The purpose of this specialty update is to serve as a primary source and
review for the general orthopaedic surgeon who wishes to stay up-to-date in
pediatric orthopaedics. The topics that have been selected have value for the
practicing orthopaedist as well as for the pediatric orthopaedic specialist.
The material is not intended to represent the only, or necessarily the best,
method or procedure appropriate for the medical situations discussed.
Sources for this article were presentations at meetings of the Pediatric
Orthopaedic Society of North America (POSNA) (Ottawa, Ontario, Canada, May 13,
14, and 15, 2005), the American Academy of Orthopaedic Surgeons (AAOS)
(Washington, DC, February 23 through 27, 2005), the Scoliosis Research Society
(SRS) (Miami, Florida, October 27 through 30, 2005), and the American Academy
of Pediatrics (AAP) (Washington, DC, October 8 through 11, 2005), and selected
references. Orthopaedic surgeons, residents, and fellows are encouraged to
attend educational programs on topics in pediatric orthopaedics presented at
the AAOS conferences and courses, Specialty Day at the AAOS annual meeting,
and the POSNA annual meeting. Upcoming educational events are listed at the
end of this update.
Brachial Plexus Birth Palsy
The timing of early microsurgical intervention in brachial plexus birth
palsy is controversial. Waters and Brauer created an economic model to compare
the costs of microsurgical treatment at three months compared with the costs
of the surgery at six months in patients with brachial plexus birth palsy who
had absent biceps function at three months. For surgery at three months to be
as cost-effective as surgery at six months, with the assumption that 40% of
patients will have a spontaneous return of biceps function between three and
six months, the success rate of early surgery would have to be nine times
higher than that of surgery at six months. If there is an 80% return of biceps
function between three and six months, then early surgery could not be more
cost-effective. This model supports waiting for six months before performing
microsurgery in most cases.
Kambhampati et al. prospectively studied 183 cases of posterior subluxation
or dislocation of the shoulder associated with brachial plexus birth palsy.
After performing shortening of the coracoid, elongation of the subscapularis,
and correction of humeral retroversion, the authors found, on the average,
improvement in the Mallet score from 9.4 to 13.0 points, an increase in
lateral rotation of 58°, and an increase in forearm supination of 51°.
They also found that the extent of secondary deformity and the result after
treatment were determined by the severity of the nerve injury and the duration
of the dislocation. Waters and Bae reviewed the results of derotational
humeral osteotomy in forty-three children with brachial plexus birth palsy and
found a mean 68° improvement in external rotation and a mean improvement
in the Mallet score from 13 to 19 points.
Forearm and Hand
James and Bagley performed a multicenter outcomes study of 499 children
with unilateral congenital below-the-elbow deficiency; 339 wore a prosthesis,
and 160 did not. Using function and quality-of-life instruments, the authors
found that use of a prosthesis did not improve function or health-related
quality of life, calling into question the standard practice of prosthetic
fitting for infants and encouraging prosthetic use by children with unilateral
congenital below-the-elbow deficiency. Lerman et al. studied the impact of
forearm length on the functional ability, with or without the use of a
prosthesis, of 499 children with unilateral congenital below-the-elbow
deficiency. They found that, overall, patients with a shorter forearm
functioned similarly to patients with a longer forearm in the majority of
specific tasks; however, patients with a longer forearm performed several
specific tasks better. Use of a prosthesis improved the performance of three
specific tasks (twisting a lid off of a drink bottle, threading a string of
beads, and using a ruler and pencil to draw a straight line) by patients with
a shorter forearm more than it improved the performance by patients with a
The prognosis of Legg-Calvé-Perthes disease is considered to be
better for patients with an earlier onset. Dimeglio and Canavese studied 166
patients, at skeletal maturity, who had had the onset of
Legg-Calvé-Perthes disease before they were six years of age. All
patients with a more benign form of the disease (Catterall type 1 or 2) had a
good result according to Stulberg's classification. Of the patients with more
severe disease (Catterall type 3 or 4), 67% had a good result; 22%, a fair
result; and 10%, a poor result. There were no significant differences between
the results of surgical treatment and those of nonsurgical treatment in the
patients with severe disease.
Developmental Dysplasia of the Hip
Thonse and Johnson performed a study of 2742 babies who had been referred
for screening for developmental dysplasia of the hip with clinical examination
and ultrasound. Of the 233 hips with abnormal findings on the ultrasound
examination, 106 (45%) were found to be normal on clinical examination. Of the
1862 clinically normal hips, 106 (6%) had abnormal findings on the ultrasound
study. Furthermore, the authors thought that a clinical examination could not
be performed on 841 babies who could not relax. Because of the concern of
missing a diagnosis of developmental dysplasia of the hip in patients who have
normal findings on clinical examination and of being unable to examine some
babies who are tense, the authors suggested that ultrasonography is useful for
all referred babies.
The Bernese periacetabular osteotomy has become an established procedure
for the correction of acetabular dysplasia in older adolescents and young
adults. Clohisy et al. reported the early results of this osteotomy in sixteen
hips in thirteen patients after 4.2 years of
was a mean improvement of 44.6° in the lateral center-edge angle,
51.0° in the anterior center-edge angle, and 25.9° in the acetabular
roof obliquity. The average Harris hip score improved from 73.4 points
preoperatively to 91.3 points at the time of the latest follow-up. Millis et
al. presented the results in their large series of 154 periacetabular
osteotomies at a minimum of five years postoperatively. Failure was based on
pain scores or conversion to a total hip replacement. Multivariate analysis
identified three predictors of failure: a labral tear, older age, and joint
incongruity. These findings suggest that the intermediate-term results of a
periacetabular osteotomy are best if the procedure is performed on congruous
hips prior to the development of a labral tear or arthrosis.
