Bracing for idiopathic scoliosis: how many patients require treatment to prevent one surgery?

BACKGROUND: Although the efficacy of bracing for adolescent idiopathic scoliosis has been debated, recent evidence indicates a strong dose-response effect with respect to preventing curve progression of ≥6°. The purpose of this study was to investigate whether bracing, prescribed with use of current criteria, prevents surgery and how many patients must be treated with bracing to prevent one surgery. METHODS: Of 126 patients with adolescent idiopathic scoliosis measuring between 25° and 45° and with a Risser sign of ≤2, 100 completed a prospective study in which they were managed with a Boston brace fitted with a heat sensor that measured brace wear. Noncompliant patients were compared both with highly compliant patients and with the entire cohort, with the end point of progression to surgery. The absolute risk reduction (ARR) was calculated and used to calculate the number needed to treat (NNT) to prevent one surgery. RESULTS: Bracing was not effective in preventing surgery unless the patient was highly compliant with brace wear. For patients who were considered to be highly compliant, based on the hours per day that they wore the brace, the NNT was 3 (95% confidence interval [CI], 2 to 7). CONCLUSIONS: Within the limitations of a nonrandomized prospective study design, bracing for adolescent idiopathic scoliosis was found to substantially decrease the risk of curve progression to a range requiring surgery when patients were highly compliant with brace wear. Since many patients avoid surgery without wearing a brace, current indications appear to lead to marked overtreatment. Bracing appears to decrease the risk of curve progression to a magnitude requiring surgery, but current bracing indications include many curves that would not have progressed to a magnitude requiring surgery even if the patient had not worn the brace, and overall compliance with brace wear is low. Identifying these lower-risk patients and improving the compliance of those likely to have curve progression could substantially improve bracing results.

A proposed scoring system for assessment of severity of illness in pediatric acute hematogenous osteomyelitis using objective clinical and laboratory findings.

BACKGROUND: Severity of illness in children with acute hematogenous osteomyelitis (AHO) is variable, ranging from mild, requiring short-duration antibiotic therapy without surgery, to severe, requiring intensive care, multiple surgeries and prolonged hospitalization. This study evaluates severity of illness among children with AHO using clinical and laboratory findings. METHODS: Fifty-six children with AHO, consecutively treated in 2009, were retrospectively studied. Objective clinical, radiographic and laboratory parameters related to severity of illness were gathered for each child. A physician panel was assembled to rank order objective clinical parameters, review clinical data and classify each child as mild, moderate or severe. Statistically significant parameters correlated with length of hospitalization were utilized to devise a severity of illness score and applied to the cohort of children for internal validation. RESULTS: The physician panel had perfect or substantial agreement regarding 7 parameters (ICU admission, intubation, pulmonary involvement, venous thrombosis, multifocal infection, surgeries and febrile days on antibiotics). Parameters that significantly correlated with total length of stay included: C-reactive protein values at admission (P < 0.0001), 48 hours (P < 0.0001) and 96 hours (P < 0.0002); febrile days on antibiotics (P < 0.0001); admission respiratory rate (P = 0.023) and evidence of disseminated disease (P = 0.016). A scoring system, derived from selected parameters, significantly differentiated children with AHO on the basis of causative organism, intensive care admission, surgeries, length of hospitalization, complications and physician panel assessment. CONCLUSIONS: Severity of illness score for AHO, derived from preliminary clinical and laboratory findings, is useful stratifying children with this disease. LEVEL OF EVIDENCE: Prognostic Level II.

Bracing in adolescent idiopathic scoliosis, surrogate outcomes, and the number needed to treat.

