The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 94, Issue 4

Specialty Update | February 15, 2012

What's New in Pediatric Orthopaedic Surgery

Ira Zaltz, MD¹; Harish Hosalkar, MD²; Dennis Wenger, MD²

¹ Department of Orthopaedic Surgery, William Beaumont Hospital, 3601 West 13 Mile Road, Royal Oak, MI 48073. E-mail address for I. Zaltz: zaltzira@gmail.com
² Rady Children's Hospital, 3020 Children's Way, San Diego, CA 92123

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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.

J Bone Joint Surg Am, 2012 Feb 15;94(4):375-381. doi: 10.2106/JBJS.K.01370

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Deformity and Limb Lengthening

Current techniques for skeletal lengthening and correcting angular deformity require accurate methods for predicting limb-length discrepancies and criteria for assessing the practicality of limb preservation. Two institutional reviews of fibular deficiency will influence clinical decision-making. After reviewing forty-five patients from A.I. duPont/Nemours, Rodriguez-Ramirez et al.¹ found a high prevalence of associated limb anomalies in mild cases of fibular deficiency. The predicted percentage of limb-length discrepancy correlated with the Achterman-Kalamchi grade, a congenital short femur, and a ball-in-socket ankle. A thirty-year review from Texas Scottish Rite Hospital demonstrated that 85% of patients had associated femoral deformities and that 82% of the limb-length discrepancies remained proportional throughout growth². The majority of patients with feet having four or five rays underwent successful reconstruction, whereas fewer than half of the patients with three rays or fewer were candidates for limb lengthening. Sanders et al.³ evaluated two methods for predicting ultimate discrepancy in patients with limb-length inequality. When the Paley multiplier method was compared with the skeletal age and growth-remaining method, the multiplier method was more accurate until the age of twelve to sixteen years, after which the skeletal age method demonstrated superior predictability.

Children with limbs that cannot be reconstructed are candidates for treatment with amputation and prosthetic fitting. An analysis of seventy-three children with different amputation levels demonstrated no difference in walking velocity, oxygen consumption, or heart rate among children with a knee disarticulation, a transtibial amputation, or Syme amputation but showed significantly reduced walking speed, elevated heart rate, and increased energy consumption among children with higher-level amputations⁴.

Modulation of physeal growth with use of traditional Vitallium staples, metallic plates, or transphyseal screws is commonly used for correcting angular deformity in skeletally immature children. A Pediatric Orthopaedic Society of North America (POSNA) study suggested that the eight-plate guided-growth system is susceptible to mechanical failure at the screw-bone interface in the most obese patients (body mass index, >37) and suggested the use of solid screws or multiple plates in these at-risk individuals⁵. A Korean study comparing transphyseal screws with staples for guided growth suggested that these techniques are equivalent in terms of deformity correction, post-deformity maintenance of alignment, and rebound effect when the implants are removed prior to skeletal maturity⁶. Treatment with transphyseal screws requires smaller incisions and less postoperative pain medication⁶.

Basic Science

Insight into molecular mechanisms of physeal growth and bone formation as well as advances in genetic sequencing have stimulated clinically applicable studies. In one study, an established animal model of Legg-Calvé-Perthes disease was used to evaluate the combined administration of ibandronate and bone morphogenetic protein-2 (BMP-2)⁷. In previous studies, ibandronate preserved femoral architecture by inhibiting osteoclastic activity. The combined use of ibandronate and BMP-2 decreased the development of femoral deformity and stimulated new bone formation⁷. A second example is the identification of a mutation in MYH3, a gene that codes for the heavy chain of myosin, in a family with distal arthrogryposis. While a variety of syndromes associated with other MYH3 mutations are known, rapid genetic sequencing enabled the identification of this mutation in a family with distal arthrogryposis⁸.