Slipped Capital Femoral Epiphysis
Vitale et al. used the Kids' Inpatient Databases from 1997 and 2000 and
United States Census Bureau data to study the epidemiology of slipped capital
femoral epiphysis. The overall incidence of slipped capital femoral epiphysis
was 10.75 per 100,000 children. It was more prevalent in males (12.52 per
100,000) than females (7.71 per 100,000) and more prevalent in black children
(18.63 per 100,000) and Hispanic children (11.85 per 100,000) than in white
children (5.38 per 100,000). The age at presentation was older in males (12.4
years) than in females (11.2 years). Furthermore, the incidence of slipped
capital femoral epiphysis varied by geographic region in the United States
(highest in the south) and household income. This study suggests that the rate
of slipped capital femoral epiphysis is somewhat higher than previously
reported and that the age of onset is becoming younger.
Hormonal disorders may predispose children to the development of slipped
capital femoral epiphysis. Papavasiliou et al. performed a comprehensive
endocrinological work-up for fourteen patients with slipped capital femoral
epiphysis. Fourteen of 168 hormonal determinations revealed abnormal values,
including those for luteinizing hormone, parathyroid hormone, follicle
stimulating hormone, and testosterone, although no cases of true
endocrinopathy were found. The authors suggested that a temporary hormonal
disorder during the early years of adolescence, and not necessarily a true
endocrinopathy, may play a role in the development of slipped capital femoral
The risk of a contralateral slipped capital femoral epiphysis is estimated
to be 25% to 40%, and some surgeons routinely perform prophylactic
contralateral pinning at the time of pinning of a unilateral slipped capital
femoral epiphysis. Stratification of the risk of contralateral slipped capital
femoral epiphysis would identify patients who are at greatest risk for a
contralateral slip and may be candidates for prophylactic pinning. In a study
of 260 patients followed through maturity, Karol et al. found that the
modified Oxford bone age was a useful predictor of a contralateral slipped
capital femoral epiphysis.
Anterior Cruciate Ligament Injury
One of us (M.S.K.) and colleagues reviewed the results of a physeal-sparing
combined extra-articular and intra-articular reconstruction of the anterior
cruciate ligament with use of the iliotibial band in forty-four prepubescent
children (mean age, 10.3
years)2. They found
a low revision rate (4.5%), excellent function, and no cases of growth
disturbance. They advocated a physeal-sparing approach in these young
Czarnecki et al. reviewed the results of fixation, with various techniques
and implants, in twenty-six knees with unstable juvenile osteochondritis
dissecans. The overall healing rate was 85% (twenty-two of twenty-six). There
was no significant difference in the healing rate according to the location of
the lesion, fixation method, or grade of the lesion. In fact, all six
completely detached lesions healed. The authors emphasized the importance of
attempting to fix unstable juvenile lesions in lieu of using chondral
resurfacing techniques given the relatively high healing rate that they
Many studies have suggested that weight plays a role in infantile Blount
disease. Scott et al. studied ninety-eight extremities with physiologic bowing
and twenty-six extremities with infantile Blount disease. They found that a
tibial metaphyseal diaphyseal angle of = 14° or an angle of =
10° associated with a body mass index of >1.8 was highly predictive of
infantile Blount disease (sensitivity, 88%; specificity, 94%).
The efficacy of staple hemiepiphysiodesis for the treatment of late-onset
tibia vara was studied by Park et
extremities in twenty-six patients were treated with lateral stapling of the
proximal part of the tibia. Additional distal femoral lateral stapling was
performed in fourteen patients. At the time of follow-up, twenty extremities
were in normal alignment, four were in mild varus, seven were in moderate
varus, and two were in valgus. The authors recommended this procedure for
patients with mild-to-moderate deformity who are younger and have sufficient
Refracture and deformity can occur after osteosynthesis of a congenital
pseudarthrosis of the tibia. Cho et al. observed refracture following
twenty-two of forty-three successful osteosynthesis procedures, at an average
of 19.4 months after union. Refracture was more common in younger children,
those without a distal tibiofibular synostosis, and those with a thinner
tibial diaphysis. In a group of seventeen patients treated with a successful
osteosynthesis, Inan found deformity in all but two patients, with a mean of
11.4° of tibial valgus, 19.4° of procurvatum, and 22.2° of ankle
Children with fibular deficiency may be managed with amputation or limb
reconstruction. There are scant data comparing health-related quality of life
and function between these two treatments. Walker et al. used multiple outcome
instruments to compare thirty-two patients treated with an amputation and
twenty-five patients treated with limb lengthening and found no difference
between the results with regard to almost all quality-of-life measures.
Compared with controls, both groups of patients were functioning with an
average or above-average health-related quality of life.
Foot and Ankle
The Ponseti technique of serial manipulations and casts has become the
standard management of congenital clubfoot, resulting in much lower rates of
major surgery. Dietz et al. reviewed Ponseti's personal experience with the
treatment of 541 feet from 1948 to 1991. The rate of relapse and the need for
surgery were higher before the use of hyperabduction in the last cast and in
patients who were noncompliant with bracing. Cummings et al. investigated the
utility of botulinum toxin injections to the gastrocnemius muscle as an
adjunct to the Ponseti method in a randomized clinical trial of thirty-two
clubfeet. The injection had no significant effect on deformity correction.
