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What's New in Pediatric Orthopaedics

Young-Jo Kim and Kenneth J. Noonan
J Bone Joint Surg Am. 2009;91:743-751. doi:10.2106/JBJS.H.01689

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The Journal of Bone and Joint Surgery
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C OPYRIGHT Ó 2009 BY T HE J OURNAL
Specialty Update
What’s New in Pediatric Orthopaedics
By Young-Jo Kim, MD, PhD, and Kenneth J. Noonan, MD
Upper Extremity
The epidemiology, treatment, and outcome assessment of
neonatal brachial plexus palsy continue to be refined. Foad
et al.1 analyzed the Kids’ Inpatient Database from 1997, 2000,
and 2003 to determine the incidence of neonatal brachial
plexus palsy in the United States and additionally to determine
the risk factors associated with brachial plexus palsy. In the
United States, the incidence was at least 1.51 ± 0.02 cases per
1000 live births, but it decreased over the study period. The
identified risk factors were shoulder dystocia (100 times in-
creased risk), exceptionally large birth weight (4.5 kg) (four-
teen times increased risk), and forceps delivery (nine times
increased risk). On the other hand, twin or multiple births and
cesarean section delivery appeared to have a protective effect.
There appeared to be other unknown factors that influenced
the incidence of brachial plexus palsy as only 46% of all chil-
dren with this condition had one or more of these risk factors.
In fact, 56% of brachial plexus palsies were not associated with
a difficult delivery. Finally, the only reliable predictor of
shoulder dystocia was a previous episode of shoulder dystocia
in the mother.
The treatment paradigm for brachial plexus birth palsy
continues to evolve. In addition to restoring function with
surgical techniques such as microsurgical nerve reconstruction,
soft-tissue release, tendon transfers, and humeral osteotomy, it
is becoming increasingly clear that, in order to achieve a good
long-term outcome, joint stability and integrity may need to be
maintained. With use of magnetic resonance imaging or com-
puted tomography scans, Waters and Bae2 demonstrated that,
in patients with preexisting glenoid deformity, appropriately
timed open reduction of the glenohumeral joint combined
with musculotendinous lengthenings and tendon transfers can
remodel the glenoid version and humeral head subluxation. As
expected, this improvement in joint morphology was also as-
Specialty Update has been developed in collaboration with the Council of
Musculoskeletal Specialty Societies (COMSS) of the American Academy of
Orthopaedic Surgeons.
Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. One or more of the
authors, or a member of his or her immediate family, received, in any one year, payments or other benefits in excess of $10,000 or a commitment or
agreement to provide such benefits from a commercial entity (Biomet).
J Bone Joint Surg Am. 2009;91:743-51 d doi:10.2106/JBJS.H.01689
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OF B ONE AND J OINT S URGERY, I NCORPORATED
sociated with improved clinical outcomes. Whether this im-
provement in joint morphology will lead to improved outcomes
over the long term remains to be demonstrated.
Pediatric trigger thumb is a common upper extremity
disorder. Definitive treatment of this condition is often opera-
tive, especially in patients older than three years of age, because
of concerns regarding persistent contractures. The rate of
spontaneous resolution of this condition is variable, but it has
been noted to be higher when the condition presents at birth.
Baek et al.3 prospectively followed seventy-one thumbs in fifty-
three children over a course of two to twelve years with use of
serial examinations. The median age of this cohort was twenty-
three months at the time of the initial visit. The authors
demonstrated that the condition resolved spontaneously in
63% of the thumbs, with the median time from the initial visit
to resolution being forty-eight months. Furthermore, even in
thumbs in which the condition did not spontaneously fully
resolve, the flexion deformity appeared to decrease over time.
That study provides data that may be useful when the options
of operative and nonoperative treatment of pediatric trigger
thumb are discussed with the family.
