimum of one year of follow-up, all patients had achieved clinical and radiographic union with full wrist motion. All patients and families were satisfied with treatment. A cost analysis demonstrated that closed reduction with the patient under sedation or anesthesia was five to six times more expensive than the authors’ preferred method. The American Academy of Orthopaedic Surgeons (AAOS) published guidelines this past year on the treatment of supracondylar humeral fractures, which have been exhaustively examined in the pediatric literature¹⁰. Key recommendations from the review included nonoperative treatment with long arm casting for Gartland type-I fractures as well as closed reduction and percutaneous fixation for the treatment of Gartland type-II and III fractures. In addition, two or three lateral entry pins were recommended for the surgical stabilization of very unstable fractures. This must be done cautiously because of the potential for ulnar nerve injury. The authors also made a consensus recommendation that patients with vascular compromise should go emergently to the operating room for treatment, with a low threshold for brachial artery exploration if perfusion does not return after reduction and fixation. No time recommendation could be made for operative fixation of fractures without neurovascular compromise, regardless of displacement.

Deformity

Sabharwal et al.¹¹ evaluated the meniscal and articular surface morphology in children with Blount disease with use of preoperative MRI and compared the findings with similar measurements in a control group. Twenty-six children (thirty-three knees) with Blount disease (mean age, 10.5 years) and twenty children without Blount disease (mean age, 9.6 years) were identified. The midcoronal medial meniscal height and width were greater in the Blount disease group. The Blount disease group also had abnormal signal changes in the medial meniscus as well as a greater mean thickness of the unossified cartilage of the proximal medial tibial epiphysis.

Elongating intramedullary rods have been used for the treatment of osteogenesis imperfecta for the past fifty years. Nicolaou et al.¹² reviewed the long-term functional outcomes and complications following the use of Sheffield telescopic intramedullary rods. Twenty-two patients with osteogenesis imperfecta who were managed with Sheffield telescopic intramedullary rods were examined at an average of nineteen years after the initial surgery. Reoperations involving thirty-three (50%) of the sixty-six rods were performed. Physeal damage was not seen following surgery, and all rods elongated with growth. All patients were satisfied with the outcome of the surgical procedure. The results of this study suggest that concerns regarding the insertion of this fixed device at the knee and ankle were unfounded, although proximal femoral fixation remains a concern.

Pediatric Hip

Developmental Dysplasia of the Hip

The overall effect of swaddling has been controversial for centuries, and its negative effect on the development of the hip is of great concern. Wang et al.¹³ conducted a prospective study in which 112 neonatal rats were divided into a control group and three experimental groups that were swaddled with use of surgical tape in a manner simulating the human practice for the first five days of life (early swaddling), the second five days (late swaddling), and the first ten days (prolonged swaddling). Rats in the prolonged-swaddling group had the highest prevalence of hip dysplasia (thirty-six of forty-four), followed by the early-swaddling group (twenty-one of forty-four). Most of the dysplastic hips in the prolonged-swaddling group were dislocated, whereas subluxation dominated in the late-swaddling group.

That study demonstrated that straight-leg swaddling increased the prevalence of developmental dysplasia of the hip in an animal model, especially if the swaddling was early or prolonged. The severity of hip impairment varied, with both early and prolonged swaddling leading to more dislocations than subluxations. The clinical relevance of the paper by Wang et al. is related to the possible harmful effects of traditional infant swaddling with the lower extremities extended and adducted, as is currently recommended to new mothers by their pediatricians.