Bilateral cavovarus foot deformity may be idiopathic or associated with an
underlying hereditary neuropathy, particularly Charcot-Marie-Tooth disease. In
a review of 148 patients who presented with bilateral cavovarus foot
deformity, Guille et al. found that 118 (80%) had Charcot-Marie-Tooth disease
as demonstrated by further neurological work-up. Thus, clinicians should have
a strong suspicion for this disease in a patient who presents with bilateral
cavovarus foot deformity.
Demographics and Growth Prediction
Vitale et al. analyzed discharge databases from New York and California
hospitals to better understand the distribution of spine deformity cases
treated by pediatric orthopaedic fellowship-trained surgeons and spine
found that more scoliosis surgery is being performed by surgeons with
pediatric fellowship training than by surgeons with spine fellowship training
in New York and that the number of procedures performed by pediatric
orthopaedic fellowship programs was four times that performed by spine
fellowship programs in California.
A prospective analysis of 324 girls with adolescent idiopathic scoliosis
determined that a risk factor for scoliotic curve progression was osteopenia
in the femoral neck on the side of the
et al. correlated the maturation of the hand phalanges with peak height
velocity and found that an uncapped phalangeal epiphysis indicated pre-peak
A study of 276 patients with adolescent idiopathic scoliosis by Sucato et
al. demonstrated that overweight patients have a greater risk of curve
progression and less successful results following orthotic treatment than do
patients who are not overweight. Moon et al. showed that the success of
bracing with a thoracolumbosacral orthosis improved when compliance with brace
wear increased and when orthotists were retrained (a success rate of 40% prior
to retraining compared with 81% after it). In a study of 365 patients who were
treated with a flexible bracing system, Rivard et al. demonstrated that 65% of
the curves were corrected, 31% were stabilized, and only 4% worsened.
Etiology of Adolescent Idiopathic Scoliosis
Considerable efforts to determine the genetic etiology of adolescent
idiopathic scoliosis continue. Wise et al. reported additional evidence to
support a role for the 8q region of chromosome 8, and Miller et al. suggested
that various regions on chromosome 17 may be involved in idiopathic scoliosis.
Using magnetic resonance imaging, Chu et al. demonstrated that patients with
severe scoliosis had a diminished spinal cord length, in relation to the
vertebral column length, when compared with patients who did not have
scoliosis or who had mild scoliosis. Kouwenhoven et al. reviewed computed
tomography images of normal individuals and found that 89% of them had
substantial axial plane rotation, which may set the stage for the development
Hedequist et al. reported that the use of allograft during fusion surgery
resulted in a low prevalence of pseudarthrosis (2.8%) and infection (0.9%). In
a study by Tsirikos and McMaster, rib anomalies were observed in 19.2% of
patients with congenital spine deformities and were most commonly seen in
patients with congenital scoliosis (especially those with a unilateral failure
of vertebral segmentation) and were less commonly seen in patients with
congenital kyphoscoliosis or
kyphosis6. Smith et
al. reported on the costotransversectomy approach for anterior and posterior
resection of a hemivertebra or for spinal osteotomy in the treatment of
congenital kyphosis in sixteen
patients7. On the
average, 31° of kyphosis correction was achieved.
Early-Onset Scoliosis and Thoracic Insufficiency
To better understand the normal thoracic dimensions, Emans et al. analyzed
the pelvic inlet width on computed tomography scans of healthy patients who
were less than twenty-one years of age, and they established gender-specific
reference ranges for spine and chest dimensions. Emans et al. also reported
their experience with the use of the vertical expandable prosthetic titanium
rib (VEPTR) in thirty-one patients who had thoracic insufficiency syndrome
associated with fused ribs. Control of the curvature of the thoracic spine
with continued growth was noted in thirty patients. The conclusion drawn from
this study was that VEPTR is a good technique for the right patient who has
chest wall deformity and scoliosis associated with fused ribs but attention to
detail, especially with respect to the soft tissues, is important. Campbell,
the developer of the VEPTR technique, reported on its use in sixteen patients
with progressive thoracic insufficiency. He found a decrease in scoliosis
(from 77° to 39°) and an improvement in the space available for the
lung, but there was only a modest improvement in the transverse dimension of
the chest. In a study of eighteen patients who had undergone thoracic fusion
before the age of eight years, Karol et al. found that eight had severe
restrictive pulmonary disease that was correlated with the percentage of
thoracic levels that were fused, the presence of rib deformity, and the
cephalad extent of the fusion.
In a multicenter study, Kishan et al. reported that the minimally invasive
thoracoscopic approach for the treatment of thoracic adolescent idiopathic
scoliosis resulted in improvement in forced vital capacity, forced expiratory
volume in one second, and total lung capacity at two years, whereas the open
thoracotomy approach led to decreases in these parameters. Kim et al. found a
significant (p = 0.015) decrease in selected pulmonary function values at two
years after open thoracotomy but not at two years after use of the
Thoracic Pedicle Screws in Scoliosis
The definition of severe scoliosis requiring anterior release may be
changing with the use of more powerful pedicle-screw techniques. A comparison
of patients in whom curves measuring between 70° and 100° had been
treated with either a posterior all-pedicle-screw construct or combined
anterior-posterior surgery demonstrated no difference in the amount of
thoracic coronal curve
similar finding was reported in a study in which forty-six patients who had
posterior instrumentation alone demonstrated a mean correction of 64% with
good outcome scores at two
years9. Kim et al.