BACKGROUND: In this manuscript we will present several evidence-based medicine concepts and tools that can be helpful to the clinician seeking answers to clinical questions. The clinical scenario used to demonstrate these concepts is one of the substantial current controversy in pediatric orthopaedics, that is the efficacy of bracing in adolescent idiopathic scoliosis. We hope to provide some important information about how to search and interpret the current literature on bracing but also to discuss the concepts related to "surrogate outcomes" and the "number needed to treat," which we believe are increasingly important in this era of evidence-based medicine. METHODS: We performed a structured literature review of scoliosis bracing and also a separate analysis of the number needed to treat (NNT) for preventing surgery in adolescent idiopathic scoliosis. RESULTS: Bracing for idiopathic scoliosis significantly reduces the rate of curve progression more than 6 degrees. However, the applicability of the 6-degree surrogate outcome compared with a more important outcome such as progression to surgery is doubtful. Bracing may decrease the risk of progression to surgery although the confidence intervals are large. The NNT for routine scoliosis bracing is about 9 patients for each surgery prevented. The NNT for patients highly compliant with bracing is about 4. We caution that these NNTs are derived from nonrandomized cohorts, and the true values from quality randomized controlled studies may be substantially different. There is no evidence for any particular brace over another although rigid bracing seems better than SpineCor bracing from 1 small randomized controlled study. CONCLUSIONS: Systematic reviews support bracing's ability to prevent curve progression of 6 degrees but not for preventing surgery. Analysis of a patient cohort does support bracing's ability to prevent surgery with NNT of 9 for all patients and 4 for highly compliant patients. LEVEL OF EVIDENCE: Systematic review-therapeutic level 2. Cohort analysis-therapeutic level 2.

Initial severity rating of idiopathic clubfeet is an outcome predictor at age two years.

This study was performed to determine if rating the severity of clubfeet before Ponseti treatment was predictive of the outcomes at age two years. Four hundred and seventy-nine idiopathic clubfeet (323 patients) were numerically rated for severity using Dimeglio classification. Eighty-six feet rated moderate, 305 feet rated severe, and 88 feet rated very severe. Outcomes were classified as Good (plantigrade foot with or without a tendoachilles lengthening), Fair (limited surgery), or Poor (posteromedial release). Significant correlation existed between initial severity of the foot and outcomes, with moderate better than severe and very severe, and severe better than very severe. Initial numerical severity rating strongly correlated with the probability of a good outcome (P<0.0001). Evaluating the severity of clubfeet before Ponseti treatment provides prognostic information for parents.

Open clavicle fractures: patterns of trauma and associated injuries.

OBJECTIVES: To describe the demographic distribution, mechanism of injury, and associated injuries of patients sustaining open clavicle fractures. DESIGN: Retrospective case series. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: Trauma registry data from all patients who required admission to the hospital from October 1995 through January 2010, specifically patients with open clavicle fractures. INTERVENTION: Not applicable. MAIN OUTCOME MEASUREMENTS: The patterns of open clavicle fractures and their association with severe, nonorthopaedic injuries (head, thoracic, and great vessel). RESULTS: Fifty-three patients with open clavicle fractures were identified, and they were organized by mechanism of injury: 21 sustained blunt injuries, 26 penetrating injuries, and six not specified. No difference between blunt and penetrating injuries existed with respect to age, Injury Severity Score, inpatient days, or mortality rates. Blunt injuries were more likely associated with head injuries (52%) versus penetrating injuries (22%), but penetrating injuries were more likely associated with a great vessel injury (27% vs 7%, respectively), all statistically significant (P = 0.0487). CONCLUSIONS: Open clavicle fractures are rare injuries. Patients often have associated head, thoracic, and great vessel injuries. Penetrating injuries have higher rates of great vessel injuries and that blunt force injuries have higher rates of head injuries.

The time of the insult/triggering event in Legg-Calvé-Perthes' disease determined by incubation period modeling and the age distribution of children with Perthes'.

The time when the insult/triggering event occurs in Legg-Calvé-Perthes' (LCPD) is unknown. the purpose of this study was to determine, using the mathematical tool of incubation period modeling, the time of such event and the incubation period for LCPD. We reviewed 2,911 children with LCPD from 10 different centers around the world. They were divided into two groups: those from India (505 children, mean age 8.1 ± 2.3 years) and those from other than India (2,406 children, mean age 5.8 ± 2.2 years). A simple distribution with an excellent fit to the data was ln(y) = a + bx + cxln(x), where y is the proportion of children with LCPD at age of diagnosis x (r(2) = 0.994 for non-Indian and 0.959 for Indian children). The age of the triggering event was 1.32 years for non-Indian and 2.77 years for Indian children; the median incubation period was 4.30 years non-Indian and 5.33 years for Indian patients. Knowing the incubation period and age of triggering event narrows the number of potential etiologies in LCPD. this study does not support a prenatal triggering event as postulated in the past. similar incubation periods with different ages at diagnosis supports a common insult which occurs at different ages in different populations dependent upon local factors such as geographic location and ethnicity.