Hip
In the adult population with acetabular dysplasia, there often is
no childhood history of developmental dysplasia of the hip. This
raises the questions of how and when these cases of occult
dysplasia develop. Song et al.4 retrospectively reviewed all ra-
diographs of children who were managed for developmental
dysplasia of the hip in infancy and were followed until matu-
rity. The prevalence of bilateral infant developmental dysplasia
of the hip was 42%. Of the contralateral hips that did not have
contralateral dysplasia during infancy, 40% had evidence of
mild acetabular dysplasia at maturity. It appears that in pa-
tients with developmental dysplasia of the hip, the contralat-
eral hip that does not have any radiographic evidence of
dysplasia in infancy is still at some risk for the development of
mild acetabular dysplasia in adulthood. This suggests that there
may be some developmental factors in adolescence responsible
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for the development of mild acetabular dysplasia. When adult
acetabular dysplasia becomes symptomatic, the treatment
options are a pelvic osteotomy or an arthroplasty. Although
not well studied, nonoperative therapy appears to be ineffec-
tive. In this context, Sharifi et al.5 analyzed the cost-effectiveness
of periacetabular osteotomy as compared with arthroplasty for
the treatment of hip dysplasia. The authors found that for
Tönnis grade-1 hips (those with minimum radiographic evi-
dence of osteoarthritis), the periacetabular osteotomy was
cost-effective if the hip survived 5.5 years and cost-saving if it
survived 10.8 years. Sensitivity analysis further demonstrated
that periacetabular osteotomy was the preferred treatment in
all tested scenarios. For Tönnis grade-2 hips (those with
moderate joint-space narrowing), the osteotomy became cost-
effective after 18.25 years. These findings highlight the im-
portance of careful counseling and patient selection, especially
in cases in which the patient has some radiographic evidence of
arthritis of the hip.
In the treatment of slipped capital femoral epiphysis, the
role of prophylactic pinning of the contralateral side remains
controversial. Yildirim et al.6, in a study of 227 patients with a
unilateral slipped capital femoral epiphysis, characterized the
complications resulting from a contralateral slipped capital
femoral epiphysis. The authors noted that 36% of the patients
had development of a contralateral slipped capital femoral
epiphysis within a mean of 6.5 months. Of the eighty-two
contralateral slips, eighteen were of moderate to severe severity
and five were associated with the development of osteonecrosis
or chondrolysis. All hips that had development of chondrolysis
had a severe slipped capital femoral epiphysis, and the one hip
that had development of osteonecrosis was unstable. Fur-
thermore, the average age of the patients who had develop-
ment of a contralateral slipped capital femoral epiphysis was
significantly lower than that of the patients who did not (11.2
compared with thirteen years). All of these data appear to be
consistent with information already in the literature. More
importantly, and very rationally, the authors utilized the data
in combination with prior decision analysis regarding pro-
phylactic pinning and concluded that for their population,
prophylactic pinning of the contralateral hip was warranted.
Legg-Calvé-Perthes disease remains a challenging con-
dition to treat. It is generally agreed that hinge abduction in
patients with this disease is associated with a poor prognosis.
However, a clear radiographic definition has been elusive.
A definition of hinge abduction should include two criteria:
widening of the medial joint space in abduction and impinge-
ment of the deformed femoral head onto the lateral lip of the
acetabulum in abduction. Nakamura et al.7 attempted to refine
the definition of hinge abduction by using quantitative mea-
sures such as a subluxation index and an impingement sign.
Although that study did not document the inter-rater and
intra-rater variability of this definition of hinge abduction, this
study is a first step toward an improved definition of this often
used radiographic sign. The treatment of hinge abduction in
W H AT ’ S N E W IN P E D I AT R I C O R T H O PA E D I C S
patients with Legg-Calvé-Perthes disease continues to be var-
iable and ranges from shelf arthroplasty to valgus osteotomy to
cheilectomy. This variability is somewhat due to varying
treatment goals and varying stages of the disease. In an un-
controlled cohort study, Freeman et al.8 demonstrated that
when some remodeling potential is still present in the femoral
head, shelf arthroplasty can be effective for achieving improved
radiographic metrics. In the older population with hinge ab-
duction, valgus osteotomy appears to be effective for im-
proving patient outcomes9. Legg-Calvé-Perthes disease
remains a subject of much controversy that demands more
precise disease staging and improved noninvasive imaging
tools to follow shape changes in both the cartilaginous and
osseous components of the hip joint in the early phase.
Lower Extremity and Sports
Self-reported outcome instruments, including generic health
surveys such as the Short Form-36 (SF-36), are increasingly
being used to assess the outcome of our surgical interventions.