evaluated the positions of thoracic pedicle screws on plain radiographs and
computed tomography scans to develop three plain radiographic criteria with
which to judge accurate placement of thoracic pedicle screws; these criteria
were a harmonious contour of the screws in the axial plane, no crossing of the
medial pedicle wall, and no violation of the midline of the vertebral
body10. This group
also reported decreases in thoracic kyphosis after treatment with thoracic
pedicle screws, but there was some increased cephalad junctional kyphosis and
loss of lumbar lordosis to maintain global sagittal balance. The superiority
of thoracic pedicle screws for correcting spinal deformity was challenged in a
study that compared twenty-five patients treated with a sublaminar wire
technique with twenty-five patients treated with thoracic pedicle screws and
demonstrated no difference in coronal plane correction or fusion
length11. A similar
conclusion was reached by Vora et al., who found that use of a hook-and-wire
construct resulted in better correction of the coronal plane deformity than
did pedicle screws when the preoperative flexibility of the curve was
considered. In a study of 203 patients selected to be treated with thoracic
fusion with thoracic pedicle screws, Suk et al. documented 69% thoracic curve
correction, with 66% correction of the segment of the spine not included in
the area of instrumentation, and coronal decompensation in 5% of the patients
at five years. Kuklo et al. reported that 96% of thoracic screws were placed
accurately and demonstrated an overall 68% correction of curves measuring
>90° without neurologic injury.
Use of modern posterior hybrid constructs for the surgical treatment of
scoliosis in patients with Marfan syndrome produces excellent results when the
fusion is extended to include the neutral and stable vertebrae, as reported by
De Silvestre et al. Milbrandt et al. reviewed a fifty-year experience with
treating scoliosis in patients with Down syndrome and reported an 8.7%
incidence of scoliosis. Treatment with a brace to prevent curve progression
was generally ineffective, and surgical treatment in seven patients was
associated with a high complication rate; however, only one reoperation was
required. In a long-term prospective follow-up study of eighty-two patients
with neuromuscular scoliosis who had undergone surgery, Larsson et al.
reported improvements in sitting and activities of daily living. They found
that patients who had been operated on at the age of twenty-one years or
younger had more improvement than those who had had the surgery later. Parent
et al. reported overall excellent results in seventy-two patients with spinal
muscular atrophy who had undergone spine fusion; life-threatening pulmonary
complications were avoided in all but one patient. Shah et al. used
multivariate analysis with logistic regression to demonstrate that intrathecal
baclofen therapy did not increase the risk of progressive scoliosis developing
in patients with cerebral palsy.
Gaines reviewed the results of L5 vertebrectomy for the surgical treatment
of fixed spondylolisthesis in thirty patients and demonstrated overall patient
satisfaction and good sagittal plane alignment; however, twenty-one patients
had a transient L5 nerve-root deficit, and two additional deficits were
permanent. In a long-term follow-up study comparing patients who had reduction
of a high-grade spondylolisthesis with those who had an in situ fusion,
Helenius et al. demonstrated better performance in nearly all measured
clinical parameters for patients with an in situ fusion.
Auerbach et al. evaluated 873 consecutive children who presented with back
pain without any positive findings on physical examination or any causes for
concern in their history. They found that a negative hyperextension test and
normal radiographic findings had a high predictive value (0.81) for the
diagnosis of mechanical back pain. This predictive value was increased to 0.94
when a negative bone scan was added, and the authors suggested that a bone
scan rather than a magnetic resonance imaging scan is the test of choice in
Spinal Cord Monitoring
Raynor et al. analyzed the utility of triggered electromyography when
placing lumbar pedicle screws and demonstrated an increasing probability of a
breach of the medial pedicle wall with decreasing triggered electromyographic
thresholds. One of us (D.J.S.) and colleagues reported that it was more
difficult to perform good baseline spinal cord monitoring when a neural axis
abnormality such as a syringomyelia was present. This resulted in a higher
rate of false-positive results compared with the rate for patients with
adolescent idiopathic scoliosis, but the monitoring still identified
Outcomes and Complications
Heddon et al. reported that 128 patients with adolescent idiopathic
scoliosis rated the appearance of their waist and their overall appearance
worse than their parents rated them. Richards et al. reported that 13.0% of
patients operated on for adolescent idiopathic scoliosis subsequently had at
least one reoperation, most commonly because of pain over the posterior
implants, pseudarthroses, or infection, and the prevalence was higher after
posterior surgery than after anterior surgery.
Playground accidents can result in fractures in children. In a study of
data from the Canadian Hospitals Injury Reporting and Prevention Program
database, Howard et al. identified 1092 children with fractures resulting from
playground accidents and found that falls from equipment were much more likely
to cause severe fractures than were falls from the child's height (odds ratio,
5.03). These data support further efforts to improve playground equipment
design, height, and surfaces.
Urgent débridement and fixation is commonly advocated for open
fractures in children. In a retrospective multicenter study of 554 open
fractures in 536 consecutive patients who were eighteen years old or younger,
Skaggs et al. found no difference in the infection rate between fractures
treated within six hours after the injury (twelve of 344) and those treated
after six hours (four of
advocated early antibiotic treatment with surgical débridement within
twenty-four hours after the injury.
Supracondylar Humeral Fractures
The standard management of completely displaced (type-3) supracondylar
humeral fractures in children is closed reduction and percutaneous pinning.
There is controversy about whether lateral entry pinning or combined medial
and lateral entry pinning is the optimal configuration. Lateral entry pinning
avoids the potential for iatrogenic ulnar nerve injury associated with the
placement of a medial pin, but it may provide less biomechanical stability.