Shoulder girdle: patterns of trauma and associated injuries.

OBJECTIVES: To develop a system of quantification of shoulder girdle injuries that stratifies their severity and to assess the association between shoulder girdle injuries and associated nonbony injuries to the head, thorax, and great vessels. DESIGN: Retrospective review. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: Trauma registry data from all patients who required admission to the hospital from October 1995 through January 2008, specifically patients with shoulder girdle injuries. Excluded were patients with isolated burns and late effects of injuries. INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: The patterns of shoulder girdle injury and their association with severe, nonorthopaedic injuries (head, thoracic, and great vessel). Also, the severity of all combinations of shoulder girdle injuries were observed using two systems (relative risk totals and injury severity score). RESULTS: Of 52,924 patients recorded, 2971 had 3811 shoulder girdle injuries. High-energy mechanisms prevailed, causing over 91% of all shoulder girdle injuries. The rates of head, great vessel, and thoracic injury in patients with a shoulder girdle injury were 31.5%, 3.9%, and 36.8%, respectively, and were significant when compared with nonshoulder girdle injuries (P < 0.001). The two most severe injury combinations included a sternum injury with either a clavicle or scapula fracture. CONCLUSIONS: Shoulder girdle injuries are strongly associated with great vessel, thoracic, and head injuries. In the presence of a sternum injury with a clavicle fracture or any open clavicle fracture, we recommend the routine use of a contrast-enhanced spiral thoracic computed tomography scan to aid in the diagnosis of a great vessel injury.

Femoral nerve palsy in Pavlik harness treatment for developmental dysplasia of the hip.

BACKGROUND: Transient femoral nerve palsy is a potential complication of the use of a Pavlik harness to treat developmental dysplasia of the hip. Our hypothesis was that patients who develop a femoral nerve palsy while undergoing Pavlik harness treatment for developmental dysplasia of the hip are more likely to have unsuccessful orthotic treatment and to require closed or open hip reduction. METHODS: We performed a retrospective review of all patients who underwent Pavlik harness treatment for developmental dysplasia of the hip within a seventeen-year period (1992 to 2008). All cases of femoral nerve palsy were identified and reviewed. Thirty infants met the study criteria and formed the palsy group. A control group of seventy-nine infants who did not develop femoral nerve palsy during treatment was randomly selected. RESULTS: Thirty cases of femoral nerve palsy were identified from a group of 1218 patients for an incidence of 2.5%. Eighty-seven percent of femoral nerve palsies presented within one week of application of the Pavlik harness. Femoral nerve palsy was more likely in older, larger patients in whom the developmental dysplasia of the hip was of higher severity. Patients whose femoral nerve palsy resolved within three days had a 70% chance of having successful treatment with the Pavlik harness, whereas those who had not recovered by ten days had a 70% chance of having treatment failure with the Pavlik harness. The success rate associated with treatment with a Pavlik harness was 94% in our control group and 47% in our palsy group. CONCLUSIONS: Femoral nerve palsy is an uncommon yet clinically important complication of Pavlik harness treatment for developmental dysplasia of the hip. This complication is strongly predictive of failure of treatment, and its impact is greatest when the developmental dysplasia of the hip is higher in severity. Early recognition and management of femoral nerve palsies may improve the success of treatment.

Effect of amputation level on energy expenditure during overground walking by children with an amputation.