Investigations into the relationship between mechanical stress and growth have advanced the understanding of physeal homeostasis. Surgical periosteal stripping has been used clinically to stimulate growth. Evidence for an inhibitory growth factor produced by periosteal tissue was established by an investigation on cultured periosteal and perichondral tissue⁹. Cells grown in cultures of increasing stiffness inhibited growth in embryonic physeal tissue. The inhibitory effect was abolished when cells were cultured with an inhibitor of actin microfilaments, suggesting that increased periosteal intracellular tension decreases physeal growth rates.

An elegant anatomic study investigated the pathogenesis of joint contractures following infant brachial plexus palsy¹⁰. While muscle excision without a brachial plexus injury did not produce joint contractures, sectioning the C5-C6 nerve root produced joint contractures associated with decreased cross-sectional area and longitudinal growth in affected muscles. Post-excision tissue culture of the affected muscles demonstrated continued myogenic potential. Thus, the authors established the importance of intact neurologic pathways for muscle growth and prevention of joint contracture.

Sports

With increasing participation in organized athletics, the evaluation and treatment of related sports injuries is a growing part of pediatric orthopaedic practice. A retrospective study of 124 skeletally immature patients with anterior cruciate ligament (ACL) reconstruction was undertaken to characterize meniscal pathology and magnetic resonance imaging (MRI) specificity¹¹. Meniscal injury was seen in 69% of patients, with lateral meniscal injuries being three times as frequent as medial meniscal or combined injuries. MRI was 58% sensitive and 91% specific for characterizing a meniscal tear. A similar retrospective MRI study on twenty patients with tibial eminence fractures demonstrated that 90% of patients had MRI evidence of a subchondral bruise and 40% had evidence of a meniscal tear, equally distributed between both menisci¹².

Reconstruction of the ACL in pediatric patients, especially prepubescent patients, has continued to challenge surgeons who balance the potential risk of physeal injury following surgical reconstruction with recurrent knee injury due to untreated knee laxity. The study by Shea et al.¹³, in which volumetric physeal damage was measured following anatomic “double-bundle” ACL reconstruction, illustrated the risk to the physis resulting from anatomic techniques used for ACL reconstruction. With the results expressed as a percentage of total physeal volume, the double-bundle technique was found to significantly increase the volume of physeal injury. Theoretically, physeal-sparing ACL reconstruction poses less risk to the physis. The outcomes for fifty-seven children with a mean age of 12.2 years at the time of surgery were reported following the use of the Clocheville technique¹⁴. This method utilizes the central patellar tendon with adjacent periosteum as graft, with intraepiphyseal tibial fixation and metaphyseal femoral fixation. Using multiple radiographic measurements on the distal part of the femur and proximal part of the tibia, the authors found no evidence of growth disturbance after a mean of 5.5 years. Lawrence et al.¹⁵ recently reported on an all-intraepiphyseal ACL reconstruction technique that enabled anatomic reconstruction in skeletally immature patients. Intraoperative computed tomography (CT) was used for tunnel localization, and fixation of the soft-tissue graft was achieved with all-intraepiphyseal interference screws. The three male patients in that initial report had no evidence of growth arrest and returned to sports.

Scoliosis and Spinal Deformity

The use of bracing for the treatment of scoliosis in children has been a controversial subject. A systematic review of the Cochrane Central Register of Controlled Trials found scant quality literature to suggest that bracing curbs curve progression¹⁶. The authors cited two studies suggesting that orthotic treatment is better than observation: a prospective cohort involving 286 female patients and a randomized controlled trial involving forty-three female patients. A subsequent prospective cohort study involving 100 female patients that involved the use of heat sensors to track hours of brace use demonstrated a dose-response relationship between brace use and progression requiring surgery, especially for Risser-0 and 1 subjects. Curve progression was halted in 82% of brace wearers, compared with 315 of poor brace wearers, with “poor” brace wear defined as less than seven hours of brace wear per day¹⁷.