The Pavlik harness is more likely to stabilize a hip with developmental dysplasia when treatment is started before the age of six months, so most clinicians are reluctant to try the Pavlik harness after that age. Also, the harness is usually abandoned if treatment is unsuccessful after four weeks because of concerns about causing greater problems if the harness is used on a dislocated hip that stays dislocated. van de Sande and Melisie¹⁴, in a study of thirty-one infants with a mean age of eight months (range, five months to thirteen months) at the time of diagnosis, reported that twenty (65%) of the thirty-one hips were successfully reduced with the Pavlik harness. An average of seven weeks (range, three to eleven weeks) were needed to obtain the reduction. Additional treatment with an abduction brace was then used for three to six months. The rate of successful reduction was higher for hips with less severe dislocations (81% for Tönnis type-2 hips, compared with 25% Tönnis type-3 and 4 hips). Five patients (15.0%) demonstrated radiographic signs of osteonecrosis. The authors concluded that prolonged use of the Pavlik harness for the treatment of late-diagnosed hip dislocation (developmental dysplasia of the hip) is acceptably safe and potentially successful for the infants in this older age group. From a practical standpoint, it is often very hard to manage a child who is more than six months old with a Pavlik harness because parental compliance with the use of the harness is often problematic.

There are growing concerns about radiation exposure in children. In spite of major advances in the field of imaging, radiographs remain the primary tool for evaluating hip dysplasia in children older than four months and are commonly used for treatment decisions. Upasani et al.¹⁵ assessed the reliability and reproducibility of the radiographic measurements that are routinely used to assess dysplasia in young children. Fifty radiographs from twenty-one children with developmental dysplasia of the hip were reviewed. The authors concluded that it is difficult to reliably measure three-dimensional pelvic shape on a frontal radiograph, especially when important pelvic landmarks have yet to ossify. This article outlines the limitations of using radiographic measurements as the sole method for the evaluation of developmental dysplasia of the hip in infancy and childhood, yet this method remains the best method currently available.

Accurate reduction of the hip is important for children with dislocated hips. Gould et al.¹⁶ reported on the use of MRI to confirm reduction in patients with developmental dysplasia of the hip. They reviewed thirty-four consecutive MRI studies that had been performed without sedation after spica cast placement in twenty-four patients with developmental hip dysplasia. Ninety-seven percent of the studies were diagnostic. T2-weighted fast spin echo sequences had the best overall scores and were performed in less than three minutes. T1 and fat-suppressed T2-weighted fast spin echo sequences did not score as well and also required less than three minutes. Sequences such as single-shot fast spin echo and three-dimensional gradient recovery sequences scored poorly. The authors concluded that MRI is a useful tool for evaluating the hip without radiation exposure and without sedation in infants and toddlers following the reduction of a subluxed or dislocated hip. Orthopaedic surgeons can request these MRI sequences for accurate assessment of concentric reduction with a potential study time of fifteen minutes. The stationary position of the child immobilized in a hip spica cast obviates the need for sedation.

In spite of good neonatal screening programs and a global push toward early diagnosis of developmental dysplasia of the hip in infants, children with developmental dysplasia of the hip and dislocated hips that need surgical intervention are still seen. Holman et al.¹⁷ reviewed 148 patients (179 dislocated hips) who were managed with open reduction for the treatment of developmental dysplasia of the hip over a forty-year period. Of these, fifty-three patients (sixty-six dislocated hips) were available for follow-up. Almost half of the children needed a second surgical procedure. Redislocation and osteonecrosis of the femoral head predicted poor outcomes. The authors also noted that the contralateral hip may develop dysplasia even though it appeared normal initially. This report outlines the unpredictable success rate following surgical procedures related to the delayed treatment of hip dysplasia.

Legg-Calvé-Perthes Disease

Larson et al.¹⁸ sought to prospectively document pain and function in a cohort of adults who had previously been managed nonoperatively for Legg-Calvé-Perthes disease. Patients were enrolled between 1984 and 1991 as part of a multicenter prospective trial and were managed with hip range-of-motion exercises or bracing. Fifty-six patients (fifty-eight hips) were examined at a mean of 20.4 years (range, 16.3 to 24.5 years). The authors noted that pain, arthritis, and ongoing hip dysfunction are common in patients with Legg-Calvé-Perthes disease who are managed nonoperatively. Hips that were rated as Stulberg type III or IV more frequently had poor or fair outcomes according to the Iowa Hip Score and the Nonarthritic Hip Score (61% and 72% for type-III hips and 77% and 60% for type-IV hips). Patients with a Herring lateral pillar type of B, B/C, or C frequently had pain and radiographic evidence of osteoarthritis. Clinical signs of femoroacetabular impingement were associated with pain and with lower functional scores. Their findings are in contrast to those reported by Boyer et al.¹⁹ and may reflect contemporary concepts, including increasing obesity in our culture, as well as a more aggressive method of questioning patients and providing “hip scores” in the “hip impingement” era.