BACKGROUND: The oxygen cost of walking by adults with an amputation has been well described, but few studies have focused on this parameter in children who have had an amputation. Children with a transtibial amputation have been reported to maintain walking speed at a 15% higher oxygen cost than able-bodied children. The purpose of this study was to determine if the level of amputation in children has a differential impact on the self-selected speed of walking and the oxygen cost, and how the performance of these children compares with that of a group of able-bodied children. METHODS: Seventy-three children who had had an amputation participated in this study. Oxygen consumption was measured with a Cosmed K4b2 oxygen analysis telemetry unit (Rome, Italy) as the participants walked overground for ten minutes at a self-selected speed. One minute of steady-state data were reduced, averaged, and standardized to control values. Children with a unilateral amputation were grouped according to the level of the amputation; there were twenty-nine Syme, thirteen transtibial, fourteen knee disarticulation, five transfemoral, and five hip disarticulation amputations. Seven children had had a bilateral amputation, and they were considered as a separate group. Comparisons were made among the five amputation groups and between all children who had undergone amputation and control subjects. The variables that were analyzed were resting VO(2) rate (mL/kg/min), resting heart rate (beats per minute [bpm]), walking VO(2) rate (mL/kg/min), walking VO(2) cost (mL/kg/m), walking heart rate (bpm), and self-selected walking velocity (m/min). RESULTS: Unilateral transfemoral and hip disarticulation amputations resulted in significantly reduced walking speed (80% and 72% of normal, respectively) and increased VO(2) cost (151% and 161% of normal, respectively), while the heart rate was significantly increased in the hip disarticulation group (124% of normal). Compared with the controls, the children with a bilateral amputation walked significantly slower (87% of normal), with an elevated heart rate (119% of normal) but a similar energy cost. Children with a Syme amputation, transtibial amputation, or knee disarticulation walked with essentially the same speed and oxygen cost as did normal children in the same age group. CONCLUSIONS: Children with an amputation through the knee or distal to the knee were able to maintain a normal walking speed without significantly increasing their energy cost. Only when the amputation is above the knee do children walk significantly slower and with an increased energy cost.

Onabotulinum toxinA injection as an adjunct in the treatment of posterior shoulder subluxation in neonatal brachial plexus palsy.

BACKGROUND: 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, posterior shoulder subluxation and dislocation are the result of muscle imbalance, in which neurologic recovery is evolving, and spasticity is not a deforming force. We postulated that temporary weakening of the shoulder internal rotator muscles with botulinum toxin A would facilitate reduction of the glenohumeral joint in such infants with early posterior shoulder subluxation or dislocation. METHODS: Thirty-five infants with posterior subluxation or dislocation of the shoulder due to brachial plexus palsy were treated with botulinum toxin A between January 1999 and December 2006, and were followed for a minimum period of one year. Records were reviewed for the severity of the palsy, age at time of treatment, recurrence of subluxation or dislocation, and the subsequent need for further treatment to reduce the glenohumeral joint. RESULTS: The average age at the time of shoulder reduction and botulinum toxin-A injection was 5.7 months. Six patients had a second injection. Reduction of the shoulder was maintained in twenty-four (69%) of the thirty-five patients. There were no complications related to the use of botulinum toxin A. CONCLUSIONS: Although there may be specific risks associated with its use, botulinum toxin-A injection into the internal rotator muscles is a useful adjunct to the treatment of early posterior subluxation or dislocation of the shoulder in infants with neonatal brachial plexus palsy, and may help to avoid the need for open surgical procedures to restore or maintain shoulder reduction.

Brace wear control of curve progression in adolescent idiopathic scoliosis.

BACKGROUND: The efficacy of brace treatment for patients with adolescent idiopathic scoliosis remains controversial, and effectiveness remains unproven. We accurately measured the number of hours of brace wear for patients with this condition to determine if increased wear correlated with lack of curve progression. METHODS: Of 126 patients with adolescent idiopathic scoliosis curves measuring between 25 degrees and 45 degrees , 100 completed a prospective study in which they were managed with a Boston brace fitted with a heat sensor that measured the exact number of hours of brace wear. Orthopaedic teams prescribed either sixteen or twenty-three hours of brace wear and were blinded to the wear data. At the completion of treatment, the number of hours of brace wear were compared with the frequency of curve progression of > or =6 degrees and with curve progression requiring surgery. RESULTS: The total number of hours of brace wear correlated with the lack of curve progression. This effect was most significant in patients who were at Risser stage 0 (p = 0.0003) or Risser stage 1 (p = 0.07) at the beginning of treatment and in patients with an open triradiate cartilage at the beginning of treatment. Logistic regression analyses showed a "dose-response" curve in which the greater number of hours of brace wear correlated with lack of curve progression. Brace wear to school and immediately afterward was most successful. Curves did not progress in 82% of patients who wore the brace more than twelve hours per day, compared with only 31% of those who wore the brace fewer than seven hours per day (p = 0.0005). The number of hours of brace wear also correlated inversely with the need for surgical treatment (p = 0.0005). The number of hours of wear were similar for the patients who were advised to wear the brace sixteen or twenty-three hours daily. CONCLUSIONS: The Boston brace is an effective means of controlling curve progression in patients with adolescent idiopathic scoliosis when worn for more than twelve hours per day.