The past year has seen many publications from sponsored multicenter spine study groups that represent large patient cohorts. The indications for MRI in patients with presumed juvenile and adolescent idiopathic scoliosis are controversial. Two reports from the Spinal Deformity Study Group may assist the clinician when contemplating neural imaging for scoliotic children. In a multicenter prospective series, 923 of 2206 patients presenting for scoliosis surgery underwent MRI¹⁸. Thirty-nine patients (4.2%) had neural MRI abnormalities, including syringomyelia (twenty-six), Chiari malformation (twelve), and a tethered cord (one). Thoracic hyperkyphosis and juvenile-onset scoliosis were associated with the highest frequency of neural abnormalities. In a related study evaluating factors associated with a positive MRI in patients presenting with right thoracic (Lenke type-1 through 4) deformities, thirty-six of 529 patients had neural abnormalities on preoperative MRI screening¹⁹. Comparative analysis showed that patients with increased thoracic rotation and hyperkyphosis were at highest risk for a neural abnormality.

Spinal fusion techniques have evolved over the past decade, and the opportunity to employ increasingly powerful fixation devices enabling greater deformity correction has necessitated critical evaluation. In a study involving 385 children with Lenke type-1 curves, the 15% of patients with the most correction were compared with the 15% of patients with the least correction²⁰. The authors found that there was less residual lumbar deformity, improved coronal plane balance, and less restoration of thoracic kyphosis in the high-correction group; however, no difference was noted between the two groups in terms of Scoliosis Research Society (SRS) scores. Sanders et al.²¹, in a study of 171 patients, evaluated the relationship between the number of fixation points and curve correction. The authors found that that absolute curve correction was best in patients who were managed with multiple fixation points, with no difference between all pedicle screws or pedicle screws with wires. There was a trend toward improved SRS scores in patients managed with multiple fixation points.

Deidentified patient information from the SRS Morbidity and Mortality database was analyzed for complications reported between 2004 and 2007²². Nineteen thousand, three hundred and sixty cases were reported. Patients with neuromuscular scoliosis had the highest complication rate (17.9%). The rates of neurological deficit varied depending on curve type, with the highest rate among patients with congenital scoliosis (2%) and the lowest rate among those with idiopathic scoliosis (0.8%). Another study from the same database evaluated complication rates following the surgical treatment of isthmic and dysplastic spondylolisthesis²³. The overall complication rate, based on 605 cases, was 10.9%. Although 50% of patients presented with neurologic signs and symptoms, a new postoperative neurological deficit was the most common complication, occurring in 5% of patients.

Pediatric Hip

Developmental Dysplasia of the Hip

The use of a Pavlik harness for the treatment of hips with a positive Ortolani sign is not always successful. White et al.²⁴ reviewed the ultrasound findings for eighty-five patients (115 hips) with an age of less than six months who were managed with a Pavlik harness for the treatment of developmental dysplasia of the hip from 1991 to 2005 at a single institution. The inclusion criteria were dislocated but reducible hip, treatment with a Pavlik harness, and an ultrasound evaluation that was performed within four weeks after treatment initiation. Pavlik harness treatment was successful for seventy-two hips (63%) and unsuccessful for forty-three hips (37%). On ultrasound evaluation, an increased beta angle, decreased femoral head coverage, an inverted labrum, decreased superior femoral head displacement relative to the labrum, and decreased total femoral head displacement were significantly correlated with Pavlik harness failure. Two new objective static ultrasound measurements associated with Pavlik harness treatment outcome were described. A femoral head positioned below the labrum was strongly associated with success, whereas a femoral head located substantially superior and lateral to the labrum was associated with failure. The authors suggested that a deficient cartilaginous anlage and an inverted labrum may be a setup for Pavlik harness failure.

Transient femoral nerve palsy is a potential complication associated with the use of a Pavlik harness for the treatment of developmental dysplasia of the hip. Murnaghan et al.²⁵ performed a retrospective review of infants who were managed with a Pavlik harness for the treatment for developmental dysplasia of the hip from 1992 to 2008. Thirty cases of femoral nerve palsy were identified among 1218 patients, for a prevalence of 2.5%. Eighty-seven percent of femoral nerve palsies presented within one week after the application of the Pavlik harness. Femoral nerve palsy was more likely in older, larger patients in whom developmental dysplasia was more severe. Patients in whom femoral nerve palsy resolved within three days had a 70% chance of successful Pavlik harness treatment, whereas those in whom it did not resolve by ten days had a 70% chance of failure of Pavlik harness treatment. The rate of successful Pavlik harness treatment was 94% in the control group and 47% in the femoral nerve palsy group. Femoral nerve palsy is strongly predictive of the failure of Pavlik harness treatment, and its impact is greatest when developmental dysplasia of the hip is more severe.

Legg-Calvé-Perthes Disease

Proximal femoral varus osteotomy is an established treatment for Legg-Calvé-Perthes disease; however, the degree of varus that optimizes the subsequent remodeling of femoral head shape and sphericity is not defined.

Kim et al.²⁶ reported the results for fifty-two patients who were managed with proximal femoral varus osteotomy. Preoperative, postoperative, and most recent follow-up femoral neck-shaft angles were measured and correlated with the Stulberg outcome²⁷. All patients were at least six years old at the time of surgery and were skeletally mature at the time of the latest follow-up. The mean neck-shaft angle was 138° ± 7° preoperatively and 115° ± 11° postoperatively, with a mean varus change of 23° ± 10°. For the lateral pillar B group²⁸, the authors noted a significant positive relationship between a higher postoperative neck-shaft angle and a Stulberg class-I or II outcome (p = 0.025), concluding that greater varus angulation does not produce a better Stulberg grade. They recommend only 10° to 15° of varus correction when performing a varus femoral osteotomy in the early stages of Legg-Calvé-Perthes disease.

Although surgical containment of the femoral head within the acetabulum is traditionally a mainstay in the treatment of Legg-Calvé-Perthes disease, traditional surgical procedures (varus osteotomy, Salter osteotomy) have limitations, including prolonged limp or inadequate containment.

Wenger et al.²⁹ reported the results of triple pelvic osteotomy for femoral head containment in a study of thirty-nine children (forty hips) ranging from five to thirteen years of age who had lateral pillar B (53%) or lateral pillar C (48%) involvement. Radiographs that were made at the time of the latest follow-up (minimum, three years) were assessed with use of the modified Stulberg system. Four patients required further treatment before the time of the latest follow-up. At the time of the latest follow-up, 42% of the patients had a good outcome (Stulberg I or II), 47% had a fair outcome (Stulberg III), and 11% had a poor outcome. Triple pelvic osteotomy resulted in maintenance of femoral head shape in lateral-pillar-B patients of all ages and in younger lateral-pillar-C patients. The results were less predictable in lateral-pillar-C patients over the age of eight years.

Trauma

Emergency room physicians commonly provide definitive care for children with simple closed fractures. Khan et al.³⁰ conducted a prospective, randomized trial to determine the difference in terms of the length of stay in the emergency department and the need for repeat intervention to restore alignment after distal forearm fracture reduction by pediatric emergency physicians as compared with postgraduate-year-three or postgraduate-year-four orthopaedic residents. A blinded attending pediatric orthopaedic surgeon evaluated prereduction, postreduction, and follow-up radiographs. Fifty-two children (mean age, 9.1 years) were managed by emergency physicians, and fifty-one children (mean age, 9.7 years) were managed by orthopaedic residents. The length of stay in the emergency department and clinical outcomes following closed reduction of forearm fractures were comparable between patients managed by trained pediatric emergency physicians and those managed by orthopaedic residents.

Minimally angulated fractures of the distal part of the radius are common in children and usually have excellent outcomes. Boutis et al.³¹ conducted a randomized controlled trial to determine whether the use of a prefabricated splint is as effective as a cast in terms of the recovery of physical function after these radial fractures. Ninety-six children with an age of five to twelve years who had a minimally angulated (≤15°) greenstick or transverse radial fracture were randomized to receive either a prefabricated wrist splint or a short arm cast for four weeks. Physical function was evaluated at six weeks with use of the performance version of the Activities Scale for Kids. In addition, the degree of bone angulation, wrist motion, grip strength, and complications were recorded. The authors concluded that minimally angulated distal radial fractures are equivalently treated with use of a splint or cast when recovery of physical function, maintenance of fracture stability, and occurrence of complications are measured.