Recent advances in surgical techniques have permitted surgical dislocation of the hip, allowing for correction of femoroacetabular impingement even in patients with Legg-Calvé-Perthes disease. Shore et al.²⁰ conducted a study to characterize the location and number of lateral epiphyseal arteries supplying the femoral head in children with healed Legg-Calvé-Perthes disease. High-resolution contrast-enhanced MRI scans were made for nineteen children (twenty-two hips) with a diagnosis of Legg-Calvé-Perthes disease and a matched control group of seventeen children (twenty hips) with developmental hip dysplasia. The authors noted that the lateral epiphyseal arteries reliably inserted on the posterior-superior aspect of the femoral neck from a superior-anterior to a superior-posterior position in both groups. The authors concluded that reperfusion of the medial femoral circumflex artery does occur in patients with Legg-Calvé-Perthes disease; however, the overall number of vessels is decreased compared with patients with developmental hip dysplasia.

Slipped Capital Femoral Epiphysis

The most important objective of clinical classifications of slipped capital femoral epiphysis is to identify hips that are associated with a high risk for osteonecrosis; however, traditional closed surgery for the treatment of slipped capital femoral epiphysis has made confirmation of physeal stability difficult.

Ziebarth et al. retrospectively reviewed eighty-two patients with slipped capital femoral epiphysis who were managed with open surgery between 1996 and 2009²¹. They categorized the clinical stability of all hips on the basis of the onset of symptoms (acute, acute-on-chronic, chronic) and the Loder system (stable, unstable). They also categorized the intraoperative stability as intact or disrupted. They then determined the sensitivity and specificity of two classification systems to determine intraoperative stability. Complete physeal disruption at the time of open surgery was seen in twenty-eight (34%) of the eighty-two hips. With classification as acute, acute-on-chronic, and chronic, the sensitivity for disrupted physes was 82% and the specificity was 44%. According to the classification system of Loder et al., the values were 39% and 76%, respectively. The authors concluded that current clinical classification systems are limited in terms of accurately diagnosing physeal stability in patients with slipped capital femoral epiphysis.

Sports

Controversy still exists with regard to the optimum surgical technique for skeletally immature patients with anterior cruciate ligament (ACL) injuries. Hui et al. examined the outcomes of transphyseal ACL reconstruction in Tanner stage-1 and 2 patients with open physes²². The authors performed transphyseal reconstruction with use of soft-tissue grafts that were placed across the physis in sixteen prepubescent patients with a mean age of twelve years. At two years after surgery, all patients had returned to strenuous activity, the International Knee Documentation Committee (IKDC) score had returned to normal or near normal in 94% of patients, and there were no cases of limb malalignment or growth arrest.

In contrast, Kennedy et al. performed a cadaveric study examining the biomechanics of three different pediatric ACL reconstruction techniques that attempt to avoid disruption of the physis: the all-epiphyseal technique, the transtibial over-the-top technique, and the iliotibial band physeal-sparing technique²³. All three techniques restored some degree of stability to the knee, although the all-epiphyseal and transtibial techniques resulted in peak anterior-posterior translations that were greater than that in the ACL-intact state. The iliotibial band technique was best able to restore both anteroposterior and rotational control but overconstrained the knee at certain degrees of flexion.

Dumont et al., in a study of 370 pediatric patients who underwent ACL reconstruction, examined the associations between meniscal tears and chondral injuries and the time elapsed from the injury, age, and weight²⁴. There was a higher rate of medial meniscal tears in patients who were managed >150 days after the time of the injury and those with an age of more than fifteen years. In addition, a weight of >65 kg was a risk factor for the development of not only medial but also lateral meniscal tears seen at the time of surgery. This study once again provides evidence that delaying ACL reconstruction in skeletally immature patients can lead to secondary meniscal damage.

The treatment of osteochondritis dissecans lesions continues to be an area of controversy. The AAOS recently published guidelines on the treatment of osteochondritis dissecans lesions of the knee²⁵. In this systematic review, the authors were unable to find sufficient or nonconflicting evidence for many diagnostic and therapeutic modalities including imaging, nonoperative care, and various surgical techniques. Several consensus recommendations were reached, including offering the option of surgery to symptomatic patients of all ages with salvageable displaced or unstable lesions, follow-up evaluation of patients who remain symptomatic after osteochondritis dissecans treatment, and the utilization of postoperative physical therapy after surgical treatment of an osteochondritis dissecans lesion.

Spine

Further advances were made in the area of pediatric spine surgery, with continued multicenter and basic science and clinical collaboration with an emphasis on patient safety.

Sponseller et al. performed a retrospective review of 1912 patients with adolescent idiopathic scoliosis to determine the associations of patient age, sex, primary curve magnitude, and Scoliosis Research Society (SRS)-22 outcome scores with the Lenke curve type²⁶. The authors found that Lenke type-1 curves were the most common and that type-4 curves were the least common. The Lenke curve type also varied by sex (with males having more major thoracic than major thoracolumbar/lumbar curves), age (with type-5 curves occurring in the oldest patients), and primary curve magnitude (with type-4 curves having the largest mean magnitude and type-1 and 5 curves having the smallest). Patients with type-4 curves had lower preoperative SRS-22 scores for self-image than patients with type-1 curves.

Roye et al. compared the ScoliScore (Axial Biotech, Salt Lake City, Utah), a saliva-based genetic test that can potentially predict adolescent idiopathic scoliosis curve progression, with traditional clinical estimates of curve progression (the Risser sign and Cobb angle) in a study of ninety-one adolescent patients with idiopathic scoliosis and curves of between 10° to 25°²⁷. When the risk of curve progression was assessed with use of the ScoliScore system, 36% of the patients were classified as low risk, 55% were classified as intermediate risk, and 9% were classified as high risk. In contrast, when the risk of curve progression was based on clinical estimates, 2% of the patients were classified as low risk, 51% were classified as intermediate risk, and 47% were classified as high risk. These findings indicated that the ScoliScore predicted sixteen times more low-risk and five times fewer high-risk patients than the clinical estimates. In addition, only the Cobb angle positively correlated with the ScoliScore.

Diab et al. examined the outcomes associated with the use of wound drains after spinal fusion in patients with adolescent idiopathic scoliosis²⁸. In this multicenter, retrospective analysis, 324 patients who had been managed with drains and 176 patients who had been managed without drains were evaluated for two years postoperatively. Complication rates did not differ between the two cohorts of patients. Of note, patients who had been managed with a drain were more likely to receive a postoperative transfusion (43.0%) than those who had not (22.0%).

Phillips et al. performed a retrospective chart review of 165 surgical procedures in twenty-eight patients with early-onset scoliosis with the diagnoses of congenital scoliosis, syndromic/chromosomal abnormalities, cerebral palsy, and spinal muscular atrophy²⁹. The authors found an 84% complication rate and an 18% mortality rate, largely as a result of pulmonary failure. This alarmingly high mortality rate suggests that additional study is necessary to decrease the complication rate associated with surgical intervention in this population.

Neuromuscular Disease

Single-event multilevel surgery is the standard of care in many institutions to address gait abnormalities in patients with bilateral spastic cerebral palsy. Thomason et al. examined eighteen children with Gross Motor Function Classification System (GMFCS) level-II and III function who were managed with single-event multilevel surgery to determine if gait and functional improvements were maintained at five years after surgery³⁰. Utilizing various outcome measures, the authors demonstrated that the improvements during early follow-up in gait and gross motor function were maintained five years after surgery.