Accessory anterolateral facet of the pediatric talus. An anatomic study.

BACKGROUND: The accessory anterolateral talar facet may be associated with talocalcaneal impingement in the painful flatfoot. We performed an anatomic study to identify this accessory facet and its associated osteologic features. METHODS: Within the Hamann-Todd Human Osteological Collection, seventy-nine paired tali and calcanei were identified among forty-three skeletons from individuals who had had an average age of 13.4 years at the time of death. Each specimen was surveyed for an accessory anterolateral talar facet, a calcaneal neck anterior extension facet, a dorsal talar beak, and the talocalcaneal facet pattern. Measurements included the angle of Gissane, posterior facet inclination, calcaneal neck length, posterior facet length, overall calcaneal and talar lengths, and accessory facet dimensions. Lateral radiographs of specimens with accessory facets were made in neutral and everted subtalar alignment. RESULTS: An accessory anterolateral talar facet was identified in twenty-seven (34%) of the seventy-nine specimens and was large in two (2.5%). Of the thirty-six skeletons with paired specimens, fifteen had an accessory facet and, of those, ten had the finding bilaterally. Degenerative changes or tarsal coalitions were not observed. Lateral radiographs demonstrated that subtalar eversion obscured observation of the facet. The accessory facet was associated with greater mean age (16.7 compared with 10.9 years; p < 0.0001), male sex (63% compared with 21%; p = 0.011), and a smaller mean angle of Gissane (116.2 degrees compared with 122.2 degrees; p = 0.018). Relative accessory facet volume was positively correlated with increased relative calcaneal posterior facet length (r = 0.53, p = 0.029). The accessory facet was significantly associated with dorsal talar beaking (29% compared with 4%; p = 0.028). CONCLUSIONS: An accessory anterolateral talar facet was found in 34% of the specimens in a pediatric osteologic collection. The facet was associated with male sex, a smaller angle of Gissane, and dorsal talar beaking.

Low bone mineral density in spinal muscular atrophy.

BACKGROUND AND PURPOSE: Pathological fractures are common in pediatric neuromuscular disorders. Dual-energy x-ray absorptiometry has become the most accepted technique for the measurement of bone mineral density (BMD) in adults and children. Limited data are available on BMD in pediatric neuromuscular diseases except Duchenne muscular dystrophy. METHODS: We retrospectively analyzed the results of all dual-energy x-ray absorptiometry scans done in a period of 23 months at a tertiary care pediatric neuromuscular center. BMD was performed on spine region L1-4. Osteopenia was classified as mild if the Z scores were between 0 and -1.5, moderate if Z scores were between -1.5 and -2.5, and severe if Z scores were > -2.5 standard deviation scores. RESULTS: Eighty-four dual-energy x-ray absorptiometry scans were performed on 79 patients between the ages of 4 months and 18 years with the mean age of 8 years. Z scores were used to compare their BMDs. BMD was lowest in patients with spinal muscular atrophy (SMA) with Z score of -2.25 +/- 0.31 standard deviation scores. The Z score for patients with Duchenne muscular dystrophy was -1.72 +/- 0.1. The BMD in nonambulatory patients with SMA was significantly decreased compared with ambulatory patients with SMA (P < 0.05). CONCLUSIONS: We conclude that osteopenia is common in children with neuromuscular disorders. Patients with SMA have the lowest BMD.

The impact of the current epidemiology of pediatric musculoskeletal infection on evaluation and treatment guidelines.