Fracture of the femoral shaft is a common injury in the pediatric population. Rigid, locked, intramedullary nailing allows for early mobilization and is usually reserved for older children and adolescents. MacNeil et al.³² conducted a systematic review to elucidate the effects of nail entry site on the risk of osteonecrosis of the femoral head. The English-language medical literature was searched, and nineteen of 1277 articles met the inclusion criteria. The prevalence of osteonecrosis was 2% when the piriformis fossa was used as the nail entry point and 1.4% when the greater trochanter was used as the entry point. No osteonecrosis was reported when the lateral aspect of the greater trochanter was used as entry point. The authors concluded that the lateral trochanter entry for rigid, locked intramedullary nailing has the lowest risk for osteonecrosis when treating pediatric femoral fractures.

Upper Extremity

Botulinum toxin A is used to treat contractures in children with spasticity by temporarily interfering with neural transmission at the motor end plate. In infants with brachial plexus palsy in whom neurologic recovery is evolving and spasticity is not a component, posterior shoulder subluxation and dislocation is caused by muscle imbalance. Ezaki et al.³³ postulated that temporary weakening of the shoulder internal rotator muscles with use of botulinum toxin A would facilitate reduction of the glenohumeral joint in infants with early posterior glenohumeral subluxation or dislocation. Thirty-five infants with brachial plexopathy and posterior glenohumeral subluxation or dislocation were managed with botulinum toxin A and were followed for at least one year. The average age at the time of shoulder reduction and botulinum toxin-A injection was 5.7 months. Six patients had two injections. Reduction of the shoulder was maintained in twenty-four patients (69%), and there were no reported complications. The authors concluded that botulinum toxin-A injection into the internal rotator muscles is a useful adjunct for treating early posterior glenohumeral subluxation or dislocation and may help to reduce the need for later open surgical procedures to restore or maintain glenohumeral joint reduction.

Functional outcomes following single-event multilevel surgery of the upper extremity for children with cerebral palsy have not been well described. In the study by Smitherman et al.³⁴, forty children with hemiplegic cerebral palsy who underwent upper-extremity single-event multilevel surgery were compared with twenty-six children who did not receive any upper-extremity interventions. On the basis of Shriners Hospital for Children Upper Extremity Evaluation, the authors concluded that single-event multilevel surgery significantly improved dynamic segmental alignment and, to a lesser degree, spontaneous use of the upper extremity in comparison with nonoperative treatment.

Infection

Differentiating between septic arthritis and transient synovitis of the hip in children can be difficult. In 1999, Kocher et al.³⁵ introduced four clinical predictors that were highly predictive (99.6%) of septic arthritis if all four were present. These included a temperature of ≥38.5°C, an inability to bear weight, a white blood-cell count of >12.0 × 100⁹ cells/L, and an erythrocyte sedimentation rate of ≥40 mm/hr. A C-reactive protein level of ≥20 mg/L was added later as a fifth predictor. Sultan and Hughes³⁶ retrospectively evaluated these predictors to differentiate septic arthritis from transient synovitis in children over a four-year period in a primary referral general hospital. When all five predictors were present, the predicted probability of septic arthritis was only 59.9%, with fever being the best predictor. When applied to low-prevalence diseases, even highly specific tests yield a high number of false-positive results and the predictive value is thereby diminished. The authors concluded that clinical predictors should be applied with caution when assessing a child with an irritable hip and emphasized that a high index of suspicion and close observation of at-risk patients should be maintained.