Lengthening of the gastrocnemius-soleus, hamstring, and adductor muscles are mainstays in the treatment of cerebral palsy, and three well-designed studies analyzed the long-term outcomes of these interventions. Dreher et al. examined gastrocnemius-soleus intramuscular aponeurotic recession as part of single-event multilevel surgery in forty-four patients with spastic diplegic cerebral palsy who were able to walk³¹. Clinical examination and three-dimensional gait analysis were performed at approximately one, three, and nine years after surgery. The improvements in gait parameters seen at one year after surgery were maintained at the time of long-term follow-up, even though there was significant loss of passive dorsiflexion and recurrence of ankle equinus in 24% of the legs. There was a persistent increase in dorsiflexor muscle strength without relevant loss of plantar flexor strength, with only 10% of legs having late-onset calcaneal gait at the time of long-term follow-up. The results of this study demonstrate that gastrocnemius-soleus recession can lead to correction of mild and moderate equinus in patients with spastic diplegic cerebral palsy without the risk of overcorrection commonly noted in association with formal Achilles tendon lengthening.

Shore et al. examined the relationship between the success of open adductor lengthening for the prevention of hip displacement in patients with cerebral palsy and walking ability as measured with the GMFCS³². In a retrospective review of 330 children (mean age, 4.2 years) with a migration percentage of >30% (mean, 43.0%) on a pelvic radiograph in at least one hip prior to surgery who underwent bilateral adductor release, the authors examined the rate of treatment “failure.” Failure was defined as the need for subsequent hip surgery or the development of a migration percentage of ≥50% in either hip. Thirty-two percent of the children had treatment success. Success rates decreased with increasing GMFCS levels: 94% for patients with level-II involvement, 49% for those with level-III involvement, 27% for those with level-IV involvement, and 14% for those with level V involvement. The results demonstrated that walking ability (level-II and III involvement) is a strong predictor of success and that patients who most commonly require this surgery because of severe disease (level-IV and V involvement) have worse outcomes.

Debate continues as to the need for isolated varus derotational osteotomy compared with combined surgery (varus derotational osteotomy in addition to open hip reduction and pelvic osteotomy) in patients with cerebral palsy who have hip subluxation or dislocation. Huh et al. retrospectively reviewed 116 hips that underwent either a varus derotational osteotomy or combined surgery³³. The decision to proceed with combined surgery was made intraoperatively. In general, patients who underwent combined surgery had higher migration percentages preoperatively (mean, 84.0% versus 51.0%). Postoperatively, radiographic parameters were similar between the groups. Of the subset of patients with a migration percentage of >50% preoperatively who underwent only varus derotational osteotomy, only 21% developed a migration percentage of ≥40% postoperatively. This suggests that isolated varus derotational osteotomy may be beneficial for many patients with spastic hip subluxation or dislocation. Intraoperative fluoroscopy and/or arthrography can be used to assess the need for combined surgery.

Foot and Ankle

Calcaneal apophysitis is most often diagnosed clinically, and many physicians believe that radiographic evaluation is unnecessary. Rachel et al.³⁴ determined the frequency of abnormal radiographic findings in a group of patients with this clinical diagnosis. Ninety-eight patients (134 feet) with a mean age of 10.8 years who had a clinical diagnosis of calcaneal apophysitis were identified. Radiographs were reviewed by three orthopaedists. Positive radiographic findings on lateral radiographs were identified in five patients (five feet); these findings included three calcaneal unicameral bone cysts, one distal tibial nonossifying fibroma, and two calcaneal stress fractures (with one patient having both a calcaneal unicameral bone cysts and a stress fracture in the same foot). The rate of abnormal radiographic findings was 5.1% among the ninety-six patients with available information and 3.75% among the 133 feet with available information. The authors concluded that despite concern about exposure to ionizing radiation and the cost of medical imaging, routine lateral radiographs appear to be justified for the screening of pediatric patients with heel pain as a lesion requiring more aggressive treatment could be missed otherwise.

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Topics

hip dislocation, congenital ; hip joint ; pediatrics

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Harish S. Hosalkar, Nirav K. Pandya, Dennis R. Wenger; What’s New in Pediatric Orthopaedics. The Journal of Bone & Joint Surgery. 2013 Feb;95(4):377-383.

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