BACKGROUND: Methicillin-resistant Staphylococcus aureus is thought to have led to an increase in the incidence of severe musculoskeletal infection in children. Our purpose was (1) to compare the current epidemiology of musculoskeletal infection with historical data at the same institution 20 years prior and (2) to evaluate the spectrum of the severity of this disease process within the current epidemiology. METHODS: Children with musculoskeletal infection, treated between January 2002 and December 2004, were studied retrospectively. Diagnoses of osteomyelitis, septic arthritis, pyomyositis, and abscess were established for each child based on overall clinical impression, laboratory indices, culture results, radiology studies, and intraoperative findings. Comparison was made with the experience reported at the same institution in 1982. Children within each diagnostic category were compared with respect to mean values of C-reactive protein and erythrocyte sedimentation rate at admission, number of surgical procedures, intensive care unit admissions, identification of deep venous thrombosis, and length of hospitalization. RESULTS: Five hundred fifty-four children were studied (osteomyelitis, n = 212; septic arthritis, n = 118; pyomyositis, n = 20; and deep abscess, n = 204). The annualized per capita incidence of osteomyelitis increased 2.8-fold, whereas that of septic arthritis was unchanged when compared with historical data from 20 years prior. Methicillin-resistant Staphylococcus aureus was isolated as the causative organism in 30% of the children. We identified increasing severity of illness according to a hierarchy of tissue involvement (osteomyelitis > septic arthritis > pyomyositis > abscess) and according to the identification of contiguous infections within in each primary diagnostic category. CONCLUSIONS: The incidence of musculoskeletal infection appears to have increased within our community. We found that a more comprehensive diagnostic classification of this disease is useful in understanding the spectrum of the severity of illness and identifying those who require the greatest amount of resources. Magnetic resonance imaging is useful early in the diagnostic process to enable a more detailed disease classification and to expedite surgical decisions. The recognition of the incidence of methicillin-resistant Staphylococcus aureus within our community has also led to a change in empirical antibiotic selection.

Pulmonary function following early thoracic fusion in non-neuromuscular scoliosis.

BACKGROUND: While early spinal fusion may halt progressive deformity in young children with scoliosis, it does not facilitate lung growth and, in certain children, it can result in thoracic insufficiency syndrome. The purpose of this study was to determine pulmonary function at intermediate-term follow-up in patients with scoliosis who underwent thoracic fusion before the age of nine years. METHODS: Patients who had thoracic spine fusions before the age of nine years with a minimum five-year follow-up underwent pulmonary function testing. Forced vital capacity, forced expiratory volume in one second, and maximum inspiratory pressure were measured and compared with age-matched normal values. Patients with neuromuscular disease, skeletal dysplasias, or preexisting pulmonary disease were excluded, while those with rib malformations were included. The relationships between forced vital capacity and age at the time of surgery, length of follow-up, extent of the fusion, proximal level of the fusion, and revision surgery were studied. RESULTS: Twenty-eight patients underwent evaluation. Twenty patients had congenital scoliosis, three had idiopathic scoliosis, three had scoliosis associated with neurofibromatosis, one had congenital kyphosis, and one had syndromic scoliosis. Seventeen patients had one spinal surgery, while eleven had additional procedures. The average age of the patients was 3.3 years at the time of surgery and 14.6 years at the time of follow-up. The average extent of the thoracic spine fused was 58.7%. The average forced vital capacity was 57.8% of age-matched normal values, and the average forced expiratory volume in one second was 54.7%. The forced vital capacity was <50% of normal in twelve of the twenty-eight patients, and two required respiratory support, implying that substantial restrictive lung disease was present. With the numbers studied, no significant correlation could be detected between the age at the time of fusion or the length of follow-up and pulmonary function. The extent of the spine fused correlated with the forced vital capacity (p = 0.01, r = -0.46). Fusions in the proximal aspect of the spine were found to be associated with diminished pulmonary function as eight of twelve patients with a proximal fusion level of T1 or T2 had a forced vital capacity of <50%, but only four of sixteen patients with a fusion beginning caudad to T2 had a forced vital capacity of <50% (p = 0.0004, r = 0.62). CONCLUSIONS: Patients with proximal thoracic deformity who require fusion of more than four segments, especially those with rib anomalies, are at the highest risk for the development of restrictive pulmonary disease. Pulmonary function tests should be performed for all patients who have an early fusion. The pursuit of alternative procedures to treat early spinal deformity is merited.