Lyme disease in children can present with joint effusion. To identify clinical factors that are useful for differentiating Lyme arthritis from septic arthritis at the time of the initial presentation, Milewski et al.³⁷ conducted a study to evaluate the prevalence of Lyme arthritis in children who had a joint aspiration at a tertiary care children's hospital in an endemic area. Of 506 patients who underwent joint aspiration, 391 met the inclusion criteria and, of those, 123 (31%) were subsequently diagnosed with Lyme arthritis. Fifty-one patients had culture-positive septic arthritis. The authors concluded that for any child presenting with a joint effusion in a Lyme-endemic area of the Northeastern United States, the likely prevalence of Lyme arthritis is 31% overall and 45% in the presence of knee effusion. Children with joint effusions resulting from Lyme disease are more likely to have knee involvement, a lower peripheral white blood-cell count, and a lower joint fluid cell count, and they are less likely to have fever or complete refusal to bear weight, when compared with children with septic arthritis. The erythrocyte sedimentation rate and the C-reactive protein level were not significantly different. Multivariate analysis demonstrated that refusal to bear weight was the strongest predictor of septic arthritis over Lyme arthritis.

Neuromuscular

Physical examination tests are commonly used to measure hip flexion contracture in patients with cerebral palsy who are able to walk. Lee et al.³⁸ studied the reliability of these measurements and their correlation with gait parameters. Thirty-six consecutive patients (twenty-two male and fourteen female patients) with a mean age of 9.8 years who had cerebral palsy (level I, II, or III on the Gross Motor Function Classification System) and thirty-seven children without cerebral palsy with a mean age of 10.0 years were prospectively enrolled in this study. Hip flexion contracture was determined with three physical examination tests: the Thomas test, the prone hip extension test (the Staheli test), and the hamstring shift test. Three-dimensional gait analysis was performed for all subjects. The Thomas test showed the highest intraclass correlation coefficient (0.501 in patients and 0.207 in controls) and the smallest mean absolute difference (5.8° in patients and 1.2° in controls). The Staheli test was found to be the most valid method in the patient group (r = 0.568 with the hip flexor index), whereas the Thomas test was the most valid in the control group (r = 0.526 with maximum hip extension in stance and r = 0.532 with the hip flexor index). The hamstring shift test had the lowest intraclass correlation coefficient and the lowest convergent validity.

Increased femoral anteversion and coxa valga are common in patients with cerebral palsy. Chung et al.³⁹ conducted a study to determine the validity and reliability of the methods that are commonly used to measure proximal femoral geometry. Thirty-six consecutive patients (mean age, 11.0 years) with cerebral palsy were enrolled. The validity and interobserver reliability of the physical examinations performed by three examiners were determined by comparing the results of a trochanteric prominence angle test, hip internal rotation measurements, and hip external rotation measurements (all with the patient in the prone position) with the amount of femoral anteversion on two-dimensional computed tomography. Validity and intraobserver and interobserver reliability were assessed by comparing the neck-shaft angle on the anteroposterior internal rotation radiograph of the hips with that on the multiplanar reformatted computed tomographic image. The trochanteric prominence angle test showed excellent concurrent validity (r = 0.862, p < 0.001) and reliability (intraclass correlation coefficient, 0.809). Hip internal rotation also showed good concurrent validity (r = 0.787, p < 0.001) and excellent reliability (intraclass correlation coefficient, 0.889), whereas hip external rotation appeared to be unsuitable for predicting femoral anteversion. The neck-shaft angle on the anteroposterior internal rotation radiograph of the hips showed excellent concurrent validity (r = 0.892, p < 0.001) and reliability (intraclass correlation coefficient, 0.912). The authors concluded that physical examination for determining femoral anteversion and the neck-shaft angle as measured on the internal rotation radiograph of the hips appear to be clinically relevant methods for evaluating the proximal femoral geometry and version in patients with cerebral palsy. Computed tomographic examination can probably be replaced by physical examination and an anteroposterior internal rotation radiograph of the hips to determine femoral version in ambulatory patients with stable hips.