One of us (M.S.K.) and colleagues performed a randomized clinical trial
comparing lateral entry with combined medial and lateral entry pinning of
type-3 supracondylar humeral fractures in fifty-one children. There was no
major loss of reduction or iatrogenic ulnar nerve injury in either group.
Thus, it was concluded that both techniques are effective and that attention
to proper technique is important. Lateral entry pins should engage both the
lateral and the central column of the distal part of the humerus. Medial
pinning was performed after lateral pinning with the elbow extended beyond
90°; a small medial incision was used to avoid the ulnar nerve.
Lateral Condylar Fractures
The management of cubitus valgus associated with an established nonunion of
the lateral condyle in children is difficult. Tien et al. described a
technique involving compression fixation of the lateral condylar nonunion and
a dome-shaped supracondylar osteotomy of the distal aspect of the humerus
through a single posterior incision; the operation resulted in successful
union and function in eight
Femoral Shaft Fractures
Flexible intramedullary nailing remains a popular method of fixation of
femoral shaft fractures in children. Mehlman et al. performed a study of 101
patients to determine the patient-related characteristics related to
complications of this method. They found that angular malunion was more likely
in patients who weighed >99 lb (45 kg) and who were more than twelve years
of age. Other treatment methods may be preferred for these heavier, older
Flexible intramedullary nails are usually routinely removed. In a study of
thirty-five children followed for a mean of three years after flexible nailing
and for whom nail removal was not routinely planned, Hoffinger et al. reported
that the nail had to be removed from seven patients because of lateral knee
pain. However, the remaining children had no symptoms and retained the
Wall et al. compared titanium nails with stainless-steel nails in
ninety-two children with a femoral shaft fracture and found no difference in
terms of complications, nonunions, or malunions. This suggests that
stainless-steel flexible nails are as effective as titanium flexible
Immediate application of a spica cast is the standard treatment for femoral
shaft fractures in children who are six years old or younger. However, spica
cast treatment has potential drawbacks. Willis et al. compared the results of
the use of a spica cast (seventeen patients) with those of flexible nailing
(fifteen patients) in a study of children with a femoral shaft fracture who
were between the ages of three and six years. They found a faster time to full
weight-bearing, full motion, and no limp in the group that had undergone the
flexible nailing. In addition, they found that those children missed fewer
days of school or daycare and had a lower rate of malunion. Mubarak et al.
drew attention to the potential disastrous complication of compartment
syndrome with the immediate use of a 90/90 spica cast for seven children.
Application of a short leg cast with a large amount of traction followed by
completion of the spica cast should be avoided.
The management of femoral shaft fractures in obese children is challenging.
Leet et al. studied the results of the treatment of 103 femoral fractures with
external fixation or a flexible intramedullary rod in
Complication rates after both treatment techniques were higher in the obese
and very heavy children.
Screws are frequently used for the management of Tillaux and triplane
fractures of the distal part of the tibia in adolescents. Charlton et al.
measured total force and peak contact pressures in adult and pediatric
cadaveric ankles before and after placement of a single 4.5-mm cannulated
screw in the distal tibial epiphysis. They found that screw placement led to
significant (p = 0.011) increases in ankle joint contact forces, which
normalized after screw removal. They hypothesized that the screw altered the
load-bearing properties of the distal part of the tibia, and they recommended
screw removal after union of these fractures.
Unicameral bone cyst is a common benign bone lesion in children that may
lead to pathologic fracture. Yandow et al. reported the results from a
multicenter bone cyst randomized clinical trial carried out through the
Pediatric Orthopaedic Society of North America (POSNA) clinical trials
network. In a group of forty-eight patients who had been followed for two
years, there was no significant difference in healing rates between those
treated with methylprednisolone injection (22%; five of twenty-three) and
those treated with bone-marrow injection (12%; three of twenty-five).
Dormans et al. reviewed their experience with the treatment of fourteen
children who had osteoblastoma. The mean age at the time of diagnosis was nine
years, and the lesions were most frequently seen in the lower extremities
(43%) or the spine (36%). The patients were treated with open incisional
biopsy and intralesional curettage, and those with a spinal lesion were also
treated with spinal fusion and instrumentation. The local recurrence rate was
28%, and all recurrences were in young children who were less than six years
Gait analysis studies have shown improvement following multilevel
orthopaedic surgery in children with cerebral palsy; however, it is unclear
whether these improvements result in changes in function and health-related
quality of life. One year after multilevel lower-extremity surgery in a series
of twentyfive children with cerebral palsy, Wren et al. found that gait
parameters were correlated with function and health-related quality-of-life
outcome measures, suggesting that gait analysis has criterion validity in
terms of outcomes assessment.
Botulinum toxin is often used as an adjunct to application of serial casts
for the management of contractures in children with cerebral palsy. In a
randomized clinical trial, Kay et al. compared the results of serial casts
alone with those of serial casts as well as botulinum toxin injections in
twenty-three children with cerebral palsy and fixed equinus
the basis of motion, spasticity, and gait parameters, the authors found that
botulinum toxin offered no additional benefit in the management of these
The optimal technique for lengthening of the Achilles tendon in patients
with cerebral palsy is controversial. Yen et al. performed a randomized
clinical trial of three different procedures (z-lengthening of the Achilles
tendon, Vulpius gastrocnemius recession, and percutaneous [Hoke] lengthening
of the Achilles tendon) in nineteen patients with spastic diplegia. They found
that all three procedures improved functional gait, but z-lengthening of the
Achilles tendon was the most effective in terms of maintenance of the initial
Hip flexion contracture is common in children with cerebral palsy who are
able to walk. Iliopsoas lengthening, in the context of multilevel
lower-extremity surgery, has been proposed to decrease this deformity and
improve function. Pirpiris et al. performed a randomized clinical trial
comparing iliopsoas lengthening with no lengthening in seventy-nine children
with cerebral palsy who were undergoing multilevel surgery. They found that
iliopsoas lengthening decreased static hip flexion contractures but did not
significantly alter the functional and health-related quality-of-life outcome
Hip subluxation and dislocation are common in spastic cerebral palsy.