Predicting scoliosis progression from skeletal maturity: a simplified classification during adolescence.

BACKGROUND: Both the Tanner-Whitehouse-III RUS score, which is based on the radiographic appearance of the epiphyses of the distal part of the radius, the distal part of the ulna, and small bones of the hand, and the digital skeletal age skeletal maturity scoring system, which is based on just the metacarpals and phalanges, correlate highly with the curve acceleration phase in girls with idiopathic scoliosis. However, these systems require an atlas and access to the scoring system, making their use impractical in a busy clinical setting. We sought to develop a simplified system that would correlate highly with scoliosis behavior but that would also be rapid and reliable for clinical practice. METHODS: A simplified staging system involving the use of the Tanner-Whitehouse-III descriptors was developed. It was tested for intraobserver and interobserver reliability by six individuals on thirty skeletal age radiographs. The system was compared with the timing of the curve acceleration phase in a cohort of twenty-two girls with idiopathic scoliosis. RESULTS: The average intraobserver unweighted kappa value was 0.88, and the average weighted kappa value was 0.96. The percentage of exact matches between readings for each rater was 89%, and 100% of the differences were within one unit. The average interobserver unweighted kappa value was 0.71, and the average weighted kappa value was 0.89. The percentage of exact matches between two reviewers was 71%, and 97% of the interobserver differences were within one stage or matched. The agreement was highest between the most experienced raters. Interobserver reliability was not improved by the use of a classification-specific atlas. The correlation of the staging system with the curve acceleration phase was 0.91. CONCLUSIONS: The simplified skeletal maturity scoring system is reliable and correlates more strongly with the behavior of idiopathic scoliosis than the Risser sign or Greulich and Pyle skeletal ages do. The system has a modest learning curve but is easily used in a clinical setting and, in conjunction with curve type and magnitude, appears to be strongly prognostic of future scoliosis curve behavior.

Deep venous thrombosis associated with osteomyelitis in children.

BACKGROUND: The association of deep venous thrombosis and deep musculoskeletal infection in children has been reported infrequently. The purpose of the present study was to evaluate the characteristics of children with osteomyelitis in whom deep venous thrombosis developed and to compare them with those of children with osteomyelitis in whom deep venous thrombosis did not develop. METHODS: A retrospective review of the records of children who were managed at our institution because of a deep musculoskeletal infection between January 2002 and December 2004 identified 212 children with osteomyelitis involving the spine, pelvis, or extremities. Children in whom deep venous thrombosis developed were compared with those in whom it did not develop with respect to age, diagnosis, causative organism, duration of symptoms prior to admission, laboratory values at the time of admission, surgical procedures, and required length of hospitalization. RESULTS: Eleven children with osteomyelitis and deep venous thrombosis were identified. The mean C-reactive protein level was 16.9 mg/dL for the group of eleven patients with osteomyelitis in whom deep venous thrombosis developed, compared with only 6.8 mg/dL for the group of 201 patients with osteomyelitis in whom deep venous thrombosis did not develop (p=0.0044). Staphylococcus aureus was the causative organism of infection in all eleven children with deep venous thrombosis and in ninety-three (46%) of the 201 children without deep venous thrombosis. Methicillin-resistant strains of Staphylococcus aureus were identified in eight of the eleven children with deep venous thrombosis and in only forty-nine of the 201 children without deep venous thrombosis. The children with osteomyelitis and deep venous thrombosis were older, had a longer duration of hospitalization, had more admissions to the intensive care unit, and required more surgical procedures than those with osteomyelitis but without deep venous thrombosis. CONCLUSIONS: Deep venous thrombosis in association with musculoskeletal infection is more common in children over the age of eight years who have osteomyelitis caused by methicillin-resistant Staphylococcus aureus and who present with a C-reactive protein level of >6 mg/dL. Diagnostic venous imaging studies should be performed to assess for the presence of deep venous thrombosis in children with osteomyelitis, especially those who have these risk factors.

Maturity assessment and curve progression in girls with idiopathic scoliosis.

BACKGROUND: Scoliosis progression during adolescence is closely related to patient maturity. Maturity has various indicators, including chronological age, height and weight changes, and skeletal and sexual maturation. It is not certain which of these indicators correlates most strongly with scoliosis progression. The purpose of the present study was to evaluate various maturity measurements and how they relate to scoliosis progression. METHODS: Physically immature girls with idiopathic scoliosis were evaluated every six months through their growth spurt with serial spinal radiographs; hand skeletal ages; Oxford pelvic scores; Risser sign determinations; height; weight; sexual staging; and serologic studies of the levels of selected growth factors, estradiol, bone-specific alkaline phosphatase, and osteocalcin. These measurements were then correlated with the curve-acceleration phase. RESULTS: The period and pattern of curve acceleration began during Risser stage 0 for all patients. Skeletal maturation scores derived with the use of the Tanner-Whitehouse-III RUS method, particularly those for the metacarpals and phalanges, were superior to all other indicators of maturity. Regression of the scores provided good estimates of maturity relative to the period of curve progression (Pearson r = 0.93). The initiation of this period occurred simultaneously with digital changes from Tanner-Whitehouse-III stage F to G. At this stage, curves also separated into rapid, moderate, and low-acceleration patterns, with specific curve types in the rapid and moderate-acceleration groups. The low-acceleration group was not confined to a specific curve type. CONCLUSIONS: The curve-acceleration phase separates curves into various types of curve progression. The Tanner-Whitehouse-III RUS scores are highly correlated with timing relative to the curve-acceleration phase and provide better maturity determination and prognosis determination during adolescence than the other parameters tested. Accurate skeletal maturity determination should be used as the primary maturity measurement in girls with idiopathic scoliosis.

Correlates of the peak height velocity in girls with idiopathic scoliosis.

STUDY DESIGN: Prospective longitudinal. OBJECTIVE: Determine correlates of the peak height velocity (PHV) in girls with idiopathic scoliosis. SUMMARY OF BACKGROUND DATA: Only identifiable retrospectively, the PHV is the most useful known maturity marker in idiopathic scoliosis. Clinically useful correlates are needed to make PHV timing helpful. METHODS: A total of 24 immature girls with idiopathic scoliosis were followed with serial heights, sexual staging, skeletal ages, spinal radiographs, insulin-like growth factor (IGF)-1, IGF binding protein-3, dehydroepiandrosterone sulfate, estradiol, bone-specific alkaline phosphatase, and osteocalcin levels. These markers were correlated to PHV timing. RESULTS: There were 14 girls who had identifiable growth peaks that averaged 10.5 +/- 1.8 cm/y at age 11.7 +/- 1 years. At the PHV, all girls were Risser 0 with open triradiate cartilages. On a skeletal age radiograph, digital uncapped phalangeal epiphyses were indicative of pre-PHV and fused epiphyses of post-PHV. Capped but unfused epiphyses were indeterminate. Tanner stage 1 for breast strongly indicates pre-PHV. Stage 3 for breast and pubic hair occurred at or after the PHV, and stage 4 always occurred after PHV. Higher IGF-1 and estradiol levels after PHV are potentially discriminatory. CONCLUSIONS: The PHV occurs during Risser 0 with open triradiate cartilages. If triradiate cartilages are open, then Tanner stages, IGF-1, estradiol levels, and the appearance of the epiphyses on a skeletal age radiograph are useful in determining status before or after PHV.

The impact on health-related quality of life from non-steroidal anti-inflammatory drugs, methotrexate, or steroids in treatment for juvenile idiopathic arthritis.

OBJECTIVE: To assess and compare the impact of medication treatments on health-related quality of life (HRQOL), family function, and medical status in children with juvenile idiopathic arthritis (JIA). METHODS: Fifty-seven children diagnosed with JIA were assessed by a pediatric rheumatologist and placed into one of three treatment groups: (1) non-steroidal anti-inflammatory; (2) methotrexate; or (3) steroids via IV methylprednisolone. Questionnaires were administered at baseline and 4-month follow-up. The attending pediatric rheumatologist provided additional medical information. RESULTS: Data document the impact of JIA on HRQOL, particularly on physical and pain domains. Steroid patients experienced improved HRQOL at follow-up relative to other groups, despite reporting more problems with side effects. CONCLUSION: These results demonstrate positive benefits of steroids in treating JIA children, despite the greatest incidence of adverse side effects.