Huffman et al.10 demonstrated that the normative SF-36 values
for intercollegiate athletes differ from the age and sex-matched
normative values for the general population. That study fur-
ther highlighted the bias that may be present if only the
postoperative outcome metrics are used in isolation. If in-
struments such as the SF-36 are to be used, having preopera-
tive and postoperative values is essential. Furthermore, the
appropriate normative values must be used for comparison.
The indications for hip arthroscopy continue to broaden
as the technique improves. Philippon et al.11 reported on a small
series of young patients (age range, eleven to sixteen years)
who underwent arthroscopic treatment of femoroacetabular
impingement. In addition to soft-tissue débridement such as
labral resection and chondroplasty, osseous débridement of the
acetabular rim and femoral head-neck junction was per-
formed. The authors reported significantly improved out-
comes in this nonrandomized uncontrolled cohort study.
Unlike the adult population, there were no cases of end-stage
full-thickness loss (Outerbridge grade-IV) chondromalacia
that required microfracture. However, trimming of the ace-
tabular rim with detachment and refixation of the labrum was
performed in fourteen of sixteen patients. The original indi-
cation for labral takedown and acetabular rim trimming was to
treat acetabular overcoverage in the presence of cartilage de-
lamination at the labral-chondral junction. With the recent
improvements in arthroscopic technique, the indications for
many of these arthroscopic procedures such as acetabular rim
resection are being broadened. A larger randomized study is
truly needed to sort out the importance of simple soft-tissue
débridement as opposed to combined soft-tissue and osseous
débridement in these hips. However, it is becoming clear that,
as is the case in the knee, athletic injury can lead to early
chondral damage even in the adolescent hip.
Acute patellar dislocations are common in the pediatric
and adolescent age groups. Palmu et al.12 compared the efficacy
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of operative and nonoperative treatment of this condition in a
prospective randomized clinical trial. Over a two-year enroll-
ment period, seventy-four patients with acute patellar dislo-
cations were randomized to operative or nonoperative
treatment. The patients in the operative arm underwent repair
of the medial retinacular structures, usually with a lateral re-
lease if the patella was dislocatable or with only a lateral release
if the patella was not dislocatable with the patient under an-
esthesia. The postoperative care was identical for both arms in
this randomized study. No sham surgery was performed, so the
patients were not blinded to the randomization. At an average
of six years, the rate of follow-up by an independent observer
was 94% and the authors demonstrated that the results of
operative and nonoperative treatment of acute patellar dislo-
cation were equivalent. The redislocation rate was approxi-
mately 70% in both arms of the study. Despite this finding, a
good clinical outcome was achieved in 75% of the patients in
both arms of the study. The single predictor of recurrent dis-
location was a positive family history of patellar instability.
Foot and Ankle
Two recent reports presented the results of reconstruction for
the treatment of late-developing cavus deformities occurring
after extensive soft-tissue releases in patients with idiopathic
clubfoot. Yong et al.13 reported good improvement in patients
with dorsal bunions who were managed with proximal transfer
of the flexor hallucis longus in combination with a first meta-
tarsal osteotomy. In the report by Weiner et al.14, more proximal
and severe cavus deformities were salvaged with use of a midfoot
dome osteotomy that was especially designed to correct three-
dimensional deformities. That large review of 139 painful and
rigid feet revealed a satisfactory result in 76% of the children.
The last ten years have seen a resurgence in nonoperative
methods for the treatment of idiopathic clubfoot. Equal num-
bers of good results can be expected in association with either
the Ponseti method or the French physiotherapy approach15.
Other reports at the Pediatric Orthopaedic Society of North
America (POSNA) annual meeting demonstrated that the
Ponseti method may be extended to children with teratologic
or arthrogrypotic clubfoot deformities, although a greater
number of casts are needed16.
The treatment of bunion in juvenile patients has been a
challenging enterprise because of high rates of recurrence and
the morbidity of using ‘‘adult’’ procedures on growing feet.