Single-event multilevel surgery is considered the standard of care to improve gait and functioning of children with diplegic spastic cerebral palsy. Thomason et al.⁴⁰ presented a randomized controlled trial of single-event multilevel surgery in children with spastic diplegia. Nineteen children with spastic diplegia were studied. Eleven children were randomized to the surgery group, and eight were randomized to the control group. The control group underwent a program of progressive resistance strength training. The randomized phase of the trial concluded at twelve months. The control group then exited the study and progressed to surgery, whereas the surgery group continued to be followed in a prospective cohort study. The primary outcome measures were the Gait Profile Score (GPS) and the Gillette Gait Index (GGI). Secondary outcome measures were gross motor function (Gross Motor Function Measure-66 [GMFM-66]), functional mobility (Functional Mobility Scale [FMS]), time spent in the upright position, and health-related quality of life (Child Health Questionnaire [CHQ]). A total of eighty-five surgical procedures were performed, with a mean (and standard deviation) of 8 ± 4 procedures per child. The surgery group had a 34% improvement in the GPS and a 57% improvement in the GGI at twelve months. The control group had a small, nonsignificant deterioration in both indices. On the basis of the results of the study, the authors concluded that single-event multilevel surgery improves the gait of children with spastic diplegic cerebral palsy when evaluated twelve months after surgery. Improvements in other domains, including gross motor function and quality of life, were not observed until twenty-four months after surgery.

Tumor

The decision to treat benign skeletal lesions surgically can be difficult. Leong et al.⁴¹ prospectively studied a group of children with a benign appendicular skeletal lesion between 2002 and 2007. The resistance of the affected bone to compressive, bending, and torsional loads was calculated with rigidity analysis performed with the use of serial transaxial quantitative computed tomography data obtained along the length of the bone containing the lesion and from homologous cross sections through the contralateral, normal bone. At each cross section, the ratio of the structural rigidity of the affected bone to that of the normal, contralateral bone was determined. Forty-one patients who had not received surgical treatment for the skeletal lesion were studied. Thirty-four (83%) of these individuals completed the activity questionnaire at least two years after the quantitative computed tomography-based rigidity analysis. None of the patients for whom no increased fracture risk had been predicted by the rigidity analysis sustained a fracture, although they had not received surgical treatment. The authors concluded that quantitative computed tomography-based rigidity analysis is more specific (97% specificity) than criteria based on radiographs (12% specificity) for predicting the risk of a pathologic fracture as fracture risk indices based on lesion size alone fail to account for the compensatory remodeling of the host bone that occurs in response to the presence of the lesion in a growing child.

Foot and Ankle

Congenital vertical talus is a fixed dorsal dislocation of the talonavicular joint and fixed equinus contracture of the hindfoot causing a rigid deformity that is recognizable at birth. The etiology and epidemiology of this condition are largely unknown, but some evidence suggests it relates to aberrations of skeletal muscle. Merrill et al.⁴² identified associated congenital anomalies and genetic abnormalities in sixty-one patients affected with vertical talus. They obtained abductor hallucis muscle biopsy specimens from the affected limbs of eleven of the sixty-one patients and compared the histopathologic characteristics with those of age-matched control subjects. All muscle biopsy specimens (n = 11) had abnormalities in comparison with those from control subjects, including combinations of abnormal variation in muscle fiber size (n = 7), type-I muscle fiber smallness (n = 6), and abnormal fiber type predominance (n = 5). Isolated vertical talus occurred in twenty-three (38%) of the sixty-one patients, whereas the remaining thirty-eight patients had associated nervous system, musculoskeletal system, and/or genetic and genomic abnormalities. Chromosomal abnormalities, all complete or partial trisomy conditions, were identified in three patients with vertical talus who had additional congenital abnormalities. The authors concluded that abnormal skeletal muscle biopsies are common in patients with vertical talus, although it is unclear whether this muscle abnormality is primary or secondary to the joint deformity. Associated anomalies are present in 62% of all cases.

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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.

Topics

legg-perthes disease ; pediatrics ; scoliosis

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Ira Zaltz, Harish Hosalkar, Dennis Wenger; What's New in Pediatric Orthopaedic Surgery. The Journal of Bone & Joint Surgery. 2012 Feb;94(4):375-381.

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