Presedo et al. studied the results in sixty-five children with cerebral palsy
who had undergone open adductor tenotomy and psoas muscle recession or
iliopsoas tenotomy at a mean age of 4.4
years16. The mean
hip migration index changed from 34% preoperatively to 18% at a mean of 10.8
years postoperatively. Nineteen patients required subsequent osseous
reconstructive procedures, and eleven required repeat soft-tissue releases.
The migration percentage at one year postoperatively was the best predictor of
the final outcome, and patients who had been able to walk preoperatively had a
better long-term outcome.
The management of angular deformity of the leg in children with X-linked
hypophosphatemic rickets is controversial, with osteotomy being the most
frequently recommended procedure. In a study of hemiepiphysiodesis in nine
patients, Stevens and Novais reported complete correction in four patients,
partial correction in two patients, and no correction in three patients who
were noncompliant with medical instructions. They recommended
hemiepiphysiodesis in younger children (less than ten years old) who were
taking appropriate medication and had mild-to-moderate deformity.
The relationship between bone mineral density and the risk of fracture in
patients with osteogenesis imperfecta has not been established. Huang et al.
correlated low spine bone mineral density to an increased rate of fractures
and surgery in twenty patients with osteogenesis imperfecta.
Improving bone mineral density is a primary goal of the medical management
of these patients. Guarniero et al. randomized fifty-five patients with
osteogenesis imperfecta into three groups—no medication, treatment with
pamidronate, and treatment with alendronate—and measured bone mineral
density initially and at one year. Pamidronate, the newer bisphosphonate,
resulted in the greatest improvement in bone mineral density (19.7%).
While treatment of osteogenesis imperfecta has been directed at improving
bone mineral density, the effect of such an improvement on functional outcome
has not been elucidated. Huang et al. correlated bone mineral density to
functional outcome, as measured with the Pediatric Outcomes Data Collection
Instrument, in twenty-four consecutive children with osteogenesis imperfecta.
They found a significant (p = 0.025) positive relationship between bone
mineral density and physical function, including upper-extremity function,
transfers, sports, and global function.
Linden et al. performed a controlled intervention study of the effect of
exercise, for three years, on bone mineral density in healthy children.
Seventy-six boys and forty-eight girls who performed forty minutes of physical
activity every school day were compared with ninety-nine age and sexmatched
children who performed the standard physical activity regimen for sixty to
ninety minutes per week. At three years after the start of the intervention,
the boys had greater spine bone mineral density and the girls had greater
spine, total body, femoral neck, and leg bone mineral density than did the
controls. This suggests that increased time spent in physical activity during
childhood can result in lasting improvements in bone mineral density, which
may help avoid the development of osteoporosis.
Bone density decreases in children who cannot walk. Snyder et al. found
increased calcaneal bone mineral density in twelve nonambulatory children who
had been treated with a program that involved standing for two hours per day,
five days per week; however, the improvements diminished with noncompliance
with the program.
The Heuter-Volkmann principle of physeal growth states that longitudinal
growth is retarded by increased compressive forces. Ballock et al.
investigated the basic science of this principle in growth-plate chondrocytes
loaded in a static compression chamber. They found that compression of
growth-plate chondrocytes inhibited differentiation into hypertrophic cells by
suppressing the expression and activity of bone morphogenetic proteins in the
Hahn et al. compared the results of femoral and tibial lengthening by means
of the Ilizarov technique (twenty-eight cases) and those of the use of an
elongating intramedullary nail (twenty-three cases) in young adults. Following
treatment with the Ilizarov technique, there were seventeen excellent, eight
good, and three fair results. Following use of the elongating intramedullary
nail, there were nineteen excellent and four good results. The authors
concluded that the elongating nail was effective and had advantages in terms
of maintaining the range of motion, avoiding pin-track infection, and
improving patient convenience.
In a prospective study of fifty-three children who had undergone aspiration
because of an irritable hip, Caird et al. found that fever, an elevated
C-reactive protein level, an elevated erythrocyte sedimentation rate,
non-weight-bearing, and an elevated serum white blood-cell count were
predictors of septic
probability of septic arthritis was estimated to be 98% when five predictors
were present, 93% when four predictors were present, and 83% when three
predictors were present.
The recent emergence of community-acquired methicillin-resistant
Staphylococcus aureus as a cause of bone and joint infections in
children is alarming. Over a four-year period from 2000 through 2003 at the
Campbell Clinic in Memphis, Tennessee, Warner et al. found that twenty-seven
(26%) of 104 cases of acute hematogenous osteomyelitis or septic arthritis
involved methicillin-resistant Staphylococcus aureus, with 41% of the
cases in the last year of the study involving that organism.
Methicillin-resistant Staphylococcus aureus infections were much more
difficult to treat, with higher rates of subperiosteal abscesses, multiple
surgical procedures, longer hospital stays, and prolonged periods for which
blood cultures tested positive. The emergence of musculoskeletal infections
with methicillin-resistant Staphylococcus aureus in children has
major implications in terms of management: (1) initial antibiotic management
may need to be changed to clindamycin or vancomycin if the local prevalence of
methicillin-resistant Staphylococcus aureus is relatively high, (2)
aspiration of the bone or joint is imperative prior to the initiation of
treatment to identify methicillin-resistant Staphylococcus aureus,
and (3) patients with infection due to methicillin-resistant
Staphylococcus aureus likely need multiple surgical procedures and
prolonged intravenous antibiotics.