Applying the principles of guided growth for the correction
of limb deformity, Davids et al.17 utilized lateral hemiepi-
physeodesis of the great-toe metatarsal to treat the juvenile
bunion. In a retrospective review, they demonstrated no fur-
ther progression of the deformity in all of the feet and im-
provement in the deformity in half of the feet. Given that this
procedure is associated with low risk and minimum morbidity,
these results seem to justify its use for the treatment of pro-
gressive and painful deformities, especially when compared
with the results of more traditional surgical approaches.
W H AT ’ S N E W IN P E D I AT R I C O R T H O PA E D I C S
Trauma
Recreational use of all-terrain vehicles continues to result in
high numbers of substantial injury in both children and ado-
lescents. Two large reviews from Arkansas and Kentucky dem-
onstrated an increased incidence of these injuries during and
after expiration of the 1988 Consent Decrees from the United
States Consumer Product Safety Commission18,19, which man-
dated a ban on three-wheel all-terrain vehicles, required re-
tailers to provide rider safety equipment and training, required
extensive warning labels on all-terrain vehicles, and prohibited
the sale of adult-sized vehicles to children under the age of
thirteen years. A preponderance of head injuries and long-
bone injuries occur in riders under the age of sixteen years, and
both the American Academy of Pediatrics and the American
Academy of Orthopaedic Surgeons have recommended that no
individual who is less than sixteen years of age should operate
these machines.
The femur is the most commonly fractured long bone,
and a host of different surgical options can be chosen, de-
pending on the age and size of the patient, the pattern and
location of the fracture, and the degree of comminution. Flex-
ible intramedullary nailing is a mainstay of treatment for many
of these fractures. Wall et al.20 compared stainless steel and
titanium nails and found superior results (less malunion) in
association with the cheaper stainless steel implants. A recent
retrospective cohort study of open femoral fractures estab-
lished that flexible intramedullary nailing is superior to ex-
ternal fixation in terms of complication rates21. As an
alternative to external fixation, locked plate fixation has also
demonstrated good results for difficult femoral fracture pat-
terns22. Although most pediatric tibial fractures are treated
with nonoperative methods, operative fixation is occasionally
needed for open fractures. External fixation of these chal-
lenging fractures has been shown to be associated with a higher
rate of complications (nonunion and malunion) in compari-
son with flexible nailing, which has been associated with better
results23.
Redisplacement of distal radial fractures after closed re-
duction and casting is common and is more likely to be seen in
association with complete fracture displacement and >30° of
fracture obliquity as well as with poor molding of the cast24.
Should redisplacement occur during standard weekly follow-
up, a variety of pin constructs appear to provide stable fixation
equally well25. Galeazzi fractures in children are rare and may
go undiagnosed, but, in a comprehensive study of these in-
juries, good function of the distal radioulnar joint was achieved
in 90% of the children when fracture reduction was achieved
and maintained in a short or long-arm cast26. Forearm frac-
tures are predominantly treated with closed methods, with
good results; however, refractures can occasionally occur, and a
recent large analysis revealed that most refractures occur
through previous fracture sites in the proximal and middle
thirds of the forearm and within ten months after the initial
injury27. In half of those cases, a fracture line was still visible on
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the latest follow-up radiograph. The authors suggested longer
immobilization for proximal forearm fractures, especially if
incomplete healing is present. Operative fixation of forearm
fractures is reserved predominantly for open and unstable
injuries with unacceptable alignment, and it continues to ap-
pear that equally good results can be obtained with either
flexible nailing or plate fixation28.
In a level-I trial, Yen and Kocher found that, following
closed reduction, displaced supracondylar humeral fractures
can be treated with a variety of pin constructs (medial and
lateral pins as opposed to all lateral pins), with equivalent re-
sults29. Higher degrees of malunion may be expected if there
is ‡10° of coronal plane or ‡20° of sagittal plane fracture
obliquity30. This is in contrast to distal humeral metaphyseal-
diaphyseal fractures, where increased fracture obliquity leads
to better results than unstable transverse fractures31. Finally,
Halanski et al.32 evaluated the risk of thermal injury associated
with contemporary casting techniques. They noted that ther-
mal injury is associated with thick plaster and a water tem-
perature of >24°C or when a curing cast is over-wrapped with
fiberglass or placed on a pillow.
In fracture treatment, adequate pain control without in-
creasing the risk of complications such as compartment syn-
drome is an important part of quality modern-day care. Wathen
et al.33, in a prospective, randomized, controlled trial, dem-
onstrated that fascia iliaca compartment block provides more
effective pain control for femoral fractures than intravenous
morphine does. The fascia iliaca compartment is located an-
terior to the iliacus muscle within the pelvis. It is bound su-
perolaterally by the iliac crest and medially merges with the
fascia overlying psoas muscle. Both the femoral nerve and the
lateral cutaneous nerve of the thigh lie under the iliacus fascia
in their intrapelvic course. In fifty-six pediatric patients, the
fascia iliaca compartment block was administered by the
emergency department physicians with use of surface land-
marks for acute pain control. The pain scores were followed
serially for as long as six hours, and potential complications
from the block and intravenous morphine were monitored.
The fascia iliaca compartment block provided rapid and
improved pain control in this group, without evidence of in-
creased complications. Similarly, White et al.34, in a prospec-
tive, randomized, controlled trial with forty-two patients with
an ankle fracture-dislocation, demonstrated that the place-
ment of an intra-articular block can be achieved more rapidly
than the administration of conscious sedation. The pain relief
afforded by both techniques was equivalent, as was the re-
duction quality.
Neuromuscular System
Intrathecal baclofen pumps have been used with increasing
frequency and success for patients with cerebral palsy with se-
vere spasticity and dystonia in the upper and lower extremities
who are unable to walk35,36. It remains controversial whether
intrathecal baclofen pumps have any effect on the natural
W H AT ’ S N E W IN P E D I AT R I C O R T H O PA E D I C S
history of scoliosis progression in patients with severe cerebral
palsy. Senaran et al.37 found no increase in the expected curve
progression in patients with cerebral palsy after intrathecal
baclofen placement, whereas Ginsburg and Lauder38 docu-
mented a significant increase in curve progression. As a result,
it is important that patients with scoliosis be appropriately
monitored. If curve progression is noted, surgical correction
can be effective, as was recently reported in a large series of
patients with cerebral palsy 39.
Many patients with cerebral palsy who are unable to walk
have progressive hip instability, which can be halted with
muscle and tendon releases. Should progression of displace-
ment continue, hip reconstruction (by means of femoral and/or
pelvic osteotomy) may become necessary. Botulinum toxin A
has been injected into the adductor muscles to treat hips at risk,
and the results of a recent level-I trial justified its use as a method
to delay hip displacement40. Botulinum toxin A is also effective
for the treatment of spastic equinus, especially if casting is
delayed after its injection41.
Finally, it appears that the epidemic of childhood obesity
is affecting children who have cerebral palsy. In a retrospective
analysis, Rogozinski et al.42 documented a significant increase
in weight, especially among children who are less than eight
years of age, who have less severe involvement, and who are
female. This problem may become a burden to those wishing
to remain able to walk over time.
Limb Deformity
Lower extremity deformity can be assessed either with standing
full-length radiographs or intraoperatively with supine fluo-
roscopy by stretching a cautery cord from the hip to the ankle
center. These two techniques appear to be equally effective,
provided that the amount of initial limb deformity is <2 cm of
mechanical axis deviation and the patient is not obese43. The
same researchers also noted that the presence of a ring fixator
on the leg will alter how the patient stands, and, in this case,
standing radiographs will not represent the true alignment.
Limb lengthening by means of external fixation can be a
challenge, and efforts have been made to develop internal-only
lengthening devices. One report on the use of a novel motorized
nail in adolescents demonstrated more rapid healing than is
observed in association with external fixation44. The authors
reported a lower complication rate in the eight limbs that were
lengthened with the motorized device in comparison with the
findings described in published reports on two other me-
chanical intramedullary lengthening devices. Comparative
studies are needed to confirm that a motorized device is better
(in terms of improved patient comfort and lower complication
rates) than mechanical intramedullary devices, which require
external manipulation.
Congenital pseudoarthrosis of the tibia remains a chal-
lenging condition to treat. When a patient presents with de-
formity and dysplastic changes of the tibia but without fracture,
osteotomy or curettage and bone-grafting may produce unac-
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ceptably high rates of nonunion. For this subset of patients, the
treatment options include bracing or allograft bypass grafting to
prevent fracture. Ofluoglu et al.45 presented the long-term
follow-up results of bypass grafting in ten patients. In that
small series, none of the patients had development of a
pseudoarthrosis of the tibia. Although the study was an un-
controlled case series, the authors noted that, in their experi-
ence, brace treatment for Crawford type-2 tibial dysplasia was
associated with unacceptable rates of fracture and pseudoar-
throsis. All patients except one had a minimum leg-length
discrepancy; however, the majority had a residual deformity of
the tibia and a compensatory deformity at the knee, which
required later surgical correction. In some patients with con-
genital pseudoarthrosis of the tibia, proximal tibial limb
lengthening may be considered to correct a leg-length dis-
crepancy, but at the risk of poor regenerate healing. Cho et al.46
reviewed a large series of patients and found that acceptable
bone-healing could be expected if distraction osteogenesis was
performed proximally in nondysplastic bone that had not had
previous surgery. Limb lengthening through this bone may be
justified in this high-risk group.
Lengthening short upper extremity stumps is another
challenging clinical problem, with little information having
been published in the literature until a recent report by Bernstein
et al.47. Those authors demonstrated a significant increase in
length, although a number of additional surgical procedures
were required to treat complications such as poor distal soft-
tissue coverage. While eight of nine patients could be fitted with
a prosthesis, the authors honestly pointed out that some patients
did not use the device and thus questioned the cost-versus-
actual-benefit ratio.
The treatment of elbow contractures in patients with ar-
throgryposis has been controversial. In a recent multicenter
review of twenty-nine elbows that were treated with posterior
release and triceps lengthening, the mean increase in elbow
flexion was a modest 36°, yet, importantly, all of the patients
could reach the hand to the mouth with passive assistance48. As a
result, the authors advocated simple posterior release and
triceps lengthening without tendon transfer to provide active
elbow flexion.
Tumors
Thankfully, most neoplastic lesions in children are benign. They
are usually discovered serendipitously or as a result of fracture or
pain. However, one must be vigilant as a recent evaluation
demonstrated that musculoskeletal pain and radiographic ab-
normalities were the presenting symptoms in 40% of 122 pa-
tients with pediatric leukemia49. Osteoid osteoma is a benign
tumor that often presents with pain. Moser et al.50, in a study of
sixty-eight children who were managed with laser ablation,
reported a 98% success rate after one or two procedures. Os-
teoblastoma is a rare tumor for which Arkader and Dormans51
advocated a four-step approach for removal. The authors
found that extensive curettage, high-speed burring, and
W H AT ’ S N E W IN P E D I AT R I C O R T H O PA E D I C S
chemical and thermal cautery were effective for removing
these tumors in fourteen of fifteen children.
Aneurysmal bone cysts and unicameral bone cysts are
commonly encountered benign tumors that can present ther-
apeutic challenges because of high recurrence rates. A multi-
center randomized clinical trial comparing bone marrow and
steroid injections into these cysts was recently published52. A
low rate of healing was noted radiographically in association
with both methods, although cysts that had been injected with
steroids healed significantly more often than those that had
been injected with bone marrow (42% compared with 23%).
Probably more importantly, though, there was no difference in
the risk of refractures, which was about 25% in both groups.
Aneurysmal bone cysts that are treated with intralesional cu-
rettage are more prone to recur than unicameral bone cysts,
with recurrence rates generally reported to be between 10%
and 30%. Two recent studies demonstrated higher recurrence
rates in patients younger than five years of age (55%)53 and in
patients with a juxtaphyseal tumor (42%)54. Despite the higher
recurrence rate, those authors recommended prudence when
considering aggressive surgical resection, which may destroy
the growth potential of the limb, as the morbidity resulting
from repeat curettage is less than that resulting from a short-
ened or malformed limb.
Infection
As reported in a large series from the Children’s Medical Center
of Dallas, there continues to be an increase in the rate of
methicillin-resistant Staphylococcus aureus osteomyelitis in
children55. In a consecutive series spanning 1999 to 2003,
the authors demonstrated that 23% of all patients had a
methicillin-resistant Staphylococcus aureus infection. A fivefold
increase in comparison with the rate of methicillin-sensitive
Staphylococcus aureus infections was noted in the later half of
the study period. Children with a methicillin-resistant Staph-
ylococcus aureus infection tended to have higher inflammatory
parameters, longer hospitalization and antibiotic needs, and a
greater number of complications than those with a methicillin-
sensitive Staphylococcus aureus infection.
Gafur et al.56 clearly demonstrated that, in comparison
with twenty years ago, the epidemiology of musculoskeletal
infections in the Dallas area has clearly changed. The per capita
incidence of osteomyelitis increased 2.8-fold, whereas the in-
cidence of septic arthritis did not. Methicillin-resistant
Staphylococcus aureus was isolated as the causative organism in
30% of children, whereas twenty years ago this organism was a
rare cause of osteomyelitis. Additionally, the incidences of
pyomyositis and deep soft-tissue abscesses increased, as did
those of multifocal osteomyelitis and complications resulting
from infections such as deep venous thrombosis and septic
thrombophlebitis. As the epidemiology changes to a more
aggressive form of infection, the therapeutic approach should
adapt as well, and Gafur et al. recommended more aggressive
early débridement, closer surveillance for deep venous
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thrombosis, and an appropriate and adequate duration of
antibiotic therapy.
Basic Science
Traditionally, culture specimens from infected joints have been
associated with a high false-negative rate. Therefore, a rapid,
highly sensitive and specific test for live bacteria in synovial fluid
has the potential to improve the treatment of septic arthritis.
Birmingham et al.57 devised a real-time quantitative reverse
transcription polymerase chain reaction test that has a 0%
false-negative rate and a detection limit of 100 to 1000 bac-
teria/100 mL. The test is rapid and can provide results in five
hours or less. The specificity of this test was achieved by tar-
geting the bacterial genes groEL or femC. The groEL gene
encodes a heat shock protein that is essential for bacterial
growth, and the femC gene of Staphylococcus is functionally
required for methicillin resistance. These two genes are closely
related to the viability of bacteria or greatly downregulated in
response to bacterial death and hence should provide speci-
ficity for the detection of viable bacteria. Additional work in
the clinical setting is required to validate this test; however, this
method of detecting live bacteria, in combination with de-
scribed methods of using polymerase chain reaction-based
molecular detection to determine species and antibiotic sen-
sitivity, has the potential to dramatically improve the diagnosis
and treatment of septic arthritis.
Recent in vitro studies have shown that even brief expo-
sure to bupivacaine may cause apoptosis of chondrocytes,
which may result in chondrolysis. Although adverse clinical
events resulting from intra-articular bupivacaine use have not
been demonstrated, the theoretical risk motivated Piper and
Kim58 to compare the toxicity of ropivacaine and bupivacaine
on chondrocytes. Those authors demonstrated, with use of
human cartilage explants, that exposure to 0.5% bupivacaine
for thirty minutes resulted in an approximately 22% decrease
in chondrocyte viability as compared with that in controls that
had been exposed to saline solution. In contrast, exposure to
ropivacaine for the same duration did not have any adverse
effect. Additional studies are necessary to determine if this
in vitro finding has clinical relevance.
Magnetic resonance imaging of cartilage continues to
advance. T1rho-weighted magnetic resonance imaging is a
noncontrast imaging technique that is designed to measure
water and extracellular matrix interactions. In cartilage, this
sequence has shown correlations with tissue proteoglycan
content, in a fashion similar to the delayed gadolinium-
enhanced magnetic resonance imaging of cartilage (dGEMRIC)
technique. In avascular tissue such as the nucleus pulposus, a
noncontrast technique such as T1rho-weighted magnetic res-
onance imaging would have a distinct advantage over a contrast
technique such as dGEMRIC. Nguyen et al.59, with use of ca-
daveric human spine specimens, demonstrated that T1r re-
laxation times correlated with the tissue-swelling pressure,
glycosaminoglycan content, and hydration but not with the
W H AT ’ S N E W IN P E D I AT R I C O R T H O PA E D I C S
modulus or the permeability of intervertebral disc. The goal of
that study was to utilize this biochemical imaging technique to
detect early disc degeneration. Although the number of spec-
imens was limited, this preliminary study appeared to dem-
onstrate that T1r relaxation times were correlated with the
presence of disc degeneration. Additional clinical studies are
necessary to demonstrate the value of this imaging technique
in clinical practice or clinical research.