Fig. 1: AAOS and POSNA public service announcement promoting pediatric
At the 2005 POSNA annual meeting, the Distinguished Achievement Award was
given to Dr. Robert Hensinger, the Arthur H. Huene Memorial Award for
excellence and promise was given to Dr. Paul Sponseller, the Angela S.M. Kuo
Young Investigator Memorial Award for recognition of an outstanding young
investigator and to promote a long-term research career was given to Dr.
Jeffrey Shilt, and the St. Giles Young Investigator Award for educational or
research endeavors was given to Dr. James McCarthy.
The AAOS and POSNA collaborated to produce a public service announcement
promoting pediatric orthopaedics (Fig.
The editorial staff of The Journal reviewed a large number of
recently published research studies related to the musculoskeletal system that
received a Level of Evidence grade of I. Over 100 medical journals were
reviewed to identify these articles, which all have high-quality study design.
In addition to articles published previously in this journal or cited already
in this Update, six level-I articles were identified that were relevant to
pediatric orthopaedics. A list of those titles is appended to this review
after the standard bibliography. We have provided a brief commentary about
each of the articles to help to guide your further reading, in an
evidence-based fashion, in this subspecialty area.
American Academy of Pediatrics: Section on Orthopaedics October 7 through
10, 2006 Atlanta, Georgia.
Third International POSNA/AAOS Pediatric Orthopaedic Symposium November 29
through December 3, 2006 Orlando, Florida.
POSNA Specialty Day Meeting February 17, 2007 San Diego, California.
POSNA One Day Course: Upper Extremity May 22, 2007 Hollywood, Florida.
POSNA Annual Meeting May 23 through 26, 2007 Hollywood, Florida.
Lanou AJ, Berkow SE, Barnard ND. Calcium, dairy products, and bone
health in children and young adults: a reevaluation of the evidence.
These authors performed a quantitative synthesis of the literature
regarding dairy products and total dietary calcium and bone integrity in
children and young adults to assess whether there is evidence to support the
current recommended calcium intake levels and the suggestion that dairy
products are better for promoting bone integrity than other calcium-containing
food sources or supplements. The authors concluded that, in clinical,
longitudinal, retrospective, and cross-sectional studies, neither increased
consumption of dairy products specifically nor total dietary calcium
consumption has shown even a modestly consistent benefit for bone health in
children or young adults. Thus, there is scant evidence to support nutrition
guidelines focused specifically on increasing milk or other dairy product
intake for promoting bone health in children and adolescents.
West S, Andrews J, Bebbington A, Ennis O, Alderman P. Buckle
fractures of the distal radius are safely treated in a soft bandage: a
randomized prospective trial of bandage versus plaster cast. J Pediatr
Thirty-nine children with a buckle fracture of the distal part of the
radius were randomized to be treated with a plaster cast for four weeks or
with a soft bandage. There were no adverse events or skin problems in either
group. The soft bandage was removed by 83% of the patients in the first week
and by 100% by the second week. Care was simpler when the bandage was used.
The authors suggested that use of a conventional cast for buckle fractures may
be overtreatment and that a soft bandage may be appropriate.
Keppler P, Salem K, Schwarting B, Kinzl L. The effectiveness of
physiotherapy after operative treatment of supracondylar humeral fractures in
children. J Pediatr Orthop. 2005;25:314-6.
Forty-three children treated with open reduction and pinning of a
supracondylar humeral fracture were randomized to receive physical therapy or
no therapy after pin removal at four weeks. At twelve and eighteen weeks
post-operatively, the range of motion was greater in the physical therapy
group, but there was no difference in the range of motion at one year. The
results of this study are not generalizable to patients treated with closed
reduction and percutaneous pinning, as that method was not studied. Closed
reduction and pinning is the most common method of treatment for these
fractures, and physical therapy is usually not utilized after the pins and
cast are removed at three to four weeks. The results of this study suggest
that physical therapy may not be necessary after open reduction and pinning of
supracondylar humeral fractures. However, physical therapy may be of some
benefit for patients who had the limb immobilized for longer than four weeks
or for older patients.
Florentino-Pineda I, Thompson GH, Poe-Kochert C, Huang RP, Haber LL,
Blakemore LC. The effect of Amicar on perioperative blood loss in
idiopathic scoliosis: the results of a prospective, randomized double-blind
study. Spine. 2004;29:233-8.
Thirty-six patients with adolescent idiopathic scoliosis who underwent
posterior spinal fusion with instrumentation and autogenous iliac crest bone
graft were randomized to receive Amicar (aminocaproic acid) or saline
solution. Amicar inhibits activation of plasminogen to plasmin. Patients in
the Amicar group demonstrated a significant decrease in the perioperative
estimated blood-volume loss (41% compared with 47% in the control group) and
the need for autologous blood transfusion (1.0 compared with 1.7 autologous
units given). The decrease in blood loss was predominantly in the
postoperative suction drainage. The patients who took Amicar had no
intraoperative or postoperative thromboembolic complications. The results of
this study support the use of Amicar to decrease blood loss and the need for
transfusion after posterior spinal surgery in patients with adolescent
Caulton JM, Ward KA, Alsop CW, Dunn G, Adams JE, Mughal MZ. A
randomized controlled trial of standing programme on bone mineral density in
non-ambulant children with cerebral palsy. Arch Dis Child.