Spine
Back Pain
Some recent work has been done to streamline and validate the
methods used to identify patients with mechanical low-back
pain. Auerbach et al.60 retrospectively studied 100 consecutive
pediatric patients with low-back pain and found that painless
hyperextension combined with a negative magnetic resonance
imaging scan and normal radiographic findings was predictive
of mechanical pain. For patients without neurological signs
and symptoms and with pain for less than six weeks, a bone
scan is the most useful screening test. A similar strategy was
utilized in a prospective study wherein bone scanning was used
in all patients with non-neurological pain, normal findings on
physical examination, and normal blood tests61. The authors
found that 78% of the patients had mechanical back pain, and
magnetic resonance imaging did not improve the diagnosis
rate unless neurological symptoms were present.
Nonoperative Treatment of Scoliosis
Jarvis et al.62 recently reported the results of nighttime bracing
in patients with juvenile idiopathic scoliosis. They believed that
the successful management of 50% of the patients in the study
was an improvement in comparison with the natural history of
this condition, which has a high risk for progression. They
hypothesized that part-time brace wear may improve com-
pliance in these patients, thus improving the ultimate effec-
tiveness of bracing. Two recent studies assessed the validity of
compliance monitors for brace wear among patients with
adolescent idiopathic scoliosis; temperature-based monitors
correlated better with self-reported logs of thoracolumbosacral
orthosis use than did pressure-based monitors63. However,
with use of the former technology, it appeared that patients
only wore the brace 47% of the time in comparison with
physician, parent, orthotist, and patient estimates of approxi-
mately 70% of the prescribed time.
Operative Treatment of Scoliosis
Scoliosis may result from the presence of a syrinx or a Chiari
malformation. Patients with a syrinx or a Chiari malformation
are usually male, have an early onset of scoliosis, and may have
symptoms or signs of neurological compromise. Radiographi-
cally, atypical curves (including thoracic kyphosis, left thoracic
curves, and spinal imbalance) are seen in approximately two-
thirds of the patients64,65. The surgical management of these
patients is associated with higher rates of neurological com-
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plications, and curve progression after fusion recently was
reported in 36% of patients with a syrinx64.
The effectiveness of spinal cord monitoring during spinal
deformity surgery was recently reported in two large studies
(involving >1000 patients), with the incidence of spinal cord
injury approaching 1%66,67. Transcranial motor-evoked poten-
tials are exquisitely sensitive to threatened spinal cord function,
and their use together with traditional somatosensory evoked
potentials improves the accuracy of spinal cord monitoring.
Somatosensory evoked potentials may not detect all problems
and may not detect problems as rapidly as transcranial motor-
evoked potentials do67, and the sensitivity of transcranial
motor-evoked potentials has led some centers to abandon
somatosensory evoked potentials in favor of motor monitoring
alone. For instance, Hsu et al.68 reported 100% sensitivity for
the detection of a clinically important neurological event in a
consecutive series of 144 patients. The authors defined a
neurological event as either a new postoperative deficit or a
50% decrease in the monitoring potential over a one-minute
period. The rapidity with which motor monitoring detects
spinal cord compromise makes it a valuable tool for sagittal
plane correction, and prompt detection of a problem can lead
to its resolution before a permanent deficit results69,70.
The systems described by King and Lenke for the classi-
fication of adolescent idiopathic scoliosis have been used to
determine what portions of the spine are excessively rigid and
require instrumentation. Both systems appear to be equally
useful for helping to determine distal fusion levels and for
identifying patients who are candidates for selective thoracic
fusion71. Selective thoracic fusion can be performed either
anteriorly or posteriorly, and there does not appear to be any
difference in the amount of lumbar correction achieved72.
Recently, less anterior scoliosis surgery has been done
because of the corrective power of pedicle screw constructs and
surgical methods designed to improve flexibility, such as pos-
terior release, posterior osteotomy, and vertebral resection.
Furthermore, we have become more aware of the effect of an-
terior surgery on pulmonary function. Specifically, improvement
in pulmonary function can be expected following posterior
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