Twenty-six nonambulatory patients with cerebral palsy were randomized to be
treated with a program that involved increased standing, compared with
baseline, in an upright or semiprone standing frame for nine months or were
randomized to a control group, and bone mineral density was measured with
quantitative computerized tomography. After the treatment period, the median
standing duration was 80.5% and 140.6% of baseline in the control and
intervention groups, respectively. There was a significant (p = 0.040) (6%)
increase in vertebral bone mineral density in the intervention group. There
was no significant increase in proximal tibial bone mineral density. The
results of this study suggest that increasing the time that nonambulatory
patients with cerebral palsy stand may increase bone density, which may reduce
Piza G, Caja VL, Gonzalez-Viejo MA, Navarro A. Hydroxyapatite-coated
external-fixation pins. The effect on pin loosening and pin-track infection in
leg lengthening for short stature. J Bone Joint Surg Br.
Twenty-three patients underwent a total of twenty-eight bilateral
lower-extremity lengthening procedures with external fixators, and a total of
322 pins, because of short stature. The patients were randomized, by side, to
be treated with either hydroxyapatite-coated pins or non-hydroxyapatite-coated
pins. The mean implantation time was 530 days, and the mean lengthening
achieved was 78% of the initial bone length. The mean extraction torque was
7611.6 Nmm/deg for the hydroxyapatite-coated pins and 85.4 Nmm/deg for the
non-hydroxyapatite-coated pins. The rate of loosening was lower for the
hydroxyapatite-coated pins (4% compared with 80%). There was no significant
difference in the prevalence of pin-track infections. The results of this
study support the use of hydroxyapatite-coated pins during limblengthening
with external fixation.
Clohisy JC, Barrett SE, Gordon JE,
Delgado ED, Schoenecker PL. Periacetabular osteotomy for the treatment of
severe acetabular dysplasia. J Bone Joint Surg Am.
Kocher MS, Garg S, Micheli LJ. Physeal
sparing reconstruction of the anterior cruciate ligament in skeletally
immature prepubescent children and adolescents. J Bone Joint Surg
Park SS, Gordon JE, Luhmann SJ, Dobbs
MB, Schoenecker PL. Outcome of hemiepiphyseal stapling for late-onset tibia
vara. J Bone Joint Surg Am.
Vitale MA, Heyworth BE, Skaggs DL, Roye
DP Jr, Lipton CB, Vitale MG. Comparison of the volume of scoliosis surgery
between spine and pediatric orthopaedic fellowship-trained surgeons in New
York and California. J Bone Joint Surg Am.
Hung VW, Qin L, Cheung CS, Lam TP, Ng
BK, Tse YK, Guo X, Lee KM, Cheng JC. Osteopenia: a new prognostic factor of
curve progression in adolescent idiopathic scoliosis. J Bone Joint Surg
Tsirikos AI, McMaster MJ. Congenital
anomalies of the ribs and chest wall associated with congenital deformities of
the spine. J Bone Joint Surg Am.
Smith JT, Gollogly S, Dunn HK.
Simultaneous anterior-posterior approach through a costotransversectomy for
the treatment of congenital kyphosis and acquired kyphoscoliotic deformities.
J Bone Joint Surg Am.
Luhmann SJ, Lenke LG, Kim YJ, Bridwell
KH, Schootman M. Thoracic adolescent idiopathic scoliosis curves between 70
degrees and 100 degrees: is anterior release necessary? Spine.
Burton DC, Sama AA, Asher MA, Burke SW,
Boachie-Adjei O, Huang RC, Green DW, Rawlins BA. The treatment of large
(>70 degrees) thoracic idiopathic scoliosis curves with posterior
instrumentation and arthrodesis: when is anterior release indicated?
Kim YJ, Lenke LG, Cheh G, Riew KD.
Evaluation of pedicle screw placement in the deformed spine using
intraoperative plain radiographs: a comparison with computerized tomography.
Cheng I, Kim Y, Gupta MC, Bridwell KH,
Hurford RK, Lee SS, Theerajunyaporn T, Lenke LG. Apical sublaminar wires
versus pedicle screws—which provides better results for surgical
correction of adolescent idiopathic scoliosis? Spine.
Skaggs DL, Friend L, Alman B, Chambers
HG, Schmitz M, Leake B, Kay RM, Flynn JM. The effect of surgical delay on
acute infection following 554 open fractures in children. J Bone Joint
Surg Am. 2005;87:
Tien YC, Chen JC, Fu YC, Chih TT, Hunag
PJ, Wang GJ. Supracondylar dome osteotomy for cubitus valgus deformity
associated with a lateral condylar nonunion in children. J Bone Joint
Surg Am. 2005;87:
Leet AI, Pichard CP, Ain MC. Surgical
treatment of femoral fractures in obese children: does excessive body weight
increase the rate of complications? J Bone Joint Surg Am.
Kay RM, Rethlefsen SA, Fern-Buneo A,
Wren TA, Skaggs DL. Botulinum toxin as an adjunct to serial casting treatment
in children with cerebral palsy. J Bone Joint Surg Am.
Presedo A, Oh CW, Dabney KW, Miller F.
Soft-tissue releases to treat spastic hip subluxation in children with
cerebral palsy. J Bone Joint Surg Am.
Caird MS, Flynn JM, Leung YL, Millman
JE, D'Italia JG, Dormans JP. Factors distinguishing septic arthritis from
transient synovitis of the hip in children. A prospective study. J Bone
Joint Surg Am. 2006;88: